THE VIRTUAL CUP OF COFFEE:
NORTHERN CANCER PATIENTS’ EXPERIENCE WITH SOCIAL WORK AND
TELEHEALTH

by

Natasha Ahlstrom
B.S.W., University of Victoria, 1998

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREEE OF
MASTER OF SOCIAL WORK

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
March 2015

© Natasha Ahlstrom, 2015

UMI Number: 1526494

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Abstract
Social work in oncology addresses the distress experienced by people dealing with cancer.
Residents of northern British Columbia have access to this service through Telehealth. Seven
people, who were dealing with cancer, were individually interviewed using semi-structured,
open ended questions about their experiences using social work through telehealth. The data
was divided into textural and structural themes and analyzed through the writer’s own
experience with providing oncology social work and telehealth to over 500 people in
Northern BC. The results are that some people with cancer 1) feel alone, 2) receive the
service at inopportune times and 3) feel discomfort with it. However, once rapport was
achieved through incorporating northern realities into the experience, participants felt the
service was helpful and comfortable; and all would recommend it. Despite this, without the
proper structural and system support, careful consideration should be made before this mode
o f oncology social work delivery is more widely used.

Table of Contents
Abstract

ii

Table of Contents

iv

Glossary of Terms

V

Acknowledgements

vii

Chapter One

Introduction
Rationale
Research Questions & Objective of the Study
Case Examples

1
2
6
6

Chapter Two

Literature Review
Cancer and Distress
Barriers to Access Services
Northern Cancer Control Strategy
Oncology Social Work
Northern Social Work Practice
Generalist Social Work Practice
Telehealth

12
12
13
15
17
21
29
32

Chapter Three

Research Methodology
Research Design
Phenomenological Qualitative Approach
Sampling
Data Collection
Data Analysis

38
38
38
42
44
45

Chapter Four

Results
Summary of Textural Description
Lack of Awareness
Feelings of Discomfort
Inopportune Timing
Comfortable
Easy and Personable
Visually Appealing Experience
Technologically Simple
Helpful
Information
Ease Isolation
Use It
Summary of Structural Description
Northern Realities
North Versus South

47
47
48
48
50
51
51
53
54
54
55
56
57
58
58
58

iv

Limited Resources
Travel
Privacy Challenges
Friendly Relationships

60
61
62
63

Discussion
Introduction
Eclectic Approach
Complexity of Northern Realities
Rapport Building
Isolation
Structural Analysis
Supervision and Structural Setting
Structural Social Work Analysis

65
65
67

Limitations and Recommendations
Gaps in Data
Costs
Psychosocial Information
Being an “Ally” Not a Southerner
Methodology Limitations
Recommendations

83
83
83
84

Conclusion

93

68
71
74
77
78
80

86
88
89

95

Map of British Columbia Health Authorities

107

Map of Northern Health Community Oncology Networks

108

Interview Questions

109

V

Glossary of Terms
Oncology: The study and practice of treating cancerous tumors. It is often subdivided into
medical, surgical and radiation oncology. (Werner - Lin & Biank, 2006)
Psychosocial Oncology: It is a specialty in cancer care concerned with understanding and
treating the social, psychological, emotional, spiritual, quality-of-life and functional aspects
o f cancer, from prevention through bereavement. It is a whole-person approach to cancer
care that addresses a range of very human needs that can improve quality of life for people
affected by cancer. (Canadian Association of Psychosocial Oncology, 2009)
Telehealth: Telehealth refers to the use o f information and communication technology to
deliver health care services, enterprise and information over long distances. (For the purpose
of this paper, Telehealth is used - however, the words more relevant lie somewhat between
tele-oncology and video-based technology.) (Institute of Health Economics, 2007)
Tele-oncology: Tele-oncology uses communication technology for provision of oncology
services to eliminate or reduce geographic barriers for cancer patients and their families.
(Institute of Health Economics, 2007)
Video-based Technology: Technology used for interactive audiovisual communications
between patient and providers, patient and family (support network), or provider and
provider, that allows timely access to specialist knowledge or enhancement of the plan of
care. Videoconference is often used as a synonym for video-based technology. (Institute of
Health Economics, 2007)

vi

Acknowledgements
I would like to thank my husband and my daughter as they are my motivation in life. I
acknowledge the hard work and dedication of the Community Oncology Network staff in
Northern Health because they provide the on-going care and compassion to people living
with cancer in northern British Columbia. I thank the participants for their time and their
willingness to allow me into their lives. I sincerely value and appreciate my thesis advisor
for her patience and compassion during the completion of this process.

Chapter One: Introduction
Cancer. Think of this word. Ponder it for a moment. It is a powerful word. It
conjures up images, memories, and for many strong emotions. Think of the statement:
“You have cancer”. Now think of living in a northern rural community of British Columbia,
hundreds of kilometers from a cancer treatment center. It is undeniable that cancer is a
distressing experience for people and for their families. This distress can have an
exponentially greater impact for people living in northern communities than in southern
communities due to the realities of northern living. People in the north often need to travel
long distances for treatment, or have little access to specialized cancer care services.
In 2005, the Northern Health Authority (NHA) formed partnerships with the Province
of British Columbia and the British Columbia Cancer Agency (BCCA) to address the
complex issues associated with people experiencing cancer in northern British Columbia
(BC). From this partnership, the Northern Cancer Control Strategy (NCCS) was formed.
One o f the objectives was to provide better cancer care service to residents of NHA; one way
this was achieved was through access to specialized cancer care service through the use of
Telehealth. The NCCS developed Telehealth systems as a way of communicating between
cancer specialists (usually located in a centralized area) and cancer patients (located in one o f
the different community cancer clinics of the NHA). The specialist and patient interact with
one another by looking and speaking into a television. They hear and see each other with
clarity and in real time. Social work is one of the specialties of cancer care; it is often referred
to as psychosocial oncology or oncology social work.

1

Rationale
Approximately five years ago, I began providing cancer patients in northern BC
oncology social work service through Telehealth. The service was based out of Prince
George and the cliental could be from any community in the NHA. Since that time, many
rich and rewarding experiences come to my mind. One in particular resonates with me and
has motivated me to look further into what are cancer patients’ experiences using social work
and Telehealth. I met with a woman (approximately 55 years old) for the first time through
Telehealth. She had a diagnosis of pancreatic cancer, and the prognosis was that she was
unlikely to survive more than three months. When I met her, she was not alone; her best
friend since she was 15 years old sat in on the Telehealth session. The best friend had arrived
from out of town and was in the patient’s community for only a few days. I began the
session by explaining the services. Then, I listened to lifelong friends talk and explore their
feelings of knowing it may be their last visit together. After an hour long session, the patient
requested to meet with me again during her next cancer treatment. I met with her two weeks
later. At the following appointment, the patient’s physical condition had visibly deteriorated;
her skin was gray yet yellow and she had a gaunt look within her eyes and cheeks. At the
end o f the session, the patient said “Thank-you. I did not know what it was going to be like
to meet with you, but after meeting with you, I feel like I have reconnected with a long lost
friend over a cup o f coffee. You have asked me questions that I didn’t know that I needed to
ask myself, like only an old friend would.” This memory has profoundly impacted me, and
has led me to my present research, “The virtual cup of coffee: Northern cancer patients’
experience with social work and Telehealth.”

2

Over the last five years, I have been witness to and involved with practicing oncology
social work through Telehealth to cancer patients of the NHA. I have interacted with cancer
patients and their support units over 500 times through Telehealth. Within my experience
many turbulent, dynamic, troublesome and endearing stories come to my mind. There are
many people and families whose stories stay with me and guide my present practice and my
drive to complete this research study.
As a person bom and raised in Northern British Columbia, and as a professional
practicing social work in a northern health care setting for almost fifteen years, the role of
providing psychosocial oncology to the entire NHA via Telehealth has intrigued me and
perplexed me. I practice from a northern social work perspective. This perspective is one in
which the social worker recognizes the unique needs, dynamics, and ebbs and flows of every
northern community (Schmidt, 2009). There are nine community oncology clinics within
NHA where social work Telehealth service is available, yet the cancer patients attending
these clinics can come from numerous communities around them, and each of these
communities have their own identity. Unfortunately, this identity is not always easy to
recognize or acknowledge by others. A northern social worker is aware that northern
communities can come from a culture of opposition (Zapf, 2002). Northern communities
often have had to conform and abide to southern political climates and ideologies that often
do little to recognize the northern way of being or functioning. Perhaps, the structure of the
system in which one social worker providing service to all cancer patients in northern BC
based in a more southern northern BC location preserves the status quo of northern
communities abiding by southern solutions. Only through a northern social work practice

3

viewpoint, can this southern ideological political cultural system be weakened when working
with cancer patients.
My northern social work perspective guides my oncology social work practice.
Psychosocial oncology, oncology social work, cancer care social work all are essentially the
same. They are concerned with providing specialized service through information, support,
counseling, referrals, and advocacy. They strive to lower distress for cancer patients and their
support systems in order to improve cancer treatment outcomes and overall quality of life for
both the patient and their support systems (Andersen, 1992; Iacovino & Reesor, 1997; and
Zabora, Brintzenhofeszoc, Curbow, Kooker, & Piantadosi, 2001). This type of social work is
eclectic in its approaches, focusing on the individual needs of the patients and their families
rather than on a specific mode of delivery (Holland et al., 2010). Over the last five years, I
have gained knowledge and skills, learning about the specialized issues that cancer patients
face both in terms o f psychological and practice matters. Blending northern social work
practice with oncology continues to be perplexing and intriguing, even more so given that
this service and intervention is provided through Telehealth.
Telehealth, as supported by the Northern Cancer Control Strategy, is the preferred
means of delivery o f specialized psychosocial care to cancer patients within the NHA. Five
years ago as a social worker with little knowledge of Telehealth, I was eager to learn,
practice, and create my skill base to provide this service effectively. I began to recognize
little nuances in my practice that were different than that of my direct face-to-face delivery.
For example with Telehealth, I found myself taking more time to build rapport with cancer
patients. This was perhaps due to my wish to make myself more comfortable for the client. I
also recognized that at times, I would become somewhat of a clown by providing big over­
4

exaggerated facial expressions. I would acknowledge the strangeness, yet point out the
modernity of Telehealth approach. “Now you can tell your grandson that you are up with
technology; you even tried something better than Skype.” Silences were more pronounced,
and I had to learn how to be more comfortable with the natural more noticeable pauses of
conversations. As a northern social worker, I readily acknowledged issues that were unique
to the northern communities. For example, one community had a large turnover of medical
staff. When a person is dealing with a potentially life threatening illness, change over in staff
can often lead to lack o f confidence in the stability of treatment and therefore outcomes of
treatment. Understanding this, as well as understanding the contextual importance for a
person living in northern BC communities, I acknowledged the fear of turnover to the patient
yet highlighted the special qualities of the north and that community specifically.
As I discovered the nuances in my practice, I searched for literature and information
to increase my skills and understandings of these Telehealth practice nuances.
Unfortunately, although perhaps one could say an array o f literature exists on tele-services
(psychology, psychiatry, oncology, psychosocial), little information was discovered on the
use of Telehealth with social work service for northern recipients dealing with medical
situations. Although the literature outlined that cancer patients found Telehealth service
beneficial and satisfactory, no specific information was discovered about why cancer patients
found it satisfactory, and what if anything the professional did to make it beneficial or not.

5

Research Question and Objective of the Study
This research study looked at how the social work specialty o f oncology attempts to
meet the psychosocial needs o f cancer patients in northern BC through Telehealth. I am a
social worker providing this specialized service and I believe it is necessary to understand
how cancer patients perceive this service. The study focused on cancer patients’ experience
receiving social work service by Telehealth. Through the use of phenomenological research,
the following two questions are addressed: 1) What was the northern BC cancer patients’
experience using Telehealth service from a social worker? 2) How should social workers
provide service to cancer patients via Telehealth in northern BC? The information obtained
in this research study may be useful as a guide to inform social workers providing Telehealth
service for cancer patients in northern BC on best practices.
Case Examples
It is important for my professional practice that learning and research is meaningful; it
needs to provide me with a way in which I can relate the learning to the people that I serve.
Given this, I often find myself identifying information into phenomenon. For the purposes of
this study, I find that outlining three fictitious case examples is useful. Although these case
examples are not completely real, they draw upon my work experience of over 500 cases.
Many elements are true and they resemble many situations.
Case Example #1 - Jo
I recall one particular time in which I was asked to help with an Aboriginal cancer
patient, “Jo” and his wife through Telehealth service. I was told that he was in hospital; he
was in a wheelchair due to limited strength and mobility; and that he was wanting to talk
6

about cancer to someone who would listen. The referral came from the chemotherapy nurse,
who warned me “he is very angry as he thinks that he is not being told the truth”. It is
important to note that within his home community, there are no social workers trained in
psychosocial oncology. He was also an inpatient in a hospital that was over 800 km away
from my location.
I met with Jo, his wife and the Aboriginal Patient Liaison Worker the following day.
It was not particularly difficult for Jo to meet with me, as his wife took him in his wheel chair
from his hospital bed down the hallway to the Telehealth room. Upon beginning, I explained
what I do, how the Telehealth system worked, and where I came from. As we began our
conversation, I asked a few o f the principle questions of social work intervention: who was
he and his wife, what was their understanding of why he was in the hospital, and who was his
support. The answers to these questions did not appear to come easy for him nor his wife.
He started to raise his voice and making comments like “why am I here”, “you can’t help at
all”, “this is a waste of time”. I realized that I needed to be careful with my wording and
truly listen to both him and his wife. They mentioned that there were struggles with his
diagnosis and prognosis (terminal pancreatic cancer); that their children were acting up; and
that all he wanted to do was go home. Unfortunately, his home was not accessible by a wheel
chair. I listened to their concerns and started to provide information about children’s
responses to a sick parent. At this point, Jo attempted to leave the room in his wheelchair
while getting caught up in the other furniture. He broke down crying, and his wife and the
aboriginal worker soothed him by patting his back. He agreed to stay if we did not talk about
his children.

7

The conversation continued. I provided information about processes for diagnosis and
treatment within NHA, and affirmed to him the time frame in which he received treatment
was the normal time frame throughout northern BC. I confirmed with him that I would
advocate for him with income assistance about helping to fund a new damage deposit for a
new rental location as he desperately wanted to return to a home so he would not die in the
hospital. Finally, I listened to his fears and frustrations about his disease and his worries
about leaving his family behind. At the end of our meeting, Jo told a couple of jokes and we
laughed together. His wife and he thanked me for my time. One week later, Jo died in the
hospital.
Case Example #2 - Alice
Alice was a 56 year old woman, who had metastatic lung cancer. I was asked to meet
with her through Telehealth, by a chemotherapy nurse in a northern BC community. The
reason for the referral was that Alice was feeling depressed and wanted to talk about this.
Her family doctor prescribed Alice with anti-depressants the day before the referral, but she
reported to the nurse that she doesn’t feel satisfied with this solution and that she believes she
is going crazy.
I met with Alice and her husband through Telehealth. Alice promptly started to cry
and her husband looked at her with hopelessness in his eyes. I asked her for the reason why
she was crying. Her answer was because “I won’t get to drive my grandkids to hockey
practice anymore.” Her husband spoke up and said that he would be able to. This dialogue
continued, and I discovered that Alice’s raison d’etre is to spend time with her grandchildren

8

and care for them which involved driving them to activities. She was told that the anti­
depressant would impair her ability to drive.
Upon further exploration and assessment of the situation, I learned that six weeks
earlier, her family doctor told her and her husband to “get her affairs in order” as it is likely
she will not live for more than six more months. This prompted them to take a month long
honeymoon, which they never had, to Hawaii. She returned one week previous to our
meeting and stated that since returning, she felt like a large jail cell door had just been
slammed shut. I learned that she cried mostly when she thought of her grandchildren and
how hard her death will be on them, that she struggled with being a future burden on her
husband, and that finally it was difficult for her to watch others do the work she normally
would have done (cook or clean). Further information was obtained and it was clear that
Alice was grieving.
I spoke with Alice about the grief and loss issues that terminal cancer patients
encounter and that many cancer patients identify with this more so than with a diagnosis of
depression. I informed her about the normalcy of grief and to recognize the various ways it
is displayed in actions, emotions and thoughts. I encouraged her to go back to her family
physician and explore the idea that maybe she might be grieving and not be clinically
depressed. I provided a reference for her and her family to read about the dying process.
After gaining her permission, I called her family doctor and spoke with him about my
observations. He agreed that perhaps antidepressants may not be the best form of
intervention.

9

One month later, I met with both of them again. She spoke of the continued grief she
felt but did not feel crazy and realized she was normal. She decided not to take the
antidepressants and was able to continue to drive her grandchildren to their activities.

Case Example #3 - A1
One afternoon, I was asked to see a man through video link despite the man being
bedridden in the hospital. After arrangements with the hospital staff, they managed to wheel
his bed into a Telehealth room in order to help support him and his family. The reason for the
referral was that he had been receiving months of chemotherapy without success and was just
recently placed on the palliative care program. He and his family were very angry and the
family was in shock that there would be no more chemotherapy. It was suspected that he did
not have many days to live.
I dialed into the Telehealth room. There were two young adults sitting next to him,
and his wife was standing. Everyone was quiet and subdued. The patient asked in a raspy
voice “do I call my daughter home.” (His daughter had just left the home community to
travel to Europe on a three month vacation. Incidentally, my experience is that it is very
common that young adult children will go and travel when a parent is so close to death). At
the same moment one young adult said “I don’t know what to do.” As delicately as possible,
I spoke to the family about the consequences of either calling the daughter or not. To address
the young adult’s question, I suggested that each of the children say the things that they want
to say to their father, the reasons the love him, the memories they have, and the lessons that
he has taught them. I encouraged them to maybe even do this in the form of a letter.

10

The mood was somber and I did not spend much more time. I hoped that I helped
through speaking of the unthinkable and unmentionable, and allowing them to consider the
ways to deal with it. I said some difficult things for the family to hear in this brief
intervention: i.e. not waiting until a better time as my experience is that there usually never
is a better time.
I did not see the family again and a few days later the patient died.
Many months later, a new acquaintance found out that I was a northern health social
worker who worked with cancer patients. Her partner was Al’s son. She did not appear to
realize that I had worked with her partner’s family. She passed along a story of how one day
when her father-in-law was first brought into the hospital a social worker came and saw the
family. Her partner called her after. He was very mad, and stated “How dare that social
worker tell our family what to do - and tell me how to talk to my father!” She said she was
glad that the social worker talked to them though because the family did call the daughter
back. More importantly she said her partner would have never written a letter to his father,
but he did write a letter to his dad, he did read it to him, and they did say “I love you” for the
first time, shortly before A1 died.

11

Chapter Two: Literature Review
Cancer & Distress
Canada is a country in which individuals and families are affected daily by cancer.
For example, it was estimated that more than 187, 600 people were diagnosed with cancer in
Canada in 2013; which was an increase of almost 10% since 2010. Additionally,
approximately 75,000 people died in 2013 year from cancer (Canadian Cancer Society,
2013). The rising pattern of statistics for the Northern Health Authority in British Columbia
is no different. In 2005 it was estimated that about 8,000 people in northern BC were living
with some form of cancer but by the year 2015, the estimate of people living with cancer will
have grown to about 11,000 people (Jago, 2006).
One can naturally assume that with a cancer diagnosis, comes distress. Distress is
defined as
a multifactor unpleasant emotional experience of a psychological (cognitive,
behavioral, emotional), social, and/or spiritual nature that may interfere with the
ability to cope effectively with cancer, its physical symptoms and its treatment.
Distress extends along a continuum, ranging from common normal feelings of
vulnerability, sadness, and fears to problems that can become disabling, such as
depression, anxiety, panic, social isolation and existential and spiritual crisis
(National Comprehensive Cancer Network, 2008, p.5).
The distress associated with cancer and its treatment can cause significant psychological
responses within individuals. One only has to imagine the ways in which cancer can ravage
the body in order to understand this. Studies demonstrate that between 25%-50% of
individuals will have psychological problems and at least 25% will meet the criteria for
12

major depressive disorder or adjustment disorder (Hopwood & Stephens, 2000; Massie &
Holland, 1990; Sellick & Crooks, 1999). Distress can have major consequences for an
individual’s quality of life (QOL), cancer treatment outcomes, and overall well-being (Meyer
& Mark, 1995). When patients experience distress, QOL decreases; when distress is
alleviated, QOL improves (Hopko & Lejuez, 2007). “Patients whose psychological needs are
met are better able to cope with their diagnoses and treatment, have better physical
functioning, greater quality of life and less utilization o f medical services” (Kash, Rajinish,&
Kunkel; 2005, p.213). White et al. (2011) completed an unmet psychological and practical
needs study o f cancer patients in rural and remote areas of Western Australia. The results
mirror previous research of cancer patients within different geographic and population bases.
This is that regardless of where one lives, cancer patients have significant distress as well as
practical and psychological needs (White et al., 2011).
Barrier to Access Social Work Services
The medical setting can impede cancer patients’ ability to address the distress
associated with cancer and its treatment. The primary role of the medical setting is to address
the physical treatment of cancer; however, the secondary role is the treatment of the
psychosocial distress associated with cancer (Siegel, 1990). Medical professionals need to
attend to the secondary role o f treatment. A cancer patient and their loved ones come to
implicitly trust, interact, and rely upon professionals to treat the cancer. Medical
professionals’ willingness and openness in addressing the psychosocial needs can strongly
influence the cancer patient and their loved ones in acknowledging and recognizing the
secondary role o f treatment: attending to the psychosocial distress of the disease (Pray,
1991). Several studies have shown that oncologists are not especially skilled at discussing
13

psychosocial problems, or recognizing anxiety and depression. (Ford et al, 1994; Hardman et
al, 1989; Newell at al., 1998; Passik et al, 1998). Pray (1991) in a survey of physicians
treating hospitalized patients found that although 90% of the practitioners were able to
identify emotionally laden medical conditions, only 41% of them made referrals to social
workers. Disappointing, but not surprising, was that social work referrals were made for
problems typically associated with discharge planning and not psychosocial distress
associated with cancer. Unfortunately, at times medical professionals do not always openly
discuss distress or recognize the symptoms of distress in cancer patients. “Most published
data suggest that the doctor’s ability to accurately detect psychosocial morbidity in cancer
patients is often little better than due to chance” (Fallowfield et al., 2001, p.1011). Eakin and
Strycker (2001) assessed the barriers to using psychosocial support and information for
cancer patients. They found that patients did not access service because of the lack of
referrals from service providers. Literature findings point to the importance of provider
referrals to and endorsements of cancer support services.
In northern and rural settings, medical professionals attuned to the psychosocial
distress o f their patients, do not have the tools, resources or time to address the complex
needs of their patients. Fedorchuck et al. (2003) explain:
There is a need to address quality of life issues more frequently and increase patient
education to empower decision making. Unfortunately however, in a community
setting such programs and social services are usually provided only to people who
either demand them or are unmistakably in distress (p.36).

14

In fact, when one looks at the case examples, all participants were referred to the social
worker later on in the journey when it was obvious that the clients were in distress.
Shepherd et al. (2006) explain that in rural and remote communities, if psychological
problems are detected for cancer patients, it is generally the nurse or general practitioner
whom responds to these problems in an informal way. A referral is not made to a
psychosocial professional and the way in which the distress is addressed is often not adhering
to best practice standards. Unfortunately, this has been my experience in some cases. I have
situations where, by chance, either a family member in distress has searched out my service,
or an alternative agency or concerned citizen has asked for my involvement to assist a patient
or family. Usually when this happens, the patient and family have not had service such as
psychosocial oncology counseling nor information and resources for support; and their
distress level is elevated.
Cancer patients in northern BC may have needs that could be addressed by an
oncology social worker; however, this may depend upon whether the medical setting
provides this referral. Furthermore, this may be challenging for those medical professionals
unclear of or uncomfortable with the use of Telehealth.
Northern Cancer Control Strategy
In 2005, the Northern Health Authority (NHA), the British Columbia Cancer Agency
(BCCA) and the Ministry of Health for British Columbia developed a comprehensive cancer
control strategy: the Northern Cancer Control Strategy (NCCS). The strategy was developed
through extensive consultation with community members and health care providers in order

15

to provide better cancer care services to patients, families and communities throughout the
cancer care continuum. Jago (2006) clarifies that
What has become clear to us during this process is that British Columbia has a
cancer care system that, while o f the highest quality, is difficult for Northerners to
access without encountering significant obstacles of distance, time and personal
expense (p.ii).
According to Jago (2006), the NCCS “responds to the epidemiology of cancer in the North
and the demographic and service delivery challenges that are unique to northern BC” (p.3).
The NCCS focuses on three major pillars that are relevant to cancer treatment along
the continuum of cancer care (from prevention through to diagnosis through to treatment to
rehabilitation). These pillars are 1) Incidence of cancer, 2) Survival from cancer, and 3)
Quality o f life and access to services for Northerners (Northern Cancer Control Strategy,
2006). The third pillar attempts to address the issues of great geographic distances of NHA
(appendix A), limited population numbers and a small human resource base. In order to
address these issues, the NCCS developed comprehensive Telehealth services including the
infrastructure, equipment, and human resources to manage it. It is used within each of the
nine community oncology clinics in northern British Columbia (BC). (Appendix B).
Through the use of Telehealth, patients and families in northern BC have access to
specialized resources that would not normally be available to them. Oncology social work is
one o f the specialized resources and access to it may provide an avenue to lower the distress
associated with having cancer.
Many o f these community oncology clinics had no previous or very little access to a
medical or health care social worker. The idea of a regional urban-based social worker may
not be viewed as something useful or needed despite the social worker being accessible to the
16

community. As Collier (2006) notes “social workers should not expect to be automatically
awarded a friendly reception simply because they align themselves with the community”
(p.50). Community members or health care professionals from the community oncology
clinics may be reluctant to engage with a person not living within their community. Further,
the NHA regional based oncology social worker, myself, is based in a possibly perceived
urban southern center, Prince George; and the service may be viewed as an imposition upon
the northern communities. “When service decisions are made at senior political and
managerial levels in the urban centre, the resulting services are unresponsive to the users, and
ultimately unrewarding places for community social workers to work” (Isaac & Stokes, 2009,
p. 179). The NCCS attempts to provide access to specialized cancer care, from a centralized
base, to northern communities through Telehealth; but, it may not be perceived by northern
communities as a welcome or beneficial service.
Oncology Social Work
Social workers provide a wide range o f service to diverse populations in a variety of
formats. Social workers provide counselling, education, advocacy, and referral services to
agencies for individuals, families, groups, and organizations. The people social workers
provide this service for could include children, the elderly, immigrants, individuals with
addiction challenges, people who are adjusting to difficult life events and those who live with
a life threatening illness such as cancer. Oncology social workers work with cancer patients
and a wide range o f issues; often this form of practice is called psychosocial oncology.

Psychosocial oncology

17

is a specialty in cancer care concerned with understanding and treating the social,
psychological, emotional, spiritual, quality - o f - life and functional aspects of
cancer, from prevention through bereavement. It is a whole - person approach to
cancer care that addresses a range of very human needs that can improve quality of
life for people affected by cancer (Canadian Association of Psychosocial Oncology,
2009).
Fedoruchuck et al. (2003) inform us that cancer patients require support from psychosocial
oncology professionals as cancer patients may not have it amongst their intimate connections,
they have difficulty coping and finally they need advocacy with financial assistance.
Wemer-Lin and Biank (2006) assert that
Social workers with specialized knowledge in psycho-oncology are familiar with the
challenges specific to varied types of cancer diagnosis and are skillful at delivering
interventions that address the adaptive and psychosocial needs of clients during the
different stages of illness development (p. 508).
Miller (2007) argues that social workers who specialize in cancer care are better able to deal
with the complex needs and issues of people experiencing cancer than those who do not have
a cancer care background. “Cancer patients who require psychosocial oncology intervention
need to be provided this service from a social worker trained, educated and aware of the
impact of cancer specifically on the lives of the individual” (Kash, et al., 1999). Oncology
social work has become a specialized field of practice with informed and effective methods
o f working with cancer patients and their families (Steams, Lauria, Hermann, & Fogelberg,
1993). It provides psychosocial assistance to cancer patients and their support unit
throughout the cancer journey: at time of diagnosis, during treatment, after treatment is
18

completed, upon a re-occurrence, and when treatment changes from cure to palliative
(Spiegel, 1990; Werner-Lin & Biank, 2006 & White, 2011) According to Zebrack, Walsh,
Burg, Maramaldi, & Lim (2008)

Oncology social workers participate on multidisciplinary teams in cancer centers and
community hospitals and sometimes in oncology group practices. Some obligate all
their time to oncology services, others rotate through oncology as well as other
medical services (p. 356).

Regardless of the workplace setting, he or she aims to address the distress that is associated
with cancer and its negative implications associated in any phase or stage (which is often
associated with prognosis) o f the cancer journey. Fedorchuck et al. (2003) looked at
prognosis of individuals and their perceived coping, support, and need for financial
assistance. The study concluded that amongst all prognosis of individuals from dismal to
excellent, people required further support. Fedorchuck et al. (2003) explained that
More than 10% o f patients with a good or excellent diagnosis had difficulty coping
emphasizing the fact that patients with a good prognosis are not exempt from the
ravaging emotional and social consequences of their disease (p. 31).
Thus the social work specialty of oncology may be needed for not only patients with a poor
prognosis but also for people in all phases of the cancer journey.
Psychosocial oncology intervention occurs with cancer patients at various stages in
their illness journey. Common psychosocial features are reflected in each stage of the
journey. For example, a new diagnosis has patients and families faced with making critical
treatment decisions amongst a time when they are learning and emerged within a new system
19

with a new language (Wemer-Lin & Biank, 2006). At this time the social worker can help
patients understand the medical system, translate medical language, and explore with patients
and families values, beliefs and concerns about cancer treatment (Wemer-Lin & Biank,
2006). The way in which the help is provided to a patient in a newly diagnosis stage is
different than after a patient has been on treatment for several month. After several months
of treatment, the patient may need help with finding solutions to the debilitating effects the
treatment has on energy levels and physical strength (Wemer-Lin & Biank, 2006).
Zebrack et al., (2008) explain that the literature on the practice of oncology social
work outline direct tasks
as being (1) screening and psychosocial assessment; (2) facilitating adjustment to
illness; (3) provision o f counseling and individual, family, and group psychotherapy;
(4|) discharge planning; (5) referral; (6) advocacy (357).
Zebrack et al., (2008) further argue that the tasks must be provided where needs are most
acute and in a manner that is appropriate and fluctuant to diverse populations. Common tasks
are to facilitate communication amongst family members and friends with the cancer patient
and to provide psychosocial education (Kash et al, 1999; Siegel, 1990, & Zebrack et al.,
2008). Often people with cancer are bombarded with remarks of being positive or o f a
problem free environment. Despite the good intentions of family members and friends, this
will inadvertently isolate and disempower patients (Siegel, 1990). It has been my working
experience that people who experience the tyranny of positive thinking express feeling
isolated with negative emotions and unable to express them freely. I provide a venue for the
cancer patient to express all emotions and to inform all involved that the cancer need not
impact all aspects of their lives.

20

There are several types o f studies assessing intervention effectiveness to adjustment
and adaptation to cancer and to the ways psychosocial oncology is conducted. Iacovino and
Ressor (1997) classify these studies into descriptive, quasi-experimental, retrospective and
controlled clinical trials. Regardless of their classification, “no particular intervention
appears to be significantly more effective than others in helping patients deal with cancer”
(Iacovino & Ressor, 1997, p. 68). Meyer and Mark (1995) conducted a meta-analysis study
to determine the efficacy of psychosocial intervention for cancer patients. After examining
over sixty-two studies, Meyer and Mark (1995) concluded that it would be inefficient use of
resources to conduct more studies addressing the question: “Is there an effect of behavioral,
educational, social support, and non-behavioral counseling and therapy interventions on the
emotional adjustment, functional adjustment and treatment related and disease related
symptoms of cancer patients?” This is because all types of psychosocial interventions have a
consistent beneficial effect on emotional and functional adjustment and on negative quality
of life symptoms related to cancer and its treatment (Meyer & Mark, 1995, p. 106).
Oncology social workers provide interventions that deal with practical matters to
existential issues with a variety of approaches. Regardless, the literature points to the
benefits this service has with assisting, helping or supporting cancer patients and it can be
transferable to any setting or community including northern, rural or remote settings.
Northern Social Work Practice
Defining the concept of the north can include geography, history, economy, politics,
and culture (Schmidt, 2008). Schmidt (2009) highlights common elements of north as being
remoteness and isolation, relatively severe climate, sparse populations, limited services,
transportation challenges, and economies dependent on single industries and resources.
21

Schmidt and Klein (2004) define a northern community as being above the 54th parallel, as
being located more than a two hour drive from an urban center, as having predominantly a
single-resource economy or a one industry community, and as having promotional material
which identifies it as being north. For the purposes of this research, communities are within
the Northern Health Authority (NHA) catchment area and are part of the NCCS community
oncology clinics. Both NHA and the NCCS promote a northern service (see Appendices A
and B). NHA community oncology clinics generally are one resource communities, identify
themselves as being northerners, are located above the 54th parallel, and most are located
greater than a two hour drive from the regional hospital center in Prince George which is
considered more of an urban center.
Northern Canadian social work practice is difficult to define given the multitude of
definitions for north and the variety of northern communities. A definition is not entirely
necessary if one has an awareness of common influences on northern practice. These
influences are physical space, climate, economy, social context, and the specific unique
northern environment of each community (Schmidt, 2009). For example, a social worker in
the winter may need to plan a support group during a weekend as opposed to a weekday
evening because it becomes dark at 4:00 pm and if it is snowing the road conditions could
become more difficult to navigate in the darkness. As well, participants of the support group
may be driving longer distances to access the group, which is a reflection of physical space.
Northern social work “appreciates the unique nature of each environmental context and never
assumes that what is true in one context applies to another” (McKee & Delaney, 2009, p. 57).
Not all the communities experience the same influences of north as other communities. In
order to understand this, social workers in the north need to practice contextually.

22

Geography is a contextual component with northern social work practice. It is a
vitally important practice ideology (Schmidt, 2009). Zapf (2002) outlines geography to
include: demographic, political, economic, cultural, and phenomenological Demographic
geography recognizes that a population figure o f less than 10,000 (< 10,000) is considered
rural, and a population figure of greater than 10,000 (> 10,000) is considered urban. O f
particular importance for social work is that natural helping systems usually are seen with
communities o f <10,000 people. In communities with > 10,000 people, members within the
community tend to rely more upon formal helping systems (Zapf, 2002). As an oncology
social worker practicing in the north, I should be cognizant of this, as some of the community
oncology clinics are based within communities of < 10,000 people whereas other
communities have higher populations. For example, a family consisting o f a young father,
mother and three children from the community of Vanderhoof (< 10,000) may rely upon the
informal network o f family and friends to look after the children if the mother or father needs
to leave the community for six weeks of cancer treatment that is not offered locally. With a
similar situation, but the family comes from Fort St. John (>10,000), the family may look
towards the formal systems to support them such as non-profit societies or provincial
services. Demographics within northern BC may then influence how and if social work
service is utilized.
Political geography is how a province enacts its political platform. This often poses
problems for service delivery to the north (Zapf, 2002). Human service delivery for the north
is often formed by politics from urban, southern settings and the control for the delivery of
service is held there as well (Zapf, 2002). Isaac and Stokes (2009) explain

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When service decisions are made at senior political and managerial levels in the urban
centre, the resulting services are unresponsive to the users, inaccessible, inflexible,
unresponsive to diversity, alienating to users, and ultimately unrewarding places for
community social workers to work (p. 179).
One can see how political geography is influential when working as a social worker in
northern settings. Economic geography is a relational aspect between north and south;
whereas, the south makes economic decisions for the north and the north provides the
geographic resources (Zapf, 2002). Many northern communities are one-industry
communities and it is usually a resource based commodity. The industry is linked with
economic geography. The global economy and its determination of the price of the
commodity greatly influences whether the community members have jobs, have value within
their homes, and have opportunities (Schmidt, 2009). Cultural geography is an ideological
framework and world-view of living and being. Phenomenological geography is the way in
which people from a specific geographic place prescribe meaning from their environmental
experiences (Zapf, 2002).Cultural and phenomenological geography are equally as important
as demographic, political, and economic geography to northern social work practice.
However, these geographic concepts may be more difficult for social workers practicing
within the north to understand especially if they are not from the north. Halverson, Brownlee
and Delaney (2009) state
Many social workers who come to the north from the south are dominated by
southern metaphors which view the north as hinterland and so internalize a social
work practice or political ideology that is southem-metaphor dominated (p 138).

24

Integrating geographic concepts of demographics, politics, economics, culture and
phenomenology are essential contextual elements for a social worker practicing in northern
BC.
Northern Canadian social work practice is different from other forms of social work
practice (Schmidt, 2009). The differences may not be exceptional on their own, but,
collectively, they provide a unique way to approach social work. Schmidt (2009) identifies
five areas of practice which make it unique: northern travel; community rhythm; role conflict
and community microscope; sense of community; and, opportunities of northern practice.
For example, as a northern oncology social worker, I may be cognizant that a cancer patient
is required to travel through a treacherous isolated dark mountain pass to come to the
regional based hospital to meet with the oncologist. Within a large urban setting, a cancer
patient may have to travel the same distance but on a double lane well lit and maintained,
well-populated highway; where it is undeniably less stressful to arrive to the medical
appointment. Another example demonstrates both role conflict and community microscope. I
may simultaneously providing support with sisters-in-laws who have cancer and who are
being treated in the same community. If one sister-in-law wants information about the other,
the social worker must retain confidentiality and cannot disclose this nor even reflect an
involvement with the other sister in law. However, due to the small community (i.e.
community microscope), they may both be suspicious of social work involvement. The code
of ethics for social workers in British Columbia state:
A social worker shall protect the confidentiality of all professionally acquired
information by disclosing such information only when required or allowed
by law to do so or when clients have consented to disclosure. (BC College of Social

25

Workers).
Confidentiality is a complex issue for northern social work practitioners. Revisiting the
earlier example of the sisters-in-law, further difficulties could arise due to role conflict. One
sister-in-law will not see the social worker and thus receive no social worker intervention, if
that social worker is perceived to be involved with the other. This is an excellent example of
an issue that would likely not be encountered by a social worker in urban practice. As
evidenced by Collier (2006):
The categories o f social problems defined by the specialist practice o f urban social
work do not reflect the conditions in rural regions. Many rural problems just do not
break down that way and are interconnected with other problems and issues (p.37).
The combined areas o f practice which northern social workers encounter are unique and
different than that of southern, urban-based social workers.
Zapf (2002) highlights a major theme that emerges when acknowledging social work
in a northern context: the “culture of opposition.” The culture o f opposition refers to how
northern social work practitioners are often pressured to live, work, and practice under the
dominant and influential ideologies related to southern/urban settings, settings which often
fails to recognize the reality o f northern social work practitioners. Isaac and Stokes (2009)
comment
When centralized, bureaucratic models of service delivery are imposed on small
northern communities, they neglect the community culture. This results in less than
optimum service for northern communities, and feelings of powerlessness, frustration
and alienation for northern practitioners (p. 179).

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With regard to my social work practice within the NHA, the culture of opposition may exist
as the residents and health care professionals of the community oncology clinics may view
the position o f that as one from the south; and I will then practice in an urban way. Doll,
Stephen and Poon (2004) asked healthcare professionals across Canada about the benefits
and drawbacks to using Telehealth service: “A few key informants spoke of the importance
of not using technology as an excuse to decrease care in rural communities” (Doll et al.,
2004, p. 18). Furthermore, this southern urban-based position may be viewed as taking away
from the northern community and thus members may be opposed to its service. Although
northern communities now have access to psychosocial care, it may be seen as way to limit
services within the north which may be a real barrier to providing service. The culture of
opposition is yet another unique feature of practicing social work in the North, and could
have a potential negative impact upon a regionalized social work position. Therefore it is
essential that a northern, rural, remote social worker, such as myself, remain cognizant of this
dichotomy when working with cancer patients in the north.
A social worker providing northern services has access to large amounts of
information. Harker (2002) interviewed northern rural health care workers to determine
strengths and weakness o f discharge planning in rural and remote communities. Harker
(2002) commented that the physicians and nurses interviewed believe that the informal
relationships that exist both between the medical staff and with the patients allow for a
thorough and accurate assessment o f the problem. Northern social work practice can provide
a context in which the informal relationships build on richer assessments. For example, a
social worker in a rural, small northern town could live proximally (such as on the same
street) with a client and that they also interact with on a professional level. This is unique and

27

different from social work in an urban setting. “It is much easier to make a decision with
certainty and confidence in a small community as opposed to a large urban center where it is
not easy to gather information to make an accurate assessment” (Schmidt, 2009, p. 13). This
capacity to assess the problem is a key and noteworthy aspect o f social work intervention
because intervention is based upon problem identification and assessment (Johnson &Yanca,
2007; Miley, O’Melia & DuBois, 1995). Vast amounts of information may also pose a
challenge. When social workers are required to make assessments they need to distinguish
between information gathered in a professional capacity versus personal interactions. For
example, a social worker living in a northern community may have children who are friends
with a client’s children. The social worker’s children may tell the social worker information
about the client as they play at the client’s house. Due to the information being learned in a
non-professional capacity, the challenge is: how does the social worker bring this information
into the client/social worker interaction? Northern social workers “need to come to terms
with challenges that arise from high visibility, accessibility, access to too much information,
and negotiating the pitfalls of multiple relationships” (Schmidt, 2009, p.l5).The excess of
client information can be further multiplied when nurses who are involved with making the
referral, may also be experiencing a duality of roles with the cancer patient. Despite this
potential challenge, within my regionalized position, I may experience less conflict with
regards to access to too much information as the position does not place me living within the
community, only working with the community members through Telehealth service.
Pugh (2006, as cited in Schmidt) points out that social workers in small communities
are highly visible; and that it is difficult to not only keep a low profile and be anonymous but
also it is easy to be scrutinized and judged by character and behavior. Schmidt and Klien
(2004) state that “in a large center the relative anonymity of workers may not expose them to
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the same level of personal blame that occurs in small isolated northern communities” (p.241).
This is an essential point when examining the role of specialized oncology social work from
a regionalized setting. As the social worker engages and works with families and healthcare
professionals within the individual remote community, there may be an exponential amount
o f pressure upon him or her because he or she is the only available resource. Generally, the
social work role in a small northern community is one that is unique and likely highly visible
within a smaller community setting unlike that o f larger urban setting. “People who receive
social work service in rural areas generally have an opportunity to appraise and assess their
social worker in ways that urban recipients of social work service cannot easily do”
(Schmidt, 2009, p. 12). Individuals living in smaller communities generally are aware of other
people’s problems and situations; this includes when a person is undergoing cancer
treatment. The way in which the social worker provides service and support to one individual
will be evaluated on multiple levels in the community (Isaac & Stokes, 2009). I work under
a microscope meaning that I may be evaluated at all levels when practicing social work to
people in the north impacted by cancer.
Generalist Social Work Practice
Generalist social work is a practice approach that takes on many definitions and
forms. Miley, O’Melia, and DuBois (1995) define it as “the interplay of personal and
collective issues and works with a variety of human systems - societies, communities,
neighborhoods, complex organizations, formal groups, informal groups, families and
individuals - to create changes maximizing social functioning” (p. 10). Marlow (2005)
defines generalist social work practice as “a form of social work practice taught in B.S.W.
programs that involves practice with different-size client systems and uses a number of
29

different interventions and practice roles” (p. 335). Johnston and Yanca (2007) define
generalist social work practice as
Practice in which the client and worker together assess the need in all of its
complexity and develop a plan for responding to that need. A strategy is chosen from
a repertoire of responses appropriate for work with individuals, families, groups,
agencies, and communities. The unit of attention is chosen by considering the system
needing to be changed. The plan is carried out and evaluated (p. 458).
There are a variety of approaches or models used with generalist social work practice.
Timberlake, Zajicek-Farber and Sabatino (2008) argue for a strength based problem solving
approach as a method o f generalist social work practice. Tolson, Reid and Garvin (2003)
believe that “mastering one practice approach, task centered approach, that has been applied
across systems and with a large array of clients and problems, produces competent generalist
social work practitioners” (p.2). Johnston and Yanca (2007) outline twenty - two models in
generalist practice and this includes psychosocial, behavior therapy, and cognitive therapy.
There are commonalities of generalist social work despite the varying focuses of
approaches. These commonalities are explained as a perspective which includes an eclectic
base of practice, a multi-method approach, a focus on social justice and finally a process
which includes an assessment, intervention and evaluation (Derezotes, 2000; Payne, 1991).
“While generalist practice suggests a wholeness in which the social worker may shift from
method to method, from strategy to tactic, and from discipline to discipline, the generalist can
gain from taking the problems and solutions to pieces and examining what can happen in a

30

variety of instances” (Collier, 2006, p. 42). An eclectic approach of generalist social work
practice is an important element of northern psychosocial oncology.
Collier (2006) argues that generalist social work practice is the best option when
working in the north. Barter (2002) discusses “generalist practice being the desired form of
practice in northern remote and rural communities” (p. 149). Johnston and Yanca (2007)
define generalist social work practice as
Practice in which the client and worker together assess the need in all of its
complexity and develop a plan for responding to that need. A strategy is chosen from
a repertoire o f responses appropriate for work with individuals, families, groups,
agencies, and communities. The unit of attention is chosen by considering the system
needing to be changed. The plan is carried out and evaluated, (p. 458).
Schmidt and Klien (2004) identified strengths of social workers who live and practice within
a northern community. The prominent theme was that the social workers believed practicing
as a generalist was a strength of practice and it fit within the geographic northern setting.
From this viewpoint then, my specialty position may need to find the balance between the
implementation of generalist social work practice, the viewpoint of northern social work
practice and the specialty knowledge of oncology social work.
“The stereotypical but often accurate image of the northern social worker is someone
who is more o f a tradesperson, relying mainly on interpersonal ability, ingenuity, and
flexibility” (Tranter, Brownlee & Delaney, 2002, p. 139). This image implies that northern
social workers are not necessarily particularly skilled or knowledgeable. Yet, the ability to be
flexible and ingenious are skills and it should not be viewed that social workers in the north

31

are less than their counterparts in the south. “Northern communities don’t have the range and
depth of specialized resources available in large urban centers, but this is not necessarily a
bad thing as the social worker learns to develop the necessary supports and address gaps in
service with local resources” (Schmidt, 2009, p. 15). Schmidt and Klien (2004) argue that
“northern generalists are also specialists. Generalist northern social work practice requires
specialized skills and knowledge” (p.241).
Telehealth
Telecommunication is a type of service delivery method for social workers that can
include telephone, computer, and video based communication. Telephone is the oldest and
most widely known use of telecommunications technology for social workers (McCarty &
Clancy, 2002). Telecommunication technology’s early history included the use of the
telephone and later progressed to video-based service. Video-based technology is used for
interactive audio-visual communications between patient and providers, patient and family
(support network) or provider and provider that allows timely access to specialist knowledge
or enhancement of the plan o f care. Videoconference is often used as a synonym for videobased technology (Institute of Health Economics, 2007). Tele-oncology uses communication
technology for provision o f oncology (cancer care) services to eliminate or reduce
geographic barriers for cancer patients and their families (IHE, 2007). Telehealth refers to the
use of information and communication technology to deliver health care services, enterprise
and information over long distances (IHE, 2007). For the purpose of my research, Telehealth
is used; however, the words more relevant lie somewhat between tele-oncology and video
based technology.

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Telehealth delivery for cancer patients needing psychosocial intervention is a delivery
approach o f social work practice that has existed since at least the 1980’s (Broadstock &
Borland, 1998). The basic premise of Telehealth service is that patients who wish to speak to
a professional can do so - regardless of whether this service is provided face to face.
Telehealth is a way in which the use of electronic communication technology can reduce or
eliminate barriers to receiving psychosocial service (Vis, Turner, Brownlee & Shalay, 2009).
The Institute of Health Economics (2007) completed a comprehensive literature
review to determine the use and benefits of tele-oncology. The literature review examined
the type of tele-oncology services developed to assist patients and families throughout the
cancer care continuum and the benefits of tele-oncology as a service delivery method. It
examined 147 studies o f tele-oncology: 45 of the studies focused on web based
communication (internet), 40 studies looked at telephone services, 39 of the studies used
interactive video based communication, and 23 of the studies did not specify a modality. It is
important to note that from 147 studies of tele-oncology, no study used the term social work
and only nine studies used either the term psychosocial care or psychotherapy. However, of
the 147 studies, 32 studies used psychosocial related terms such as coping, support groups,
counselling or emotional well-being. O f these 32 studies, only one used video based
interactive communication (i.e. Telehealth). Further, only four studies referred specifically to
rural or remote population bases; no study referred to north. The lack of studies with regards
to Telehealth, social work and north may be reflective o f the complexity of providing
northern social work services via Telehealth.
Two issues with regards to psychosocial care and technology use are 1) that users
must be comfortable with the technology and 2) that the therapeutic relationship may be
33

hindered (Doll, Stephen, & Poon, 2004). Doll et al. (2004) revealed that “several key
informants indicated that discomfort with innovative communicative technologies on the part
o f health care providers as well as patients present a barrier to the use of technology” (p. 26).
Additionally, technology may hinder the inherent interpersonal relationship between cancer
patient and social worker due to greater difficulty in accessing non-verbal cues, establishing
emotional connections, and dehumanizing patients due to lack of physical contact (Doll, et
al.,2004). Cancer patients, however, may not view these issues as concerns.
Cancer patients indicate a willingness to engage with psychosocial support service via
technology (Bauer, 2001; Eng et al., 1998; Gotay & Bottomley, 1998;). Kaplan (1997)
compared therapeutic relationships in face to face or through face to face via video­
conference and reported that an effective and therapeutic relationship is formed in both cases.
McCarty and Clancy (2002) examined how relationship and effectiveness between social
work counseling interactions is negatively impacted by Telehealth communication; none
were discovered. Vis et al. (2009) state “technology is a more efficient and effective way
than person-to-person therapy to service mental health needs of people living in rural areas”
(p.95). Bauer (2001) discovered that therapeutic relationships are established through the use
of technology and cancer patients report to having benefited from them. Studies demonstrate
that cancer patients who receive psychosocial intervention through telephone or Telehealth
have better emotional symptom management, have more confidence in the treatment in
which they are receiving and have overall perception of improved quality of life. (Alter, et
al., 1996; Cluver, et al., 2005; Kroenke, et al., 2010; Ohinmaa, et al., 2001). Not only are
cancer patients willing to engage with psychosocial support (social work) via technology but
also cancer patients benefit from the interaction.

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A pilot study completed by Shepherd et al. (2006) focuses on delivering psychosocial
care to rural cancer patients in Australia through video conferencing. The study’s hypothesis
is that psychological care through brief cognitive intervention to rural cancer patients via
Telehealth will not only improve anxiety, depression, and quality of life but will also be an
acceptable form of delivery. As well, the study aims “to determine whether video
conferencing for cancer patients is an acceptable, satisfying and practical mode of delivery”
(Shepherd et al., 2006, p.545). Cancer patients in rural and remote Australia who were
identified as being distressed saw a clinical psychologist between one and six sessions via
Telehealth. The results of this study are that patients QOL improved, anxiety and depression
decreased, and that the majority of the patients were highly satisfied with the service.
Shepherd et al. (2006) highlight that in communities with geographic isolation, conditions
similar to northern BC, cancer patients often do not have access to specialized care dealing
with psychological issues as well many cancer patient would not fill comfortable talking to a
local professional in their community due to lack o f anonymity. Both of these are likely to
be conditions and opinions similar to cancer patients in northern BC. While Shepherd, et al.
(2006) demonstrate that cancer patients in rural communities find benefit from clinical
psychology intervention via Telehealth, the study did not examine whether the cancer
patients would have received benefit through social work interaction via Telehealth.
In a similar study, Bums et al. (2012) attempt to determine what cancer patients and
professionals experience when providing Telehealth. Patients had access to specialized
oncology multidisciplinary care through Telehealth, and the patient and clinician rated the
Telehealth sessions as highly satisfactory. Bums et al. (2012) point out financial benefits.
“There appeared to be a financial savings for the patient, because by receiving specialist

35

intervention at a local facility, they avoided the travel expense above those subsidized by the
health service” (p. 446). This study points to the benefit of Telehealth yet does not
specifically examine social work intervention.
One potential drawback to using Telehealth service is that “most social workers tend
to be attracted to social work precisely because o f its personal rather than technological
orientation. This is probably nowhere more true than in northern agencies which are very
people orientated and community minded.” (Tranter, Brownlee, & Delaney, 2002, p. 140). I
agree with this statement because I needed to learn to be comfortable with the new
technology in place. Through much trial and error, I grew to be comfortable in providing
service in a different mode of delivery. However, throughout the years, the lack of face to
face contact and engaging in and maintaining rapport with communities via technology was
challenging at times. In the five years of providing this service to northern communities, I
also had to consistently remind myself that I should not replace service which is already
available within northern communities, despite fluctuations in each community's service
level. “The challenge to northern agencies is to maintain the community focus that already
exists within the north while using information technology to enhance the lives of those that
live within it” (Tranter, Brownlee, & Delaney, 2002, p. 146).
I am a Northern Health oncology social worker who uses Telehealth to engage with
people and their families who experience cancer. I have worked in this role for over five
years and with hundreds of people. The literature tends to support the value of Telehealth and
the value of psychosocial oncology; yet, there is a gap in research with regards to Telehealth
with social work. My professional experience has led me to believe that despite the gap in
research, oncology Telehealth social work is beneficial to northern communities and has
36

value for patients: “The greatest value of technology was that it could gain patients access to
programs that might not otherwise be available (e.g., for patients living in remote
communities)” (Doll, et al., 2004, p. 18). Through my work experience and from the
literature, I have come to believe that it is valid to consider using Telehealth to help decrease
distress and increase access o f specialized care to people with cancer living in northern BC.

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Chapter Three: Research Methodology

Research Design
The research design focused on gathering rich data about how Telehealth is provided
to cancer patients who require or wish to have psychosocial service (essentially social work)
within northern BC. It was hoped that the data would help bring meaning to my practical
experience of providing this service to hundreds of people. It is through the use of
phenomenological qualitative research that the following two questions are explored: 1)
What was northern BC cancer patients ’ experience using Telehealth service from a social
worker? 2) What do social workers need to know in order to provide social work service to
cancer patients via Telehealth? The information obtained in this research study may be used
to guide my, or others, future social work service to cancer patients in northern BC via
Telehealth and to inform us on providing this service through evidence based practice. The
following will describe the qualitative phenomenology approach, specific to this research.
Then an explanation of the type of sampling, data collection and finally data analysis will be
outlined.
Phenomenological Qualitative Approach
The virtual cup o f coffee: Northern cancer patients ’ experience with social work and
Telehealth is best suited for qualitative research study using phenomenology. This study
examines several individuals experience with a common phenomenon. They all have cancer;
they all used social worker services within the period of January 2010 to December 2011;
they all used this service through Telehealth; and they all live in northern BC. Furthermore, I
provided this service to all the participants. Thus the participants’ and my experience are

38

representative of the phenomenon. Our experiences will perhaps provide insight into
recipients receiving oncology social work and also guidance for future practitioners. A
qualitative approach was used because “rich descriptions of phenomenon can be produced”
(Marlow, 2005, p. 32). I focused the research primarily from the viewpoint that the
participants’ experience is based upon the assumption that they have a reality that is
constructed based upon the societal context, an element o f phenomenological qualitative
research (Lopez & Willis, 2004), and that this reality is living within a northern rural setting.
According to Creswell (2007)
The best problem suited for phenomenological research is one in which it
is important to understand several individuals’ common experiences of a
phenomenon. It would be important to understand these experiences in
order to develop practices or policies, or to develop a deeper
understanding about the features of the phenomenon (p. 60).
A qualitative approach is best suited for research when there is not a great deal of
knowledge about the topic being researched (Marlow, 2005). It is important to
understand cancer patients’ experience of social work service through Telehealth
in or to help direct future social work intervention using this method; further
understanding of this through integrating a practitioners experience, my own,
enriches the data and knowledge gained. Although my own experience is rich
and meaningful, little data is available about social work intervention for cancer
patients using Telehealth for Northern residents in BC. Thus the
phenomenological approach fits for this study.

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Another critical aspect about qualitative research, and more specifically the
phenomenological approach to qualitative research, is that the researcher explicitly
acknowledges the researcher’s biases and values (Lopez & Willis, 2004; Marlow, 2005). I
wanted to be cognizant that as the practitioner who worked with the participants, I had my
own experience in providing the service. This experience led to certain interpretations on
how I anticipated participants within their societal reality would respond to the questions. I
did not want the phenomenon of my experience to unduly influence respondents’ answers
and my interpretations o f those answers. Throughout the study, I openly acknowledged my
biases and brought in social work values - mostly through the lens of northern social work
practice. My literature review highlights generalist social work practice, and northern
practice in connection with oncology. During the data collection with participants, I
acknowledged this bias and encouraged participants to comment on it. For example, with one
participant, I stated
This is the last question, and it’s a pretty general question. But it comes from my bias
and my bias is that I live in the north, and I work with people from the north, and I
think that it’s important to be able to provide services from a north kind of
perspective. And I want to be able to give whatever information the participants I
have to other people that might be interested in doing this kind of services in the
future. Now, because of that, I’m just wondering if you have any comments about
that, or anything that you believe might be important to pass along around doing
social work and Telehealth in the north.
Although this is one statement to a participant, with the others, similar statements were made.

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Within the phenomenological approach, open disclosure of bias is critical in order to
help to avoid undue influence upon the participants being researched (Creswell, 2007). This
open disclosure also helps to insure that the reported meaning and understanding o f the
participants’ experience is truly reflective of it and not an overly biased interpretation based
on the researchers pre-understanding.
While freely admitting one’s bias is important, a researcher must go further in order
to ensure that bias does not affect the study and that the study is considered meaningful in its
enquiry. A further step which I took to shelter my biases from the data was that I was
interviewed in a semi-structured interview process using the same open ended questions that
participants were going to be asked. I gave my assumptions as the answers to the questions.
My interview occurred three months prior to the actual interview of the participants. The
interview was recorded and transcribed by another. I believed this was critical because I did
not want the data analysis to only reflect my experience and my bias. I wanted the data to be
available to two types of interpretations of the phenomenon: 1) what the cancer participants’
experience was in their societal context and 2) what future social workers need to know about
how practice can be influenced while providing this service while living within this
phenomenon. Recording my interview was a critical step as it allowed me to look back upon
my specific answers to the questions during the data analysis, and then to examine whether or
not my questions posed in the interview process could be leading unduly towards my biases.
If discovered, I was prepared to go back and re-interview the participant acknowledging the
misleading interview question, and exploring the answer with the participant again.
Interestingly, in the data analysis process I discovered that I used very similar language in my
answers as many participants such as “comfortable”, “personable”, and “friendly”. Once

41

recognizing this, I looked at my questions to see if I used these words in the questions posed
to the participants. I did find that I used the word comfortable in one question to participants
Sara and Shawna. Fortunately, after close examination I realized that I used the word
comfortable in a question after Shawna had used this word in a previous answer. I concluded
that using the word comfortable did not come from my biases but was a reflection of
previous statements made from the participants. I felt that engaging in this step was
important as I did not want my biases to guide my interview processes or interpretations of
the data, as the emphasis o f this study was not on my presumptions but on participants’
experience. I wanted to discover new meaning and explanations about the phenomenon
under study.
Sampling
The participants were obtained through a blend of purposive and purposeful
sampling. “Purposive sampling allows the researcher to handpick the sample according to the
nature of the research problem and the phenomenon under study” (Marlow, 2005, p. 13 8).
The type of purposive sampling was criterion and availability. First, participants were
residents o f northern BC with cancer or had been treated for cancer and they had used social
work services through Telehealth within the time frame of January 2010 to December 2011which meets the definition of criterion sampling (Marlow, 2005). Secondly, the participants
were available and able to participate in the interview, meeting the definition of availability
sampling (Marlow, 2005). Recruitment o f the sample was obtained through a poster
describing the study within the cancer clinics in northern BC. There were seven participants
recruited. Unfortunately, I believe not all potentially eligible cancer patients were available
for interviews due to the nature of their cancer disease. A purposeful sampling method was
42

also used in recruiting participants. “In purposeful sampling, the most important guiding
principle is maximum variation; that is researchers should seek to include people who
represent the widest variety of perspective possible within the range specified by their
purposes” (Higginbottom, 2004, p. 17). At first, I believed that maximum variation would
require turning away potential participants who would request to be in the study. However,
this was not the case. All participants came from various northern BC communities. Their
cancer stages and diagnosis were different. Their reasons for social work intervention or
service vary. The number of sessions with a social worker fluctuated amongst participants.
Finally, participants had varying partner statuses; some participants were interviewed with
their partners, others without and some did not have a significant life partner. Perhaps due to
the way in which cancer can impact anyone in society or due to large geographical area in
which I have provided service or due to the personality or disease stage o f people who first
saw and requested to be in the study, I was able to find variation within the first seven people
who responded to the poster advertisement.
There is often debate about how many participants in a sample are needed for data
collection in qualitative research. Some argue that a particular number of participants is not
necessary per se; but the meaning or interpretations which result from the data obtained is
what matters (Sandelowski, 1995). Others argue that in qualitative research, data saturation is
what needs to occur in order to provide meaning to data (Mason, 2010). Data saturation is
when no new or emerging information is obtained or needed in order to make theories or
elicit new knowledge o f a phenomenon (Saumure & Given, 2008). Guest, Bunce and
Johnson (2006) argue that it is possible to achieve saturation of data with a sample number
o f six for a phenomenology qualitative research; Creswell (2007) recommends between 5-25.

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In this research study, the data collected was through a sample size of seven participants. For
the purposes o f anonymity the names of the participants were changed to the following:
Chris (cancer patient) and his partner Jenny; Sara (patient) and her partner Shawna; Pam;
Bob; and, Sandra. Although seven participants may appear to be a somewhat small sample
number, I found that the data obtained from the participants was rich and meaningful and that
common themes seemed to emerge from the responses.

Data Collection
In order to collect the data, I conducted interviews with the seven participants that
were semi- structured with a list of open ended questions. (Appendix C) This allowed me
“more freedom to pursue hunches and improvise with questions” (Marlow, 2005, p. 167). The
open ended questions were chosen in a way to help focus the research on gathering the
textural description and structural description, which meet criteria of qualitative research
(Creswell, 2007). Although in principle, I had the ability to pursue more questions in the
interviews, I did not stray much due to being a novice researcher. As well, given my practice
knowledge of all the participants, and a clear message from the NHA Ethics Committee, I
was very careful not to pursue questions that may lead to some coaching or information or to
identification of the participants. In the interviews, I also clearly outlined at the beginning of
the interviews that firstly in no way would the information that they shared impact their
health care treatment and that secondly if they felt uncomfortable with being interviewed by
myself or if they preferred someone else to conduct the interview, this could be arranged.
None o f the participants articulated that they wished to pursue this option; participants
appeared to freely discuss and answer the questions. The interviews fluctuated in length with
the shortest interview lasting 31 minutes and the longest interview was 1 hour and 12
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minutes. The majority of the interviews were approximately 45 minutes. The interviews were
tape recorded and transcribed for data collection.

Data Analysis
The data was analyzed through techniques outlined by Creswell (2007) when using a
phenomenological approach to research. The first step was to fully describe the researcher’s
own experience with the phenomenon under study. This was achieved through myself being
interviewed (as previously mentioned) three months before the interviews were conducted. In
my interview, I described what I thought the participants would state. I shared common
viewpoints with the participants yet some of the themes that emerged or did not from the
interviewees were not expected. (This will be expanded on within the discussion section).
The next step in data analysis was to develop a list o f significant statements from the

interviews with participants. Although this step appears simple in nature, for myself, I
struggled. The focus was to have a comprehensive non-repetitive list. Often this technique is
referred to as horizonalization o f the data. Unfortunately, many participants had similar
significant statements, which led me to grouping and categorizing the data into themes early
within the process. I was eager to form interpretations from the data, making the data
meaningful for myself. I believe this was in part due to my professional attachment to the
answers found within the data; I was working with this research population base and wanted
to improve upon my practice. I often jumped into the discussion portion of the analysis
without truly completing it. After many struggles of finding the analysis lacking, I re-grouped
and recognized that I needed to start over. I printed up all the interviews, and literally, I went
through the interviews word for word and statement by statement cutting out with scissors
anything that appeared to be significant. I had over 200 significant statements. From this
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significant statement list, I then had the potentially difficult task of categorizing statements
into themes. Luckily, an unfortunate accident occurred which provided a means of
transforming this task from being difficult to falling into place. Due to a year leave from the
analysis because of a car accident, I was able to look at the significant statement list with a
fresh perspective. I believe this fresh perspective allowed me to accomplish a thorough
analysis of the data, and not a premature closure of data interpretation. I then wrote a
comprehensive description o f what the participants experienced, normally referred to as
textural description. In addition to this, I made a diagram in order to visually grasp the
textural description making the “what” more easy to identify. Following this, another
comprehensive description was written detailing the structural context essentially the “why”
within the phenomenon. Again a diagram helped me to see it. After this, I reviewed my
initial interview of myself and incorporated my comments into both descriptions. The last
step was to incorporate both the textural description and the structural description into a
thorough interpretation providing the essence of the experience (Creswell, 2007). An
important element o f the essence is the blend of the participants’ phenomenon of social work
service through Telehealth and my experience of a practitioner providing it. This excerpt is
ultimately outlined later in the discussion section of this paper. My work experience and
literature review were used to layer the textural (what) and the structural (why) phenomenon
to stimulate understanding for future social work practitioners providing this service.

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Chapter Four: Results

Summary of Textural Description

The data results for the textural description are broken into three themes: being
unaware of the service; being comfortable with the process; and finding the service helpful.
A general lack of awareness resulted in two sub-themes: feelings of discomfort and
inopportune timing. The theme o f being comfortable with the process had three sub-themes:
easy and personable, visually appealing, and technologically simple. The last main textural
theme was finding the service helpful; and it produced three sub-themes: information, ease
isolation, and use it. Each o f these textural themes and sub themes describes the what of the
experience essentially what happened in the service.

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Lack of Awareness
When asked if the participants knew of the service before using it, the answers were
universally similar: no they did not; or, they had heard of it, but did not know what it actually
was. Pam’s response to the question of if she was aware of the service was: “No I wasn’t. I
was, when I went up to the oncology here in town here, the nurses there, they informed me
of, they sort of explained it to me before the teleconference started”.
Sara responded to the question of her prior knowledge of this service as “actually not a clue.”
Sandra explained
I really didn’t know what it would be like. Would they be helping us? Would they
tell us what to do, or did they just say you know whatever, were they there to help us?
Like I honestly didn’t know what it was all about.
Bob stated
I really wasn’t aware o f what or what it would be or I didn’t really have a clue of
what was going to happen or it was pretty it was pretty all new to me actually.
Due to the general lack o f awareness of cancer care social work service through Telehealth,
participants felt discomfort and believed that the timing of the service was inopportune.
Feelings of Discomfort
The lack o f awareness of cancer care social work service via Telehealth led to being
nervous, apprehensive or uneasy about the service and interaction - generally feelings of
discomfort. These feelings were based upon not understanding the role of social work with
cancer patients or the way Telehealth works. Pam stated that “I didn’t know what to expect or
48

what to, you know, to do or whatever”. Sara stated “it was really, really good for me, and I
was I was nervous going into it”. Chris’ partner, Jenny, explained
due to some horrible, horrible incidences with social work at Children’s Hospital and
more recently with our daughter having had back surgeries down in the spinal cord
unit in Vancouver and her dealings with the social workers down there we had really
hoped that we would not have to deal with social workers in the predicament that
we’re in.
Sandra explained
It was very helpful once I got over being nervous wondering what was going to
happen. Speaking to you everything was fine, it’s just I didn’t know what to expect
or what to you know to do or whatever, but once like once I knew what was going on
then it was fine. I felt more at ease and could get help.
The feeling of discomfort was not an unexpected theme to emerge as I believed that
participants would imply this. I had been told by patients and health care providers that
people are apprehensive to use Telehealth and felt uncomfortable and that many people with
cancer in northern BC do not recognize the value of social work for their situation. So, the
combination of meeting with a social worker through Telehealth would perhaps provoke
feelings o f unease. In my response of the interview of what I believed participants would say,
I stated
I’ve had feedback that it wasn’t as painful as they thought it was going to be. I think
that they’ll say that perhaps the first few minutes they were a little bit uncomfortable,
but then they actually just forgot that it was there.
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Inopportune Timing
Because participants were unaware that this type of service was available to them or
how it would benefit them, they did not always engage with it at the right moment. Once they
were made aware and then agreed to use it, participants felt that they would have benefited if
they used the service earlier. Pam described that before using the social work service, she had
already been given information to help her. She also disclosed that she had previously known
about the social worker service but elected not to engage with it until her health care provider
recommended it. Pam stated that interaction with the social worker as:
asking you about financial stuff and all that, but then that was sort of, I had that all
arranged through like where I worked .. .it was like making sure that I had all the
information and if I knew about how to access you know certain things that I’d
already been informed through my boss here in town.
Jenny stated in reference to information and resources as “a lot of these things were not
pointed out to us until either right at the time, or after the fact.” Chris described his
experience in trying to find information, and that the social worker was not particularly
efficient in getting it to them at the opportune moments. He suggested that the social worker
improve in getting information to patients.
I know it seems like you know there might be a lot of homework initially to set up a
database but to me once it’s in there it could even be advertise a small website like go
here, and here is everything that you need to know about every possible avenue of
help. Financial, buses, accommodations, and everything, but right now you have your
little area and you know sort of what you know. In whatever form I guess that you or
the social workers would be able to and during a Telehealth conference as you’re

50

getting to know the people cuz now we’re getting personable, right? And then you
know as appropriately as it comes up and then be able to say well this is you know
here’s the information place to go. Here’s the website number or you know we can
email you uh you know the information you need, and I think and I would, from a
stress point of view I think that would that would help.
Comfortable
Participants described their experiences as being comfortable which is the second
main textural theme. Pam stated “I felt quite comfortable. I was just sort o f listening to them
and uh asked a few questions.” Sara’s partner, Shawna, explained that it “was pretty good
experience because it worked really well. Very comfortable.” Sandra spoke o f her
comfortable experience as
the person that I was speaking to was very calming you know and explained things to
me and asked different questions that was you know was great, but yes it was very
easy to speak to the person. Made me feel at ease.

Easy and Personable
The participants remarked that the experience was easy and personable; both are
subtheme attributes o f the comfortable experience. Sara described the experience as “it was
very easy”. Shawna explained further “it worked so well that when you actually came to see
us in the hospital in person it was like we knew you.” Pam recommended that the service
continue to be easy in the future:

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One of the things is make sure it’s set up for the patient so that it’s easy for
them .. .and all we have to do on this end is turn it on. I’m not very good at all this
technology business, but this way it worked.
Bob highlighted his easy and personable experience through his recommendations to future
social workers providing this service.
For my perspective to make it personable like don’t just go in and okay you know this
is it, you gotta keep a stiff upper lip, I was I was made to feel like real comfortable,
it’s you know make the, get the person comfortable because it’s a big shock, and
make it easier feeling you know they’re there for them and it almost make it easier for
them to open up if they’re comfortable more dialogue going. Sometimes it even takes
maybe it might take five or ten minutes because if you don’t, if you’re not getting the
feelings out what the person’s really going through. It may not be as effective.
Whereas if you take your time and sometimes you can be talking about the weather
that it just takes that to get, this person to feel comfortable with this person. So it’s
that kind of thing like take the time to get to know the person that’s on the other end.
Jenny describes the experience in the following way
Like you put us at ease right away. You personalized it by calling us by our first
names, which I truly appreciated, you acknowledged that we were wearing coats so
you asked about the weather. You just gently eased us into what we had thought was
going to be a very difficult, non-beneficial situation. You walked us through it all and
I know for myself I felt very comfortable and with the giggles that we shared and you
know, close to a few tears a few times you were able to walk us through the whole

52

process. We left our first meeting thinking “Boy, we have an awesome contact.” We
felt a huge relief. We honestly felt that we had been helped.
Visually Appealing Experience
A sub-theme of a comfortable experience was based on the ability to visually see the
social worker. Bob described
It was just like it was a human being there. It was something that like I’ve talked on
the phone before but you know with people in in different parts of the world for work
and you sometimes you just get the opinion, think that they’re just sort o f saying
yeah, yeah, yeah, and off the phone and to the next person or whatever. Whereas
here, seeing that face, seeing the body movement, the expressions, the smiles, they
just made you feel so much more comfortable.
Chris informed that
Initially like we were thinking oh jeez this, I don’t know if I’m gonna like this being
kind of a not much of a telephone person, and I wasn’t really sure what to expect, but
after having you know it only took a few minutes into the initial one that we had and
it seemed to work out well and you know I think putting a face to a name and that
really helps and I think barring having a one-on-one personal meeting I think it it’s
the next best thing, for me anyway.
Finally, both Sara and Shawna spoke o f the ability to see the social worker aided in their
general overall satisfaction and comfort with the experience. These comments are closely tied
together with the other sub-category of technologically simple.

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Technologically Simple
A sub-category o f comfortable related to the simple way the technological was
blended into the experience. Sara and Shawna commented on the technologically simple
experience. Sara states, “It was it was it was very odd at first because we’re not really up on
technology. I mean we know it exists but we had never ever seen it working in action and be
involved.” Shawna elaborated about how the Telehealth experience, the technology worked
with the service.
It be like little details like the bell curve that you drew. Yeah. And you can you can,
we could see it very easily and you know you hold up the paper and then it’s
magnified on the screen, so that worked very well.
Dave explained
the cancer care team you know ensured that the room was set up and you know
everything was done on time and you know the door was closed for privacy and stuff.
So I mean they also did their job I think their bit to encourage the process too.
Pam explained “all we have to do on this end is turn it on. I’m not very good at all this
technology business, but it was simple”
Helpful
Participants described social work services as being helpful. Chris’s partner Jenny
stated “ you have certainly been very very helpful with us you know any way that we can
give a little back that’s what we would like to do.” Sandra stated “it was very helpful once I
got over being nervous wondering what was going to happen.” Sub - themes existed in the

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way in which it was helpful. These are information relevant to cancer patient’s experience,
easing isolation of the cancer experience, and recommendations to use it.

Information
Jenny spoke o f the help they received in social work experience through the
information provided: “even if you don’t have the answer you seem to know who to point us
to and the follow up that has been provided up here to ensure that we have received those
answers has just been amazing.” Despite Jenny speaking positively about the information that
they received, Jenny also stated
Now I know that our experience has been nobody has ever told me one place to go for
information like even just as simple as you know if you’re having a hard time with
money you know that you can get a hold of BC Medical and have your premiums
waived. You know what I mean? Like looking at one-stop shopping for potentially
all the avenues of help.
Pam described her thoughts prior to and after contact with the cancer care social worker.
“And I just thought well it would be good to go through it and probably be very informative,
which it was you know”. Sandra stated
I think it was really helpful because you, we could you know, make, give ideas to
you and the other way that you know we wouldn’t maybe have otherwise anywhere
else. Maybe not so much for myself because I have, you know my husband is a solid
supporter, but and questions I have and you know so I think that a social worker, the
way you are doing it, was just fantastic.

55

Sara’s partner, Shawna highlighted that the social worker provided information for them
relevant to the cancer experience and eased their distress and isolation.
Actually you know I thought this is something you have to go through all by yourself
and then if you think of something you can always phone one up and ask. I don’t
know. But I never thought it would be such an important part of the process as it is.
There’s so much we didn’t know.
Ease Isolation
Shawna’s statement above also speaks of how the cancer experience with a social
worker eased their isolation. Bob spoke o f the cancer social worker experience as helping to
ease his isolation o f the cancer experience.
You know what, the biggest I think doing it that way was I know I’m not alone.
There’s help there.... It’s like you know aside from the doctors, aside from the nurses,
there’s somebody there that’s you know what, you can ask a tough question or you
can ask like how just, they’re there with you. It’s just that they’re there to help you.
They’re, it’s just so more personable I guess, more comfortable. And you know to
get, like I didn’t I didn’t even, you know except for the people at work, I didn’t tell
anybody except for my immediate coworkers, not even the guys on my crew and stuff
like that. And after I talked with the social worker it was, I just, you just, I felt so
much more at ease that, you know what, like I’m not the only one out there, there’s
you know, there’s help there and it made me more comfortable even to discuss it with
other people.

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Use It
All the participants stated that they would refer others to use the service. The
participants stated this in varying ways. Although Pam had spoken about the fact she had
been helped before her interaction with the oncology social worker, she stated that she would
tell future patients that “it pays to, it pays to talk to them (social worker) about it (cancer
experience).” Jenny said “Try it. Until you have experienced it don’t have any preconceived
notions about entering into it. Try it.” Her partner Chris expanded onto Jenny’s comment;
Yeah I agree. Like I said you know I was going into it thinking that I really don’t you
know not being a telephone person I didn’t know what to expect so I think to go into
it with an open mind.
Shawna stated that she would tell other people experiencing cancer that “It was important to
us to be able to connect with a social worker and I didn’t think it would be.” In response to
the question o f what Bob would tell other cancer patients about social work and Telehealth,
he stated “I’d just say it’s a fantastic thing and use it.” Sandra’s response to the same
question as Bob’s was simply “Go for it”. Interestingly, these answers were what I predicted
the participants would state, and in fact many of the participants used the same words as me.
“Go for it. D oit. Give it a try because you have nothing to lose. There’s probably not a
service in your home community.”

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Summary of Structural Description: Northern Realities

The structural description of the data can be simply summed up in one theme:
northern realities. The structural description is different than the textural description. As
mentioned earlier, the textural description was the “what” of the experience; however, the
structural description goes deeper and draws out the meanings of the what. It is the “why” of
the experience. The theme of northern reality was displayed through five why subthemes:
north versus south, limited resources, privacy challenges, travel, and, friendly relationships.
North versus South
Chris’s partner Jenny described the north versus south context in the following way:
You treated us as a friend. Somebody that needed your help and you went above and
beyond to provide that. The social workers that we dealt with in the Lower Mainland
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we and our daughter were treated as a number. We felt like a total inconvenience to
them. And other than providing us with minimal information, they would not or could
not think outside of the box and they just basically blurted out a bunch of facts that I
think they read from a book o f regulations and they would not discuss anything
beyond that point. Our daughter tried to make arrangements to get home from
Vancouver after being air - ambulanced down there. The social worker advised her
“you’ve been given your prescriptions. You need to fill them.” Our daughter was in
a wheelchair. She had to wheel herself out of the hospital, I’m not sure how far to the
drugstore to try and get these prescriptions filled. She was on a very short time frame
for having to catch her flight. She handed in her prescriptions. She waited for almost
an hour before the pharmacist got back to her and said “your surgeon used the
incorrect prescription pad. We cannot fill this.” She had to make her own way, in the
wheelchair, back to the hospital to get the prescriptions corrected and then wheel
herself back to the drugstore and then back to the hospital. She again contacted the
social worker. By this point she was in tears, in a great deal of pain. She asked for
some assistance to get to the airport and the social worker said “All I can do is give
you a voucher for the taxi” and basically turned her back on my daughter and walked
away.
Sandra stated “it seems like we do not have as much help in the north as they do in the south
area.” Bob attempted to explain the importance of northern interactions through his
interactions with support during his journey. He explained that the benefit of the northern
cancer social worker: “but to me it’s like the you know um you know work from the north
and it’s like you know you take care of our own.” Chris stated

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what appears is that in Northern Health, say you and everybody included treat people
like human beings up here like you know, the old hometown kind of people. Whereas
down there you are just a number that as quick as we can get you in and out, get lost
and I gotta move on to my next person or client or whatever the term that we’re going
to use today, right? So, if, I think in the Northern way if we look at keeping that style
of work going which I think is, would be effective and it’s good.
Chris also mentioned that once the research was complete
I would love a copy o f that and I would love to take it down to the Lower Mainland
and strongly suggest to them that they do a practicum or be mentored up in the North
before they start practicing down in the Lower Mainland.
Limited Resources
A subtheme of Northern realities is resources. As a structural description from the
participants, resources as it relates to the lived experience appeared in subtle yet very
important ways. In looking at the way lack of resources is highlighted, Pam highlighted the
importance o f the Telehealth availability:
Well it would probably inconvenience a lot of people because you have to drive well
an hour in, an hour and a half in, and then an hour and a half out depending how fast
you drive. And then you are probably spending a couple hours in there.
Shawna mentioned something very similar and then suggested that the service be expanded
as despite it being available, it was not easily accessible.
Well it’s a big deal because you know when we drove to the hospital when we got

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your service, that’s an hour and a half drive, but some people are further away than
that and so it’s I think it’s really important to expand it if it isn’t all over.
Participant Bob explained that “the service is there and you know and I firmly believe in the
you know you have to use it or you could lose these services, right?” Participant Bob’s doubt
in the sustainability of the service demonstrates the northern context of limited resources.
Participant Bob further explained “I was happy to do it because you know you know any
services that we can keep and get in the north is I think it’s fantastic”. Chris spoke o f the
lack of services in the following way:
you know there are services that people really need, really need, and there are
services that people that should and can, can and should be paying for by themselves,
and I don’t know if that falls into you know anybody’s line of work, but it it’s just one
of those, resources are limited, right?
Travel
Travel and the amount of time it involved for people with cancer in the North was a
subcategory o f northern realities. Chris spoke of it this way:
I guess my perspective I’d be looking at for social work services probably unique up
North is that we don’t you know we’re not just driving you know fifteen minutes or
an hour into you know the major centre we can get all our treatment. We spend a
really large amount of time I think in the North, either flying or driving, and I think
it’s important for information-wise, to know what services are available.
Shawna described the impact of traveling to receive service.

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It’s a big deal because you know when we drove to the hospital when we got your
service, that’s an hour and a half drive, but some people are further away than that
and so it’s I think it’s really important to expand it if it isn’t all over.. ..I still think the
best difference is that we that we have the service right there while we were in the
hospital in that little office. We didn’t have to go anywhere else.
Sara spoke of the travel in relation to the service as “we didn’t have to drive who knows
where to actually see someone.” Pam mentions:
If it wasn’t through the teleconference, then I probably would have had to go to Prince
George, right? And travel. I don’t know if they have anyone around “community”. I
doubt it. Not through oncology, or else they wouldn’t be having it on the
teleconference thing.
Privacy Challenges
Sandra spoke of the benefit of Telehealth in that it facilitated privacy which is
difficult to achieve within the North.
There’s lots of questions that you know, maybe wouldn’t ask somebody else you
know, like me and my husband we do, but I think there’s other people that are
struggling a lot and this I think would be helpful if they realize that once they’re over
their nervousness and it’s all confidential, there’s nothing they cannot ask, it’s great.
Sara spoke of privacy in that that “we were in that little office by ourselves, so it we had
privacy. And we didn’t have to drive who knows where to actually see someone.” Chris
agreed to his wife’s, Jenny’s, statement that after the first interaction they felt that they had
been helped. In reference to how he felt he was helped, he stated “the cancer care team you
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know ensured that the room was set up and you know everything was done on time and you
know the door was closed for privacy and stuff.” Jenny stated “I think it helps a person uh
‘cause you don’t know this person so you can kind of talk freely, more open than if you do if
you know somebody”. I too also believed that participants would allude to privacy issues.
I think some participants might actually say it was beneficial to them because they
felt more comfortable talking to me um about counselling matters than somebody in
their own community because the anonymity um is remaining there. So I think, that’s
what I think they’re going to say

Friendly Relationships
A further subcategory to the northern realities is relationships. Relationship for the
participants’ was defined slightly differently, but all highlighted the relational interaction
within their experience as friendly, informal professional contact. As Bob commented
You know you come in and it was like, I think we even made the comment on the
coffee cup, like it was just the whole thing. And, you know what, that may not mean
anything, but to me it’s just, it was like I wished I could have had a coffee with ya.
Two friends having, you know two friends you know going to the coffee shop and
talking and you know having that heart-to-heart talk. And to me that that’s that that
that just hit it off for me and right away I knew right “You know what, this is going to
be okay. This experience is going to be okay.” Because it connected on that level
and in some instances it might not have been the coffee cup, maybe it was, it could
have been the person does bouquets and there was a bouquet on the table or you
know, but it’s finding that that common bond with that person who’s going to be
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pretty pretty nervous to begin with and I think you were very good at it. It just it was
good.
Shawna described the following situation according to Sara “she said that it worked so well
that when you actually came to see us in the hospital in person it was like we knew you.”
Sara further added, “that personal touch is there whether you’re in your office or on the
screen”. Jenny gave recommendations to future social workers providing Telehealth
if you’re going into it I think on a friendly note, as personal a note as you could and I
guess still maintaining you know a fairly I guess a bit you know I don’t want to say
business-like but kind of on-track I suppose, if that makes sense
Further Jenny remarked “You treated us as a friend. Somebody that needed your help and
you went above and beyond to provide that”. Later she elaborates
It was almost like you were just sitting across the table having a cup of coffee with us.
You know having never experienced anything like that before, when we first went in I
thought “Okay so what is this? Basically just like a televised show where this person
is going to be sitting there telling us what we need to do, what we should be doing,
how we should be feeling.” But because you acknowledged you know what we were
wearing, how we were seated, like I say, it was like you were sitting across the table
from us and it made it very informative, but very informal, which we, or I,
appreciated.

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Chapter Five: Discussion

Introduction
The study was undertaken to provide some meaning to two questions: what is
northern BC cancer patients’ experience with social work and Telehealth, and what do social
workers need to know in order to provide this service? Interestingly, as the data analysis is
separated into the textural and structural, meaning is provided for the first question of the
study. I believe further discussion is needed that specifically looks at how the textural and
structural analysis can be interpreted in such a way as to address the second question. The
textural component has been described as the “what”. I view the “what” as the practical
element of social work practice. It is the actions of the social worker and interactions with
him or her and the client through Telehealth. This helps me to translate the data into practical
information that social workers can use in the future. The structural analysis provides the
“why” to the data. I believe this provides the theory to the practical elements. It helps social
workers join the practical elements to the theory of practice. This theory is grounded in the
political and societal context of northern social work.
Initially, the textural analysis appeared to produce a greater number of themes or
insights into practice components of social work than the structural analysis or the theory of
practice; however, this is misleading. Each theme within the textural analysis is represented
in some way within the structural analysis. Not surprisingly these are northern realities. To
sum it up, Issac and Stokes (2009) speak of being northern minded
Socially and psychologically, people self - define their daily life experience as being
northern, small community, or rural. It is this experience that differentiates the

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inhabitants of these communities from the majority of Canadians living in larger,
urban, often (but not necessarily) southern cities, (p. 171).
An excellent example of how important northern realities are is when participant
Jenny spoke of her daughter’s experience with social work in the lower mainland (p 60).
Viewing Jenny’s daughter experience without a northern lens, one may not see the hardship
which the social worker exacerbated. One may see that it is unfortunate for this woman in a
wheel chair to have to wait and be inconvenienced with traveling back and forth, to hospital
and then drugstore, but these events are normal. However, when one views this from a
northern lens, one can understand the urgency and distress that each task places on the
woman. Firstly, when people are flown via air ambulance to the lower mainland, it usually is
on an emergent basis and rarely do people arrive knowing that they will be discharged from
the lower mainland and expected to return to home community on their own. Thus the
patients are unprepared. The patients are discharged from hospital and need to find a
pharmacy in a location and city that for many is foreign, busy, and perceived as the big
dangerous city. While they venture into the city, they may further have the aspect of pain due
to recent surgery and be impaired due to medications. If they are flying home, for some there
may be only one flight a day leaving the south for home, and if they do not catch the flight,
they are then required to find a hotel and spend yet another day away from family, friends
and the comforts of home. Furthering this urgency to not miss the flight is the fear and
burden of additional costs for missing a flight; depending on where in northern BC the
patient is from these costs can be over $1000. When viewing the situation from the Northern
lens, one could see easily why the interviewee expressed the social work experience as being
horrible.

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In order to help future practitioners, a discussion that highlights the way in which the
textural analysis is embedded within northern realities needs to occur. This discussion will
draw upon literature, northern social work principles of practice, psychosocial oncology, and
my practical experience.

Eclectic Approach to Practice
As mentioned in the literature review, psychosocial oncology and generalist social
work practice is eclectic in its approaches, and has a wide variety of subject matter or
situations in which to deal with. One can see with the case examples the variety of issues
that faced these people dealing with cancer. For Joe, he experienced housing issues and a
serious deteriorating health; the social work interaction dealt with lack of resources and
provided advocacy. For Alice, social work interaction focused on clinical counseling skills
in order to assess grief and loss versus depression. Finally, for Al, an eclectic approach was
needed using support and crisis intervention combined with knowledge of palliative care. The
data gathered demonstrated that a large knowledge base as well as skill set is needed when
working with the patients interviewed. Some discussed that practical solutions and
information was important to them. Sara states “we were just kind of hoping that there was
some little tidbit (of information) that would give us some help because we were pretty much
in shock and desperate.” This was a textural theme of information. Others spoke about the
need to talk about anything related to cancer so as not to feel alone, reflective of textural
theme of ease isolation. As Bob stated
It’s a big shock when you find out you have cancer and then right away it’s you know
it’s almost like you’re left in your own little comer of the world by yourself, and to
know that that that option was there was fantastic.
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Jenny states in reference to dealing with social workers from the lower mainland,
the next person you phone, they only know what they know, and they don’t think
outside the box to tell you even another person to phone. You spend a lot of time and
anxiety trying to find these potential services.
This statement can fit into the textural theme of lack of awareness. It is also reflective of
northern realities: north versus south, and limited resources. Further it shows that northern
social workers need to think outside of the box due to lack of northern resources and
geography. Another participant suggested a large data base of resources in order to help
people in the north from the onset would be helpful instead of northern residents searching
and looking for relevant information on their own is indicative of both the textural theme of
inopportune timing or lack of awareness and the structural theme of lack of resources.
I believe that looking at the participants’ statements on their own would be
detrimental to any future social worker attempting to provide cancer care services in the
north. This is because the data does more than just suggest being eclectic in approaches. It
highlights the need to understand the reality o f being northern minded and living in northern
BC.
Complexity of Northern Realities
Complexity o f northern realities is demonstrated through the data in terms of the what
within the analysis. For example themes that arose in the textural data were that the service
was helpful; yet, there was a lack o f awareness that the service existed. I believe that the
themes o f helpfulness and lack of awareness were embedded in northern realities and
reflected within the themes of limited resources and friendly relationships. The way in which

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these themes join together has been very difficult for me to grasp and to articulate. Sellick
and Delaney (1996) describe
To insiders contextual patterns may be so transparently obvious and ‘given’ that they
may be difficult to even identify or articulate to outsiders until they have been
violated. However, for ‘outsiders’, contextual patterns may be so transparent and
unspoken as to be mystifyingly invisible. (p42).
In my situation, I feel that I walk in between two worlds at times; as an insider because I
identify myself as a northerner but also as an outsider because I do not live within many of
the communities I serve.
As I mentioned earlier, I had an accident which provided me with the ability to re­
examine the data and to process the literature review several months later, thus, arriving to
the following conclusion.
As a social worker who has worked with northern BC health care for over ten years, I
understand the importance of the relationships between patient and health care practitioner.
Before interviewing the participants, I believed that patients used the service because o f the
relationship with the health care practitioner and the referral from this person. In the
interview in which I provided my assumptions’ to participants’ responses, I stated
I think the majority o f them have learned through direct referral from the general
practitioner o f oncology GPO, or the nurses that are working with them in the chemo
clinic. I think that’s really the only way that they’ve learned.
Despite this expectation, I was still surprised that the participants did not seek this service or
know o f this service prior to the referral from the health care practitioner. As the promoter of
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the resource, I know that I not only informed the different key stakeholders of the community
of the service (oncology nurses, General Practitioners of Oncology, Allied Health Services,
Canadian Cancer Society) but I also had posters placed in the community oncology clinics
and pamphlets of my service given to every new patient. The literature states that cancer
patients regardless of their stage in treatment or in prognosis experience distress (Andersen,
1992 & Zabora et al., 2001). The participants did not engage with the service even though
they may have been experiencing distress; and, they did not have to travel long distances to
receive help. If this is the case, then why not seek out services available within the health
care community? Why did the participants not know this service existed? There are several
possible answers. Patients when in distress may not be able to focus on or recognize
information that is given to them. Patients may not realize the importance of seeking help for
the psychosocial aspects o f their cancer treatment. Patients may not have the energy to
engage in any other aspects o f treatment except the medical treatment. Patients may have
heard that the provider of the service was not helpful due to northern concept of community
microscope. Patients may dismiss the notion that a social worker has skills or values pertinent
to their situation. O f all the possible answers, my experience with now over 500 patients
speaks to the fact that northerners value, acknowledge, recognize and utilize service when it
has been recommended; especially when that recommendation comes from their own health
care provider. Kraetschmet et al. (2009) speak about how important health care professionals
are in connecting patients with resources in rural settings; essentially they play a gatekeeping
role.
Health services researchers define ‘gatekeeper’ as a provider who is responsible for
overseeing and coordinating all medical needs of a patient. The gatekeeper must

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authorize any referral of the patient to a specialist or hospital. We found that the
requirement for a Telehealth activity to be scheduled at the provider site acted as a
form of gatekeeping that controls, if not eliminates, the opportunity for individuals
outside the predefined geographical area of a Telehealth program to access the service
unless permission is granted. (Kraetschmer et al., 2009, p.661).
Regrettably cancer patients in the north may wish to receive social work support; but,
because o f their reliance on the expert health care practitioner for access, they may never
receive the professional service. This leads back to interconnecting themes of helpful,
comfortable, lack of awareness, limited resources and friendly relationships. I believe the link
with them all is the inherent importance o f relationships in the north. A social worker
wishing to provide Telehealth service requires a working relationship, perhaps even a
friendly relationship, with the ‘gatekeepers’ of the service.
Rapport Building
At first glance relationships are an important element in providing social work service
in the north through Telehealth. However, if one digs deeper, it appears that what is equally
if not more essential is the skill o f rapport building. Rapport building is essential to any
social work intervention (Derezotes, 2000; Johnson & Yanca, 2007; and Miley, 1995). With
regard to Telehealth, its impact and the way it is achieved has perhaps greater implications on
the service satisfaction than through traditional forms of interaction like face to face contact
(McCarty & Clancy, 2002). Rapport building was imbedded in both the textural and
structural components of the data. Participants spoke of the importance of friendly and

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personable contact with the social worker through Telehealth. One way this was achieved
through taking time to connect. For example Pam states
the person that I was speaking to was very calming you know and explained things to
me and asked different questions that was you know was great, but yes it was very
easy to speak to the person. Made me feel at ease.
Behaving in a calm not rushed manner appeared to be an element that allowed Pam’s
experience to be comfortable. Addressing Chris and Jenny through the use of first names
seemed to provide a friendly environment to the Telehealth interaction. Bob expressed his
comfort and the importance o f the relationship within in the interaction in the earlier
mentioned statement of:
two friends having, you know two friends going to the coffee shop and talking and
you know having that heart-to-heart talk. And to me that just hit it off for me and
right away I knew right away. You know what, this is going to be okay.
The importance o f the rapport building and the relationship was not surprising to me as I
anticipated the following in my statement
I think that they would say that don’t be quick in your interactions. Take the time to
establish a relationship a little bit. Don’t just come in there and say okay this is what
I’m going to talk about and do a checklist. That’s my bias. Just in working with it,
but also in like literature around what is important for northern clients. Like they
really hugely value relationships and meaning and that connection versus what type
of information they get. So they actually perceive that they are getting better service
if they’ve connected with a relationship even if you know clinically they might not
have got as good a service.
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Inherent within the rapport building is recognition of northern realities. Jenny spoke
o f the fact that during the social work interaction, I commented on their coats. She states
Like you put us at ease right away. You personalized it by calling us by our first
names, which I truly appreciated, you acknowledged that we were wearing coats so
you asked about the weather.
Gifford et al., (2012) highlight the importance o f a therapist understanding and
acknowledging a client’s culture and unique location as a core competency for delivering
Telehealth services. My comment on the participants’ coats is a reflection of my
understanding that northern travel conditions, especially in the winter, are challenging and
that it is likely that both Jenny and Chris just experienced difficult road conditions, given the
time of year when they received service. As Schmidt (2009) comments
While weather may exert some influence in an urban setting, the effect is minimal
compared to the influence it exerts in northern social work practice. Many of us who
work in the north experience the uncertainties of the roads that shift and change with
the seasons (p.9).
A social worker with a southern or urban contextual viewpoint may miss this subtle yet so
important reality to the patients he or she is working with, especially if this service is
provided through Telehealth.
Understanding contextual patterns in northern communities presents a complex
challenge. While northern communities share common characteristics which may
help social workers situate a community within historical/political/geographic
contexts, efforts to understand a particular community solely in terms of those

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common characteristics will inevitably fail in conveying richness, diversity, and
uniqueness o f that community. (Sellick & Dellaney, 1996, p.41).
There is a real complexity of rapport building in order to engage in and maintain workable
relationships in a northern setting. Rapport building is used to establish and maintain
relationships. It is a critical component to the perceived usefulness of social work service in a
northern setting and even moreso through the use of Telehealth.
Isolation
Interestingly, I myself did not anticipate that participants would highlight that the
service eased isolation; however, this is not an unexpected theme to arise for cancer patients.
When one is confronted with the fear of death and with the reality of one’s health betraying
them, inevitably people feel alone and isolated from the world (Kuhl, 2002). The impact of
isolation for northerners is exacerbated due to the northern reality of lack of services, often
geographically great distances from families, and smaller population bases to rely upon for
support. It would be a somewhat obvious conclusion to draw that the service helped to ease
isolation; yet, I was surprised by this theme, whereas other themes which emerged I had
anticipated. In order to make the data, the research, and this study meaningful, I was
compelled to dig deeper into this unexpected theme.
Throughout this study, I have mentioned that the service provision has been provided
by myself to the people in the north. I worked with over 500 patients and families through
Telehealth. I have been the only person providing this service and I have no other similar co­
workers to draw upon for support or guidance. In essence, I have been isolated within in my
practice. This practice isolation may be so inherently part of the work that it is difficult to

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articulate, acknowledge, and even make connections with how important easing isolation is
to both myself and my clients. I am obliged to explore how easing isolation is important and
how this is connected because without a further exploration, my study may lack an important
element of meaning. Some following statements may be relevant to this understanding.
People in northern Canada innately feel isolated from other people for the simple reason of
geographic differences. People in northern Canada can feel powerless and isolated due to
decisions being made about their lives from the south (Zapf, 2012). People experiencing
cancer feel isolated from their peers and support people. People experiencing grief and loss
feel isolated and disconnected. Almost all people dealing with cancer experience grief and
loss.
This last explanation fundamentally rings true for me in a way that can fit and join the
three other explanations together. The work which involves Telehealth creates a geographic
isolation factor for the worker providing the service. Additionally, this type o f work as a
specialty and within the context of its provision isolates the social worker, myself, from other
co-workers as their duties and responsibilities are vastly different on multiple levels but on
the simple and obvious level: the Telehealth aspect. Finally, as a social worker connecting
often periodically for years with people on intimate matters that are often heart wrenching
and tragic, I experience grief and loss. This is very common for oncology social workers.
As Joubert, Hockingralph, and Hampson (2013) point out
Social work in oncology presents a unique challenge. The direct practice work with
patients and their families is frequently both physically and emotionally taxing and,
despite our best efforts, the work does not make cancer go away. As families require

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ongoing intervention and consultation, social workers build long-term relationships
with clients, many of whom will die. (p.6).
This grief and loss is well documented in the literature and is often called vicarious trauma or
compassion fatigue or bum out. (Cashevelly et al., 2008; Rohen, 2005; Simon et al., 2007;
Wemer-Lin & Biank, 2006). 1 view it as something slightly different from any of these
terms. Grief and loss occurs for me within this context of delivery not because of the trauma
of being witness to the tragic stories and not because of the experiencing too much loss due
to the nature of the work but because of the isolation of the work (being separated from the
patients and the other members of the team - geographic isolation); the lack of peer support
from other social workers (professional isolation); and finally, the inability to create policies
and practices which would minimize the grief and loss aspects of the work (political
isolation). These three isolation aspects, which I believe increase and intensify grief and loss,
are not different from those mentioned by the participants or within the case examples. Alice
was experiencing grief and loss yet the system in place to assist her increased her feelings of
isolation by recommending an antidepressant which would take away her raison d’etre.
Arguably this could be categorized as a political isolation aspect because the policy and
practices are not reflective of the needs and realities of the users of the service. Participant
Bob highlighted his isolation from his peers and thus support in his statement “I didn’t tell
anybody ...., not even the guys on my crew and stuff like that”. With the case example of Jo,
he was angry because he could not return home due to his deteriorating health condition
which required him to stay in a wheel chair. As well, he had argued that his medical
treatment was inadequate. From my practice experience as well as my real lived experience
as a northerner, this is not an uncommon feeling. Residents of northern Canada often
perceive that if they lived in the south, services would be more abundant. If one looks back
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at Jo through the eyes o f a man experiencing grief and loss, one can then see how geographic
and political isolation intensify these feelings.
I believe that future social workers who may provide Telehealth service to people
living in the North need to be prepared for isolation: geographic, political, and professional.
As well, social workers need to understand that their isolation is quite similar yet
exponentially less distressing than the isolation experienced by their clients with cancer.
Furthermore, grief and loss exacerbated by isolation is an essential component of the social
work practice for both the client and the social worker.

Structural Analysis
One of the purposes of this study was to provide some information to future social
workers working with Telehealth to northern population bases and more specifically to
northern BC. The data demonstrates that the structural reality of living in the north impacts
or influences service provision. I believe that social workers then need to incorporate this
into their practice. The challenge however is adding the element of Telehealth to the mode of
service delivery. If someone was to ask me in the future, “What would you recommend
doing when providing psychosocial care to cancer patients via Telehealth?”, I believe it
would be difficult to break down the information into doing, or the practical elements of
social work without including the understanding, or the theory of northern social work. This
understanding or theory of practice is better understood one when looks at the position in a
structural analytical way. Firstly, it is gained through examining the structural set up of the
supervision component with the position and the structural setting of the position. Secondly,
it is enriched by a structural social work analysis.

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Supervision and Structural Setting
As mentioned previously, my position was formed out of the Northern Cancer
Control Strategy (NCCS). My position, which I resigned from in November 2013, was based
in Prince George, which many would likely argue is considered to be south in comparison to
the rest o f Northern Health which is seen as north and rural. The structural setting of this
position was formulated to provide psychosocial oncology services to all cancer patients
receiving treatment from their local cancer clinic (appendix B). I was the person hired into
the position in January 2009.
Interestingly, the supervisor of this position was the head of the social work
department at the University Hospital of Northern BC (formerly known as Prince George
Regional Hospital). Social work supervision is extremely valuable to the supervisee but also
to the maintenance of high quality practice and program delivery.
The aim o f professional supervision is to provide an on-going opportunity to for critical
reflection and learning that takes into account the political, organizational, professional,
and practical, administration and cultural contexts of practice. Consideration of the
emotional impact upon the social worker is integral to this process of critical reflection.
(Beddoe & Egan, 2009, p. 410).
The structural setting o f this position was placed under the management and direction of a
person who is only responsible for services within Prince George; therefore, there was a
fundamental gap in understanding of the unique differences and challenges each community
faces outside the Prince George area. This gap contributed to incongruence between the
social work practice to the communities in the north and how as a worker, I needed to be

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cognizant of that and adapt service for it. Additionally, the supervision was provided by
someone who was not an oncology social worker.
Social work supervision has a focus on both short-term (educational supervision,
promoting effective social work practice and supporting the social worker to feel about
doing the work), which aligns with the long-term— and critical—objective of providing
clients with the most effective and efficient service that the agency is mandated to offer.
(Kadushin & Harkness, 2002).
The specialty of providing psychosocial cancer care to northern residents was not under the
umbrella o f the experts for BC in this field: the Patient and Family Counseling (PFC)
Department for the British Columbia Cancer Agency (BCCA). This caused me to have both
internal and external system conflict. The internal system conflict arose when recognizing
that added knowledge and direction in terms of increasing competency was needed but there
was no person within the system to address this need. The external system conflict arose
when recognizing that some policies and procedures from the experts did not meet the needs
of northern BC cancer patients and families. For example, in searching for clinical
consultation from my supervisor or other co-workers about psychosocial care for the case
example of Alice, I likely would be told that the patient would need to engage with their
mental health counselor in their home community. This would be based on the reasoning that
within the hospital system in Prince George, social workers do not address mental health
issues in a clinical manner; they refer to the mental health system. An example of how the
external system would cause angst is how as a Northern Health worker, I felt powerless to
address how the policy of PFC BCCA of referring to home community to address
psychosocial issues lacked awareness of the resources with home communities. For

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example, for those few hospitals in Northern Health which have social workers, all have
discharge planning to in-patients as their priority and dealing with psychosocial issues and
practical matters of an outpatient cancer clinic is not a focus of attention. This policy also
does not address what a patient is to do if there are no home based services. Often as the sole
based cancer care social worker for Northern Health, I was conflicted in how to achieve the
best service level for cancer patients and their families.

Structural Social Work Analysis
It would be lacking to attempt to provide meaning and guidance for future social
workers wishing to provide Telehealth service for oncology patients in the north without
discussing the aspect of this position within its context and system. In order to achieve this, I
use structural social work theory. Structural social work practitioners who work within a
system, or in this study a health care setting, I believe need to follow the principles of
practice o f interpersonal work and personal is political. According to structural social work
theory interpersonal work is important and “it must not de-contextualize human activity or
treat it as a de-socialized or a historical way” (Mullaly, 2007, p. 292). This recognizes that
both the client and the provider interact with each other and have a real impact on the
interaction. Future social workers coming into this position should try to be aware o f this and
perhaps the previously highlighted points in the discussion about isolation, grief and loss, and
northern realities will provide a guide.
Personal is political within structural social work practice always makes the link
between the personal problems and the structural causes for them. Individuals and their
families who face cancer and need life sustaining treatment are often dependent upon a

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system, a health care setting, which can be structurally oppressive. With regards to the
northern health psychosocial oncology position, one individual was put into place to be
available to provide service to potentially thousands of people. The structure was set up to
provide service delivery to individuals with cancer via Telehealth. The British Columbia
Cancer Agency predicted that almost 1400 people living in the Northern Health Authority
were diagnosed with cancer in 2013 (BCCA, 2013). Structural social work examines the
ways in which structures in society perpetuate oppression and inequality. The theme of
inopportune timing demonstrated that the service was not always available for the
participants. Participant Jenny commented that in order to improve access to service
You do realize though, you will have to clone yourself, (laughter) You will not be
allowed to take holidays or have days off, and you will have to be available for us
24/7.
“Structural inequality is a somewhat abstract, technical, bourgeois and polite term that covers
up its violent outcomes. We should call it what it is - socially sanctioned structural violence”
(Mullaly, 2007 p.276). I believe that my former position, which albeit does provide some
services to some people, perpetuates oppression and inequality and more so, it condones it.
This is due to the obvious - how is one person able to provide quality service to potentially
thousands in need? How then is it not structural violence when people who require the
service do not receive it?
Northern Health and the Northern Cancer Control Strategy sanctioned structural
inequality by putting in a structural setting for a position into place for delivery of service via
Telehealth, yet it did not provide evidence-based training on how to implement the service.

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Further, it placed this position under the management and guidance of a supervisor with little
to no responsibility or knowledge of the complexity o f northern realities. Finally, there was
no formalized evaluation on how the patients perceived this method of delivery nor on how
the health care providers in the community cancer clinics saw benefit to the service. How
does one truly wish to meet the needs to the users of service when they don’t ask them about
the service? This gap led to this research study as I believe as a social worker it is my
professional responsibility to not only follow evidence based practice or emerging body of
knowledge but also aid to the body of knowledge through research and evaluation.

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Chapter Six: Limitations and Recommendations

Gaps in Data
Costs
A gap in the data from the participants is the notion of costs: whether the costs
savings to using the service or the financial burden of cancer treatment in general. I expected
that all the participants would discuss finances in the interviews, and this was demonstrated
in my statement:
I think a lot of patients are going to say my understanding is that social workers
helped with financial um services. Especially the participants who might come from
the northeast, just because if they come from the northeast and have gone to Alberta,
that’s all their social workers do is um help with financial services. They don’t help
with anything else so I think that’s what patients will say.
I was surprised by the lack o f discussion around finances because unfortunately, all too often
the financial implications for cancer patients are life altering. The Canadian Cancer Society
(2013) states
Nine out of ten Canadian families touched by cancer report some form of financial
challenge as incomes decline and household costs rise. For some, a cancer diagnosis
begins a financial tailspin that pushes ordinary people over the edge resulting in debt,
distress, bankruptcy and even a lifetime on social assistance.
Only two of the seven participants mentioned that costs of cancer were a financial hardship to
them. Interestingly, in a study by Shepherd et al. (2006) the financial savings to cancer
patients in rural and remote locations of Australia receiving tele-psychology service was a

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major benefit to the participants. Similar findings exist in other studies. Stalfors, Bjoijolt,
and Westin (2005) examine costs to the health care system and patient to implement and use
Telehealth equipment for health care versus face to face care: “The direct non-medical costs
i.e. costs for travel, were higher in the face-to-face group compared with the telemedicine
group” (Stalfors et al., 2005, p.207). The direct medical costs would be significantly lower
once the telemedicine equipment costs are absorbed and not part o f the startup. Therefore for
both the non-medical costs and medical costs, telemedicine is a more cost effective way of
delivering health care to rural and remote patients. (Stalfors et al., 2005). In a study on
utilizing Telehealth service in Northwestern Ontario, Sevean et al. (2008), identify that
people who use Telehealth service value and highlight that this mode of medical service
results in less financial burden to them. Perhaps in the future, if research looked at the
financial implications specifically to northern BC residents in receiving cancer treatment both
via Telehealth and through extended travel, participant answers may reflect that of previous
research.
Psychosocial Information
Cancer and its impact on people living in the north was not an explicitly stated
objective of the study; however, some discussion about cancer for northern residents would
be expected especially regarding people experiencing cancer and their involvement with
social work services. In fact, I anticipated that participants would likely speak about
receiving psychosocial oncology services. In my own interview prior to the participants’, I
stated

84

I think they’re going to just perhaps they’ll say grief and loss issues, sexuality issues,
finance issues, understanding of cancer illness issues, advanced care planning issues,
like any of the above. Anything that might come up for somebody that’s
experiencing cancer: body image issues, family dynamics, I think those are the sorts
o f things that I talk about with patients most often

Finances, coping with a

diagnosis, and like anxiety issues. Anxiety related to the diagnosis, anxiety related to
sleep, anxiety related to the next coming up test. I think those would be the top three.
As a researcher and practitioner, I was hoping that participants would highlight the type of
service received such as “we talked about my anxiety and fear of death.” In this way, future
social workers would be able to have a clearer idea of what issues northern residents of BC
experience when dealing with cancer and thus be able to guide their learning and perhaps
practice.
Unfortunately, participants did not speak of what the social worker, myself, did in
terms of intervention. There could be a multitude of reasons for this; and I believe some
exploration of this reasons are pertinent to helping address the two main questions o f the
study. What was northern BC cancer patients ’ experience using Telehealth service from a
social worker? 2) What do social workers need to know in order to provide social work
service to cancer patients via Telehealth?
One reason could be that the participants did not remember much of the specific
details as it is quite common for people undergoing cancer treatment to have memory loss
(Silverman & Davidson, 2009). Another reason could be that the participants did not wish to
speak of specifics in great detail as it is often difficult and distressing to talk about issues

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such as death and dying or loss of financial freedom or grief over control of one’s own body.
I believe though that it likely is a combination of the above mentioned reasons and mostly the
following explanation.
I provided each o f the participants in this study the social work services via
Telehealth that they were questioned about. It may be possible that the participants did not
feel the need to explicitly state what the interaction included as this information was mutual
knowledge. As a novice researcher, I did not probe or ask questions of the participants about
the specifics of psychosocial interaction and I did not recognize that the information was not
stated within the interviews until much later in the research analysis process. I thought about
reaching out to ask more information. Unfortunately, most of the participants are deceased
and it would be insensitive to go back and ask those living partners. If in the future a similar
study was to occur, it would be perhaps more advantageous to have a separate person
conduct the study and not the social worker who delivers the service, as he or she may gleam
more information regarding the content of the interaction. This option though is unlikely to
occur for the same reasons of why I myself sought and studied the phenomenon. Northern
and rural residents of Canada are often not included in mainstream research; and if the
research is conducted it is either through a southern political metaphor or else completed by
the person providing the service delivery.
Being an Ally Not a Southerner
Telehealth oncology social work service is centralized in its location yet the service is
provided throughout the Northern Health region, to its Community Oncology Networks. As
the Telehealth oncology social worker, I am not from the cancer patients’ community and

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could be viewed as an outsider. Outsiders entering into northern communities can encounter
resistance and opposition. Sellick & Dellaney state (1996)
Communities quite naturally then may resist ‘outsiders’ attempt to ‘know’ them
because that knowledge, which is partial and so often vested with outside interests,
violates their sense o f who they are and limits their imagining of who they become.
(p.42)
Given this, it would be likely to receive feedback from the interview participants that either
the service should occur within the cancer patient’s community or that the service was not
responsive to the needs of the patient. In fact, I anticipated that on some level comments like
this would be mentioned. I stated in my research bias interview, “I know that I’m often
viewed as a southern person implementing southern regional policies into northern

communities, or I could be perceived as that way.” Although the participants did not overtly
mention this within the interviews, there were a few comments that alluded to elements of
opposition which was discussed earlier. Non-overt statements could be a reflection that the
participants were not aware of their own subtle culture of opposition. It could have been a
reflection that the participants did not want to disrupt the program in any way for fear of it
being taken away and the community being left with nothing. It could have been due to
feeling uneasy in expressing dissatisfaction with the service given the service provider,
myself, was conducting the interview. Finally, it could have been due to the fact that I
practice from a northern social work framework; a northern social work framework is one
that acknowledges northern realities, and values and understands the importance of northern
relationships. Thus, the participants may not find the need to bring the service to their
community or they may not believe the service was unresponsive to their needs. Perhaps,

due to my own northern metaphoric way of being, I could be considered an ally not a
southerner.

Methodology Limitations
As mentioned, my social work availability to communities could be seen as an
imposition versus a welcome. This is perhaps reflected in earlier mentioned gatekeeping
element of the Telehealth service. Thus although the study has attempted to provide some
meaning to the lived experience of cancer patients using social work service via Telehealth in
northern BC, it has only used data and work experience of those who have accessed the
service versus those who have not. Questions which could be explored in future research
would be “what are the barriers to utilizing oncology social work service in northern BC?”
“How would you like to see psychosocial support offered to cancer patients in your
community or to you in your community?
The study only interviewed five patients plus two partners who met the criteria:
having experienced a cancer diagnosis within the last 48 months, having seen a social worker
through Telehealth service, and living within the northern health authority. Perhaps if more
people were interviewed, the sensation of the experiences would not be reflected as positive
as it was. As well, maybe the people interviewed, choose to participate in the study because
of their positive experiences and those that did not participate choose so because their
experiences were more negative. People with a negative view point on the service may not
have wished to participate in the study because the person conducting the study was myself
and this could be difficult. They may have felt awkward to come forth and be interviewed
even by another person which was an option in the study due to these difficult feelings or

88

opinions to express. As well, I believe that a potential participant may feel vulnerable
providing negative feedback on a service which his or her health care provider
recommended; especially if this health care provider may be responsible in the future for
providing him or her life sustaining medical treatment. It may be interesting to repeat the
study with participants who utilized the service without a recommendation or referral from
their health care provider.
This study examined only those participants who accessed service through
Telehealth; it did not focus on individuals who did not access as it was technology and not
face -to -face service. “It has been suggested that as remote tele-care technologies are
introduced more widely, some form of digital inequality will persist and it is possible that
those who demand purely face to face interactions will receive a residual service” (Waltin &
Rogers, 2012, p. 111). Future work with regards to looking at people who use Telehealth
versus those who choose not to may help to identify and modify services to meet the needs of
all cancer patients in the north and not just those willing to use Telehealth.
Recommendations
The points outlined at the beginning of this chapter provide some direction and
recommendations for future social workers wishing to provide a specialty in health care via
Telehealth to a northern population. The first recommendation is that the social worker
should be provided with some training on how to utilize Telehealth equipment while
engaging in clinical interaction. The data analysis demonstrated that participants appeared to
value or appreciate the service when it was simple to use, when the visual aspect of service

89

appeared somewhat like face to face, and when the interaction was friendly and relaxed. My
experience concurs with the data obtained from the participants.
As mentioned in the discussion section, critical to the positive Telehealth experience is
rapport building and this is achieved clinically in subtle different ways than within a face to
face setting. The training in the use of Telehealth would include both the technology
component and the clinical elements with an aim at rapport building. For the technical
components, I would highlight that sometimes the actions that what we do that seem
intuitively correct, are not. For example, with my experience, I realized that if a person had
difficultly hearing me, it did not mean that I was to speak louder or lean into the television to
get closer to it. Instead the person on the other end needed to turn up the volume on the
television. I also learned that if I looked into the camera placed upon the top of the television
screen, believing that I was focusing my attention on them, my clients’ experience would be
that I was not looking at them. My eyes would be focusing above their heads. I needed to
look at the person on the television screen and not at the camera. These are small but critical
technical aspects o f Telehealth and should be part of training.
Once the technical elements of using the equipment are understood, training on the
clinical components should occur. This training does not need to be extensive; but certain key
pieces o f information should be explained. For example, I have found that it is important to
acknowledge the different interaction and talk about it. A simple statement like “people find
this a little odd at first, but soon it becomes almost like face to face” is helpful. At the end of
the session, acknowledge the distance through a simple gesture of a virtual hug or hand shake
is nice. It can be useful to have a box of Kleenex in both the clinician and client’s room. In
this way, I have held up a box o f Kleenex when someone is crying, and they then look for the
90

one within the room. It is also critical to be at ease with silence as the silence can seem more
pronounced with Telehealth than in person. I learned not to fill in the silence with words too
quickly. Finally, I found that it is essential to be relaxed and comfortable both with the
technology and clinical interaction through Telehealth. The more this occurred for me, the
more rewarding, meaningful and easy my interaction with cancer patients in Northern BC
through Telehealth became. I believe that training should allow novice social workers the
opportunity to witness more experienced clinicians engaging with clients in this way to help
them become relaxed and comfortable. I strongly recommend training with the use of social
work and Telehealth and believe that it can occur within the workplace or through the
university setting.
The second and third recommendations are more so about the system or the structure of
the position. The second recommendation focuses on supervision and the third
recommendation highlights the importance of robust services. These recommendations, I
believe will help future social workers understand the why of their position and advocate for
it to be in line with the structural themes of the data.
According to Joubert, Hockingralph, and Hampson (2013), social work supervision is a
key component to oncology social workers. Without an appropriate management and
supervisory structure, these social workers are at greater risk for burnout and vicarious
trauma. Critical components to reduce bumout and vicarious trauma include formal and
informal supervision. The formal includes a supervisor who actively guides and consults with
his or her worker and provides every opportunity to increase the worker’s knowledge base;
inherent in the guidance and direction is that the social work supervisor is a practitioner of
oncology. The informal supervision is the ability to connect with peers on not only a
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scheduled basis but on ad - hoc basis as well. I recommend that a system is in place in which
supervision is provided by another social worker actively involved with cancer care.
It is not uncommon for social workers in northern settings to suffer from bumout
(Brownlee, Delaney, & Tranter, 2002). I believe oncology social workers practicing in
northern locations have a greater potential for vicarious trauma and bumout. They often
work in isolation and are not part of a system in which they can connect with co-workers
providing similar duties and in this setting of NHA, he or she is not supervised by a social
work oncology practitioner. It is not possible to provide quality psychosocial oncology
service to northern health residents by one person. I strongly recommend that more than one
position and person provide this service. In addition, I recommend northern oncology social
workers do not practice in isolation; instead they should have an empathetic robust team that
works within the same scope o f practice.

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Chapter Seven: Conclusion
The experience o f cancer patients living in northern BC who access Telehealth social
work service may be difficult to fully understand in this study. However, there are important
realities and meanings which exist for the participants and perhaps for others who have
utilized the service. Participants and perhaps myself who happens to be the researcher, albeit
difficult to admit, who deal with cancer in northern BC, feel alone. The participants received
the service at inopportune times which could be reflective o f the gatekeeping element of
community professionals and the perceived notion that the service was from the south.
Participants were unaware o f the service and felt discomfort with it. However, once rapport
was achieved through incorporating northern realities into the experience, participants felt the
service was helpful and comfortable. Ways in which this occurred was through taking time to
connect with the participants almost on a personal note. It was also important to keep the
technology process simple, to incorporate regular one on one techniques such as showing
diagrams in the process, and to provide useful practical information. The Telehealth method
of delivery provided them access to a service which without it they may not have had such a
service due to their geographic location. Despite the positive elements found with using
Telehealth and oncology social work to northern residents, careful consideration should be
made before this mode of delivery is more widely used.
While the rhetoric around Telehealth cites improved access for regions and for
persons who are more marginal in their ability to access services under the current
system, there needs to be a recognition that technological, administrative, and funding
patterns may restrict (it)... despite the rhetoric of ‘virtual health care’. (Kraetschmer
et al., 2009, p. 662).
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I would suggest that system and structural support be more thoroughly implemented in order
to help achieve an experience in which the cancer patient in the north ‘has a virtual cup of
coffee’ with the social worker from the south.

94

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Appendix A - Health Authority Areas

BC Health Authorities and
Health Delivery Areas
■
■

Northern
Vancouver Coastal

■
■

Fraser
Vancouver Island
Yukon
Prtwinoal Health Services
Authority (province wide)

Map o f British Columbia. The area in blue depicts the Northern Health Authority

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Appendix B - Northern Health Community Oncology Networks

This is a picture of the Northern Health Authority. It demonstrates the areas that have
Community Oncology Networks.

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Appendix C - Interview Questions
Evaluating Cancer Patients Experience o f Telehealth
Social Work Intervention
Thank-you for agreeing to participate in this interview. You have been chosen because
within the last year, you spoke with a cancer care social worker via Telehealth Service. The
purpose o f this interview is to gain feedback of the use of Telehealth service with social work
intervention. The information will be used for the purpose o f gaining insight into ways in
which social work service can be used with Telehealth for cancer patients living in Northern
British Columbia. It will be valuable in guiding future social work service and practice for
cancer patients. No identifying information of the participants will be revealed.
1. Were you aware o f cancer care social work service prior to meeting with him/her via
Telehealth? (If yes, answer question 2 do not answer 3. If no, go to question 3.)
Yes

No

2. Please describe your prior understanding of this service.

3. Please describe what you thought the social work service would be like before using it.

4. How did you learn of cancer social worker service availability through Telehealth?

5. Please describe your Telehealth experience.

6.Please describe the interaction with the social worker thru Telehealth.

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7. Please describe your impression of social work service using Telehealth.

8. What would you tell other cancer patients about if they were to use social work service via
Telehealth?

9. What would you tell other cancer care social workers if they were to use Telehealth with
patients in the future?

10. Please comment on anything else that you believe is important about your experience
with cancer care social worker and Telehealth.

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