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The Relationship Between Vicarious Traumatization and Quality of Life and Purpose in Life of Healthcare Providers of Can...

Permanent Link: http://ufdc.ufl.edu/UFE0042423/00001

Material Information

Title: The Relationship Between Vicarious Traumatization and Quality of Life and Purpose in Life of Healthcare Providers of Cancer Patients in Botswana
Physical Description: 1 online resource (134 p.)
Language: english
Creator: Majuta, Aaron
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: botswana, cancer, healthcare, professional, purpose, traumatization, vicarious
Human Development and Organizational Studies in Education -- Dissertations, Academic -- UF
Genre: Mental Health Counseling thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The purpose of this study was to establish the relationship between vicarious traumatization and professional quality of life and purpose in life among healthcare providers of cancer patients in Botswana. Based on the constructivist self development theory, data were collected through a cross sectional survey in nine hospitals in Botswana among 83 health care providers of cancer patients. The three instruments used for data collection were; trauma and attachment belief scale (TABS), professional quality of life scale (ProQOL) and purpose in life test (PIL). Presence and levels of trauma were established by computing t-scores from responses on the TABS using the profile autoscore sheet and interpretation table from the test manual. Across the ten subscales, the minimum score recorded was 13 (other safety) followed by 24 (self intimacy) and 24 (self control) indicating minimal disruption in these areas. The maximum or highest t-scores recorded were 80 (other trust), 80 (self trust), 79 (other esteem), 74 (self control), 73 (self safety) and 72 (self intimacy), indicating that these were areas where there was an extremely high level of disruption in the sample Bivariate correlations between TABS and ProQOL were run and yielded r= -.11 (not significant) indicating that there is a weak negative 13 relationship. Bivariate correlations were also run between TABS and PIL resulting in a r= -.28 (significant) which is a weak negative relationship. Multinomial logistic regression was conducted among the three variables to determine if vicarious trauma predicted both professional quality of life and purpose in life among health care providers. While holding PIL constant, result showed that vicarious trauma did not predict professional quality of life. By the same token, vicarious trauma did not predict purpose in life when professional quality of life was held constant.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Aaron Majuta.
Thesis: Thesis (Ph.D.)--University of Florida, 2010.
Local: Adviser: Torres-Rivera, Edil.
Local: Co-adviser: West-Olatunji, Cirecie.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2011-06-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042423:00001

Permanent Link: http://ufdc.ufl.edu/UFE0042423/00001

Material Information

Title: The Relationship Between Vicarious Traumatization and Quality of Life and Purpose in Life of Healthcare Providers of Cancer Patients in Botswana
Physical Description: 1 online resource (134 p.)
Language: english
Creator: Majuta, Aaron
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: botswana, cancer, healthcare, professional, purpose, traumatization, vicarious
Human Development and Organizational Studies in Education -- Dissertations, Academic -- UF
Genre: Mental Health Counseling thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The purpose of this study was to establish the relationship between vicarious traumatization and professional quality of life and purpose in life among healthcare providers of cancer patients in Botswana. Based on the constructivist self development theory, data were collected through a cross sectional survey in nine hospitals in Botswana among 83 health care providers of cancer patients. The three instruments used for data collection were; trauma and attachment belief scale (TABS), professional quality of life scale (ProQOL) and purpose in life test (PIL). Presence and levels of trauma were established by computing t-scores from responses on the TABS using the profile autoscore sheet and interpretation table from the test manual. Across the ten subscales, the minimum score recorded was 13 (other safety) followed by 24 (self intimacy) and 24 (self control) indicating minimal disruption in these areas. The maximum or highest t-scores recorded were 80 (other trust), 80 (self trust), 79 (other esteem), 74 (self control), 73 (self safety) and 72 (self intimacy), indicating that these were areas where there was an extremely high level of disruption in the sample Bivariate correlations between TABS and ProQOL were run and yielded r= -.11 (not significant) indicating that there is a weak negative 13 relationship. Bivariate correlations were also run between TABS and PIL resulting in a r= -.28 (significant) which is a weak negative relationship. Multinomial logistic regression was conducted among the three variables to determine if vicarious trauma predicted both professional quality of life and purpose in life among health care providers. While holding PIL constant, result showed that vicarious trauma did not predict professional quality of life. By the same token, vicarious trauma did not predict purpose in life when professional quality of life was held constant.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Aaron Majuta.
Thesis: Thesis (Ph.D.)--University of Florida, 2010.
Local: Adviser: Torres-Rivera, Edil.
Local: Co-adviser: West-Olatunji, Cirecie.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2011-06-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042423:00001


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1 THE RELATIONSHIP BETWEEN VICARIOUS TRAUMATIZATION AND QUALITY OF LIFE AND PURPOSE IN LIFE OF HEALTHCARE PROVIDERS OF CANCER PATIENTS IN BOTSWANA By AARON RONNIE MAJUTA A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2010

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2 2010 Aaron Ronnie Majuta

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3 Dedication In memory of my mother, Balindi Maphoto for her batt le against cancer and my sister Rachel Majuta, a great nurse and friend. Death be not proud, though some have called thee Mighty and dreadfull, for thou art not so, Die not, poore death John Don ne (1572 1631) Holy Sonnet 10

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4 ACKNOWLEDGMENTS I would like to thank many individuals and organizations that have helped me go through the process of putting this work together. Firstly I would like to thank the University of Botswana (my employer) for its resources, Ministry of Health (Botswana) and various hospitals and hospices that agreed to participate in this study. This could not have been done without their great sense of understanding. Next, I extend my sincere gratitude to my doctoral committ ee chair Dr. Edil Torres Rivera for being available and reminding me to be present, persistent and endure the process. His empathy and humor kept me going. Under his guidance I understood the meaning of independent studies. Dr. Cirecie West Olatunji has been my inspiration through her hands on approach to guidance. Through her traveling experiences, research projects, and critique I understood the tools and dimensions of the research tool box. I thank her greatly. Dr. Linda Behar Horenstein was instrument al in helping me shape the topic, research questions and the proposal in general. Without her invaluable support and critique, this work would not have turned into what it eventually became. My sincere gratitude goes to her. Thanks to Dr. Wayne Griffin for teaching me so passionately about trauma and crisis. That became an avenue for understanding a big part of life in my country, also a propeller that kept me going as I was writing this work. Thank you. I would like to thank Dr. Sondra Smith and fellow stu dents who were my support system through my doctoral studies at the University of Florida; Kevin Andrew Tate has been a friend and brother, Rachael Goodman my mentor, Lauren Shure, Blaire Cholewa, Richmond Wynn, Carrone Rush, Isabel Thompson, Anton Pustave r, Laura Reid, Laura Shannonhouse, Ryan Reese, Jessica Young, Niyama Ramlall and Jacque Huan Ye. My gratitude also go to my friends

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5 in Botswana for their support, Dr. Olekae Thakadu and his wife Grace, Dr. Naomi Moswete and her husband, Jeff McLucas, Josep h Tsimako and Dr. Bothepha Mosetlhi. I owe a deep sense of gratitude to my family. Firstly my beloved wife Neo Nompi Majuta for kind and encouraging words from across the Atlantic. Her patience and belief in this process and goal was unsurpassed. My first son Mompati deserves many thanks for believing in me, and reminding me constantly to bring the degree home. As for my second son Tiboke, his few words over the phone reminded me that I needed to be home soonest. Lastly, the thought of my daughter Wandipa, always reminded me how I enjoy her big personality, and I could not work fast enough to share the joy until today!

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6 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ ............... 4 LIST OF TABLES ................................ ................................ ................................ ........................... 9 LIST OF FIGURES ................................ ................................ ................................ ....................... 11 ABSTRACT ................................ ................................ ................................ ................................ ... 12 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .................. 14 Rationale for the Study ................................ ................................ ................................ ........... 15 Stat ement of the Problem ................................ ................................ ................................ ........ 16 Theoretical Perspectives ................................ ................................ ................................ ......... 19 Purpose of the Study ................................ ................................ ................................ ............... 21 Objectives of the Study ................................ ................................ ................................ ........... 21 Research Questions ................................ ................................ ................................ ................. 22 Hypotheses ................................ ................................ ................................ .............................. 22 Significance of the Study ................................ ................................ ................................ ........ 23 Limitations of the Study ................................ ................................ ................................ ......... 24 Definition of Terms ................................ ................................ ................................ ................ 24 2 REVIEW OF LITERATURE ................................ ................................ ................................ 26 s Health Planning and Development Strategies .......................... 26 Botswana Health System and Healthcare Provider Trauma ................................ ................... 28 ................................ .......... 29 Research on Trauma Related Issues of Healthcare Providers ................................ ................ 30 Research on Vicarious Traumatization of Healthcare Providers ................................ ............ 34 Quality of Life of Healthcare Provid ers of Cancer Patients ................................ ................... 37 Purpose in Life Research on Healthcare Providers of Cancer Patients ................................ .. 41 3 METHODOLOGY ................................ ................................ ................................ ................. 43 The Setting of the Study ................................ ................................ ................................ ......... 43 Sampling Procedures ................................ ................................ ................................ .............. 44 Sample Size ................................ ................................ ................................ ............................ 44 Description of Participants in the Study ................................ ................................ ................. 45 Design and Ethical Issues ................................ ................................ ................................ ....... 46 Variables ................................ ................................ ................................ ................................ 47 Vicarious Traumatization ................................ ................................ ................................ 47 Professional Quality of Life (ProQOL) ................................ ................................ ........... 48 Purpose in Life ................................ ................................ ................................ ................ 49

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7 Instrumentation ................................ ................................ ................................ ....................... 50 Trauma and Attachment Belief Scale (TABS). ................................ ............................... 50 Professional Quality of Life Scale (ProQOL R V) ................................ ......................... 52 Purpose in Life Scale (PIL) ................................ ................................ ............................. 53 Data Collection ................................ ................................ ................................ ....................... 55 Data Analyses ................................ ................................ ................................ ......................... 55 Limitations of the Methods ................................ ................................ ................................ ..... 59 4 DATA ANALYSES AND RESULTS ................................ ................................ ................... 60 Demographic Overview ................................ ................................ ................................ .......... 60 Variable s ................................ ................................ ................................ ................................ 61 Statistical Methods ................................ ................................ ................................ .................. 62 Descriptive Statistics ................................ ................................ ................................ .............. 62 Analyses Results Reporting ................................ ................................ ................................ .... 65 Hypothesis 1 ................................ ................................ ................................ .................... 65 Hypothesis 2 ................................ ................................ ................................ .................... 67 Hypothesis 3 ................................ ................................ ................................ .................... 70 Hypothesis 4 ................................ ................................ ................................ .................... 71 Hypothesis 5 ................................ ................................ ................................ .................... 72 Summary ................................ ................................ ................................ ................................ 73 5 DI SCUSSION, RECOMMENDATIONS AND CONCLUSION ................................ .......... 74 Overview of the Chapter ................................ ................................ ................................ ......... 74 Significance of Results ................................ ................................ ................................ ........... 75 Rese arch Question 1: Do Healthcare Providers of Cancer Patients in Botswana Experience Vicarious Traumatization? ................................ ................................ ............... 75 Research Question 2: What is the Relationship between Vicarious Traumatization and Professional Quality of Life among Healthcare Providers of Cancer Patients in Botswana? ................................ ................................ ................................ ........................... 76 Research Question 3: What is the Relationship between Vicarious Traumatization and Purpose in Life among Healthcare Providers of Cancer Patients in Botswana as Measured by the Purpose in Life Scale? ................................ ................................ ............. 78 Research Question 4: Does Vicarious Traumatization Predict Professional Quality of Life among Healthcare Providers of Cancer Patients in Botswana? ................................ ... 79 Research Question 5: Does Vicarious Traumatization Predict Purpose in Life among Healthcare Providers of Cancer Patients in Bo tswana? ................................ ...................... 80 Recommendations ................................ ................................ ................................ ................... 81 Research Question 1 ................................ ................................ ................................ ........ 81 Research Question 2 ................................ ................................ ................................ ........ 83 Research Question 3 ................................ ................................ ................................ ........ 84 Research Questions 4 ................................ ................................ ................................ ...... 85 Limitations of the Study ................................ ................................ ................................ ......... 85 Future Research ................................ ................................ ................................ ...................... 86 Summary ................................ ................................ ................................ ................................ 88

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8 APPENDIX A UFIRB APPROVAL OF PROTOCOL FOR THE STUDY ................................ ................ 108 B PERMISSION LETTER FROM WESTERN PSYCHOLOGICAL SERVICES ................ 110 C DEMOGRAPHIC INFORMATION FOR SURVEY ................................ .......................... 111 D TRAUMA AND ATTACHMENT BELIEF SCALE ................................ ........................... 112 E VERSION ALLOWED AS APPENDIX ................................ ................................ ............. 112 F PROFESSIONAL QUALITY OF LIFE SCALE ................................ ................................ 113 G PURPOSE IN LIFE TEST ................................ ................................ ................................ 114 H RESEARCH GRANT LETTER ................................ ................................ ........................... 117 I RE SEARCH STUDY ADVERTIS ING FLYER ................................ ................................ .. 118 J RESEARCH PERMISSION FROM THE MINISTRY OF HEALTH ................................ 119 K RESEARCH PERMISSION FROM PRINCESS MARINA HOSPITAL ........................... 121 L RESEARCH PERMISSION FROM DEBORAH RETIEF MEMORIAL HOSPITAL ...... 122 M RESEARCH PERMISSION FROM BAMALETE LUTHERAN HOSPITAL ................... 123 N RESEARCH PERMISSION FROM NYANGABWE REF ERRAL HOSPITAL ............... 124 LIST OF REFERENCES ................................ ................................ ................................ ............. 125 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ....... 134

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9 LIST OF TABLES Table page 3 1 Nationality of Healthcare Providers ................................ ................................ ................... 89 3 2 Gender of Healthcare Providers ................................ ................................ ......................... 89 3 3 Age groups of Healthcare Providers ................................ ................................ .................. 89 3 4 Marital Status ................................ ................................ ................................ ..................... 90 3 5 Occupation of Healthcare Providers ................................ ................................ .................. 90 3 6 Qualifications of Providers in Various Healthcare Disciplines ................................ ......... 91 3 7 Area of Specialization in Healthcare ................................ ................................ ................. 92 3 8 Organizations Healthcare Providers Work for ................................ ................................ ... 92 3 9 Years of Experience as a Healthcare Provider ................................ ................................ ... 93 3 10 Years of Experience with Cancer Treatment ................................ ................................ ..... 94 3 11 Healthcare Provider Frequency of Contact with Cancer Patients ................................ ...... 94 4 1 Descriptive Statistics for survey response on TABS subscales ................................ ......... 95 4 2 Descriptive Statistics for Compassion Satisfaction Subscale ................................ ............ 95 4 3 Descriptive Statistics for Burnout Subscale ................................ ................................ ....... 95 4 4 Descriptive Statistics for the Compassi on Fatigue Subscale ................................ ............. 96 4 5 Descriptive Statistics for the Purpose In Life scale ................................ ........................... 96 4 6 Descriptive Statistics of Sample on Each Instrument ................................ ........................ 97 4 7 Bivariate Correlations: Vicarious Trauma and Professional Quality of Life .................... 97 4 8 Bivariate Correlations: Vicarious Trauma and Purpose in Life ................................ ......... 97 4 9 Bivariate Correlations: Purpose in Life and Professional Quality of Life ......................... 97 4 10 Reliability Test for the Trauma and Attachment Belief Scale ................................ ........... 98 4 11 Reliability Test for the Professional Quality of Life Scale ................................ ................ 98 4 12 Reliability Test for t he Purpose in Life Scale ................................ ................................ .... 98

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10 4 13 Model Fitting Information ................................ ................................ ................................ 98 4 14 Goodness of Fit ................................ ................................ ................................ ................. 98 4 15 Pseudo R Square ................................ ................................ ................................ ................ 98 4 16 Likelihood R atio Tests ................................ ................................ ................................ ....... 99 4 17 Multinomial Logistic Regression for Trauma (TABS) and PIL: Model Fitting Information ................................ ................................ ................................ ........................ 99 4 18 Goodness of Fit ................................ ................................ ................................ ................. 99 4 19 Pseudo R Square ................................ ................................ ................................ ................ 99 4 20 Likelihood R atio Tests ................................ ................................ ................................ ....... 99 4 21 Results of Hypothesis Testing ................................ ................................ ......................... 100

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11 LIST OF FIGURES Figure page 4 1 Scatterplot: Vicarious Trauma and Professional Quality of Life ................................ ..... 101 4 2 Scatter Plot: Vicarious Trauma and Purpose in Life ................................ ....................... 102 4 3 Scatter Plot: Purpose in Life and Professional Quality of Life ................................ ........ 103 4 4 Histogram of Normal Distribution of Trauma ................................ ................................ 104 4 5 Histogram: Normal Distribution of Professional Quality of Life Data ........................... 104 4 6 Histogram: Normal Distribution of Purpose in Life Data ................................ ............... 105 4 9 Curve Fit Scatterp lot for TABS and ProQOL ................................ ................................ .. 107 4 10 Curve Fit Scatter Plot for TABS and PIL ................................ ................................ ........ 107 A 1 UFRIB approval of protocol for the study. ................................ ................................ ...... 108 B 1 Permission letter from Western Psychological Services ................................ ................. 110 D 1 Trauma and Attachment Belief Scale, version al lowed as appendix ............................... 112 E 1 Professional quality of life scale ................................ ................................ ...................... 113 F 1 Purpose in life test ................................ ................................ ................................ ............ 114 G 1 Research grant letter ................................ ................................ ................................ ........ 117 I 1 Research permission from the Ministry of Health ................................ ........................... 119 J 1 Research permission from Princess Marina Hospital ................................ ...................... 121 K 1 Research permission from Deborah Retief Memorial Hospital ................................ ....... 122 L 1 Research permission from Bamalete Lutheran Hospital ................................ ................. 123 M 1 Research permission from Nyangab we Referral Hospital ................................ ............... 124

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12 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE RELATIONSHIP BETWEEN VICARIOUS TRAUMATIZATION AND QUALITY OF LIFE AND PURPOSE IN LIFE OF HEALTHCARE PROVIDERS OF CANCER PATIENTS IN BOTSWANA By Aaron Ronnie Majuta December 2010 Chair: Edil Torres Rivera Co chair: Cirecie West Olatunji Major: Mental Health Counseling The purpose of this study was to establish the relationship between vicarious traumatization and professional quality of life and purpose in life among healthcare providers of cancer patients in Botswana. Based on the constructivist self development theory data were collected through a cross sectional survey in nine hospitals in Botswana among 83 health care providers of cancer patients. The three instruments used for data collection were; trauma and attachment belief scale (TABS), professional quality of life scale (ProQOL) and purpose in life test (PIL). Presence and levels of trauma were established by computing t scores from responses on the TABS using the profile autoscore sheet and interpretation table from the test manual. Across the ten subscales, t he minimum score recorded was 13 (other safety) followed by 24 (self intimacy) and 24 (self control) indicating minimal disruption in these areas. The maximum or highest t scores recorded were 80 (other trust), 80 (self trust), 79 (other esteem), 74 (self control), 73 (self safety) and 72 (self intimacy), indicating that these were areas where there was an extremely high level of disruption in the sample Bivariate correlations between TABS and ProQ OL were run and yielded r= .11 (not significant) indicating that there is a weak negative

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13 relationship. Bivariate correlations were also run between TABS and PIL resulting in a r= .28 (significant) which is a weak negative relationship. Multinomial logistic regression was conducted among the three variables to de termine if vicarious trauma predicted both professional quality of life and purpose in life among health care providers. While holding PIL constant, result showed that vicarious trauma did not predict professional quality of life. By the same token, vicari ous trauma did not predict purpose in life when professional quality of life was held constant.

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14 CHAPTER 1 INTRODUCTION Providing care for cancer patients places healthcare providers at risk for experiencing elevated levels of stress (Swartz & Keir experiences of physical and mental traumas such as acute and chronic pains; existential distress and a sense of powerlessness that then vicariously affect healthcare providers. These experiences t with purpose of life (Lee, Cohen, Edgar, Laizer & Gagnon, 2006). In the advanced stages of cancer, in addition to the physical pain, patients suffer from high levels of depression coupled with hopelessness and anxiety (Mystakidou, Parpa, Tsilika, Athanasouli, Pathiaki, Galanos, & Pagoropoulou, 2008). Delirium is another common mental health complication of cancer, occurring among 88% of patients prior to their death (Buss, Vanderwerker, Inouye, Bahui Zhang, Block & Prigerson, 2007). For the most part people who have been called upon to provide care are family members who provide physical, emotional, social, financial and spiritual support (Seloilwe, 2006; Mbata Ndaba & Seloilwe, 2000; Swartz & Keir, 2007). In hospital and hospice settings, healthcare providers assume the primary role of taking care of the welfare and wellbeing of cancer patients. They see these patients in pain, provide chemotherapy, administer medication and listen to their stories and inadvertently absorb these experiences that demand high levels of bio affective and cognitive energy (Buss, et al, 2007) Given a plethora of mental health issues associated with cancer that affect patients, a stu dy of how this close interaction between the traumatized patients and healthcare providers manifests itself in professionals is essential to identifying ways of augmenting care giving while meetings self care needs at the same time.

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15 Rationale for the Study Addressing vicarious traumatization and providing care among healthcare providers who work with traumatized cancer patients is vital in the current era especially in Africa where half a million people die from the disease every year. The World Health Org anization (WHO, 2002) estimated that by 2020, seventy percent of new cancer cases will be in developing countries and in 50 years the projected growth rate for the cancer disease in Africa will be 400%. This phenomenon puts the healthcare providers at risk first by realizing the magnitude of care giving that lies ahead of them and secondly by getting actively involved in the provision of palliative care which is physically and emotional exhausting. For example, in Botswana, doctors in the Princess Marina Ho spital oncology department have been seeing on average 20 30 patients a day working seven days a week (Staff writers, 2006). awareness of mental health issues among polic y makers and ensure necessary support for the provision of services and resources for people with mental health problems and promotion of numbers of cancer pat ients in the country, implementation of this objective would go a long way ts of the definition of a vulnerable group in society excludes healthcare providers of cancer patients, a group which is the most vulnerable to mental disorders d ue to exposure. Instead its definition of 10). As a means of advocat ing for the healthcare providers and contributing to public awareness

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16 and policy makers, a relationship needs to be established between vicarious trauma, quality of life and purpose in life in this vulnerable group in Botswana in order to find out the rate at which trauma occurs and affects them. Statement of the Problem Healthcare providers are directly and indirectly exposed to the trauma experienced by the patients. This exposure may put them at risk for poor mental health in the form of depression (Sw artz & Keir, 2007), generalized anxiety (Buss, et al 2007), compassion fatigue (Figley, 1995) and others. While studies have documented factors associated with stress in cancer caregiver population and other chronic illnesses (Swartz & Keir, 2007), littl e has been documented about the mental health status of healthcare providers or vicarious trauma situations they experience in health settings especially in Africa, and Botswana in particular. Despite a lack of focus on and commitment to the mental health of healthcare providers, they still have to deal with escalating challenges associated with HIV/AIDS and cancer as evidenced by their active implementation of the National Strategic Framework (National Aids Coordinating Agency, 2003). An even bigger challe nge arises when the question of their success in the care giving process surfaces calling into question, their professional quality of life It is apparent for most oncology staff especially in hospice situations that their patients will eventually die (R unning, Tolle, & Girard, 2008). Although during their hospitalization the situation might not present a bleak outlook, death is still prevalent among cancer patients. Caregiver success and compassion satisfaction become a continually illusive ideal to whic h research attention needs to be directed especially in Botswana. In Africa each year, 2.5 million people die from HIV/AIDS, more than half a million die of cancer and about 80% of them will have pain in the terminal phase of their disease (Sepulveda, Habi yambere, Amandua, Borok, Kikule, Mudanga, Ngoma & Solomon, 2003). This

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17 phenomenon requires the empathy of the healthcare providers who in turn get affected compassion f atigue (Sabo, 2006). In Botswana most healthcare providers have experienced multiple losses and pain due to HIV/AIDS in both their professional and private lives. The Nurse Association of Botswana (n. d) has observed that failure to adequately acknowledge and express feelings of sadness, anger, and frustration may result in bereavement overload, burnout and perhaps high rates of attrition. Healthcare providers need to realize that self care is crucial to survival and turning away or ignoring it only perpetr ates the distress (Nurses Association of Botswana, n. d). Yet little research has explored these consequences of care giving in Botswana. Nurses and other health professionals in Botswana whose work used to be oriented towards cure are now increasingly f ocused on caring for the dying. Healthcare providers administer treatment to alleviate suffering with a goal to cure diseases; however, if this goal is sabotaged by caring for the dying, dead and bereaved, professionals will feel a heightened sense of inad equacy, helplessness and grief (Nurses Association of Botswana, n. d). Given this scenario, at a critical time when there is uncertainty about the national he alth status that requires health workers attention. While the National Policy on Mental Health of Botswana acknowledges that counseling services are a critical factor for chronically ill patients and their families, little consideration has been given to t he psychological well being of the healthcare providers and how it affects their quality of life, their view of meanin gful life and professional quality of life Countries that are plagued by some chronic illnesses need some form of palliative care struct ures such as counseling services, spirituality, and nutrition in their health system. Most

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18 comprised of an interdisciplinary team of oncology nurses, physicians, socia l workers, physical and music therapists, psychologists and other professionals (Granda Cameron, Viola, Lynch & Polomano, 2008). However, various counseling models have been provided for both patients and families. Despite numerous research reports about t hese health services, psychological needs for healthcare providers are rarely reported in published work (Harding & Higginson, 2005). This study therefore seeks to make a contribution by raising awareness about the mental health needs of healthcare provide rs in Botswana and also reduce the dearth of literature in this area. The improvement of quality of health care for chronic conditions has been a preoccupation for many researchers and practitioners in developing countries. Issues of resources such as per sonnel and finance, physical and professional structures, cultural dimensions and service models have occupied the center stage (Harding & Higginson, 2005). However, non communicable conditions and mental disorders have been reported as accounting for fort y seven percent of the global disease burden in 2002 (Epping Jordan, Pruitt, Bengoa, & Wagner, 2004). In these reports there is no evidence of the mental health status of healthcare providers despite reports about noticeable increase of cancer among other non communicable diseases in Botswana (Epping Jordan, et.al 2004). These omissions together with other emerging national health issues that healthcare providers have to deal with in the foreseeable future provide rationale for investigating psychological i ssues of this vulnerable group in Botswana, hence the production of the current study. Mental health professionals generally agree that caregivers working with victims of violence (Pross, 2006), sexual abuse (Bell et al 2003) and cancer (Buss, 2007) ar e at a high risk of suffering from vicarious traumatization if necessary steps are not taken to prevent this occurrence. Although the concept of mental health and its practice has been in place for a long in

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19 Botswana (Seloilwe, 2006), the counseling profes sion in the country is still new (Ministry of Education, 1996). Resources are limited care, professional training in psychotherapy, therapeutic self awareness, regular self examination by collegial and external supervision and li traumatization of healthcare providers and how it affects professional quality of life and purpose in life in the care giving process is essential to broaden the philosophy and co ncept of mental health in the country. This will help to shift the understanding of the concept from the institutional care perspective to an all encompassing model inclusive of professionals. This will further align this model with current global evidence d based and empirically accepted mental health practices. Theoretical Perspectives The theoretical framework used in this study is the Constructivist Self Development Theory (CSDT) of trauma propounded by MacCann and Pearlman (1990) The CSDT is a product of several theoretical and empirical contributions of people who studied trauma from a self development and constructivist perspective (MacCann & Pearlman, 1990). In a way it is a repacking of developmental theory, self psychology, social learning and cogn itive theory. Its main focus is that experience is the basis from which individuals order and assign new meanings to new experiences. For this reason, its other focal point is on the interaction between the person and the situation. This interactive approa unique adaptation to trauma because it encompasses characteristics of the event and personal characteristics beyond pre existing conditions. It emphasizes the importance of the individual as an active ag ent in creating and constructing his or her reality. It further posits that adaptation to trauma is a complex interplay between life experiences including personal history, specific traumatic events, the social and cultural context and the developing self which encompasses ego

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20 resources, psychological needs and cognitive schemas (MacCann & Pearlman, 1990). In this case healthcare providers of cancer patients construct their personal realities and meanings as they interact with cancer patients on a day to da y basis. The way they respond to treating cancer is a complex process that extends to the deepest parts of their beings thus leading to coping and adaptation or lack thereof. MacCann and Pearlman (1990) maintain that the basic tenets or assumptions of the ir theory are that; 1) the experience of trauma begins with exposure to a non normative or highly distressing event that disrupts the self. 2). The individual unique response to trauma is a complex process that includes personal meanings and images of the event and extends to the deepest parts Individuals possess the inherent capacity to construct their own personal realities as they interact with their environmen t. 4) Continuing psychological development depends on the evolution of differentiated psychological systems. The three psychological systems include; firstly the d negotiate relationships with others. Secondly, the psychological systems include needs that motivate behavior and, the cognitive schemas for organizing and interpreting experiences. 5). Trauma requires accommodation or modification in schemas. It disrupt s at least temporarily, the psychological growth of an individual. The re experiencing of traumatic imagery by healthcare providers of cancer patients is painful and disruptive and creating a defensive tendency to avoid this material. Using this theory, th is study seeks to find out the relationship between healthcare The study of trauma has evolved over many years and has acquired different interpretations ranging from ranging from t he psychiatric version of post traumatic stress

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21 disorder (PTSD) which perceives it as a sudden, unexpected, overwhelming blow assaulting the person from outside (Terr, 1990), to systemic oppression (Sue, 2002) and compassion fatigue (Figley, 1995) and vica rious traumatization (VT) (MacCann & Pearlman, 1990) which are responses to emotional demands on the therapists and social network members from exposure to 2002). Vicarious traumatization in particular has been defined as a permanent transformation in the inner experiences of a therapist or helper that comes about as a result of empathic The main identity, worldview, spirituality, affect tolerance, fundamental psychological needs, deeply held beliefs about self and others, interpersonal relationships, internal imagery and ph ysical presence in the world (Pearlman & Saakvitne, 1995). Given this theoretical understanding, VT thus adds to further development of the Constructivist Self Development Theory. The Constructivist Self Development Theory (CDST) of trauma in general is st ill evolving; a fine line still exists between VT, secondary traumatization (compassion fatigue) and burnout. The focus of this study is on vicarious traumatization. Purpose of the Study The purpose of this study is to investigate the relationship between vicarious traumatization, the professional quality of life ( Pro QOL) and purpose in life (PIL) of healthcare providers of cancer patients in Botswana. Objectives of the Study 1. The first obj ective is to find out if healthcare providers in Botswana do experience vicarious tra u matization as a result of providing care to cancer patients. Literature especially in the Western countries attests to the fact that healthcare providers working with tra umatized clients do experience trauma vicariously or secondarily. The objective here is to establish if providers in Botswana share the same experiences

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22 2. The second objective is to establish the relationship between vicarious traumatization and quality of l ife of the healthcare providers as measured by the Professional Quality of Life scale. Professional quality of life entails whether or not professionals experience compassion satisfaction, job satisfaction or dissatisfaction. Through the interaction of the se variables, the strength and direction of the relationship will be established thereby pointing out to the influence vicarious trauma has on healthcare providers and their work. 3. The other objective is to determine the relationship between vicarious traum atization and purpose in life of healthcare providers as measured by the Purpose in Life scale. Purpose in life entails having a meaningful life, set life goals, the use of religion and spirituality for coping and having positive emotions to counter despai r and hopelessness. This objective sets out to establish if healthcare providers still find life meaningful in the face of trauma of their cancer patients. 4. Finally, the study seeks to find out if vicarious traumatization can predict the professional quali ty of life and purpose in life of healthcare providers of cancer patients in Botswana. Predicting trauma among healthcare providers through this study is intended to provide information to policy makers who can restructure the system to alleviate healthcar e provider burden. Research Questions 1. Do healthcare providers of cancer patients in Botswana experience vicarious traumatization as measured by the Trauma Attachment Belief Scale (TABS)? 2. What is the relationship between vicarious traumatization and profess ional quality of life of healthcare providers of cancers patients as measured by the Professional Quality of Life Scale (ProQOL)? 3. What is the relationship between vicarious traumatization and purpose in life of healthcare providers of cancers patients as measured by Purpose in Life scale (PIL)? 4. Does vicarious traumatization predict quality of life and purpose in life of healthcare providers of cancer patients in Botswana? Hypotheses Ho 1 : Healthcare providers of cancer patients in Botswana experience vicar ious traumatization. Ho 2 : There is a positive relationship between vicarious traumatization and professional quality of life among healthcare providers of cancer patients in Botswana. Ho 3 : There is a positive relationship between vicarious traumatization and purpose in life among healthcare providers of cancer patients in Botswana.

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23 Ho 4 : Vicarious traumatization predicts professional quality of life among healthcare providers of cancer patients in Botswana. Ho 5 : Vicarious traumatization pr edicts purpose in life among healthcare providers of cancer patients in Botswana Significance of the Study Botswana once had the highest HIV/AIDS infection rate and cancer related illnesses in the world. This exposes the country to psychological hazards for which mental health needs for healthcare providers have to be in place. Although the Nursing Association of Botswana (NAB) has compiled a working document from conferences and textbooks detailing self care practices of these professionals, research add ressing this need is almost non existent in the country. This study is an attempt to find the relationship between healthcare service provision and trauma in Botswana with the goal to inform healthcare policy makers, counselors, counselor educators and res earchers so that they can respond accordingly in a way that will help sustain professional quality of life of healthcare providers. It is hoped that the study will also bridge the gap in the mental health care literature in Botswana. Also, it is envisaged that this study will open an avenue for further exploration of mental health interventions in healthcare, an essential tool for the implementation of clinical practice standards of self care, training in counseling, collegial and external supervision and c ase load reduction among human service workers in the country (Pross, 2006). The study could have a greater impact in the country in terms of addressing the mental health counseling audience. The mental health practice service delivery could also be extend ed beyond a limited number of groups deemed vulnerable by the National Policy on Mental Health in Botswana. Currently, healthcare providers are not considered as a mentally vulnerable group by the National Policy on Mental Health in Botswana.

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24 Limitations o f the Study years, the country still experiences limited resources and personnel with regards to treatment and care for HIV/AIDS (Phirinyane, Kaunda, Salkin, Kaboyakgosi, Thupeng & Batsetswe, 2006) and cancer patients. These limitations are even more confounded by the small number of specialized professionals in the fields of both medical and psycho oncology. For these reasons, the sample is not random but a criterion base d, meaning that participants are chosen on the basis of specific characteristics they have (Dooley, 200 1). In this case the choice was specific to those healthcare providers working with cancer patients. Survey research requires a significantly large sampl ing frame if the results are going to be generalized to the entire population. In this case a b sence of such a condition imposed limits on the statistical power of the study (Shavelson, 1996). Data collection was in the form of self reports achieved through the administration of instrument by pencil and paper. Reliance on self report for the measurement of both dependent and independent variables raises concern about the validity of causal conclusions for a range of reasons. Sometimes there is lack of system atic response among participants because of their intervening personal factors such as inattention due to fatigue, time of the day or lack of interest. This study was not immune to these conditions. The psychometric properties of the questionnaire such as its level of intrusiveness especially that it requires statements on personal trauma may have cause d the participant s to withhold vital information. It is possible that t his factor may lead to social desirability bias a phenomenon where the participant provi des a response that puts him or her in a favorable light (Razavi, 2001). Definition of Terms C ANCER PATIENTS Patients suffering from any form of cancer irrespective of the source of the source or place of the tumor in the body.

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25 CARE GIVING. T he proc ess of attending to cancer patients that involves observation, assessment, active listening, praying for, physical support, feeding, dressing, administering medication, radiology and chemotherapy. CONSTRUCTIVISM. A postmodern philosophy derived from Latin which means to meaning and significance (Sexton, 1997). MEANING MAKING A coping mechanism during which professional caregivers engage in thought processes of decid ing what makes sense by asking questions such as why cancer occurs, how it occurs, whether their patients deserve to suffer and the reconciliation of their shattered attempts with renewed energy to move forward (Melton & Schelenberg, 2008). HEALTHCARE PROV IDERS Physical and mental health care providers involved in the process of observation, assessment, counseling or active listening, praying for, physical support, feeding, dressing, and administering medication, radiology and chemotherapy. Such professionals in clude but are not limited to nurses, doctors, counselors, psychologists, social workers, radiologists, and hospital based pastors (Sepulveda, et al, 2003). PURPOSE IN LIFE a state of having a sense of meaning in life, having goals and a sense of direction a feeling that there is meaning to life and holding a belief that gives life essence and having a ims and objectives for living (MacArthur & MacA rthur, 1997). QUALITY OF LIFE Stable emotional, cognitive and spiritual functioning (Hugginson & Carr, 2001). VICARIOUS TRAUMATIZATION

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26 CHAPTER 2 REVIEW OF LITERATURE An Overview of Botswana Health Planning and Devel opment Strategies Botswana is a country in the sub Saharan Africa with four surrounding neighbors; South Africa in the south, Namibia in the west, Zambia in the north and Zimbabwe in the north east. Diamond mining is the driving force of the economy providing a significant portion of the annual budgets to education and health. Several institutions in Botswana including the health sector are guided by various policy documents such as vision 2016, National Development Plans (NDP 10 started March, 2009) (World Health Organizati on, 2003). These documents outline the philosophies, mission statements, overall objectives and policy implementation strategies for sectors for which they have been designed. The Ministry of Health (MOH) continues to be guided by the Health Policy, Strate gic Framework 2000, Corporate Performance Plan, 2000 2005, National HIV/AIDS policy and the National Policy on Mental Health of 2003 to mention just a few. Vision 2016 highlights government goals to be achieved by 2016; an educated informed nation; a pro ductive and innovative nation; a just and caring nation; a safe and secure nation; an open democratic and accountable nation; a moral and tolerant nation; and a united and proud nation (Presidential Task Group, 1997). The vision aspires that all Batswana w ill have access to good quality health care services. The NDP 8 of 1999 2003 has operationalized part of that vision (World Health Organization, 2007). The National Development Plan 9 of 2004 2008 has addressed the issue of HIV/AIDS campaigns and treatme nt through various programs. The Botswana National Health Policy (Ministry of Health, 1996) states that its health care system is based on the principles of Primary Health Care (PHC) which puts health promotion, care and disease prevention as some of its priorities (National Development Plan 9, n.d). PHC

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27 also emphasizes community participation and inter sectoral collaboration and equity. The PHC has considerations to protect its perceived high risk groups such as children, adolescents, pregnant women, the elderly, disabled persons, and workers whose occupations or professions justify such measures (NDP 9 n.d ). In general, health care promotion and avoidance of ill health through behavior modification services such as health education, health counseling and environmental sanitation are major aspects of health care system in Botswana. Despite policies geared towards a commitment to social justice for all citizens, none of these policies makes a conscious effort to recognize healthcare providers as a part of t he population that is at risk. This disconnection becomes more clear when viewed in terms of on in the PHC delivery system level of development wher e the disease pattern is predominantly determined by poverty, low Federation of Trade Unions, 2007, p. 11). Viewed in this light, healthcare providers are less likely to be perceived as experiencing these conditions that the PHC strives to work on. The Ministry of Health (2003) through the National Policy on Mental Health seeks to establish a framework for the protection of the rights and civil liberties of all citizens as set out in the constitution of Botswana, Botswana Mental Health Act, and the Botswana National Health Policy. It also seeks to provide mental health services relevant to the needs of special or vulnerable groups and encourage the development o f high quality and uniform national standards of care for mental health services, and systems for assessing whether or not services are meeting these standards (p. 5). From this brief overview, a study on vicarious traumatization of care givers resonates w ell with the policy document which seeks to provide relevant mental health services to vulnerable groups

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28 such as healthcare providers and mental health workers (Ministry of Health, 1 996, Ministry of Health, 2003) Botswana Health System and Healthcare Provider Trauma The distress faced by healthcare providers in Botswana can best be understood within the lenging task of providing health care to a nation that is highly traumatized by the HIV/AIDS scourge which in many cases develops into different forms of cancer (World Health Organization, 2007). Until the advent of HIV/AIDS epidemic, the health status of Batswana as a nation had improved, the vital health indicators were among the best in the southern African region (World Health Organization, 2007). The HIV/AIDS pandemic has now taken the center stage; it has become the most important public health chall enge for Botswana and its surrounding neighbors in the region. Healthcare providers who are mostly in hospitals are in a crisis situation that requires mental health programs geared towards treating patients and these professionals too. The WHO (2007) cou ntry cooperation strategy for Botswana document captures the effect of HIV/AIDS in a succinct manner; The response to HIV/AIDS epidemic has brought on an extraordinary strain to bear on the people (especially healthcare providers), the health system and th e government. Up to 70% of all in patients in medical wards of referral hospitals are HIV related cases. The extra functions that have to be performed by the health system have put great demands on the limited resources of the system. The human resources a comprehensive counseling services on a full time basis (p.7). The magnitude of this shortage of health personnel in the health system of Botswana is further revealed through the doctor p atient and nurse patient ratios. In the type of health workers and ratio by population survey conducted in 1999 results showed that there was one doctor per 3,440 people, one dentist to 44, 181, one nurse to 410, one pharmacist to 11, 823 and one enviro nmental health officer to 12, four hundred and thirty six people (Health Statistics

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29 Report, 1998) In 2006 the doctor patient ratio was 1:15 in a private facility and 1:25 per day in government hospitals (World Health Organization, 2006) In all the lists of duties outlined there is no mention of mental health professionals such as psychologists, counselors, psychiatrists or social workers despite public knowledge that they are employed as part of the Botswana health personnel and were equally burdened. T technicians and janitors because of shortage of cadres of health professionals ( WHO, 2007, p. 18).There have been reports of sick healthcare providers especially among nurses. This has created an acute shortage of health personnel which was further worsened by the migration of Batswana nurses to developed countries such as Britain (Na tional Manpower Plan, 2001). New government interventions on HIV/AIDS such as the Voluntary Counseling and Testing services (VCT) and prevention of mother to child transmission (PMTCT) and antiretroviral (ARV) programs resulted in many nurses leaving hospi tal settings to join these new programs (WHO, 2007; National Aids Coordinating Agency, 2003). The HIV/AIDS crisis still remains a burden in each one of these sectors. Healthcare providers still remained exposed and vulnerable to the trauma and the crisis t hat their patients experience. Healthcare Exposure to Cancer Trauma in Botswana Each year in the continent of Africa about 2.5 million people die from HIV/AIDS and a combined total of 80 800 from Botswana, Ethiopia, Tanzania, Uganda and Zimbabwe die from cancer (Sepulveda, et al 2003). The World Health Organization (WHO, 2003) estimated that by 2020, seventy percent of the new cases of cancer will be in the developing world, Botswana in cluded. In a draft report on the Botswana rapid situation analysis of non communicable diseases in 2001, the 1600 cancer cases reported in 1996 were more than four times the number

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30 that had been reported previously. Reported cases of mental disorders had a lso risen from about 100 in 1980 to about 1500 in 1996 (World Health Organization, 2007). In anot her study it was found that 21 on over the age of fifteen that use tobacco products increase cancer cases thus adding to the alrea dy existing healthcare provider burden caused by HIV/AIDS (Epping Jordan et.al, 2004). In a survey carried about the end of life experience in Botswana among nine two terminally ill patients infected with HIV and some suffering from cancer, one of the mos t acute problems reported were pain and irregular (Sepulveda, et al., 200 3). These are some of the indicators that point out the extent to which healthcare providers in Botswana are exposed to trauma in their day to day duties of providi ng care. Research on Trauma Related Issues of Healthcare Providers Several studies have documented various conceptualizations of the effect of trauma on professional caregivers in the form of secondary traumatic stress (compassion fatigue), burnout and vic ariou s traumatization (Bell, et.al, 2003; Buchanan, et.al, 2006; Dutton & Rubinstein, 1995; Figley, 1995, Pearlman & Saakvitne, 1995 & Sabo, 2006). Earlier studies have viewed trauma in terms of an individual witnessing or being involved in actual threat o r injury that is detrimental to the physical integrity of the self or other (Dutton & Rubinstein, 1995). However, healthcare providers or trauma workers such as nurses, physicians, mental health workers, lawyers and case managers for the most part may not experience the agent directly causing harm, but are exposed to traumatic stress of their clients who may have witnessed or got involved in the actual threat, injury or death of close associates. According to (Dutton & Rubinstein, 1995) this exposure resul ts in secondary traumatic stress (STS) reactions, also known secondary of behaviors and emo tions

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31 resulting from knowing about a traumatizing event experienced by a significant other or the There is an overlap of the indicators of psychological distre ss between secondary traumatic experiencing secondary traumatic stress h ave been reported to present with grief, depression, fear and shame; intrusive imagery such as nightmares or flashbacks; addictive or compulsive behaviors and cognitive shifts (Dutton & Rubinstein, 1995). These psychological dysfunctions point out to the r isk professional caregivers are facing. The current body of literature on secondary traumatic stress (STS) (Badger, Roy se, & Craig, 2008; Buchanan, et al ., 2006 ; and Jenkins & Baird, 2002) has not generated any new conceptualizations or theoretical framew ork of this idea but continues to tap directly from the pioneers such as Figley, (1995) and Pearlman and Saakvitne, (1995). Literature on secondary traumatization of health workers or any healthcare providers in Botswana is completely lacking. However, the re are several emerging studies on secondary traumatic stress especially among hospital workers helping patients in emergency situations and chronic illness and oncology departments in developed countries where the same theoretical framework is being used. It is noteworthy that a review of literature in the oncology and professional direct service provision presents volumes of information on nursing, but little on other disciplines, including social work and mental health counseling (Simon, Pryce, Roff, & K lemmack, 2005). It is also not yet clear whether or not there is a difference in secondary exposure between mental health and health providers (Robbins, Meltzer, & Zelikovsky, 2008).

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32 The nature of taking care of cancer patients involves chronic loss to bot h healthcare (Simon, et.al, 2005). Providing care also entails pain and symptom control, giving food, emotional and spiritual support, advocacy and sometimes legal hel p (Harding & Higginson, complications. For example in a study investigating prevalence and correlates of workplace depression in the National Co morbidity Surv ey Replication it was found that a total of 6.4% of employees had major depressive disorder in the past twelve months and an additional 1.1% had major depressive episodes (Kessler, Merikangas & Wang, 2008). Nurses in emergency department also go through si milar experiences. Exploratory comparative studies of nurses in different hospitals have revealed that emergency nurses who cared for persons exposed to traumatic events suffered from secondary traumatic stress (STS) or compassion fatigue (CF) with symptom s such as irritability, avoidance and intrusion (Dominguez Gomez & Rutledge, 2008). Social workers in hospital settings li ke any helping professionals exposed to trauma experience secondary trauma related tho ughts and behaviors (Badger, et al 2008; Bride, 2007) due to emotional work they do with clients. Badger (2008) and others studied factors that contribute to the development of STS in hospital social workers with predictive independent variables being empathy, emotional separation, occupational stress and social support. Empathy is usually considered to be a gateway for emotional vulnerability (Figley, 1995). Findings pointed out that emotional separation from the patient also a component of empathy was associated with professional vulnerability and could lead to the development of STS. On the other end of the continuum emotional separation was also associated with a reduction of STS. Occupational stress or burnout was also found to be a predictor of STS. In a study of frequency

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33 of individual sym ptoms and frequency with diagnostic criteria for PTSD, findings pointed out that social workers were likely to experience STS and some may meet the criteria for PTSD (Bride, 2007). In a study of oncology social workers, a Compassion Fatigue and Satisfacti on Self Test for Helpers (CFS) was used to measure among other things, STS and burnout and the reliability level for both was .78 (Simons, Pryce, Roff, & Klemmack, 2005). Social workers were found to have experienced STS and burnout. However, satisfaction with work, colleagues and burnout were found to be related to the organization and management. STS and burnout were found to be related in the sense that the more the workers experienced STS the more the likelihood of developing burnout in the process. In essence it is generally agre ed that healthcare providers working with individuals who have been exposed to direct, indirect trauma, injury or life threatening illnesses face the risk of developing secondary traumatic stress/compassion fatigue which may es calate into Posttraumatic Stress Disorder (PTSD) if not monitored (Dutton & Rubinstein, 1995; Pearlman & Saakvitne, 1995; Robins, Meltzer, & Zelinosky, 2008). Burnout is another concept related to secondary traumatic stress and vicarious traumatization. T his syndrome consists of physical and emotional exhaustion that results from problematic work conditions such as work overload, lack of social support, negative job attitudes which lead to loss of concern for clients ( Jenkins & Baird, 2002; Rosenberg & Pa ce, 2006). Burnout among healthcare providers in Botswana has not been documented in terms of specific research on the construct itself or related areas of study, however there is an abundance of literature on the status of the national health care deliver y system that indicates its prevalence (Ndaba Mbata & Seloilwe, 2000; S eloilwe, 2007. & Sepulveda, et al 2003). The burden of

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34 lifestyle illnesses, HIV/AIDS and other non communicable diseases such as cancer are some of the poor health indicators leading to burnout among the health professionals in Botswana. For s that necessitate community based the health costs. T he effe cts of [foreign] aid withdrawal, morbidity and mortality are also high in health worker s (Harding & Higginson, 2005, p. 365). The number of vacancies in the public health sector also accounts to such burnout and this has been aggravated by the migration o f Batswana nurses and other health professionals to developed countries (World Health Organization Country Cooperation Strategy, 2007). The doctor patient ratio, nurse patient ratios have also shown to be some of the factors associated with burnout in Bots wana. Literature on burnout in the western world attests that it is a familiar phenomenon in the healthcare system (Pross, 2006). Various disciplines of study have generally centered on symptoms, risk factors a s well as prevention of burnout; investigati ons have also documented burnout as being experienced by psychologists, social workers (Rosenberg & Pace, 2006) and mental health counselors (Buchanan, et al 2006). Research on Vicarious Traumatization of Healthcare Providers Healthcare providers working with cancer patients are usually the physicians, nurses, psychologists and, radiologists, chemotherapy specialists, social workers and mental health counselors. These professionals are vicariously traumatized by various manifestations of the disease rangi ng from acute and chronic pain to psychological disorders. Theoretically, vicarious inner experience resulting from empathic engagement with clients trauma mater Saakvitne, 1995, p. 151). Accordingly, these effects accumulate over a long period of time; they

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35 and personal life. Vicarious traumatization is therefore an occupational hazard for those who work with trauma survivors (Pearlman & Mac Ian, 1995). Further, vicarious traumatization has implications on the [caregivers] enduring ways of experiencing the self, others and the world (Pearlman, et al, 199 5). Previous studies on vicarious traumatization have explored its impact on specific helping professionals such as social workers (Ba dgers, et al., 2008; Bride, 2007 ), emergency nurses (Dominguez Gomez & Rutledge, 2008), [counselors], psychologists and he alth science graduates (Iliffe & Steed, 2000) but not as a collective group. The general consensus among these studies is that caregivers exposed to traumatized patients material were more likely to have intrusion; arousal and avoidance symptoms and for th e most part their symptoms fit the PTSD profile. For example in a study conducted to investigate the effects of vicarious traumatization amongst sixty beliefs and 25% of the participants reported at least one symptom of PTSD, non productive coping was related to disruptions in cognitive beliefs while strong supervisory alliance was lower Although vi carious traumatization has been studied among mental health professionals in Europe and the United States, there still is a lack of literature concerning their experiences in working with cancer patients in hospital settings especially in Botswana. Profess ionals who take care of cancer patients in hospital settings in Africa include radiologists, chemotherapists, oncology nurses and physician specialists; their experience of vicarious trauma is only stated in implicit terms. While it is widely documented th at nurses elsewhere experience work related stress (Sinclair & Hamill, 2007), there is no evidence to confirm the effects of vicarious traumatization on o ncology specialists in Botswana.

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36 In the study of other professionals especially in mental health, cert ain characteristics are thought to influence vicarious traumatization. Characteristics such as personal trauma history, the meaning of traumatic life events to the therapist, psychological style, interpersonal style, professional development and current st ressors are attributed to this phenomenon (Pearlman & Mac Ian, 1995). Notwithstanding these characteristics, oncology specialists like other human service workers remain vulnerable and susceptible to trauma. Sinclair & Hamill (2007) observed dividual has been traumatized as a result of a cancer diagnosis and shares this (p.348). In the light of the definition of PTSD as expanding to include a dia gnosis of a life threatening illness as a traumatic experience, nurses and other professional caregivers in the hospital settings who listen to such diagnoses on a frequent basis are at risk of being vicariously traumatized. In a qualitative study geared towards providing pro active social support targeted to care givers of patients with lung cancer, researchers found that support for care givers is usually secondary and reactive rather than planned (Ryan, Howell, Jones & Hardy, 2008). In addition nurses d o not usually have time to access valuable support from colleagues or to build alliances with other members of the multidisciplinary team. Potentially, this leaves them with negative emotions when they leave work which they may not discuss outside the wor k setting due to the ethical standard of confidentiality (Sinclair & Hamill, 2007). Previous positivist quantitative studies have fallen short of providing enough evidence due to the exploratory nature of vicarious traumatization in oncology care. However, findings from the qualitative interpretive studies provide enough evidence for this phenomenon (Sabin Farrell & Turpin, 2003). Whatever the

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37 case, PTSD symptoms are prevalent among cancer populat ions and healthcare providers working with this group face a high risk due to trauma material of the patients. Quality of Life of Healthcare Providers of Cancer Patients The concept of quality of life is broad and sometimes ambiguous as well as multifaceted and multidisciplinary. From the traditional welfare economi cs standpoint it has been viewed as goods (Culyer, 1990). From a non utility perspective, Culyer (1990) notes that quality of life may include but not limit ed to relative deprivation of commodities, genetic endowment of health, and moral worthiness of an individual or their deservingness of certain privileges. Some proponents of the human development movement understand the quality of life in terms of the bas looking after oneself and others, earning a living and having a discussion about the quality of related to the character of relationships between people, for example, the quality of friendships, community support for the individual when in need, social isolation, or changes of status from marital to non marital (Culyer, 1990). In the mental health services discipline, living conditions and social functioning components such as accommodation, employment, leisure and finance are usually viewed as elements of quality of life used as outcome measures to evaluate mental health services (Barry & Zissi, 19 97). In modern medicine the traditional way of assessing change and quality of life of patients is to focus on clinical tests and other complex levels of analysis of body functions. While these procedures give important information about the progression or non progression of personal and social context (Higginson & Carr, 2001). Since professional caregivers of cancer

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38 patients are involved in the clinical assessment of their individual patients, their quality of life can be captured within the personal intra psychic and social realms. A considerable amount of research has been done on quality of life in health settings but mainly based on HIV/AIDS and cancer patient s (Granda Cameron, et al 2008 Ndaba Mbata &Seloilwe, 2000; Sepulveda, et al 2003). Literature that deals with quality of life of cancer patients is in abundance in the United States and Europe, but still falls short with regards to health care profess ionals. The National Consensus Project for Quality Palliative Care (2004) of the United States recommends that a comprehensive interdisciplinary social assessment be of patients with cancer have concentrated on the physical, psychological and spiritual domains (Prince Paul, 2008). However, the fact that the work environment significantly affects the physical, psychological, emotional and spiritual well being of care gi vers just like patients is unquestionable (Sabo, 2008). Evidence shows that professional caregivers experience compassion fatigue, which manifests itself through flashbacks of traumatic events, avoidance, persistent arousal and other effects of cumulative stress (Figley, 1995). Nurses experience burnout which is characterized by emotional exhaustion, depersonalization and reduced personal accomplishment. They also go through bouts of vicarious traumatization which manifest itself in n & Saakvitne, 1995). The quality of life of healthcare providers can be juxtaposed to those of others in the white collar professions in order to draw parallels. For example, one cross sectional survey study,

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39 associations of psychosocial factors at work lifestyle and stressful life events on the health and work ability of white collar workers in a commercial setting was conducted. The main outcome variables were work ability, measured by work ability index (WAI) and mental health measured by short form health survey (SF 12). Individual and psychosocial factors at work, stressful life events and lifestyle were assessed through a questionnaire (van der Berg, Alvinia, Bredt, Lindeboom, Elders & Burdorf, 2007). Results of this study showed that there was a s trong association between psychosocial factors such as teamwork, stress handling and self development and to a lesser extent, the stressful life events, lack of physical activity and obesity. Determinants of mental health were similar to psychosocial facto rs and physical health was influenced by lifestyle. While the mental health of professional caregivers of cancer patients is important as a measure of quality of life in the face of vicarious traumatization, from this study is it evident that social, inter The quality of life with regards to the cancer disease has been measured by the health related quality of life (HRQL) measures. Guyatt (1999) indicates that two basic approaches are use d in the measurement of HRQL; generic instrument that includes health profiles, physical functioning, bodily pain and self esteem. Another form of generic instrument considered to be a utility measure of quality HRQL is derived from economic and decision t heory and reflects relative preference for treatment process (Guyatt, 1999). Although HRQL seems to integrate both utility and non utility (people based) aspects of life Culyer (1990) further emphasize s the importance of value judgments in measuring qual which usually do not appear in the exchange of knowledge about quality of life that is not informed by the utili ty theory. The emphasis on value judgments is further corroborated in a

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40 study documenting the role of health care providers and significant others in the evaluation of patients with chronic disease (Kommer, Sneeuw, Mirjam, Sprangers, Neil, & Aaronson, 2002 ). The area of quality of life of the caregivers in Africa and in particular, Botswana still requires more resear ch Like in the western countries studies about QOL in Botswana mainly reports on the general population or the chronically ill patients. It is noteworthy to point out that the concept of QOL has been ill defined in previous literature; it was often used interchangeably 2002). Other theorists believe that a more appropriate definition of quality of life in African ity; the ability to stay health, avoid hunger In other previous studies about Botswana QOL included in its definition and measurement; income distribution, employment and unemployment, poverty datum li ne (PDL), human development index (HDI), HIV/AIDS status, access to food, income, sanitation disposal; freedom from illness or health risk behaviors and access to housing which is more cumbersome in towns where some professionals commute (Akinsola & Popovi ch, 2002; Hudson & Isaksen, 1998). It is evident from the literature gap that the quality of life among professional caregivers of cancer patients still needs further investigation in Botswana. Studies have also shown that QOL in Botswana is perceived in terms of both utility and non utility indicators and efforts are made to integrate economic welfare and health related models to cater for the basic needs of the people. One QOL indicator that permeates across all demographic divides is the HIV/AIDS

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41 status ; it affects professional caregivers both at professional and personal levels. Because of these unique and varied factors about Botswana situation, this study concentrates on QOL of professional caregivers from a psychological standpoint In this case prof essional quality of life which addresses compassion satisfaction, burnout and compassion fatigue will be the focus of study in relation to vicarious traumatization. Purpose in Life Research on Healthcare Providers of Cancer Patients Psychological concepts such as purpose in life and meaning of life were developed from concentration camps during World War II (Boeree, 2006; MacArthur & MacArthur, 1999). Frankl observed tha t life has meaning in all conditions and that it is psychologically damaging associated with psychopathology while positive life meaning was associated with strong religious beliefs, membership in groups, and dedication to a cause, life values and clear goals (MacArthur & MacArthur, 1999). for people suffering from terminal illness es such as cancer. Meaning making is characterized by a distressing but necessary confrontation with loss. If followed by a plan to fulfill a purpose of life, it can lead to improved psychological well being (Lee, Cohen, Edgar, Laizner, Gagnon, 2006b). Whe nt with purpose of patients.

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42 The Diagnostic Statistical Manual of Mental Disorders (DSM IV TR, 2000) adds that e to a noxious agent that causes death or harm to another (Dutton, et al, 1995). Since healthcare providers working in oncology are exposed to ing some of the patients die, their sense of achievement in the workplace is put to test. They also start to question their own mortality and foundation for their lives since the sense of purpose in life is shaken. Just like their patients, it is evident tha t healthcare providers need specific mental health counseling in order to understand and cope with their situations. Because dealing with a life threatening illness like cancer brings out questions about meaning and purpose of life; meaning making clinical interventions (Lee, et al 2006), therapy work, cultivation of positive well being (Linley & Joseph, 2007) and stress reduction programs (Swartz, et al 2007) have been suggested as some of the ways through which healthcare providers could deal with pro vider terminal care for their patients. Meaning making interventions entail supportive, expressive, cognitive behavioral and other psycho educational intervention (Lee, et al 2006). Some of the mental health interventions include personal therapy, superv ision, therapeutic training and orientation (Linley, et al 2007) and body mind techniques (2007).

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43 CHAPTER 3 METHODOLOGY The purpose of this study wa s to investigate the relationship between vicarious traumatization, the quality of life and purpose in life of healthcare providers of cancer patients in Botswana The study sought to firstly find out if vicarious traumatization affe cts these professionals and also establish r elations hips between vicarious traumatization and professional quality of life; or between vicarious traumatization and purpose in life. A correlation research design was chosen for this study becaus e it is used to describe and measure the degree of association or relationships between two or more variables (Cresswell, 2002) This was line with the objectives of establishing the relationship between vicarious traumatization and professional quality of life and purpose in life and also finding out if vicarious traumatization can predict the two dependent variables. For this re ason correlation Variables in correlation studies naturally occur; therefore there was no experimentation or manipulation of variables (Dooley, 2001). The Sett ing of the Study The study was carried out in Botswana, in southern Africa. Sites for the study included hospices which are day care centers for HIV/AIDS and cancer patients. It also covered government, missionary supported, private and referral hospitals. In Gaborone, sites that participated in the st udy we re Princess Marina Hospital, Gaborone Private Hospital, Bokamoso Private Hospital, and Holy Cross Hospice. Other participating sites in the peri urban areas were Bamalete Lutheran Hospital in Ramotswa, S cottish Livingstone Molepolole, and Deborah Retief Memorial in Mochudi. Nyangabwe Referral Hospital in the city of Francistown and Tutume Primary Hospital in Tutume village in northern Botswana also participated.

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44 Sampling Procedures A non probability samp ling method known as criterion sampling was used. In criterion sampling, individuals, groups or settings that meet unique characteristics specific to the study are selected (Onwuegbuzie, Jiao & Bostick, 2004). In this study healthcare providers who are res ponsible for treating cancer patients in hospitals and ho spices by providing palliative care, chemotherapy, radiological services, counseling were used to ensure that the respondents represent this particular desired group. Because of a limited number of q ualified specialists in the area of oncology, participants taking care of cancer patients were not available in ubiquitous amounts, thus ruling out the expectation of a random sample. Thus, all individual professionals treating or helping cancer patients i n the stated sites were asked to participate. Sample Size The issue of how many participants are needed in a specific study is a controversial one and there is still no agreed upon number for specific types of research. Even professional journals still us e too few participants to have statistical power to detect powerful effects (Cone, & Forster, 2006). There are several things to deal with for one to establish relationship between sample size and accuracy of the study in survey research. For a population in which most people will answer a question in the same or similar way, a small sample will do (De Vaus, 2002). In this study, a criterion sampled group of healthcare providers treating or helping cancer patients was deemed adequate. In determining sampl e size, an example of another study attempting to determine the number of subjects required to do a regression analysis (Green, 1991) was followed. In the study an alpha of .05 and a power of .80 were used to calculate effect sizes and also assign them to subjective levels of small, medium and large. The sample sizes based on power analysis were compared to sample sizes based on the rule of thumb where one independent or predictor

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45 variable is represented by (N=50) + m which represents dependent variables. Given that a re gression analysis was used in this study which has one predictor variable and two dependent variables, this makes the sample size of one independent variable (N=50) + two dependent variables (50 + 2 m ) = 52 participants which was able to det ect medium effects in other studies (Green, 1991). Despite this sample size, nine seven (97) participants were recruited and eighty five (85) (87.6%) returned the questionnaires. Two participants did not fill out the eight four (84) items for the Trauma an d Attachment Belief Scale (TABS); they were taken out of the study, leaving only eighty three (83) questionnaires for analysis. Description of Participants in the Study A total of eighty three (83) healthcare providers participated in the study. The par ticipants were radiologists, chemotherapists, nurses and doctors in the oncology units, hospital social workers, psychologists para professional counselors, counselors, nurse aids, oncology clerks and human resource personnel. Family caregivers were not included in this study because they were not within the planned sampling frame Participants were recruited from sites stated above. They comprised of Botswana citizens (74.7%) and foreign nationals (25.3%) (Table 3 1) Foreign nationals came from other pa rts of Africa, U.S.A, Europe, the Caribbean and China for the provision of health care services. Other demographic characteristics that add to the diversity of the group were considered. These included age, marital status, and area of treatment specializat ion, qualifications and length of time in treating cancer. In terms of gender (Table 3 2) women comprised (63.9%) and men (36.1%). Of the participants, (42.2%) reported being married while (47%) were single and the rest being divorced, widowed or separated (Table 3 4). About (61.4%) of the healthcare providers were nurses, (12%) doctors the rest were in other health professions. Only (13.3%) reported being oncology specialists while the others worked as experienced generalists (Table 3 7). In terms of frequ ency of contact with cancer patients,

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46 (72.3%) reported daily contact, (8.4%) reported weekly encounters while (16.9%) treated cancer on monthly basis as displayed in Table 3 11. Design and Ethical Issues Getting acc ess to the participants required several steps. The process started with obtaining approval from the Institutional Review Board of the University at Florida (Appendix A ). The next step involved the University of Botswana the funder of the project so that the researcher could travel around the country since telephone and mail methods are not viable in Botswana. The university approved the study (Appendix G ). The proposal was then submitted to the Ministry of Health which deals direct ly with hospitals and health issues to determine if the study presents any ethical issues or potential to harm the participants. The research permit was approved after forty five days (7 weeks) (Appendix I ). In Botswana each hospital has its own institutio nal review board independent of the Ministry of Health even though they can only start their own review after receiving the main approval from the ministry. After receiving the research permit from the Ministry of Healt h, applications were made to all the participatin g hospitals (see Appendices J, K, L and M ). Other sites such as Holy Cross Hospice, Gaborone Private, Scottish Livingstone, Bokamoso Private and Tutume Primary Hospitals reviewed the proposal package and gave verbal permission Once these sites approved the study, recruitment meetings were held with various heads of departments, medical teams, wards and shift managers in or der for self introduction explain ing the study, rapport creation and distribution of flyers. Flyers were put on notice boar ds in the wards (Appendix H) Letters were distributed to po tential participants (Appendix A ). In the recruitment letter three basic ethical principles were emphasized namely; respect for persons, beneficence and justice (Dell, Shmidt, & Meara, 2006). Acco rding to these authors, for persons involved in the study there is need for informed consent to be stated in terms of what will happen or will not happen to them. This involves possible

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47 benefits, risks, alternative procedures if treatment is involved, and the option to drop out of the study and what the data will be used for. This recruitment tool was stated in such a way that the participants felt a sense of voluntariness rather than coercion to participate. The issue of justice underscores the importance of not taking advantage of ethnic minorities, ill or incapacitated The questionnaire was administered through a simple pen and paper procedure. T he identity of the particip ants was not to be revealed since they received the questionnaires in sealed envelopes. Participants filled out the questionnaire booklets and then re sealed envelopes without ceable. Because this survey used psychological instruments that included sensitive material, participants who felt that their past traumatic moments could resurface in the process were provided with an avenue to talk briefly with the researcher. Participan ts were also provided with an option of a referral to professional counselors at the University of Botswana counseling center either in person or by phone. Arrangements to cater for such circumstances were made with the center through a formal letter to th e center and to the participants i n the consent letter (Appendix A ). Variables Vicarious Traumatization Vicarious traumatization material and the effects accumulate across time and other helping relationships (Pearlman & Mac I cognitive frame of reference, identity, worldview, spirituality, affect and belief system (Pearlman & Saakvitne, 1995), the experience of the trauma is a solitary experience that can only be almost accurately captured through a self report measure from the participant in the study. For this

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48 reason this ind ependent variable was subjected to measurement only and not manipulation or sc ientific experimentation. The purpose of this study was to determine relationship between vicarious traumatization and professional quality of life and purpose in life among professional caregivers of cancer patients in Botswana. In the study it was hypoth esized that t he i ndependent variable would positively correlate and predict professional quality of life and purpose in life of healthcare providers. It was assumed that a strong relationship with de pendent variables was going to show. Professional Qualit y of Life ( Pro QOL) Professional quality of life is one of the dependent variable s in the study. As a concept quality of life (QOL) has been written about in various disciplines and it has elicited multiple and dissimilar definitions (Baldwin, Godfrey & Pr Burckhardt, 1999), but it is perceived as an important outcome of health care intervention. Viewed in health terms and state of complete physical, mental and social well being and not merely the absence of disease and infirmity (Anderson & Burckhardt, 1999). The health related quality of life perspective ( people agree that it represents physical, social, emotional and other dimensions such as cognitive, int imacy and sexual functioning depending on the nature of the trial and its not professionals for the most part. For this reason, the Professional Quality of Life scale which captures compassion satisfaction, burnout and compassion fatigue was used for data collection.

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49 Purpose in Life The existential theory posits that individuals need to find meaning and sense in everyday life and that overall existence is basic to health and well being (Marsh, Smith, Piek, 2003, Capuzzi & Gross, 2007; Archer & McCarthy, 2007). In hospital settings, especially in oncology units, cancer patients and healthcare providers struggle to adjust to the disease; this process brings existential distress where both may feel a sense of confrontation with their ow n death. Also both patients and healthcare providers deal with feelings of powerlessness, disappointment, futility, meaninglessness, remorse, death anxiety and see no purpose or meaning in life (Kissane, 2000). Earlier studies do concur that t here is a relationship between poor meaning in life and mental health problems as well as high meaning of life and psychological well being (Marsh, Smith, Piek, 2003). The concept of purpose in life is seen as having critical functional elements such as ha ving enthusiasm and excitement about life (Marsh, Smith, Piek, 2003) The idea of purpose and and logotherapy This notion has been applied to mental health as a representation of positive psychological functioning (MacArthur & MacArthur, 1997). According to Victor Frankl life has meaning under all conditions and that it is psychologically damaging when a purpose ful search for meaning is blocked. For this reason, meaning making or seeking purpose in life for professional caregive rs of cancer patients is vital to their well being as well as enhancing their enthusiasm in providing care.

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50 Instrumentation Trauma and Attachment Belief Scale (TABS). The Trauma and Attachment Belief Scale (TABS) (Appendix D), formerly known as the Traumatic Stress Institute Belief Scale (TSI BSL) was used in this study to measure vicarious traumatization. The TSI Belief Scale was designed to measure disruptions in beli efs about self and others (that is, cognitive schemas such as safety, trust, esteem, control and intimacy) which resulted from psychological trauma or from vicarious exposure to trauma material through psychotherapy or other helping relationships. The scal e was designed to assess the possibility of a trauma history in clients, as well as to indicate specific psychological need areas requiring attention during psychotherapy (McCann & Pearlman, 1990a). Also it was intended to be used in conjunction with other measures, to diagnose the existence of vicarious trauma (McCann & Pearlman, 1990b; Pearlman & Saakvitne, 2003) in helpers. This scale is also consistent with the theoretical conceptualization of vicarious traumatization (Zimmering, Munroe, & Gulliver, 200 3) connection, identity, and world view, psychological needs, belief about self and others, interpersonal relationships, sensory memory and 1995, p. 151). In its current form just like the former the TSI BSL, TABS still assesses the five areas of safety, trust, esteem, intimacy and control that are highly affected by trauma. It assesses long term impact of trauma and can be used to help coun selors to design effective individualized treatment plans. Its norms were based on a sample of 1, 743 adults and 1,242 youths in the United States ranging in age from 9 to 18. The TABS is a self report pencil and paper test composed of 84 items that yield ten subscale scores and a total score (Pearlman, 2003). The higher the scores the greater the disruption in the beliefs. On the interpretation table, a range of

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51 70 and above (T scores) indicates an extreme level of trauma or disruption of cognitive schema s, 60 69 is very high, 56 60 is high average, 45 55 is average, 40 45 is low average and a range of 0 29T denotes extremely low disruption or trauma (Pearlman, 2003). The items are scored on a six point Likert scale ranging from 1 representing; strongly di sagree, 2 disagree, 3 disagree somewhat, 5 agree and 6 representing strongly agree. This instrument is estimated to have an internal consistency of 0.96 and a test retest correlation of 0.75 for the total score (Pearlman, 2003). Different forms of validit y like the face, construct and criterion were reported to be high. For example, hundred items were collected from statements made by trauma survivor clients that were reflective of six areas originally identified by Constructivist Self Development Theory ( Pearlman, 2003). In the earlier version of the TABS some aspects of construct validity such as concurrent and discriminant validity for non clinical and clinical samples were found to be convincingly available (Stalker, Palmer, Wright & Gebotys (2005). Another benefit for this instrument is that its items do not pathologize participants (Pearlman, 2003), it is brief, 15 minutes for administration, it is easy to read and highly sensitive to specific effects of traumatic experience. The researcher is quite aware that this instrument was designed for application to mental health care providers, however, healthcare providers such as nurses, doctors and other support staff like radiologist s and chemotherapists is in daily contact and taking care of cancer pati ents. Their empathic emotional investment in the welfare of the patients undoubtedly exposes them to the risk of vicarious traumatization as supported by literature. For these reasons, the instrument was used to measure the independent variable. Modificat ions were made on its demographic section (Appendices C and D ) owing to its application to a different cultural and professional setting from which it was originally normed.

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52 Professional Quality of Life Scale (ProQOL R V) Various instruments have been use d for measuring quality of life in health settings dealing with cancer patients. For example, the Cancer Quality of Life Questionnaire (QLQ C30) (McLachlan, Devins & Goodwin, 1997), and the Quality of Life Index (QL I) (Moinpour, Lyons, Schmidt, Chansky & Patchell, 2000). In this study, the Professi onal Quality of Life Revision V (ProQOL R V 2009 ) was used. The ProQOL R V is the latest version (Appendix E) of the old Compassion Fatigue Self Test (CFST) (Figley, 1995). It addresses three constructs namely ; Compassion Satisfaction, Burnout and Compassion Fatigue/ Secondary Trauma (Stamm, 2009). Stamm (2009) also notes that Compassion Satisfaction deals with the feeling of satisfaction or pleasure that professionals derive from the work place, their colleagu es and their contribution to society in general. Compassion Satisfaction is represented by items 3, 6, 12, 16, 18, 20, 22, 24, 27 and 30 on the scale. The second subscale, Burnout echoes feelings of hopelessness among professionals due to a non supportive work environment or the burden of the amount of work that one carries. The Burnout subscale is represented by items; 1, 4, 8, 10, 15, 17, 19, 21, 26 and 29. Lastly, Compassion Fatigue deals with secondary exposure to highly stressful events, situations or conversations that may result in images or flashbacks of the upsetting event 2001 ). Compassion Fatigue is represented by items 2, 5, 7, 9, 11, 13, 14, 23, 25, and 28 on the scale. Th e instrument was normed on 1000 participants and it can be applied to professionals across several human services disciplines. The reliabilities of this instrument have risen significantly since its modification from the first version which had 66 items. T he current version which has 30 items has Compassion Satisfaction alpha of .87, Burnout alpha .90 and Compassion Fatigue alpha of .87 (Stamm, 2005). In the manual developed by Stamm (2005) the author claimed ev idence of construct validity were proved throu gh reports on multiple articles in

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53 peer reviewed literature addressing these constructs especially with regards to complementarity between Purpose in Life (PIL) and Seeking of Noetic Goals (SONG) scales. In addition, the author provides reports that there are minimal inter scale correlations between these three constructs, thus further attesting to the validity of the instrument. Purpose in Life Scale (PIL) Various instruments designed to measure meaning and purpose in life do exist but they stacles including pragmatic concerns such as measuring subjective experiences 2008, p. 31). Despite different viewpoints owing to the subjectivity and abstraction of the concept, mental health counselors seek scientific basis for counseling to guide mental health services (Wampold, 2001). Some of the assessment tools used to measure meaning include Purpose in Life test (PIL), the Life Purpose Questionnaire (LPQ), th e Seeking of Noetic Goals test (SONG), the Meaning in Suffering Test (MIST) and the Life Attitude Profile Revised (LAP R) (Melton & Schulenberg, 2008). In this study the Purpose in Life (PIL) instrument (Appendix F) was used to measure a sense of purpose for healthcare providers of cancer patients in Botswana. Earlier studies have shown that high scores in meaning of life measures are correlated with low levels of psychological distress and high levels of happiness and self esteem. The findings indicate t hat those with meaningful lives are more emotionally stable (Melton & Schulenberug, 2008). In terms of disposition, relationships and attitudes, Melton & Schulenberug, (2008) reported that people who score high on the PIL view themselves as in control of t heir circumstances and have participants who experienced loss of a loved one reported greater happiness, more purpose in life and fewer grief reactions when they indicated that they had accepted death (Robak & Griffin,

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54 2000). High levels of meaning in life as measured by the PIL are associated with minimum levels of proneness to boredom (Melton & Schulenberg, 2007). The PIL is a 20 item self report attitude scale that measures the extent to which people perceive their lives to have purpose or meaning (Marsh, et al, 2003). Items are scored by a dichotomous Likert scale ranging from 1 (low purpose) to 7 (high purpose) with 4 being the neutral point (MacArthur & MacA rthur, 1997). Specific descriptors between 1 through 7 vary from item to item. Total scores are achieved by adding the 20 items which may range from 20 to 140 (De Witz, 2002). For a long time the structure of PIL has been assumed to be a uni dimensional me asure. However, some researchers have shown that the scale is comprised of one to six factors ( Marsh, et al, 2003). The t wo major factors reported were existence and death. Although it is perceived to be measuring different constructs such as life meaning or purpose, life satisfaction, freedom, fear of death and how one values their existence, it is generally agreed that it is a uni dimensional assessment tool based on existential theory and the logotherapy technique in particular. With regards to the reli ability of this scale alpha level of .86 to .97; .77 to .85 on the split half reliabilities which have been corrected to .87 and .92 respectively The test retest reliabilities have been recorded at .66 to .82 on 1, 6, 8 and 12 weeks intervals (MacArthur & MacArthur, 1997; Melton & Schulenberg, 2008). The validity of the PIL seems convincing since others have reported significant differences among various groups with and without mental illness. Positive asso ciations have been reported between PIL

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55 Data Collection Data for this study were collected through a survey questionnaire. Data were collected by administering the Trauma Attachment Belief Scale (TABS), Professional Qua lity of Life Sc ale Revised version (ProQOL R V) and the Purpose in Life (PIL) all in one sitting. All these instruments were se lf report scales that required paper and pencil resources during administration. Data collection in this study presented a uniqu e situation in which the usual conventional survey methods of mail (post and internet) or phone commonly used in the United States were not used in the strict sense. This is because data were collected in Botswana; a developing country that still struggles to keep pace with equitable distribution of electronic communication and efficient paper mail system that uses physical addresses. Although survey can be distributed via mail, internet, telephone, (Dillman, 2000; Czaja & Blair, 2005), in this study face to face method, was used. Once the protocol with various gatekeepers was cleared and flyers distributed, the researcher appeared in person with questionnaire packages to explain the purpose of the visit to participants. The packet included three instrument s, consent letter, University of Florida protocol and a pen. All these were hand delivered to each participant. The majority of participants filled out the questionnaires in one sitting and finished, while others preferred to fill them out in the privacy o f their homes after work without the interference of co workers. Completed questionnaires were returned in sealed envelopes to the researcher in person while in some instances envelopes were deposited at a central area at the work place where the researche r could pick them. Data Analyse s The data of this survey were analyzed using Statistical Package for Social Science (SPSS) version 13. The analyses applied both descriptive and inferential statistics. Fi rstly demographic information such as nationality, gender, age, educational level (Burns, 2004), area of

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56 specialization, years of treatment in the area of cancer treatment and frequency of contact with cancer patients were presented to show the nature o f the p opulations D escriptive statistics were shown to help provide a clear picture of categories that have more cases, the typicality of ce ntral tendency, whether cases we re concentrated on few categories or spread fairly or skewed (De Vaus, 2002). Descriptive statistics were also ideal for summarizing data and checking statistical assumptions (Dickter, 2006) and discover patterns and processes (De Vaus, 2002). As part of descriptive statistics, frequency tables were used to present categories of variables, perc entages of the whole sample. Means and standard deviations provide d important information about the representative scores and amount of variation in the data (Dickter, 2006). One of the challenges in the data analyses stage was the discovery of missing data. Resolving this issue is important because missing data has the potential to reduce effective sample size which may result in loss of statistical power. Missing data also ma ke it difficult to listwise deletion showed that only 64 out of 83 cases were valid. The 21 cases that had some missing responses in the questionnaire were retai ned. Listwise was not used to solve the problem of missing data. Pairwise was also not used to avoid complications of alternating analysis for one variable that had all responses and avoiding one that did not. To resolve the issue of missing data, average values for the entire sample were used to represent missing sample. This method is deemed more appropriate especially that the sample for this study had a normal distribution; In establishing relationships, correlations are used to measure variables in order to determine the size, direction and degree (Tabachnick & Fidell, 2001) strength of the relationships. Bivariate correlations were used in the study because they measure associations

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57 with no distinctions necessary between independent and dependent variables (Tabachnick & Fidell, 2001). Thus, running bivariate correlations helped to establish the associations between each pair of the three variables in the study. Additionally, through bivar iate correlations, non causal descriptive patterns of correlation could be identified to determine if there were any relationships between any two pairs of the variables stated. For example, in the first step vicarious traumatization was correlated with qu ality of life and purpose in life to find out if there were any reciprocal, indirect or interactive causation (De Vaus, 2002). However performing correlation of any two variables runs the risk of missing out additional variables that may have the causal ef fect (Dooley, 2001). This notion attests that observing a correlation does not necessarily imply causal connections. This is the limitation of this form of analysis. In the second step, multinomial logistic regression analysis was performed to predict if there wa s a direct relationship among variables. Multinomial logistic regression is a multiple regression approach but with an outcome variable that is categorical and a predictor variable that is continuous or categorical (Field, 2009). Linear regression was not used in the study because with linear regression, the assumption is that the relationship between variables is linear. When the outcome variable is categorical or (ordinal) the assumption of linearity is violated, which was the case in this study. Thus the multinomial logistic type regression is more suitable for this study because it has one predictor variable and two outcome variables, hence the best fit since the variables are ordinal. In summary, research questions and null hypotheses were addre ssed by performing the following analyses; Research question 1. Do healthcare providers of cancer patients in Botswana experience vicarious traumatization as measured by the Trauma Attachment Belief Scale (TABS)?

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58 Hypothesis 1. Healthcare providers of cance r patients in Botswana experience vicarious traumatization Descriptive statistics were run to reflect the minimum, maximum figures and standard deviations showing the ten subscales of Trauma and Attachment Belief Scale. Research question 2. What is the re lationship between vicarious traumatization and professional quality of life of healthcare providers of cancers patients as measured by the Professional Quality of Life Scale (ProQOL ). Hypothesis 2. There is a positive relationship between vicarious trauma tization and professional quality of life among healthcare providers of cancer patients in Botswana. Bivariate correlations were run between vicarious traumatization and professional quality of life while controlling for purpose in life. Research question 3. What is the relationship between vicarious traumatization and purpose in life of healthcare providers of cancers patients as measured by Purpose in Life scale (PIL)? Hypothesis 3. There is a positive relationship between vicarious traumatization and p urpose in life among healthcare providers of cancer patients in Botswana. Bivariate correlations were performed between vicarious traumatization and purpose in life while controlling for professional quality of life. Research question 4. Does vicarious tra umatization predict quality of life and purpose in life of healthcare providers of cancer patients in Botswana? Hypothesis 4. Vicarious traumatization predicts professional quality of life among healthcare providers of cancer patients in Botswana Multinomial logistic regression analyses were performed to find out if vicarious traumatization predicted professional quality of life of healthcare providers of cancer patients in Botswana. Hypothesis 5. Vicarious traumatization predicts purpose in life a mong healthcare providers of cancer patients in Botswana Multinomial logistic regression analyses were performed to find out if vicarious traumatization predicted purpose in life among healthcare providers of cancer patients in Botswana.

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59 Limitations of the Methods S urvey research relies on samples that are at a particular place at a particular time (De Vaus, 2002) and it targets the events happening during a specific period. For this reason, true replication of results may be difficult to achieve depending on the volume of cancer patients admission, severity of symptoms and healthcare provider cognitive capacities at specific times Also depending on factors such as a small sample size, the chosen ever evolving multinomial logistic regression analysi s metho d, the results may be affected. In addition regression analyses reveal relationships between vari ables and but it do not assume causal ity Causality is an experimental rather than a statistical issue (Tabachnick, et al, 2001). Thus the results of the stud y may not be reported in terms of cause and effect.

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60 CHAPTER 4 DATA ANALYSE S AND RESULTS Demographic Overview The purpose of this study was to determine the relationship between vicarious traumatization, professional quality of life and purpose in life of healthcare providers of cancer patients in Botswana. The population of study, the healthcare providers, was recruited from eight hospitals and one hospice in Botswana. The total number of participants was eighty three (83). In the healthcare provid er population, 10 were medical doctors (12%), nurses 51 (61.4%), nurse assistants 5 (6%) and 7 radiation oncologists (8.4%). There was 1 psychologist (1.2%), 5 social workers (6%), 1 oncology clerk (1.2%), 1 human resource specialist (1.2%), 1 youth office r (1.2%), and 1 lay counselor (1.2%) (Table 3 5). Regarding other demographic variables, 62 participants were Botswana nationals (74.7%) while 21 (25.3%) were foreign nationals (Table 3 1). The number of male participants was 30 (36.1%) while that of fem ales was 53 (63.9%) (Table 3 2). Age was another demographic variable considered in varying age brackets. For ages 18 24 there were 10 participants (12%), for 25 30 there were 26 participants (31.3%), for ages 31 36 there were 17 participants (20.5%), the 37 42 age bracket had 15 participants (18.1%), 43 48 had 5 participants (6%), the 49 54 group had 6 participants (7.2%) while the oldest 55 60 bracket had 4 participants (4.8%) (Table 3 3). nine (39) participants (47%) stated that they were single, 35 were married (42.2%), 3 were separated (3.6%), 3 were divorced (3.6%) and 3 were widowed (3.6%) (Table 3 4). Regarding the number of years that healthcare providers have been treating cancer, 22 particip ants (26.5%) had one year experience, 15 participants (18.1%) had 2 years experience, 11 participants (13.3%) had three years, 4 participants (4.8%) had four years, 3 participants (3.6%) had five years, 3 participants (3.6%)

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61 had six years, 4 participants ( 4.8%) had seven years, 6 participants (7.2%) had ten years, 2 participants (2.4%) had 15 years while the remaining 8 participants each accounting for (1.2%) had 16, 17, 19, 20, 21, 22, 26 and 31 years of experience in treating cancer (Table 3 10). The las t crucial variable for this population was their frequency of contact with cancer patients. Of the 83 participants, 60 of them (72.3%) reported having daily contact with cancer patients, 7 participants (8.4%) had contact with cancer patients at least once a week, 14 participants (16.9%) reported a contact of at least once a months with cancer patients and 2 participants (2.4%) reported contact with patients at least once a year (Table 3 11). Variables There are three variables for this study. The independe nt variable is vicarious traumatization and the two dependent variables are professional quality of life and purpose in life. Vicarious traumatization describes the inner experiences of helpers or healthcare providers of cancer patients that are a result o f empathic care for the patient who is traumatized. The constructivist self development theory maintains that helpers who have been vicariously traumatized experience disturbances in their cognitive frame of reference, identity, world view, spirituality, a ffect and belief system (Pearlman & Mac Ian (1995, Pearlman & Saakvitne, 1995). levels of compassion satisfaction with their work, the burnout they experien ce as well as the fatigue they experience as a result of engaging with patients (Stamm, 2005). The other dependent variable in the study, purpose in life is derived from the existential theoretical framework especially the logotherapy perspective. It expla Smith & Piek, 2003).

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62 Statistical Methods In this study, three main statistical methods were used. Descriptiv e statistics were used for data exploration and visualization. Descriptive statistics also helped in determining the minimum, maximum, means and standard deviations for variables being measured. The Pearson coefficient bivariate correlation was used to fin d out the relationship between vicarious traumatization and professional quality of life and also between vicarious traumatization and purpose in life. Bivariate correlation determines the strength and direction of any two variables regardless of whether t hey are independent or dependent (Fields, 2009). The other statistical method that was applied to the study was the multinomial logistic regression and it was used to find out if vicarious traumatization predicted professional quality of life and purpose i n life among the healthcare providers of cancer patients in Botswana. Descriptive Statistics This section displays an overview of the descriptive statistics for the variables in the study. Vicarious traumatization was measured by the Trauma and Attachment Belief Scale (TABS), a ten (10) subscales measure with eighty four items. The interpretation table for this scale indicates that T scores of <29 are extre mely low and show very little trauma or disruption. Scores of 30 39 are very low, 40 44 is low averag e, 45 55 is average, 56 59 is high average, 60 69 is very high while >70 is extremely high and indicates substantial disruption. After applying the descriptive statistics, the ten subscales showed the following levels of trauma or disruptions among the hea lthcare providers. Self Safety showed a minimum t score of 34, a maximum of 73 and mean score of 54.72 indicating that some individuals in sample were extremely affected by trauma to the extent that they did not feel safe on the job. The Other Safety subs cale scored a minimum of 13, a maximum of 80 and an average score of 55.14. Despite the lowest reported minimum of 13 in the whole sample, the results to the other extreme reflect a highly disrupted section of

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63 healthcare providers indicating that they eith er concerned about the safety of the people they are helping, they are traumatized themselves and therefore worry about the safety of loved ones (Pearlman 2003). The Self Trust subscale recorded a minimum of 31 (very low disruption), a maximum of 80 (extr eme disruption) and a mean score of 51 (average). While on average the sample may show a moderate level of disruption, there is proof from scores that some individuals experience high levels of trauma in this area. Individuals with high scores in this area may be struggling to trust their own judgment and decision making abilities and for the most part may depend on the assistance of others (Pearlman, 2003). The Other Trust subscale on the other hand had a minimum t score of 25 (low disruption), a maximum o f 69 (very high disruption) and a mean t score of 54.45 for the whole sample which is considered average level disruption. Individuals who attained high scores on this subscale are regarded to be most likely cautious and not ready to form trusting relation ships with others or rely on them. The Self Esteem subscale scored a minimum t scores of 32 (very low disruption) and a maximum of 68 (very high disruption) indicating a low level of self worth for individuals with high scores. The mean t score for the whole sample was 48.61 indicating an average level of disruption. The Other Esteem subscale had a minimum of 27 (very little disruption) and a maximum of 79 (extremely high disruption or trauma). Respondents with elevated Other Esteem scores view others wi th disdain and disrespect (Pearlman, 2003), a phenomenon that may be a result of their childhood maltreatment. There is a high possibility that their schemas about other people have been imprinted negatively. The workplace is analogous to a family system ( Everstine & Everstine, 2006), an authority figure who is perceived by an employee as not

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64 meeting the expectations or neglectful may fall a victim of disrespect or rebellion from the employee, hence the elevated t scores for this subscale. In the Self Inti macy subscale the mean score for the whole sample was 55.25 representing the highest mean score for all ten subscales. However, a score of 55 is considered an average level of disruption. The minimum t score was 24 (very little disruption) while the maximu m was 72 (extremely high disruption). Pearlman & McCann (1990) assert that people who have had their intimacy schemas disrupted experience feelings of loneliness and being alienated. For individuals with a high score of Self Intimacy as shown here may refl ect a certain degree of current or childhood trauma that has disrupted a true experience of their inner self. This means that individuals in the sample of healthcare providers may find time alone challenging and may avoid it altogether and use dissociation as a means of coping and avoiding self reflection (Pearlman, 2003). The Other Intimacy scale had a minimum of 33 (very low disruption), maximum of 62 (very high disruption) and a mean score of 50.28 (average). In this category, individuals who have high scores may be isolated and disconnected from others emotionally and interpersonally (Pearlman, 2003) thus having implications on healthcare providers ability to connect with their co workers or the clientele they are serve. The last set of subscales for t he Trauma and Attachment Belief Scale are Self Control and Other Control. The minimum t score recorded for the Self Control subscale was 24 (extremely low disruption), a maximum of 74 (extremely high disruption) and a mean score of 50(average). The Pearlma n (2003) interpretation table states that individuals with high scores on self control may have some anxiety over losing control of their emotions or behaviors under certain circumstances and may use dissociation as a coping mechanism. The Other Control su bscale scored a minimum of 25 (very little disruption), a maximum of 66 (very high disruption) and a

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65 mean score of 48.53 indicating an average level of vicarious traumatization for all the study participants. Analyses Results Reporting This section deals with the reporting of the findings of the study in relation to hypotheses formulated. Hypothesis 1 Ho 1: Healthcare providers of cancer patients in Botswana experience vicarious traumatization The first hypothesis posits that healthcare providers of c ancer patients in Botswana experience vicarious traumatization. The research question related to this hypothesis was posed; Research Question: Do healthcare providers of cancer patients in Botswana experience vicarious traumatization as measured by the Tra uma Attachment and Belief Scale (TABS) ? The TABS was used to gather the information in order to answer the question and to verify the hypothesis statement The TABS instrument has ten subscales of Self Safety, Other Safety, Self Trust, Other Trust, Sel f Esteem, Other Esteem, Self Intimacy, Other Intimacy, Self Control and Other Control. In order to determine the overall level of vicarious traumatization and that of each subscale, an interpretation of table of trauma scores was used as outlined in the TABS T Score Ranges table Pearlman, (2003) presents the table as follows; T scores of <29 are extremely low and indicate very little trauma or disruption. Scores of 30 39 are very low, 40 44 is low average, 45 55 is average, 56 59 is high average, 60 69 is very high while >70 is extremely high and indicates substantial disruption. Across the ten subscales (Table 4 1) the minimum score recorded was 13 (other safety) followed by 24 (self intimacy) and 24 (self control) indicating minimal disruption in these areas. The maximum or highest t scores recorded were 80 (other trust), 80 (self trust), 79 (other esteem), 74 (self control), 73 (self safety) and 72 (self intimacy), indicating that these were areas

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66 where there was an extremely high level of disrupt ion in the sample. However, the mean scores recorded from each subscale in the sample yielded minimum scores of 48.53 (other control) and 48.61 (self esteem) indicating an overall average level of disruption or vicarious trauma. The remaining eight subscal e mean scores range from low to mid fifties with the highest being 55.25 (self intimacy) and 55.14 (other safety) indicating an average level of disruption according to the TABS interpretation table. This is supported by the one sample t test that yielded (t value= .000, p>.05), indicating significant statistical outcome. The result of this analysis supports the hypothesis that healthcare providers of cancer patients in Botswana experience vicarious traumatization. In the ten subscales, results show that a portion of the sample scored Extremely High levels of trauma for Self Safety, Other Safety, Self Trust, Other Esteem, Self Intimacy and Self Control while Very High levels of trauma for Other Trust, Self Esteem, Other Intimacy and Other Control. While th e level of trauma may be average for the general sample, it does not suggest that trauma among healthcare providers of cancer patients in Botswana is minimal. The impact and gravity of vicarious traumatization has reference, self capacities, ego resources, psychological needs, cognitive schemas and imagery (Pearlman & Saakvitne, 1995; Sinclair & Hamill, 2007). spiritualit y are disrupted and become murky. There is a sense of demoralization, pessimism and hopelessness (Mc Cann & Pearlman, 1990); it may not be far fetched to consider healthcare providers whose scores reflect extreme disruption to be experiencing an equally di srupted frame of reference. Individuals who have experienced trauma also have their self capacities disrupted, tend to be intolerant of strong emotions, may find calming themselves down a problem (Pearlman &

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67 Saakvitne, 1995; Sinclair & Hamill, 2007) and ex perience interpersonal difficulties (Trippany, White Kress & Wilcoxon, 2004). This assertion is corroborated by a score of 79 (extremely high trauma) on the Other Esteem subscale in this study, showing that respondents with such scores view others with dis dain and disrespect which may be a result of previous or childhood maltreatment (Pearlman, 2003). Hypothesis 2 Ho 2: There is a positive relationship between vicarious traumatization and professional quality of life among healthcare providers of cancer patients in Bots wana. Research Question: What is the relationship between vicarious traumatization and professional quality of life among healthcare providers of cancer patients in Bots wana? The second hypothesis stated that there is a positive relationship between vicarious traumatization and professional quality of life among healthcare providers of cancer patients in Botswana. For testing this hypothesis, a bivariate correlation set f or Pearson correlation coefficient ( r) was performed (Table 4 7) A bivariate correlation is used to show the relationship between any two variables (Field, 2009). A bivariate correlation also reflects the direction and strength of the relationship between two variables (De Vaus, 2002). In this study t here was a relationship between vicarious traumatization and professional quality of life, r = .11, thus indicating a negative relationship which is almost close to a zero (no relationship). The significance value was .956, p (two tailed)> .05. That means the relationship between vicarious traumatization and professional quality of li fe for the research group is not significant because the significance value was more than .05 ). Reliability test for this sample was conducted and it The relationship between vicarious traumatization and professional quality of life for this sample is a negative one. This is so for various reasons. Vicarious traumatization focuses on the negative im pact of working with individuals who have been traumatized and does not

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68 acknowledge the many positive aspects of trauma work such as professional development and satisfaction derived from client or patient care (Cropley & Millward Purvis, 2004; Sinclair & Hamill, 2007). That is, it is geared towards examining the impact of the trauma on the victim or the person interacting with the victim. However, professional quality of life on the other hand is a more robust concept whose scale has constructs such as Com passion Satisfaction (CS), Burnout (BO) and Compassion Fatigue (CF) which intersect with some of the aspect of vicarious trauma although not a large extent. An outline of individual subscales of ProQOL sheds some light on aspects that contributed to the ne gative and minimal relationship between TABS and ProQOL. The Compassion Satisfaction subscale which has ten (10) items is more health and positive sounding than the Trauma and Attachment Belief Scale. The CS subscale has values ranging from a minimum 1= n ever, 2= rarely, 3= sometimes, 4= often and 5=very often being the maximum. In a sample size of N=83, item Q3b had a mean score of 4.40 out of a possible maximum of 5 (highest satisfaction rate). The subsequent mean scores on the CS were, 3.27, 4.24, 4.13, 3.41, 3.87, 4.09, 4.30, 3.65 and 3.90 respectively out of a possible 5. All these mean scores indicate a high level of satisfaction exhibited by healthcare providers despite the reported high levels of vicarious trauma for some cases. Based on this observ ation, it is possible to build an argument that healthcare providers may experience vicarious trauma and compassion satisfaction at the same time making the two mutually exclusive as evidenced in the correlation coefficient. The second subscale of Professi onal Quality of Life is Burnout (BO). Burnout is viewed as exhaustion of physical or emotional strength as a result of prolonged stress or frustration (Felton, 1998), difficult clients (Trippany, Kress & Allen Wilcoxon, 2004) or work overload (Pross,

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69 2006) It is also viewed as prolonged response to chronic emotional and interpersonal stressors on the job and is defined by three dimensions of exhaustion, cynicism and inefficacy (Maslach, Schaufeli & Leiter, 2001). The BO subscale has ten (10) items with the same values ranging from 1 to 5 just like the CS. The sum of mean scores derived from each is item is 40.7 out of a possible 50 (Table 4 3) This means that there is 80% burnout prevalence in the sample, making this phenomenon as well as VT high among hea lthcare providers of cancer patients in Botswana if the results are generalized. The definitions of these concepts however, bring out fundamental differences between vicarious trauma and burnout. While VT deals with complexity and chronicity of clients/pa tients problems, BO deals more with work overload. While VT may deal with issues of trust, self behavioral symptoms that are work related (Trippany, Kress & Allen Wilcoxon, 2004). Based on the conceptual differences in the literature, the relationship between BO as an aspect of professional quality of life and vicarious traumatization is minimal if there is any at all. Like in the case of VT and CS, it is possible t hat professionals who work with traumatized populations experience both BO and VT at the same time (Trippany, Kress & Allen Wilcoxon, 2004) but without either one influencing the other, hence the non significant correlation between TABS and ProQOL r = .01 (p>.05) = .956 (2 tailed). The last subscale in the Professional Quality of Life scale is the Compassion Fatigue (CF). CF also has ten (10) items with values ranging from 1 to 5 like its previous counterparts. The recorded overall mean score for the items in this subscale is 33.01 o ut of a possible 50, making it 66% prevalence in the sample studied. On the whole CF in this group is lower than CS (78%) and BO (80%). Conceptually, CF denotes negative experience just like vicarious trauma or

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70 trauma in general. CF has been defined as a n atural consequence of behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other the stress resulting from helping or wanting to help a traumatized or suffering person (Sabo, 2008; Figley, 1995). VT reacti ons are also related to specific client traumatic experiences. Compassion fatigue deals more with the advanced empathy and care that professionals invest on their client, while ay not be associated with professional workload. From a content validity stand point, the relationship between vicarious trauma and compassion fatigue is minimal if there is any at all, and it does not amount to statistically significant correlation for th e sample st udied here. Hypothesis 3 Ho 3 There is a positive relationship between vicarious traumatization and purpose in life among healthcare providers of cancer patients in Botswana Research Question: What is the relationship between vicarious trauma tization and purpose in life among healthcare providers of cancer patients in Botswana? The third hypothesis stated that there is a positive relationship between vicarious traumatization and purpose in life among healthcare providers of cancer patients in Botswana. A bivariate co rrelation analysis was also performed (Table 4 8) and set for Pearson correlation coefficient (r). The results show that t here was a relationship between vicarious traumatization and purpose in life, r = .28, also indicating a nega tive relationship. The alpha level was set a t .05 (two tailed) but yielded significant value of .010 at the 0.01 level (two tailed). The result is significant. The finding of a negative relationship between vicarious trauma and purpose in life is consistent with assessment assumptions of the constructivist self development theory (CSDT) of

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71 trauma. This theory posits that when cognitive schemas of reference are di srupted, the affected individuals tend to believe that the world is no longer meaningful or coherent. They also experience a sense of demoralization, pessimism and hopelessness (McCann & Pearlman, 1990). emas are not disrupted, this worldview may not be represented in their responses as discovered in the results of this study. For example, t he mean scores for the purpose in life scale (PIL) for items Q3c, Q4c, Q11c and Q12c that represent this construct a re 6.27, 6.13, 6.30, and 5.61 out of a maximum of 7 on the scale. The scores show that on average participants did not have disruptions with regard to their meaning making, worldview or purpose in life. The finding is also consistent with results from stu dies conducted to test relationship between posttraumatic growth, religi on and cognitive processing. The study found correlation coefficient of .25 between posttraumatic growth and religious participation (Calhoun, Cann, Tedeshi & McMillan, 2000), indicat ing that religious participation which is associated with purpose in life was negatively related to trauma ; that is, people who participate in religious practices tend to be more resilient because they have discovered a sense of purpose in life than people who do not. Hypothesis 4 Ho4: Vicarious traumatization predicts professional quality of life among healthcare providers of cancer patients in Botswana. Research Question: Does vicarious trauma tization predict professional quality of life of healthcar e providers of cancer patients in Botswana? This hypothesis stated that vicarious traumatization predicts professional quality of life among healthcare providers of cancer patients in Botswana. A multinomial logistic regression was used to analyze instead of the simple linear or multiple regression for various reasons. Firstly the ProQOL scale is ordinal and it can only work logistically with Ordinal Logistic Regression, Multinomial Regression (Murat Kayri* and may okluk, 2010 ) or a mixed model

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72 of the two Secondly, the assumptions of linearity (Figures4 9 & 4 10) and homoscedasticity (Figures 4 7 & 4 8) were violated. In the model used, the following were entered; main effects, chi square statistics, pseudo square, likelihoo d ratios and goodness of fit. T he recorded chi square was 198.74 under the likelihood ratio test. High chi square values indicate a low probability that the observed unusual figures are due to random chance. When the chi squar e value results in a p value that is less than 0.05, it is co nsidered statistically significant. In this case the significance value was 1.000 (Table 4 13) indicating that the result is not statistically significant. The Pseudo R Square yielde d a Cox and Snell of .909 (9 0 .9 %), Nagelkerke of .909 (9 0 .9%) and a McFad den of .332 (3 3 2%). The R This means that the effect of vicarious trauma is only accounted for by 9.1%, 9.1% and 62.8% respectively. This is an indic ation that vicarious trauma did not predict professional quality of life for the healthcare providers of cancer patients in Botswana. Hypothesis 5 Ho 5: Vicarious traumatization predicts purpose in life among healthcare providers of cancer patients in Botswana. The fifth hypothesis states that vicarious traumatization predicts purpose in life among healthcare providers of cancer patients in Botswana. A multinomial logistic regre ssion analysis was used to detect prediction. As conducted for the previous hypothesis, the components entered into the model were; model fitting information, goodness of fit, Pseudo R Square and likelihood ratio tests. Chi square, degrees of freedom and significant values did not yield anything for the likelihood ratio tests and goodness of it, indicating absence of relationships. The Pseudo R square sp ewed a Cox and Snell of .986 (9 8 .6 %), Nagelkerke of .987 (9 8 .7%) and a McFadden of .582 (5 8 2%). This means that the effect of trauma is only accounted for by 1.4%, 1.3% and

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73 41.8% respectively. The se low percentages also show the small effect that vicarious trauma has on purpose in life of healthcare providers in Botswana. Summary This chapter dealt with procedures for analyzing data and repo rting the results. Under analyse s of procedures, hypothesis 1 was dealt with using the procedures stipulated in the Trauma and Attachment Belief Scale (TABS) manual in order to get the level of traum a of th e healthcare providers of cancer patients in Botswana. A test statistic was also conducted to determine the significance level which was found to be significant. For hypotheses 2 and 3, bivariate correlation methods were used to establish relationsh ips between vicarious traumatization and professional quality of life and purpose in life among the healthcare providers of cancer patients in Botswana. The results for Hypothesis 1 were statistically significant. The outcome for Hypothesis 2 was not signi ficant while Hypothesis 3 yielded a s ignificant p value. For hypotheses 4 and 5 multinomial logistic regression was used to establish if vicarious traumatization predicts professional quality of life and purpose in life. In both cases it was found that vic arious traumatization does not have the predictive power, hence the decision to reject both null hypotheses because the results were not statistically significant (Table 4 21)

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74 CHAPTER 5 DI SCUSSION, RECOMMENDA TIONS AND CONCLUSION Overview of the Chapter This chapter deals with discussion of the results of statistical procedures performed to test the hypotheses stated, that is, what the results mean or imply about the population studied. The chapter also discusses recommendations for counseling practitione rs and counselor educators by highlighting how they might intervene in their attempts to help the population under study. Lastly, the chapter seeks to make recommendations for future research on the basis of statistical outcomes presented. The results of f or each hypothesis were as follows; Ho1 Healthcare providers of cancer patients in Botswana experience vicarious traumatization. Results: Significant. Ho2 There is a positive relationship between vicarious traumatization and professional quality of life among healthcare providers of cancer patients in Botswana. Results: Not significant. Ho3 There is a positive relationship between vicarious traumatization and purpose in life among healthcare providers of cancer patient s in Botswana. Results: Significant. Ho4 Vicarious traumatization predicts professional quality of life among healthcare providers of cancer patients in Botswana. Results: Not significant. Ho5 Vicarious traumatization pre dicts purpose in life among healthcare providers of cancer patients in Botswana. Results: Not significant.

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75 Significance of Results As a precursor to reporting the significance or implications of results, it is important to note that statistical significance is usually the main deter minant of the importance of outcomes in various research studies. However, (Thompson, 2002) argues that counselors should not only consider statistical significance, but should also report on practical and clinical significance. Practical significance emph asizes importance of effect sizes which in this study are reported in the form of correlations between variables. The general principle is to also provide enough information to assess the magnitude of the observed effect or relationship (Gliner, Leech & Mo rgan, 2002). Clinical significance on the other hand may be guided by score cut off points [if assessment and data collection instruments used] or diagnostic criteria (Thompson, 2002). Therefore, the significance of the results will be based on these three types of significance. Research Question 1: Do Healthcare Providers of Cancer Patients in Botswana Experience Vicarious Traumatization? The statistical significance of results obtained in Hypothesis 1 (t value= .000, p>.05) confirm the assumption initiall y made about healthcare providers of cancer patients as experiencing vicarious traumatization. This means that the assumption was a close estimate of what is actually happening among healthcare providers in Botswana. However, statistical significance alone does not evaluate the importance of results (Thompson, 2002), but practical significance which is concerned with whether the result is useful in the real world (Kirk, 1996) is also useful. What proofs useful and practical in answering this research questi on is the data that also supports the hypothesis. For example, all the ten subscales of Trauma and Attachment Belief Scale indicate maximum values tagged at Very high and Extremely high levels of trauma or disruption among the healthcare providers of cance r patients in Botswana (Table 4 1). What this means in the real world is that this group of people provides critical and end of life care which

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76 negatively impacts on their cognitive schemas with the potential to develop psychological behaviors that work at cross purposes with their mandate, providing care. These behaviors strain coping capacities, narrow or dull attention, reduce learning capacity and affect organization of thought and experience (Litz & Gary, 2004). This assertion is also consistent with t he constructivist self development theory of trauma that posits that individuals experiencing trauma tend have their self esteem, ego capacities and frame of reference altered (McCann & Pearlman, 1990). It is also important to note that the data, rather t han just the statistical significance helps to bring into play the concept of clinical significance. For example, the cut off points in the TABS interpretation table are clinically significant in pointing out the extent to which the population under study is experiencing vicarious trauma. To further illustrate, a t score of 70 or above is critical and it may not be ignored by any clinician because it represents extreme trauma among certain individuals in the sample as reflected in the Self Safety, Other Saf ety, Self Trust, Other Esteem, Self Intimacy and Self Control subscales. In this case what is more important is the clinical significant rather than the statistical or practical significance, and mental counselors should pay more attention to it when work ing with healthcare providers of cancer patients in Botswana. Research Question 2: What is the Relationship between Vicarious Traumatization and Professional Quality of Life among Healthcare Providers of Cancer Patients in Botswana? The statistical result outcome. This means that the significance value was larger than the p value, indicating a less than conventional 95% confidence in the results. The problem with this statistical resu lt is that it does not indicate the strength of the relationship between variables because p values do not provide information about the size or strength of the effect (Gliner, Leech & Morgan, 2002). For

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77 this reason, the statistical significance results al one may not be meaningful to mental health maintain that the best practice is to report effect size which reflects the strength of the relationship between the i ndependent and the dependent variable. In this case the result for this question is .11 which is far removed from a perfect negative relationship of 1. This means a weak negative relationship between vicarious traumatization and professional quality of l ife. This also means that there is no practical significance between the two variables. The results to this research question are also supported by the conceptual disparities reflected by the theory. The constructivist self development theory of trauma fo cuses on the negative effects of trauma on individuals (McCann & Pearlman, 1990) in which the sense of safety, self esteem, trust, intimacy and control are compromised. On the other hand professional quality of life focuses on some positive aspects such co mpassion satisfaction (Stamm, 2009), but also on some negative aspects such as burnout which is a work related impairment comprising of emotional exhaustion, depersonalization and reduced personal efficacy (Awa, Plaumann & Walter, 2008). Burnout does not l ead to changes in trust, safety concerns or intimacy, although it is possible for a population working with traumatized clients to experience both vicarious traumatization and burnout simultaneously (Trippany, Kress & Wilcoxon, 2004). Practically, what is significant for counselors to note with regards to this question is to assess whether healthcare providers of cancer patients in Botswana experience both vicarious traumatization, burnout or compassion satisfaction and intervene appropriately according to the needs at group and individuals levels (Stamm, 2009). For example, score for vicarious traumatization subscales are high, professional quality of life subscales indicate a mean of 39.26 out of a possible 50 for compassion satisfaction (very high) while burnout and compassion fatigue score 40.7 and 33.01

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78 respectively. This means that both trauma and burnout occur at the same time in the same group but are mutually exclusive, hence the weak negative correlation between variables. The results are also clin ically significant because the cut off points to determine whether an individual is experiencing a high level of burnout prompt mental health counselors to make categorical decisions as to whether there should be an intervention or not. Research Question 3 : What is the Relationship between Vicarious Traumatization and Purpose in Life among Healthcare Providers of Cancer Patients in Botswana as Measured by the Purpose in Life Scale? tatistical outcome. This means that the significance value (.010) was less than the p value (.05) indicating that there was indeed a relationship between vicarious traumatization and purpose in life among healthcare providers of cancer patients in Botswana The effect size of .28 obtained from the correlation of the two variables means that there is a weak negative relationship. Practically this means vicarious traumatization does not affect purpose in life of the healthcare providers in the sample. This r esult is consistent with the findings from studies conducted to test the relationship between posttraumatic growth, growth and cognitive processing. The study found a correlation of .25 between posttraumatic growth and religious participation (Calhoun, Ca nn, Tedeshi & McMillan, 2000), indicating that religious participation which is associated with purpose in life was negatively related to trauma. People who have a high sense of purpose in life are less likely to be affected by trauma. For this study, the high scores in the purpose in life scale and a weak negative correlation confirm the little impact that trauma has people with a high purpose in life. On a clinical significance level based on this study, mental health counselors may have to pay more atten tion to facilitating exercises that promote spirituality among healthcare providers as a buffer against vicarious trauma.

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79 Research Question 4: Does Vicarious Traumatization Predict Professional Quality of Life among Healthcare Providers of Cancer Patients in Botswana? with a significance value of 1.000, meaning that vicarious traumatization does not predict whether or not there will be improved or diminished professional quality of life. Practically, the R Square which is a substantive measure of effects (Field, 2009) has not yielded any substantial or high figures to warrant any major effec ts of vicarious trauma on professional quality of life of healthcare providers. Literature on whether stressful or negative events such as trauma predict positive or negative professional quality of life is not readily available. However, a major question that still lurks among traumatologists that mental health counselors should also be asking themselves is aylor, 2000; p.7). In a study of cancer patients positive social relationships, priorities and activities were reported, but changes in their views about themselves and the world were mixed (Updegraff & Taylor, 2000), thus corroborating the constructivist self development theory on cognitive assessment findings on traumatized individuals (McCann & Pearlman, 1990). Updegraff & Taylor, ( 2000) further report a positive quality of life for cancer patients in a study where they were compared to a sample without cancer. West Olatunji & Goodman (2008) also state that in resiliency theory individuals face challenges and also develop coping mechanisms that allow them to overcome challenges. Based on these results of other studies, it is not surprising that finding b enefits in traumatic events may be associate d with better psychological adjustment to those events. It is equally not surprising that vicarious trauma had a minimal predictive value and a negative correlation with professional quality of life for healthcar e providers of cancer patients in Botswana. What the

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80 statistical results to this question mean is that mental health counselors may need to find out about other factors that predict professional quality of life since vicarious traumatization does not. The need to find out more about these factors is even more valid given that the high scores of burnout reflected on the data and the literature reporting unfavorable working conditions of healthcare providers in Botswana (World Health Organization, 2007). Res earch Question 5: Does Vicarious Traumatization Predict Purpose in Life among Healthcare Providers of Cancer Patients in Botswana? outcome; meaning that the signif icance value of 1.000 was greater than .05 (Tables 4 17 to 4 20). The Pseudo R Square reflects minor effects of vicarious trauma on purpose in life of healthcare providers through its Cox and Snell, Nagelkerke and McFadden on table 4 19. The results presen t a contradictory view to the picture painted by constructivist self development theory of trauma and to the data on the Trauma and Attachment Belief Scale (TABS). According to the constructivist self development theory, individuals who have had encounter s with trauma (directly or vicariously), experience a disturbed frame of reference in which they start to belief that the world is no longer meaningful, or coherent, they believe the world is unpredictable, dangerous and incoherent and uncontrollable and h ave an overwhelming sense of demoralization, pessimism and hopelessness (McCann & Pearlman, 1990). The data of the purpose in life scale show no proof that those healthcare providers of cancer patients in Botswana experience any disrupted sense of purpose. Out of a possible 140 the mean score for the sample for the purpose in life test was 112.37 representing an 80% of the sample having a high sense of purpose in their lives (Table 4 5). Also on the contrary, the data on the TABS reflects a highly traumatiz ed team of healthcare providers in some areas of the subscale (Table 4 1). Does it mean trauma does or does not influence purpose in life? Sigmund (2003) states that

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81 trauma evokes existential questions and exploration of trauma related existential conflict s in individuals are essential. As a way of mitigating the contradictory findings for the last question, it is essential to note that a lthough the constructivist self development theory of trauma posits that individuals who are being affecte d by major str essful events such as taking care of cancer patients alters the adaptation theory on the other hand states that people are motivated to restore their self esteem an d sense of meaning and mastery by the production of self enhancing cognitions (Updegraff & Taylor, 2000). The cognitive adaptation theory further states that positive interpretation; selective focus and evaluation are mechanisms by which individuals resto re their views of themselves and the significance result may b e suggesting active and intentional personal growth on the part of healthcare providers. In view of this thought, this can help de construct the victim and helplessness perspective usually presumed about individuals experiencing traumatic events This can a lso help mental health counselors to conduct individual and group spiritual assessment before intervening on the basis of the literature from different contexts or setting. Recommendations Research Question 1 T he results of study of the first research ques tion show average mean scores for all ten subscales of the Trauma and Attachment Belief Scale, indicating a generally moderate level of vicarious trauma among healthcare providers of cancer patients in Botswana. However, the maximum scores indicate extremely high or substantial disruptions for a significant numbe r of individuals

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82 in the sample in the areas of Self Safety, Other Safety, Self Trust, Other Esteem, Self Intimacy and Self Control. These results are clinically significant and therefore cal l for some action from mental health counselor practitioners, counselor educators and healthcare policy makers. One of the interventions recommended for counselors to use for a population experiencing trauma and grief the loss of people close to them is th e Trauma Focused Cognitive Behavior Therapy (TF CBT). The TF CBT is a hybrid counseling approach that integrates cognitive behavioral techniques, attachment issues, client empowerment and some humanistic approaches (Cohen, Mannarino, & Deblinger, 2006; We rth & Crow, 2009). This intervention can be used for both individual and group counseling sessions to help clients to process their traumatic experiences through cognitive rehearsals, disputing faulty beliefs, journaling and guided discovery. These same t echniques can be used to help the healthcare providers to detach emotionally from patients they have lost through cancer. International counseling bodies such as the American Counseling Association also advocate inclusion of standards for disaster, trauma and crisis counseling in graduate counselor training programs (Webber & Mascari, 2009). An adoption of such standards in Botswana counselor preparation programs will also go a long way in addressing issues of psychological trauma and crisis in the healthca re system and other sectors. The clinical significance of the results also calls for the health legislators and policy makers to advocate and implement mental health policies that are inclusive of all healthcare providers. The Botswana government runs a Na tional Strategic Framework (NSF) for combating HIV/AIDS a responsive health program to the scourge in the country. A mental health responsive program that runs parallel with the NSF is critical to address healthcare providers psychological needs because t he current National Policy on Mental Health excludes healthcare

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83 professionals despite literature attesting to poor mental health outcomes for cancer patients caregivers ((Buss, et al 2007; Swartz & Keir, 2007). Research Question 2 The finding to this que stion shows a negative correlation between vicarious trauma and professional quality of life, a result which is practically not significant but clinically significant when viewed in terms of high scores on the vicarious trauma scale and the burnout subscal e. It is therefore important to note that many professionals working with traumatized populations generally experience both burnout and vicarious trauamatization (Trippany, Kress & Wilcoxon, 2004). While quantitative studies have relied more on the data fr om the research instruments, proponents of the wellness model encourage mental health counselors to conduct a qualitative assessment of clients as an additional critical step to intervention (Roscoe, 2009). Other recommended individual level intervention s trategies that could follow include Trauma Focused Cognitive Behavioral Therapy aimed at alleviating vicarious trauma, burnout and compassion fatigue (Cohen, Mannarino, & Deblinger, 2006) and empowerment of clients by encouraging them to shed the role of expert, expressing feelings openly about the job and obtaining social support, setting boundaries and separating work from private lives (Rosenberg & Pace, 2006). One important intervention at group level for healthcare providers is to provide psycho educa tional sessions aimed at personal growth in the form communication or interaction with patients, team building (Felton, 1998), knowing job descriptions and individual roles in relation to the whole employment establishment. At organizational level, consul tations are recommended. Two general models, mental health consultation and systemic organizational consultation (Moe & Pereira Diltz, 2009) are appropriate for counselors to engage as consultants for the healthcare provider organizations in Botswana. In addition to providing counseling related services under the mental health model, in the systemic organizational model, the

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84 consultant identifies aspects of the organization that impede the organization from achieving its intended workforce wellness goal. Counselor education programs also need to expand the counselor preparation program to include courses in consultation in order to respond empathically to the current and contextual needs of Botswana. Research Question 3 The statistical result addressing th is question show that there is a significant negative relationship between vicarious traumatization and purpose in life among healthcare providers of cancer patients in Botswana. Clinical significance of the answer to this question can be gleaned from the data which shows high levels of both trauma and purpose in life. What this means for counselors is that a group of people affected by trauma can still have a high sense of purpose in their lives. While many counselors do not have training in religious and spiritual issues, the same obtains for the clergy who do not have training in mental health counseling yet both groups deal with the same issues in their practice. A collaborative relationship is recommended between mental health counselors and the clergy is recommended. Mental health counselors should invite the clergy to address issues pertaining to religion and spirituality in the work place when the need arises; referrals are also in order for individual cases (Weaver, Flannelly, Flannelly & Oppenheimer 2003). This model seems suitable because for a long time Botswana has been Workshops, conferences and research projects addressing these issues are recommended. Sig mund (2003) recommends cross professional mental health training and the clergy. The counselor education curriculum in Botswana should consider a pastoral counseling specialization in the current wake of daunting cancer and HIV/AIDS and the upsurge of vari ous religious domains in the country.

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85 Research Questions 4 Vicarious traumatization does not predict professional quality of life and purpose in life among healthcare providers of cancer patients in Botswana. Besides conducting a survey or qualitative ass essment it would be difficult to know what factors affect the professional quality of life and purpose in life for this population. For this reason a holistic wellness model is recommended when working with healthcare providers in Botswana. There are vario us wellness models but most include life tasks of spiritual, physical, social, emotional, intellectual, occupational wellness, friendship and love (Roscoe, 2009). The systems perspective posits that all these elements within the environment contribute to a large whole (the healthcare provider). Viewed in this way, mental health counselors can promote psychological well being by centering their treatment on the core dimensions of wellness and also structure their therapy around wellness themes (Roscoe, 2009) Limitations of the Study The study is a survey self report which is known to have limitations inherent in the design. Both theory and research indicate that self report measures are a product of psychological, sociological, linguistic, contextual and experiential variables which s ometimes have little to do with the construct meas ured (Razavi, 2001). The author beliefs that because of these issues, it is never clear what is measured. In this case, my study was conducted in Botswana and the instrument was normed basing on a populatio n in the United States where the stated demographic variables are totally different for the population under study in Botswana. The setting in which the research is conducted has also been known to be a threat to internal validity in survey research (Wall en & Fraenkel, 2001). This study was conducted among healthcare providers in hospitals in Botswana. The administration was carried out in these hospital settings during working hours for easy access to the participants; however, responding to

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86 the question in such an environment might have influenced the responses. Razavi (2001) may influence the way they respo nd Since the research was intrusive and required their responses regarding their level of trauma, compassion satisfaction, burnout and compassion fatigue, it is possible that their responses were intentionally patterned to sound pro establishment and also to not present them as dysfunctional professionals. Additionally, organizational research is prone to deliberate misrepresentation as participants may feel that their responses will have a bearing on the promotion either positively or negatively. One of t he limitations of this study is that there was one predictor variable. In multiple regression analysis partial regression is usually performed between a dependent variable and one independent variable while holding other independent variables constant so t hat only the effect on this one variable in the model is determined. In this study, one variable was used without other explanatory varia bles thereby limiting the view of other intervening factors. Thus TABS as a single measure, does not expand the breadth of the study to provide a picture of other factors at play in the population under investigation. Future Research In this study one predictor variable (vicarious traumatization) was used to find out if it has any association with professional quality of life and purpose in life among healthcare providers of cancer patients in Botswana. The results on the Trauma and Attachment Belief Scale show high levels of trauma in some study participants but it is not clear what other factors are associated with the h igh levels of disruption. In order to expand this study, future research will use more than one predictor variable by incorporating some elements of the demographics (Tables 3 1 to 3 11) such as level of training, length of experience in treating cancer pa tients,

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87 frequency of contact with patients, marital status and others. This study is cross sectional, in future if resources permit, it will be ideal to conduct longitudinal studies in order to identify patterns over trauma of healthcare providers overtime mediating factors as well as comparing groups in various health settings. Providing resources for longitudinal research is also consistent with the projections of the World Health Organization (2007) Predictions of the World Health Organization indicate a growth of 400% in the next 50 years especially in the developing countries. Mental health intervention in the form of education, consultation and counseling and research is critical as a sustainable means to reducing healthcare provider burden. Future r esearch should also be conceptual, defining accurately but contextually issues of mental health, vulnerable groups, inclusion and exclusion. In that way such research attempts could start a dialogue wi th policy makers, educators, research ers and healthcare providers on the importance of an all inclusive mental health service provision rather than the limited one targeting few specific groups listed in the National Mental Health Policy (2003). Future research should also focus on more structured studies add ressing issues of compassion satisfaction, burnout and compassion fatigue as separate entities affecting healthcare providers of cancer patients in Botswana rather than as a broad conceptual framework. Rather than focusing on the negative impact that traum a has on healthcare providers, research on the different aspects of professional quality of life will bring more redirect attention to the issues of wellness in the work place, a research domain still unexplored in Botswana. The clergy have been known to function as mental health workers for a long time. Various studies conducted over 40 years in the United States also provide that evidence (Weaver, Flannelly, Flannelly & Oppenheimer, 2003). In Botswana the clergy also play a pivotal role in alleviating me ntal anguish of their congregants and the public in general. Future research on

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88 issues of religion, spirituality and mental health in Botswana is essential. A substantial amount of qualitative data in this area can be collected during cross training worksh ops and conferences between the clergy and professional counselors. Also, structured qualitative research in this area can be helpful bearing in mind that this study was conducted through quantitative survey, with theoretical frameworks based in European a nd North American settings; it will be ideal to their interpretive and phenomenological view points. Summary This chapter focused on the discussion of the resu lts, recommendations emanating from a study of the relationship between vicarious traumatization and professional quality of life and purpose in life among healthcare providers of cancer patients in Botswana. Recommendations for mental health counselors an d counselor educators in the form of trauma focused counseling consultation, education in crisis and disaster and collaboration with, the clergy and policy makers were outlined as implications for the study. An outline of relevant areas for future studies was laid out. In general, the findings of the study point to presence of vicarious trauma among healthcare providers but to the extent that it does not predict burnout, compassion fatigue and compassion satisfaction. However, there is an abundance of evid ence from other studies clinical significance and data that vicarious traumatization can occur simultaneously with these outlined factors as has been the case in this study

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89 Table 3 1. Nationality of Healthcare Providers Frequency Percent Valid Perc ent Cumulative Percent Valid Botswana 62 74.7 74.7 74.7 Foreign 21 25.3 25.3 100.0 Total 83 100.0 100.0 Table 3 2. Gender of Healthcare Providers Frequency Percent Valid Percent Cumulative Percent Valid Male 30 36.1 36.1 36.1 Female 53 63.9 63.9 100.0 Total 83 100.0 100.0 Table 3 3. Age groups of Healthcare Providers Age group in years Frequency Percent Valid Percent Cumulative Percent 18 24 10 12.0 12.0 12.0 25 30 26 31.3 31.3 43.4 31 36 17 20.5 20.5 63.9 37 42 15 18.1 18.1 81.9 43 48 5 6.0 6.0 88.0 49 54 6 7.2 7.2 95.2 55 60 4 4.8 4.8 97.6 Total 83 100.0 100.0

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90 Table 3 4. Marital Status Frequency Percent Valid Percent Cumulative Percent Married 35 42.2 42.7 42.7 Separated 3 3.6 3.7 46.3 Divorced 3 3.6 3.7 50.0 Widowed 3 2.4 2.4 52.4 Single 39 47.0 47.6 100.0 Total 83 100.0 100.0 Table 3 5. Occupation of Healthcare Providers Frequency Percent Valid Percent Cumulative Percent Medical doc 10 12.0 12.0 12.0 Nurse 51 61.4 61.4 73.5 Nurse assistant 5 6.0 6.0 79.5 Radiation Therapist 7 8.4 8.4 88.0 Psychologist 1 1.2 1.2 89.2 Social Worker 5 6.0 6.0 95.2 Oncology Clerk 1 1.2 1.2 96.4 Human Resource 1 1.2 1.2 97.6 Youth Officer 1 1.2 1.2 98.8 Lay Counselor 1 1.2 1.2 100.0 Total 83 100.0 100.0

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91 Table 3 6. Qualifications of Providers in Various Healthcare Disciplines Discipline Frequency Percent Valid Percent Cumulative Percent Nursing Diploma 35 42.2 42.7 42.7 Nursing Degree 17 20.5 20.7 63.4 Med. Radiation. Oncology 1 1.2 1.2 64.6 Diploma Secretarial Oncology 1 1.2 1.2 65.9 BA Admin. 2 2.4 2.4 68.3 MSc Radiation 2 2.4 2.4 70.7 MBBS/ BMBch 2 2.4 2.4 73.2 BSc Radiology 2 2.4 2.4 75.6 Dip. Radio graphy 1 1.2 1.2 76.8 DCRT 4 4.8 4.9 81.7 CPUHW 5 6.0 6.1 87.8 BSc Physics 1 1.2 1.2 89.0 BSW 1 1.2 1.2 90.2 MSc Nursing 3 3.6 3.7 93.9 COSC 2 2.4 2.4 96.3 MBchB 1 1.2 1.2 97.6 MSc Medicine 1 1.2 1.2 98.8 BSc Counseling 2 1.2 1.2 100.0 Total 83 100.0 100.0

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92 Table 3 7. Area of Specialization in Healthcare Frequency Percent Valid Percent Cumulative Percent Nurse Generalist 38 45.8 45.8 45.8 Gen.Med. Practitioner 4 4.8 4.8 50.6 Oncology 11 13.3 13.3 63.9 Radiology 6 7.2 7.2 71.1 Psychology 2 2.4 2.4 73.5 Social Work 4 4.8 4.8 78.3 Clerical Oncology 1 1.2 1.2 79.5 Human Resource 1 1.2 1.2 80.7 None 8 9.6 9.6 90.4 Surgery 4 4.8 4.8 95.2 ENT 1 1.2 1.2 96.4 Internal Medicine 1 1.2 1.2 97.6 Public Health 1 1.2 1.2 98.8 Counseling 1 1.2 1.2 100.0 Total 83 100.0 100.0 Table 3 8. Organizations Healthcare Providers Work for Frequency Percent Valid Percent Cumulative Percent Princess Marina Hospital 19 22.9 22.9 22.9 Gaborone Private Hospital 15 18.1 18.1 41.0 Bokamoso Private Hospital 1 1.2 1.2 42.2 Holy Cross Hospice 5 6.0 6.0 48.2 Deborah Retief Memorial Hospital 6 7.2 7.2 55.4 Scottish Livingstone Hospital 1 1.2 1.2 56.6 Bamalete L. Hospital 6 7.2 7.2 63.9 Nyangabwe Referral Hospital 25 30.1 30.1 94.0 Tutume Primary Hospital 5 6.0 6.0 100.0 Total 83 100.0 100.0

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93 Table 3 9. Years of Experience as a Healthcare Provider Cases Frequency Percent Valid Percent Cumulative Percent 1 10 12.0 12.0 12.0 2 6 7.2 7.2 19.3 3 13 15.7 15.7 34.9 4 1 1.2 1.2 36.1 5 6 7.2 7.2 43.4 6 3 3.6 3.6 47.0 7 4 4.8 4.8 51.8 8 4 4.8 4.8 56.6 9 2 2.4 2.4 59.0 10 7 8.4 8.4 67.5 13 2 2.4 2.4 69.9 14 3 3.6 3.6 73.5 15 2 2.4 2.4 75.9 16 1 1.2 1.2 77.1 17 6 7.2 7.2 84.3 18 4 4.8 4.8 89.2 19 2 2.4 2.4 91.6 20 1 1.2 1.2 92.8 25 2 2.4 2.4 95.2 30 3 3.6 3.6 98.8 31 1 1.2 1.2 100.0 Total 83 100.0 100.0

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94 Table 3 10. Years of Experience with Cancer Treatment Frequency Percent Valid Percent Cumulative Percent 1.0 22 26.5 26.5 26.5 2.0 15 18.1 18.1 44.6 3.0 11 13.3 13.3 57.8 3.5 1 1.2 1.2 59.0 4.0 4 4.8 4.8 63.9 5.0 3 3.6 3.6 67.5 6.0 3 3.6 3.6 71.1 7.0 4 4.8 4.8 75.9 8.0 1 1.2 1.2 77.1 9.0 1 1.2 1.2 78.3 10.0 6 7.2 7.2 85.5 11.0 1 1.2 1.2 86.7 13.0 1 1.2 1.2 88.0 15.0 2 2.4 2.4 90.4 16.0 1 1.2 1.2 91.6 17.0 1 1.2 1.2 92.8 19.0 1 1.2 1.2 94.0 20.0 1 1.2 1.2 95.2 21.0 1 1.2 1.2 96.4 22.0 1 1.2 1.2 97.6 26.0 1 1.2 1.2 98.8 31.0 1 1.2 1.2 100.0 Total 83 100.0 100.0 Table 3 11. Healthcare Provider Frequency of Contact with Cancer Patients Frequency Percent Valid Percent Cumulative Percent Daily 60 72.3 72.3 72.3 Weekly 7 8.4 8.4 80.7 Monthly 14 16.9 16.9 97.6 Yearly 2 2.4 2.4 100.0 Total 83 100.0 100.0

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95 Table 4 1. Descriptive Statistics for survey response on TABS subscales N Minimum Maximum Mean Std. Deviation Self Safety 83 34.00 73.00 54.7229 9.11487 Other Safety 83 13.00 80.00 55.1446 14.61634 Self Trust 83 31.00 80.00 51.6265 10.21203 Other Trust 83 25.00 69.00 54.4578 9.45890 Self Esteem 83 32.00 68.00 48.6145 8.57937 Other Esteem 83 27.00 79.00 54.6988 10.85911 Self Intimacy 83 24.00 72.00 55.2530 9.79901 Other Intimacy 83 33.00 62.00 50.2892 7.06853 Self Control 83 24.00 74.00 50.0120 10.59394 Other Control 83 25.00 66.00 48.5301 9.98821 Table 4 2. Descriptive Statistics for Compassion Satisfaction Subscale N Minimum Maximum Sum Mean Std. Deviation Q3b 83 3 5 365 4.40 .748 Q6b 83 1 5 265 3.27 1.173 Q12b 83 1 5 352 4.24 .983 Q16b 83 1 5 343 4.13 .960 Q18b 83 1 5 283 3.41 1.137 Q20b 83 1 5 322 3.87 .927 Q22b 83 2 5 340 4.09 .918 Q24b 83 1 5 357 4.30 .907 Q27b 83 1 5 303 3.65 1.029 Q30b 83 1 5 324 3.90 1.276 Table 4 3 Descriptive Statistics for Burnout Subscale N Minimum Maximum Sum Mean Std. Deviation Q1b 83 1 5 299 3.65 1.104 Q4b 83 2 5 330 3.98 .796 Q8b 83 1 5 176 2.15 1.090 Q10b 83 1 5 214 2.58 1.298 Q15b 83 1 5 324 3.90 1.196 Q17b 83 1 5 322 3.88 1.162 Q19b 83 1 5 228 2.78 1.144 Q21b 83 1 5 272 3.28 1.281 Q26b 83 1 5 244 3.01 1.156 Q29b 83 1 5 383 4.61 .659

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96 Table 4 4 Descriptive Statistics for the Compassion Fatigue Subscale N Minimum Maximum Sum Mean Std. Deviation Q2b 83 1 5 316 3.80 .904 Q5b 83 1 5 193 2.33 1.049 Q7b 83 1 5 239 2.91 1.269 Q9b 83 1 5 228 2.75 1.238 Q11b 83 1 5 223 2.68 1.260 Q13b 83 1 5 255 3.07 .960 Q14b 83 1 5 241 2.90 1.165 Q23b 83 1 5 201 2.42 1.354 Q25b 83 1 5 196 2.36 1.265 Q28b 83 1 5 181 2.18 .965 Table 4 5. Descriptive Statistics for the Purpose In Life scale N Minimum Maximum Sum Mean Std. Deviation Q1c 83 1 7 385 4.63 1.349 Q2c 83 1 7 366 4.41 1.570 Q3c 83 4 7 520 6.27 .813 Q4c 83 2 7 509 6.13 1.045 Q5c 83 1 7 434 5.23 1.525 Q6c 83 3 7 496 5.98 1.082 Q7c 83 4 7 526 6.34 .873 Q8c 83 1 7 414 4.99 1.311 Q9c 83 1 7 419 5.04 1.247 Q10c 83 2 7 481 5.80 1.166 Q11c 83 3 7 523 6.30 .880 Q12c 83 2 7 466 5.61 1.057 Q13c 83 4 7 540 6.51 .722 Q14c 83 1 7 441 5.31 1.697 Q15c 83 1 7 358 4.42 1.974 Q16c 83 1 7 525 6.56 1.089 Q17c 83 4 7 499 6.01 .901 Q18c 83 4 7 483 5.81 .914 Q19c 83 1 7 444 5.35 1.457 Q20c 83 3 7 471 5.67 1.040

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97 Table 4 6. Descriptive Statistics of Sample on Each Instrument N Minimum Maximum Sum Mean Std. Deviation TABS 83 1.1667 3.9167 232.9850 2.807048 .4524541 ProQOL 83 2.4000 4.5667 279.1424 3.363162 .3596724 PIL 83 4.0 6.8 469.1 5.652 .7096 Table 4 7. Bivariate Correlations: Vicarious Trauma and Professional Quality of Life Trauma ProQOL Trauma Pearson Correlation 1 .107 Sig. (2 tailed) .956 N 83 83 ProQOL Pearson Correlation .107 1 Sig. (2 tailed) .956 N 83 83 Table 4 8. Bivariate Correlations: Vicarious Trauma and Purpose in Life Trauma PIL Trauma Pearson Correlation 1 .282(**) Sig. (2 tailed) .010 N 83 83 PIL Pearson Correlation .282(**) 1 Sig. (2 tailed) .010 N 83 83 ** Correlation is significant at the 0.01 level (2 tailed). Table 4 9 Bivariate Correlations: Purpose in Life and Professional Quality of Life PIL ProQOL PIL Pearson Correlation 1 .116 Sig. (2 tailed) .298 N 83 83 ProQOL Pearson Correlation .116 1 Sig. (2 tailed) .298 N 83 83

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98 Table 4 10. Reliability Test for the Trauma and Attachment Belief Scale Cronbach's Alpha N of Items .911 84 Table 4 11. Reliability Test for the Professional Quality of Life Scale Cronbach's Alpha N of Items .736 30 Table 4 12. Reliability Test for the Purpose in Life Scale Cronbach's Alpha N of Items .897 20 Table 4 13. Model Fitting Information Model Model Fitting Criteria Likelihood Ratio Tests 2 Log Likelihood Chi Square df Sig. Intercept Only 578.208 Final 379.461 198.747 3060 1.000 Table 4 14. Goodness of Fit Chi Square df Sig. Pearson .000 0 Deviance .000 0 Table 4 15. Pseudo R Square Cox and Snell .909 Nagelkerke .909 McFadden .332

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99 Table 4 16. Likelihood Ratio Tests Effect Model Fitting Criteria Likelihood Ratio Tests 2 Log Likelihood of Reduced Model Chi Square df Sig. Intercept 379.461(a) .000 0 Trauma 578.208 198.747 3060 1.000 The chi square statistic is the difference in 2 log likelihoods between the final model and a reduced model. The reduced model is formed by omitting an effect from the final model. The null hypothesis is that all parameters of that effect are 0. a This reduced model is equivalent to the final model because omitting the effect does not increase the degrees of freedom. Table 4 17. Multinomial Logistic Regression for Trauma (TABS) and PIL: Model Fitting Information Model Model Fitting Criteria Likelihood Ratio Tests 2 Log Likelihood Chi Square df Sig. Intercept Only 591.168 Final 234.138 357.030 3196 1.000 Table 4 18. Goodness of Fit Chi Square df Sig. Pearson .000 0 Deviance .000 0 Table 4 19. Pseudo R Square Cox and Snell .986 Nagelkerke .987 McFadden .582 Table 4 20. Likelihood Ratio Tests Effect Model Fitting Criteria Likelihood Ratio Tests 2 Log Likelihood of Reduced Model Chi Square df Sig. Intercept 234.138(a) .000 0 Trauma 591.168 357.030 3196 1.000 The chi square statistic is the difference in 2 log likelihoods between the final model and a reduced model. The reduced model is formed by omitting an effect from the final model. The null hypothesis is that all parameters of that effect are 0.

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100 Table 4 21. Results of Hypothesis Testing Hypothesis Result Ho 1 Significant Ho 2 Not significant Ho 3 Significant Ho 4 Not significant Ho 5 Not significant

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101 Figure 4 1. Scatterplot: Vicarious Trauma and Professional Quality of Life

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102 Figure 4 2. Scatter Plot: Vicarious Trauma and Purpose in Life

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103 Figure 4 3 Scatter Plot: Purpose in Life and Professional Quality of Life

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104 Figure 4 4 Histogram of Normal Distribution of Trauma Figure 4 5 Histogram: Normal Distribution of Professional Quality of Life Data

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105 Figure 4 6 Histogram: Normal Distribution of Purpose in Life Data Figure 4 7

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106 Figure 4 8 (TABS and PIL )

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107 Figure 4 9 Curve Fit Scatterplot for TABS and ProQOL Figure 4 10 Curve Fit Scatter Plot for TABS and P IL

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108 APPENDIX A UFIRB APPROVAL OF PR OTOCOL FOR THE STUDY Figure A 1. UFRIB approval of protocol for the study.

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109 Figure A 1. Continued

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110 APPENDIX B PERMISSION LETTER FR OM WESTERN PSYCHOLOG ICAL SERVICES Figure B 1. Permission letter from Western Psychological Services

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111 APPENDIX C DEMOGRAPHIC INFORMAT ION FOR SURVEY Title of study: The Relationship between Vicarious Traumatization and Quality of Life and Purpose in Life of Healthcare Providers of Cancer Patients in Botswana. Instruction: Please complete information about yourself below. Nationality _________________ ______ Gender (M/F) ____________ Age_______ Marital status (single/married/separated/divorced/ widowed)____________ Occupation______________________ Qualifications (e.g., B. A Psy.D)______________ Area of specialization_______________________________ Organization you work for____________ Years of experience__________ Experience with cancer treatment (e.g. one month, one year) ________________________ Frequency of contact with cance r patients (e.g., everyday, weekly, month yearly )_

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112 APPENDIX D TRAUMA AND ATTACHMEN T BELIEF SCALE VERSION ALLOWED AS A PPENDIX Figure D 1. Trauma and Attachment Belief Scale, version allowed as appendix

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113 APPENDIX E PROFESSIONAL QUALITY OF LIFE SCALE Figure E 1. Professional quality of life scale

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114 APPENDIX F PURPOSE IN LIFE TEST Figure F 1. Purpose in life test

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115 Figure F 1. Continued

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116 Figure F 1. Continued

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117 APPENDIX G RESEARCH GRANT LETTE R Figure G 1. Research grant letter

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118 APPENDIX H RESEARCH STUDY ADVERTISING FLYER TRAUMA STUDY March April, 2010 Are you a healthcare provider who works in a hospital or hospice setting and treat or provide any form of care for cancer patients? If you answered YES to the above question you qualify for parti cipation in this study. You are cordially invited to participate by filling out a 45 minutes questionnaire in a study entitled : THE RELATIONSHIP BETWEEN VICARIOUS TRAUMATIZATION AND QUALITY OF LIFE AND PURPOSE IN LIFE OF HEALTHCARE PROVIDERS OF CANCER PAT IENTS IN Ministry of Health Approved, Protocol # HRDC 00549 GOAL: It is expected that this study will bring to the awareness of educators, researchers and policy makers some of the traumatic experiences that healthcare providers experience during caregiving and thus intervene through provision of counseling and other sup port services. For details contact Principal Investigator: Aaron Ronnie Majuta Phone: 355 4174 (office) Email: amajuta@ufl.edu

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119 APPENDIX I RESEARCH PERMISSION FROM THE MINISTRY OF HEALTH Figure I 1. Research p ermission from the Ministry of Health

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120 Figure I 1. Continued

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121 APPENDIX J RESEARCH PERMISSION FROM PRINCESS MARINA HOSPITAL Figure J 1. Research p ermission from Princess Marina Hospital

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122 APPENDIX K RESEARCH PERMISSION FROM DEBORAH RETIEF MEMORIAL HOSPITAL Figure K 1. Research p ermission from Deborah Retief Memorial Hospital

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123 APPENDIX L RESEARCH PERMISSION FROM BAMALETE LUTHER AN HOSPITAL Figure L 1. Research p ermission from Bamalete Lutheran Hospital

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124 APPENDIX M RESEARCH PERMISSION FROM NYANGABWE REFER RAL HOSPITAL Figure M 1. Research p ermission from Nyangabwe Referral Hospital

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134 BIOGRAPHICAL SKETCH sixth son and the third and last child to his adoptive mother Florence Majuta. He graduated from d a post graduate diploma in secondary education. He taught social studies, English and guidance counseling in community junior secondary school for five years before he went and earned another post graduate diploma in counseling education. After this qual ification he taught history and guidance counseling in a senior secondary school for one year. In 1998 Aaron was recruited for the position of staff development fellow to teach guidance and counseling at a three year teachers training college, a post he r etained for two years before he enrolled for a Master of A rts in community agency counseling degree with the University of Alabama at Birmingham, U.S.A. Upon completion Aaron went back to Botswana and taught for one year at the teachers college before he j oined the University of Botswana in 2003 as faculty. In the fall of 2007 Aaron was admitted into the doctoral program in the Department of Counselor Education at the University of Florida, U.S.A. While studying there he was and by the Office of the Dean in the College of Education.