Origrnal Article

Yonago Acta medica 2015;58:69–75

The Skills of Facilitator Nurses in Psycho-Social Group Intervention for Cancer
Patients
Masami Chujo* and Hitoshi Okamura†*Department of Adult and Elderly Nursing, School of Health Science, Tottori University Faculty of Medicine,Yonago 683-8503, Japanand †Department of Psychosocial Rehabilitation, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima 7348553, Japan

ABSTRACT
Background

The objective of this study was to provide cancer patients with a psychosocial group intervention consisting of 3 parts, i.e., education on how to copewith stress and solve problems, group discussions, andprogressive muscle relaxation, and to investigate the intervention techniques of Japanese facilitators.
Methods Group interventions for breast cancer patients performed by 3 facilitators were analyzed qualitatively and inductively using a phenomenological approach.
Results The skills of facilitators included 10 intervention techniques and 1 problem in interventions. Intervention techniques, which promote group dynamics andthereby help participants acquire improvements in theircoping abilities and quality of life (QOL), were somewhat different between new and experienced facilitators,
with the content showing immaturity and maturity inthe new and experienced facilitators, respectively. Bothexperienced and new facilitators faced the risk of experiencing problems in interventions, which countered
the purpose of the intervention of improving the participants’ coping abilities or QOL.
Conclusion While intervention skills are necessary
for facilitators to execute group interventions, it must beborne in mind, that even well-experienced facilitators
may not always be able to accomplish skillful intervention.

Thus, increasing attention has been paid to the psychosocial problems of breast cancer patients, and studies
have been conducted to verify the effectiveness of psychosocial interventions for reducing the psychologicalburden of breast cancer patients and for improving their
quality of life (QOL).2–4 Group interventions, often consisting of education on how to cope with stress and how
to solve problems, group discussions and progressive
muscle relaxation (PMR)4 were first developed in Western countries, and have also been verified to be effectivein Japan.2, 3
Many attempts have been made to undertake psychosocial group interventions for cancer patients, andthese interventions are expected to spread in popularity in the future. Therefore, it is our task to improve thetherapeutic environment for providing group interventions. One of the problems in this task is the shortage of
people who can act as facilitators. Facilitators executeinterventions, while perhaps having difficulty in managing participants with problems and in overcoming
anxiety due to a lack of knowledge and fear of executing
such interventions.6 Under such circumstances, there
are no systematic reports on the facilitators’ intervention
methods.
Based on the above background, we undertook psychosocial group intervention in this study consisting of
3 parts, i.e., education on how to cope with stress andsolve problems, group discussions and PMR, which has
been shown to be useful for Japanese breast cancer patients,2 with the aim of investigating the actual intervention skills employed in the intervention methods used
by Japanese facilitators. Clarification of the facilitators’intervention styles in group interventions for cancer patients in this study is expected to form one of the bases
for finding the direction for facilitator education and forcontributing to the dissemination of group interventions.

Key words group intervention; facilitator; nurse; art ofintervention; cancer patient
Recent advances in cancer treatment have enabled breast
cancer patients to live longer and longer. Accordingly,
the problem of breast cancer patients carrying psychological burdens, such as anxiety and depression, andliving their lives with psychosocial problems1 has appeared.

SUBJECTS AND METHODSCorresponding author: Masami Chujo, RN, PhD
chujo@med.tottori-u.ac.jp
Received 2015 February 24
Accepted 2015 March 15
Abbreviations: PMR, progressive muscle relaxation; QOL, qualityof life

Subjects
Facilitators

Group intervention facilitators in cancer centers A and
B were eligible for the study if they i) had experience
as nurses for 5 years or more, ii) had received facilitator69

M. Chujo and H. Okamura

Analysis methods

training in advance and iii) wished to play a role in facilitating discussions among the participants (as facilitators).

For the analysis, we used a method of qualitatively andinductively extracting the facilitators’ intervention styles
from verbatim transcripts according to the purpose of
the study, by reference to the phenomenological method.7 First, we repeatedly read the verbatim transcripts tograsp the whole context, and then divided and classified
the transcripts into expressions with similar meanings.
Next, we comparatively investigated the relationships
among these expressions and gave them names withmeanings. We reviewed the verbatim transcripts again
and again to check whether the given names represented
the true nature of the data, further divided and classified
the expressions according to their meanings, and comparatively investigated the relationships among them.
We gradually abstracted the expressions by repeatingthese procedures, which allowed extraction of the true
nature of each expression, and obtained the facilitators’intervention methods.
In this process, we repeatedly held discussions toimprove the reliability and validity of the study, i.e.,
investigated whether the results were reliable and represented the “real” world of the study subjects (reliability),
and whether the study was conducted in context considering the environment of the study subjects and all
circumstances (meaning in context), whether all possible
explanations and interpretations were thoroughly considered, and whether the results found in this study wereapplicable to other similar contexts or situations (transferability).

Participants of the group intervention

Breast cancer patients followed in cancer centers A and
B were eligible for the study if they met the following
criteria: i) adult women aged 20 years or older; ii) histological diagnosis of breast cancer and presence of histologically and/or clinically evident breast cancer; iii) noserious systemic conditions; iv) no active double cancer;v) no clinical need for psychiatric treatment (that is, nodepression, adjustment disorder, etc.); vi) no difficulty inunderstanding the purpose of the study (that is, no impairment of consciousness including advanced dementia
and delirium, mental retardation, etc.) and vii) pertaining to the disease stage, first recurrence in cancer center
A and during or after chemotherapy in cancer center B.
The eligible patients were asked to participate in the
study from June 2002 to April 2003 in cancer center A
and from October 2006 to February 2008 in cancer center B.
Intervention methods

This study employed a short-term (6-week) psychosocialgroup intervention, which has been verified to be effective in Japanese primary and recurrent breast cancer
patients.2
In the group intervention, a total of six 90-min
weekly sessions were undertaken for groups of 3 to 8
participants each. Each session consisted of education
on how to cope with stress and how to solve problems(20 min), discussion on the ability to cope (50 min) andtraining for PMR (20 min).

RESULTS
Subjects’ characteristics
Experienced facilitator

Intervention scenes were recorded with a digital video
camera or IC recorder and later transcribed verbatim.
The original recorded data were discarded after the verbatim transcripts were prepared.

One facilitator in cancer center A who had experience as
a nurse for more than 10 years, had 3 years’ experienceof nursing breast cancer patients, had received facilitator
training and had 3 years’ experience as a group intervention facilitator took charge of a total of 18 sessions for 3
groups.

Ethical considerations

New facilitators

Evaluation

The study was approved by the Ethical Committees ofthe 2 research facilities and the Fukuoka Prefectural
University. The outline of the study, the voluntary natureof participation and the preservation of anonymity wereexplained verbally and in writing to the study subjects
and group intervention participants, and written consent
to participate in the study was obtained from each of theparticipants.

Each of the 2 facilitators in cancer center B who had
experience as a nurse for more than 10 years on average and had received facilitator training took charge of
6 sessions for 1 group each (total 12 sessions). Thesefacilitators performed the 6-session intervention for the
first time.
Skills of facilitators

The analysis of the facilitator nurses’ intervention methods enabled extraction of the “skills of facilitators” as
the core category (Table 1). In addition, there was a dif70

The skills of facilitators in group intervention

ference in the categories derived from this core category
between the experienced and new facilitators. Hereinafter, the core category is shown in “ ”, the categories in [ ],the subcategories in < >, the discussion themes in italics
with *, and the facilitators’ interventions based on which
the categories were extracted in bold.

Table 1. Comparison of the skill of facilitators between experienced and new facilitators
Core category

Categories

Subcategories (experienced facilitators)

Skill of facilitators Intervention skills To proceed with the intervention
To speak for the participants

Subcategories (new facilitators)
To proceed with the intervention

To speak for the participants
To encourage participants to reflect on themTo encourage participants to reflect on themselves
selvesTo protect the participants’ physical health
To protect the participants’ physical health
To protect the participants’ mental health
To protect the participants’ mental health
To face participants with the facilitators’ reality To face participants with facilitators’ reality
Presence
Presence
To grasp the context
To grasp the context
To return the topic to the theme
To return the topic to the theme
To weave different skills together

Problem in interventions

Inability to perform skillful interventions“Skills of facilitators”

Inability to perform skillful interventions

answer medical questions, if they think that it would
reduce the participants’ anxiety and thereby allow theintervention to go on more smoothly. This is an intervention technique with which facilitators proceed withinterventions not as the chair, but by taking an overview
of the whole group and grasping the participants’ feelings.

This core category refers to facilitators steering the discussion according to the theme with the aim of making
the group dynamics work, toward a decrease in psychological burden and improvement in the QOL, which are
the purposes of group interventions, and use the necessary techniques for the participants. The categories of[intervention techniques] and [problem in interventions]were extracted from this core category.

Participant 26: “Oyster supplement, I know that. It issaid to be good for health, particularly for people withcancer.”Participant 20: “A small bottle is very expensive, andcosts 10,000 yen, but my mother worries about me andsends me several bottles of the supplement. Like so,people around me worry about me.”Facilitator A: “Well, it may depend on how you tellpeople around you. This topic is the theme in the next
week, and I hope you will talk a lot about it again
next week. Now, let’s begin relaxation.”(Start of relaxation)[Intervention techniques]This category means that facilitators promote groupdynamics when performing group interventions. Thiswas useful for the participants to acquire improvementin their coping ability and QOL. From this category thefollowing subcategories were extracted: <to proceedwith the intervention>, <to speak for participants>, <toencourage participants to reflect on themselves>, <toprotect the participants’ physical health>, <to protect theparticipants’ mental health>, <to face participants withthe facilitators’ reality>, <presence>, <to grasp the context>, <to return the topic to the theme> and <to weave
different skills together>. Of these, <to weave different
techniques together> was only extracted in the experienced facilitator.

<To speak for the participants>

This subcategory is an intervention method in which facilitators sympathize with and express in words what theparticipants really want to say and how they feel. The
participants were often unable to well express their feelings in words, and their true intentions often lay behind
their words.

<To proceed with the intervention>

This subcategory is an intervention method in whichfacilitators take care so that the group intervention goeson without problems, by correctly allocating time toeach part of the group intervention and giving each participant an equal opportunity to speak. Facilitators may

Participant 31: “Colleagues in the workplace are in their
20s and 30s, and I told them, ‘You should at least undergo breast cancer screening’. I actually let them touch my71

M. Chujo and H. Okamura

breast, saying ‘This stiffness! If you feel this stiffness inyour breast, it’s absolutely too late!’”Facilitator B: “Those people will never forget it. You
don’t want them to suffer as you do. I suppose that is
the thought dominating your mind.”Participant 31: “That’s right.”sues) It is important to express your feelings, andnobody will laugh or be put off. This is a place that
we can share, that is protected, and that we try toprotect.”
Participant 30: “Thank you (she continued to shedtears).”<To encourage the participants to reflect onthemselves>
This subcategory is an intervention method in whichfacilitators try to make the participants aware of coping
and management methods that the participants themselves may not be aware of from the various experiencesthat are talked about. The purpose of this intervention
method is to make participants understand their own
trends in coping and other people’s coping methods andutilize such understanding in the future.

<To face participants with facilitators’ reality>

This subcategory is an intervention method in which
the facilitators frankly speak what they themselves feel
while facing the participants. The relationship between
facilitators and participants is not the same as the relationship between therapists and patients; a facilitatoris always one of the group members who views thingsfrom the perspective as the participants.
Participant 1: “I visited palliative care unit in my daughter’s workplace. How would you feel if your parent wereadmitted to your workplace…palliative care unit…Ms A(facilitator), will you find it burdensome?”
Facilitator A: “…Let me think about that?... No, I
don’t think so…What does your daughter say about
that?”
Participant 1: “My daughter says, ‘You can come to our
hospital.’”Participant 3: “We are planning to go to Tokyo, and thisis the second visit to Tokyo in my life. So, I’m looking
forward to it. I am going to expand my activities. Now I
take very good care of myself to avoid becoming ill.”
Facilitator A: “In your story you seem to enjoy yourlife more than ever before….”
Participant 3: “Yes…, it seems like I am freed frommy fetters. I was a housewife and I kept to my house. I
used to feel timid when I went on a visit and stayed oversomewhere.”<Presence>

This subcategory is an intervention method in which thefacilitators share space with the participants, stay withthem, and understand, or try to understand, and share
their natural feelings. The facilitators focused on what
was going on among the participants here and now andstayed with their feelings at each moment.

<To protect the participants’ physical health>This subcategory is an intervention method in which facilitators show that they try to support participants, prevent a participant isolated from the others in discussions,consider the participants’ health status, etc.
The facilitators took care of the participants’ health,asked them in advance about any physical problems
such as pain, and provided cushions for everybody if any
participants of the group had pain. In addition, because
most participants were receiving chemotherapy, the facilitators provided them with water or hot tea for hydration.

Participant 15: “Clothes…, my husband ask me to buy
clothes a lot, but before I die, I won’t wear the clothes…
But, now I think I will buy some…. I’ve come to feellike this. I also bought clothes for the first time in several
years.” (everyone laughed.)
Facilitator A: “That’s a great change, isn’t it? (joyfully)”
Participant 15: “Yes! That’s really a great change.”<To protect the participants’ mental health><To grasp the context>

This subcategory is an intervention method in whichfacilitators provide participants with a safe, easy-to-talkplace by keeping the discussion confidential themselves
and asking the participants also to do so.

This subcategory is an intervention method in whichfacilitators judge what the topic of the participants’
discussion is at each moment and whether the topic is
consistent with the theme of the session or would leadto an improvement in the participants’ QOL and coping
ability.

Participant 30: “(After self-introduction) Every day there
are times when I feel tremendously blue, and every day I
shed tears. Please don’t be put off! I am naturally sentimental (while shedding tears).”
Facilitator B: “(While handing Participant 30 facial tis72*Under circumstances in which the number of times
PMR exercises performed by the participants had

The skills of facilitators in group intervention

decreased
Participant 26: “Some time ago I was told I should notcarry heavy things after shopping in supermarkets.”
Participant 27: “In my case, so many people deliverthings to me saying, ‘I did shopping around here, so I
thought I would buy for you.”
Participant 20: “I thought the diseased limb just hungdown from the body, but I used it a lot.”
Participant 27: “I exercise gymnastics in my bed.”
Facilitator A: “Oh, really?” (in response to the remark concerning PMR, the facilitator directed thediscussion to the initiation of PMR.)

Participant 1: “After my drugs were changed, I felt uneasy and I visited the doctor every week. Then the doctor told me, ‘How about participating in a clinical trial?’
The instruction brochure for the trial said, ‘For patientswith bone metastases from breast cancer’, and I knew
immediately that I had bone metastases.”Participant 2: “I feel both uneasy and positive. Sometimes I am depressed, and sometimes I feel positive andthink I have to work hard. I was told about recurrence…
and of course I was shocked. But my feeling of uneasiness and fear of recurrence were gone, and in this sense
I felt relieved.”
Facilitator A: “Both of you sometimes think you will
work hard and sometimes feel uneasy, but maybe you
will eventually work hard by finding your own way
to cope. I wonder whether other participants have
similar experiences… (while looking at Participant3)”
Participant 3: “I don’t particularly have such experiences… My initial symptoms were not so severe and I
was optimistic. Other participants experience times ofserious despair, and I am surprised.”<To return the topic to the theme>

This subcategory is an intervention method used when
the topic of the group discussion deviates from thetheme. The facilitators fully explained the theme to theparticipants in advance to avoid deviation of the topic
of discussion from the selected theme. When the topic
of discussion deviated from the theme, the facilitators
found parts of the topic overlapping with the theme andpointed out the relationship between those parts of the
topic and the theme to return the topic to the theme, or
directly pointed out the deviation from the theme.

[Problem in interventions]

Facilitators always have to keep this category in mind
when performing group interventions. This category
does not contribute to improvement of the participants’coping ability or QOL, and both experienced and new
facilitators face the risk of experiencing this problem.
This category included the subcategory of <Inability toperform skillful interventions>.

*Theme: “from surgery to disclosure of the diagnosisof recurrence”
Participant 10: “On some occasions from the thirdyear…and because I had a job (laughing)…(omission) I
worked a little too hard, and I developed recurrence in alittle over 4 years. Maybe I was overconfident.” (the participants agreed.)
Participant 10: “I had recurrence in the bone…(omission).”Facilitator A: “A moment ago you told me that you
were overconfident… (the facilitator repeated what
the participant said about the condition before recurrence).”
Participant 10: “That is right. I had surgery in my rightbreast, and the right breast had been swollen for a longtime.”<Inability to perform skillful interventions>This subcategory refers to facilitators becoming enthralled by the participants’ words and forgetting theirrole as therapists and becoming too confused to decide
how to intervene. This was more commonly extracted in
the new facilitators than in the experienced facilitator.
Participant 35: “But, if I have recurrence, I will think
differently…in such a case. So, the first thing I want tothink about now is how to prevent recurrence. If I can
prevent recurrence by thinking positively, I think I haveto think positively.”
Facilitator B: (the facilitator’s mind went blank, withthe body frozen and the face down, looking at thefeet.)<To weave different techniques together>

This subcategory is an intervention method that was
extracted only in the experienced facilitator. The facilitator performed the intervention for multiple participants
according to the situation quick-wittedly, combining
humor with his/her intervention techniques and dealing
with problems that could not be solved at that moment
sometime later in the sessions.
*To execute the intervention while considering theparticipants’ feelings

DISCUSSION[Intervention techniques], one of the 2 categories under
the core category of “skills of facilitators”, included thefollowing 10 subcategories: <to proceed with the intervention>, <to speak for participants>, <to encourage73

M. Chujo and H. Okamura

participants to reflect on themselves>, <to protect theparticipants’ physical health>, <to protect the participants’ mental health>, <to face participants with a facilitator’s reality>, <presence>, <to grasp the context>, <toreturn the topic to the theme>, and <to weave different
techniques together>; the other category, namely, [problem in interventions], included one subcategory, that is,<inability to perform skillful interventions>.
At first, the subcategory of <inability to performskillful interventions> under the category of [problem ininterventions] was commonly observed in the new facilitators. The new facilitators, like the experienced facilitator, also had long experience of interacting with cancer
patients in clinical settings and experienced simulation
training for facilitators as group intervention facilitatorsand patients. However, they supported actual patientsin group interventions for the first time, and it seemed
difficult for them to cope with each situation. Classen8
reported that interventions by new facilitators cannot
contribute to improvement of the participants’ QOL.
The effect of the intervention was not investigated in thisstudy, however, considering from the results, it is difficult to rule out the possibility that the participants’ QOL
was not improved by the new facilitators’ intervention.
In addition, even experienced facilitators sometimes
cannot maintain concentration during the 50-min sessions and sometimes cannot instantly grasp the meaning of what the participants are saying. It was revealed
that <inability to perform skillful interventions> is aproblem that can be faced by both new and experienced
facilitators, suggesting that it is necessary for both newand experienced facilitators to continue to earnestly faceparticipants, as described by Spiegel et al.9 and Kiba andMaruguchi.10
Regarding [intervention techniques], we were afraidthat there might be facilitator techniques that new facilitators may not be able to use with ease. However, both
new and experienced facilitators could use all techniqueswith equal ease, except for the applied techniques of <toweave different techniques together>. This seemed tobe because the facilitators were explained the purposes,
methods and effects of group interventions in advancein the facilitator training, therefore, even new facilitators
understood the concept of group interventions. On theother hand, both new and experienced facilitators faced
the risk of experiencing [problem in interventions]. In
addition, the facilitators were also provided simulation
training on the techniques necessary for all 6 sessionsof the group intervention by role playing. Therefore, it
seemed that all the facilitators could use most facilitator techniques effectively. Previous studies10, 11 havealso pointed out the necessity of role-play training, andthe results of this study also revealed the effectivenessof facilitator training prior to group interventions. In
addition, in this study, the facilitators held discussions
about the condition of each participant and trends ineach group before and after each group intervention session, which enabled even the new facilitators to understand the direction of their own group and to use mosttechniques efficiently. However, <to weave different
techniques together> is an applied skill using which facilitators can execute effective interventions for multiple
participants at the same time, and it appeared that thistechnique could be used only by the experienced facilitator. The art of intervention revealed in this study wasdifferent from that reported by Yalom.12 This difference
could be attributed to cultural differences between Japanand western countries.
Previous reports on group interventions have focused on the effects of the interventions and the facilitators’ anxiety and understanding of their roles, but not
fully addressed the role of role playing.11 For reducing
the facilitators’ anxiety,6 it is necessary to provide themwith a deeper understanding of the interactions between
facilitators and participants in group interventions andto provide simulation training on the skills necessary forfacilitators. For this purpose, it is considered necessary
to develop programs in which the trainees can spend
much time in role playing as simulation training.
The authors declare no conflict of interest.
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