Contemporary Nurse

ISSN: 1037-6178 (Print) 1839-3535 (Online) Journal homepage: http://www.tandfonline.com/loi/rcnj20

Factors promoting resilience among breast cancer

patients: a qualitative study

Ting Zhang, Huiping Li, Annuo Liu, Huixue Wang, Yaqi Mei & Wanjun Dou

To cite this article: Ting Zhang, Huiping Li, Annuo Liu, Huixue Wang, Yaqi Mei & Wanjun
Dou (2018): Factors promoting resilience among breast cancer patients: a qualitative study,
Contemporary Nurse, DOI: 10.1080/10376178.2018.1502615

To link to this article: https://doi.org/10.1080/10376178.2018.1502615

Published online: 24 Jul 2018.

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Contemporary Nurse, 2018
https://doi.org/10.1080/10376178.2018.1502615

Factors promoting resilience among breast cancer patients:

a qualitative study
Ting Zhang, Huiping Li*, Annuo Liu, Huixue Wang, Yaqi Mei and Wanjun Dou

School of Nursing, Anhui Medical University, No. 81 Mei Shan Road, Shu Shan District, Hefei, Anhui
Province, People’s Republic of China
(Received 1 September 2014; accepted 18 June 2018)

Objective: The purpose of this study was to investigate resilience factors that helped Chinese
breast cancer patients adapt to the trauma in the traditional Chinese cultural context. Method:
Checklist-guided in-depth interviews were conducted on 15 Chinese breast cancer patients
recruited from two affiliated teaching hospitals. All had adapted to the illness successfully.
All interviews were guided by checklist-guided interview guidelines based on the social
ecosystem theory. They were recorded digitally and transcribed verbatim. Data analysis was
performed using published content analysis approach.
Findings: The main themes found to be relevant included hope for rehabilitation, hardiness,
confidence in situation, optimistic attitude to the disease, gratitude to supporters, mastery of
life. Each level of these individual resource interacted with each other, which was consistent
with the micro system of social ecosystem theory.
Conclusion: This study showed that individual resource played a significant role in helping the
Chinese breast cancer patients deal with the illness. There is a clear need to develop a
comprehensive evaluation system to help clinical nurses assess patients’ individual resource
and promote better adaption to breast cancer.
Keywords: resilience; Chinese; breast cancer; cancer; nursing

Impact statement
Findings shed new lights on breast cancer survivors’ resilience factors in traditional Chinese cul-
tural context and inform future clinical nursing practice for considering individual resource.
Cancer is an increasing public health problem in the world (Farmer et al., 2010). As estimated,
by 2030, the incidence of cancer worldwide will reach 26.4 million. Developing countries,
especially India and China, are at higher risk of these new cases (Tunstall-Pedoe, 2006).
Among all these kinds of cancers, breast cancer is the most prevalent in women worldwide
(Downs-Holmes & Silverman, 2011). Fortunately, because of the improvement of screening
and treatment, the number of breast cancer survivors is increasing (Ussher, Perz, & Gilbert,
2013). Quality of life (QOL) and mental health are becoming increasingly important to survivors.
According to literature review, diagnosis or treatment of breast cancer are a traumatic series of
events that lead to poor consequences, including emotional distress, especially anxiety and fear
(Lim, Devi, & Ang, 2011; Schnur et al., 2009). These significant emotional responses may
even persist beyond treatment (Gerber, Freund, & Reimer, 2010). Numerous studies have

*Corresponding author. Email: hulihuizi@163.com

© 2018 Informa UK Limited, trading as Taylor & Francis Group

2 T. Zhang et al.

demonstrated that there are huge discrepancies in psychological coping among patients. Some
patients reacted quite well, being able to address the disease optimistically, maintain relatively
good psychological status and QOL; while others suffered from severe negative feelings. Resili-
ence was found to play a critical role in these adaptive behaviors (Hou, Law, Yin, & Fu, 2010;
Richardson, 2002). Resilience is here defined as a capacity to maintain healthy physical and
mental states in severe situations with risk factors (Connor & Davidson, 2003). Researchers
tend to treat it as an interactive dynamic construct, focusing on protective factors and positive
adaptation in traumatic events, rather than considering risk factors (Hjemdal, 2007). There is evi-
dence that protective resources individuals owned determined the level of resilience after growing
up (Cederblad, 1996; Rutter, 1985; Werner, 2001). Kumpfer also suggested that traumatic events
not balanced by resilience factors may lead to maladjustment (Kumpfer, 2002). Psychologists
believe that individual resilience can be promoted by training under certain circumstances
(Cho & Oh, 2011; Loprinzi, Prasad, Schroeder, & Sood, 2011). This study is an attempt to ident-
ify individual protective resources that may help breast cancer survivors increase their level of
resilience and reduce their distress.
Prior studies about resilience of breast cancer patients are limited. Researchers tried to
verify the relationship between several factors and resilience among patients. For example,
Stewart and Yuen (2011) found that psychological factors of physically ill individuals associ-
ated with predicting or promoting resilience were self-efficacy, self-esteem, internal locus of
control, optimism, mastery, hardiness, hope, self-empowerment, acceptance of illness, and
determination in a systematic review (Stewart & Yuen, 2011). In order to broaden the study
of resilience, the resilience factors should be examined in relation to other aspects of the indi-
vidual response, such as biological domain, which is consistent with holistic nursing (Grimes,
2013). Chinese history runs back thousands of years. Chinese traditional culture has a pro-
found effect on the lives of modern individuals (Ding, Hu, & Hallberg, 2015). Because of
the interactive and dynamic nature of resilience, the factors promoting resilience among
breast cancer patients in different cultural context might differ from that of physical illness.
Therefore, this study may shed new lights on breast cancer survivors’ resilience and related
factors in traditional Chinese cultural context.
This study was guided by the micro system of social ecosystem theory. The theory defines
adaptation as people’s ability to adjust to surrounding environment. Successful adaption means
individuals’ effective interactions with diverse factors of social environment, which is in line
with the concept of resilience. Zastrow and Kirst-Ashman classified the social environment
into three systems: micro system, mezzo system and macro system (2006). The micro
system includes psychological resources, biological resources, material resources, age and
gender. The mezzo system includes family, occupational groups and other social groups.
The macro system contains culture, community, convention, institution, and organization.
Among these three systems, micro system is very important to evaluate the individual resource
of persons’ behavior.
The purpose of this study was to investigate the individual factors promoting resilience among
Chinese breast cancer patients.

Methods
Design
This study used a qualitative research design consisting of checklist-guided in-depth interviews.
This design was chosen because the purpose of the study was to gain deep understanding of resi-
lience factors among Chinese breast cancer patients, not to assess the quantification of resilience.
 Contemporary Nurse 3

Sampling strategy
Purposeful sampling was used to select participants from three departments of two teaching hos-
pitals in Anhui province, China. To be eligible for this study, the participant needed to meet the
following criteria: (1) ≥18 years of age, (2) diagnosis of breast cancer having lasted more than one
month (Lam et al., 2010), (3) scored at least 64 points on the Chinese version of the Resilience
Scale (RS-14) (Tian & Hong, 2013), (4) lack of psychotic episode, (5) agreement to participation
in the interview and complete recording of talks. In total, 15 breast cancer patients were recruited
based on the criterion of saturation (Marshall & Rossman, 2010).

Data collection
The interview checklist was developed by a master of nursing, and was based on the social ecosys-
tem theory. After ethical approval was obtained from the Ethics Committee of the Anhui Medical
University and directors from each department, two nursing faculties who had been trained by the
study team screened the potential interviewees using the criteria listed above via electronic medical
records system and contacted them. After providing informed consent, the participants were invited
to go to these two hospitals and fill in the RS-14 to exclude anyone with low resilience. The inter-
views were conducted by these two nursing faculties. Each interview lasted about 40–60 min and
digital sound recordings were made. All interviews were conducted in the head nurse’s office or the
director’s office, which was a quiet and relaxing for the participants. The checklist covered biologi-
cal, psychological, material resources, age and gender of micro system according to the social eco-
system theory (Appendix 1). Lead by this checklist and two investigators, the interview proceeded
with open questions exploring how they had become resilient to the disease.

Ethical consideration
After approval by the ethics committee of the Anhui Medical University and directors of related
departments, the researchers explained the purpose and methods of the study to all potential inter-
viewees. The confidentiality of the data was ensured, and the written informed consent was
obtained from all the participants. Upon agreeing to participate in the study, the participants
were invited to initiate the interviews.

Data analysis
Data analysis was performed using methods proposed by Miles and Huberman (1994). It con-
sisted of five steps. First, the audio recordings were transcribed verbatim. Second, the transcripts
were read and re-read several times to confirm the participants’ experiences in their adaption to
breast cancer. Third, the verbatim transcripts were read closely to identify and code significant
statements or phrases. Fourth, significant phrases with similar meaning were compared and
divided into categories. Fifth, the transcripts were re-read to confirm the categories and sub-cat-
egories. Two master’s students in nursing performed data analysis independently and each gen-
erated a set of categories. They then sat together, compared their findings, discussed any
discrepancies, and produced a unified set of categories (Miles & Huberman, 1994).

Trustworthiness
In order to ensure credibility, all qualitative interviews were guided by a pre-designed checklist
and two trained interviewers participated in interviews. Participants were paired with two
female interviewers. The first author who was 26 years old conducted the interviews with
young participants. And the other one was hired to conduct the interviews with middle and old
4 T. Zhang et al.

aged interviewees. In addition, two researchers finished the data analysis. All interviewers and
investigators did not have a clinical relationship with the participants prior to, or after recruitment
which may have a coercive effect. Finally, all participants confirmed the accuracy of their own
transcripts and categories. One professor who was an expert in nursing psychology and interper-
sonal communication audited the research methods to ensure dependability and conformability.
The trail was documented in details to facilitate transferability for future studies (Lincoln &
Guba, 1985).

Findings
Participants
Initially 15 participants were recruited. All 15 of these Chinese breast cancer patients were
married women. Details of the participants’ information are given in Table 1.

Themes
Six themes of relevant factors were established from biological and psychological resources: hope
for rehabilitation, hardiness, confidence in situation, optimistic attitude to the disease, gratitude to
supporters, mastery of life. Verbatim quotes from interviewees are given below to illustrate
themes with numbers.

Hope for rehabilitation

The study identified that patients were inspired by several biological factors. These were good
physical condition, mild case, good early treatment outcomes. Participants argued that these

Table 1. Participant information.

Variable M (SD) or N (%)
Age (years)
Mean (SD) 48.9 (7.7)
Religion
Buddhism 2(13.3%)
Christianism 2(13.3%)
No religion 11(73.3%)
Education level
Primary school 4(26.7%)
Secondary school 7(46.7%)
Bachelor degree or above 4(26.7%)
Breast cancer stage
≤I 1(6.7%)
II 10(66.7%)
≥III 4(26.7%)
Relapse
Yes 1(6.7%)
No 14(93.3%)
Metastasis
Yes 4(26.7%)
No 11(73.3%)
RS-14 score
Mean (SD) 80.7(8.4)
 Contemporary Nurse 5

factors were the key to rehabilitation. Hope reduce stress and urge them to adapt to the situation.
Moreover, only hope may prevent patients from giving up all necessary treatments. Of the 15
patients, two believed that prior health status was vital to defeating diseases. “My prior physical
condition is good. I am more physically active than others. People always believe that a starved
camel is bigger than a horse. Breast cancer is a common disease in my eyes,” said Patient 6.
For several patients (n = 3) in this study, the most important thing was confirming the clinical
stage of tumor. Patient 1 commented, “Actually, when my doctor told me the diagnose, I was very
sad. However, I felt so lucky after asking for details about my condition. I will get well soon,”
Another strong point of concern for the patients was the size and site of breast lump. Patient 3
pointed out:

When my hand touched a small breast lump in a shower, I was so scared that I told my husband. He
took me to a hospital as quickly as possible. Then my doctor told me that the size and site of my tumor
would make it easier to operate. I saw the light of life.

Early treatment outcomes not only provided an important foundation for further therapy, but also
allowed two patients to build up courage: “At first, I worried about the side-effect of chemother-
apy before the operation. However, the shrinkage of my tumor was apparent after preoperative
chemotherapy. This was a good news to me,” said Patient 10.

Hardiness
Hardiness was defined as a set of attitudes toward challenge, life, and disease. Five participants
regretted that there were so many things they wanted to do during their lives but could not. They
believed their lives had not reached their full potential. And they lived with hardiness to create
more value. “Five years ago, my son was diagnosed with uremia and underwent transplantation
with one of his father’s kidneys. Recently, his illness relapsed. At present, I’m sorry that I cannot
take care of them. I must be strong,” said Patient 7.

Confidence in situation
Confidence was identified as a positive kind of awareness of the present situation. Some patients
(n = 7) felt sad at the time of being informed of the diagnosis. However they became more and
more confident after getting relevant knowledge about breast cancer, which they did in various
ways. They believed the disease would be conquered with advanced medical science and
technology.

At the beginning of treatment, I knew little about breast cancer that bad mood troubled me for a long
period. After learning relevant knowledge, I realized that the five-year survival rate of breast cancer
patients was far higher than I had previously anticipated. I felt lucky and grateful. (Patient 12)

Several interviewees (n = 3) treated the disease positively, informed by their prior knowledge of
breast cancer. “A friend of mine was diagnosed with breast cancer 7 years ago. Before I got sick,
She told me that breast cancer could be cured.”
Ten interviewees were inspired by the experience of role models who had adapted to breast
cancer successfully.

During treatment, I read a book about a film star who was a cancer survivor. I was grateful for all the
useful experience it shared with me at early stage of my treatment. I would make a remarkable recov-
ery like her. (Patient 13)
6 T. Zhang et al.

Extreme fear of cancer compelled several patients to change their perspective of present state of
life. In our study, five women tried to improve life satisfaction by downward comparisons with
people who were more poor in their eyes. Patient 14 reported, “I know there are a lot of other
kinds of cancer patients, many of them are more miserable than me. I would be confident
when I thought of them.” Several interviewees (n = 5) tended to compare the current situation
with their worst experience. They believed their present lives to be much better than before.

Ten years ago, I was injured seriously from a car accident which taught me that life could change.
When I was depressed, I always recalled the accident. After comparing these two events, I was con-
vinced that breast cancer was just a change in my life as well. No pressure was needed, I just needed to
be confident to adapt to it. (Patient 6)

Optimistic attitude to the disease

Some interviewees developed a more optimistic outlook on their own uncertain future. Patients
tried actively to seek effective ways to adapt to the disease. They also became more optimistic
from these coping strategies. During treatment, the majority of patients stopped working
so that they had more free time to schedule their everyday lives on their own. Several people
(n = 8) took time to cultivate interests or find new hobbies.

I am a open-minded person. After receiving treatment, I wanted to enrich my life with new hobbies. I
spent almost all of my free time knitting. My friends liked my achievement very much. I felt more and
more pride with these beautiful clothes. (Patient 11)

Some optimistic patients tried to get comfort from religion. A few interviewees (n = 2) who
believe in Buddhism held the opinion that their soul would existed in other forms after they
passed away. They also believed that bodhisattva would bless them if they did more things
that were beneficial to others. “Everyone has to die eventually. But my soul would exist
forever. Furthermore, I have helped a lot of people. I believed Buddha would bless me. I am
not afraid to die,” reported Patient 1. Christian patients (n = 2) believed that everything in the uni-
verse is subject to the will of God. They regarded disease as part of God’s design and prayed to get
well. “God has arranged everything for us. And we should accept the reality. After I was diag-
nosed with cancer, I prayed for my health everyday. I believe I will get well soon,” reported
Patient 11.

Gratitude to supporters
Gratitude was defined as a feeling of appreciation. All of the interviewees got good care from
different kinds of social supporters. They wanted to do something to express their appreciation.
And grateful thinking increased patients’ levels of resilience. Several of them (n = 4) tried their
best to maintain closer relationships with their families.

During the treatment, I was very sensitive to my own mood. I did my best to disclose positive feelings
with my families in order to maintain harmonious relationships and make them happy. If I could not
help controlling my bad feelings, I would take action immediately to relieve my low mood and apol-
ogized. (Patient 7)

Some (n = 3) of the participants got supports from people outside their families. So they tried to
build good relationships with these people and decide to practice altruism to repay these favor.
 Contemporary Nurse 7

I had many good ward-mates in hospital. We kept in contact with each other almost every week. It
brought us a lot of joy. Sometimes, I also made appointments with my colleagues. We talked about
both my disease and our work. I am very grateful for their supports. I intended to do something
helpful for the society. (Patient 13).

Mastery of life
Some patients believed their ability to deal with the disease, alongside an awareness that there
would always be new changes that would need to be confronted. In order to adapt to their new
situation, patients changed direction in their lives. They derived more energy from making
new decisions. Patients were well aware of the reality that their lives were threatened by the
disease. They (n = 8) wanted to do something new for themselves.

I know how to deal with my hard life. I must change my concept of life. My previous life goal in life
was to make a lot of money to enjoy life. In order to realize the plan, I worked hard and ignored my
health. After treatment, I want to enjoy present life. (Patient 5)

Discussion
Although each year around 169,000 new cases of breast cancer are diagnosed in China, this is the
first qualitative study to explore the resilience factors of these patients. This study deepens our
understanding of resilience in facing adversity and highlights the inner strength of these breast
cancer survivors. Their experiences provide internal protective mechanisms that allow them to
cope with traumatic events effectively. The study showed that resilience factors centered
around biological and psychological concerns.
With regard to biological resources, the current study showed that hope for rehabilitation,
specifically three factors, which included prior health status, a mild case, and better early treat-
ment outcomes is an important promoters of resilience among Chinese breast cancer patients.
Patients tend to be most concerned with physiological status during their treatment since its
closely linked to prognosis. This is consistent with previous studies. A Chinese researcher
found chemotherapy course and cancer clinical stages to be predictors of resilience among
Chinese breast cancer patients (Huang, Xu, & Jiang, 2013). The results of one longitudinal
study showed that better early post-operative treatment outcomes predicted resilience among
Chinese women diagnosed with breast cancer (Lam et al., 2010). Doctors and nurses should
provide patients with adequate physiological information to prevent unnecessary worry.
We also found several psychological factors to participants. The first was hardiness. Partici-
pants’ attitudes toward the disease were influenced by the Chinese traditional concept of family.
Chinese women are more likely to value their family roles than Western women (Lai, 1995). In the
current study, all the participants were married and some of them had been caring for both the
children and their parents. Especially for patients who were suffering from negative family
events, their family role made it crucial that they face the illness bravely for the sake of their
relatives.
The current study revealed that participants’ confidence in situation rendered them more resi-
lient. Consistent with the result of a qualitative study showing that patients’ responses to the diag-
nose of breast cancer were affected by their prior knowledge (Kwok & White, 2011), our current
study indicated that some participants were confident about breast cancer after getting relevant
knowledge about breast cancer. One study of Chinese cancer patients showed that support in
the form of information was often urgently needed but not available (Hong, Song, Liu, Wang,
& Wang, 2014). This calls for clinical nurses to pay more attention to identifying and meeting
8 T. Zhang et al.

this need. Current study suggests that role models have important effects on patients’ resilience.
This is supported by other studies like the Pink Ribbon Mentorship Program implemented by the
Mayo Clinic. Previous survivors served as mentors to provide coping strategies and encourage-
ment to patients newly diagnosed with breast cancer (Loprinzi et al., 2011). After internalizing
useful experience from the previous patients, the current patients became more confident in
coping with the disease. Making full use of role models and other resources should be added
to the clinical psychological nursing curriculum. This study also supports the findings of a quan-
titative study that showed that the effect of satisfaction with life on resilience in breast cancer
patients (Kaczmarek, Sęk, Ziarko, & Marzec, 2012). Life satisfaction has significant and negative
correlation with depressive symptoms and stress among patients diagnosed with cancer (Hamdan-
Mansour, Al Abeiat, Alzoghaibi, Ghannam, & Hanouneh, 2014). Effective downward compari-
son promoted their confidence and life satisfaction, and finally increased their resilience.
Optimism was frequently demonstrated to be a predictive factor of better resilience (Stewart &
Yuen, 2011). Optimistic people tend to cope with challenge by positive coping style, such as
talking with others, finding new hobbies (Liu, Zhang, & Shi, 2017). Religious and spiritual
approaches are the most commonly used strategies to helping patients solve problems and
make decisions in Western countries (Babamohamadi, Negarandeh, & Dehghan-Nayeri, 2011).
In China, traditional culture is compatible with many different kinds of religions. In current
study, participants who believed in the religious doctrines of Buddhism and Christianity actively
sought help from their respective deities by praying or visiting places of worship.
Gratitude is an individual’s trait to respond with appreciation for perceived benefits or sup-
ports of one’s life. It may reduce the negative influence of disease (Fagley, 2012; McCullough,
Emmons, & Tsang, 2002). Social support can be distinguished as kin and non-kin. For
Chinese people, the family is generally a source of core support and they always emphasize estab-
lishing and maintaining a harmonious relationship with family members (Bond, 1996). In
addition, mutual benefits and diversified functions corresponding to a much wider variety of
social networks also urge them to communicate actively with non-related individuals (Lin &
Wang, 2011). Altruism showed a close link with religion and spirituality (Duriez, 2004; Huber
& MacDonald, 2012). And repayment is virtue rooted in Chinese tradition and participants
wanted to perform acts beneficial to others. Some patients were propelled by religious doctrines
saying that helping others would bring them more blessings from the divine. They listed altruism
as part of their new plans to guide themselves through adversity and fulfill the commands of their
faiths.
Mastery was independently associated with psychological well-being (Emlet, Shiu, & Kim,
2017). Our study showed that participants’ mastery of life promoted their resilience. Improved
goal attainment was found to be associated with increasing patients’ mastery. The diagnosis of
breast cancer affects patients’ QOL as well as their long-term plans (Blanckenburg et al.,
2014). Modifying life goals accordingly and exerting more effort toward realizing these modified
goals may be one mechanism by which patients may adapt to illness (Blanckenburg et al., 2014).
Trying to understand patients’ experience gained from the treatment and help them to set proper
life goals should be an important part of clinical nursing.
As described above, this study demonstrate that individual characteristics are important for
promoting resilience in Chinese breast cancer patients. Participants are more likely to have bio-
logical and psychological resources to draw upon. According to the results of the current study,
good physiological status increased the participants’ hope to fight the illness. Because of their
hardiness, optimism, confidence, gratitude and mastery, they actively tried many different
methods to adapt to adversity. However, if participants’ psychological resources were promoted
very well, adaption to breast cancer would become easier and their physical health may be
 Contemporary Nurse 9

influenced positively. The individual resources of breast cancer patients as a whole should be con-
sidered in the analysis of patients’ adaptive behavior in response to illness.

Study limitations
This study has several limitations. Firstly, the relatively small sample was drawn from only two
teaching hospitals in China and may not indicate the extent and diversity of resilience factors
among breast cancer patients in Chinese minorities or other groups within China. Second, all par-
ticipants were female and this prevented any identification of differences in resilience factors
between men and women.

Impact statement
Gaining further understanding of patients’ individual resource promoting resilience through
qualitative interviews is a useful step to enable us to describe survivors’ experiences to coping
with breast cancer directly using their own language. To our knowledge, there is a lack of quali-
tative study in traditional Chinese cultural context exploring the individual resource of patients
with breast cancer. We paid attention to psychological resources, biological resources, material
resources, age and gender according to the micro system of social ecosystem theory. This
study was part of a series aimed at promoting breast cancer patients’ resilience from different
aspect of society. Some potential advices on nursing were identified.

Conclusion
This study describes the individual resources used by Chinese breast cancer survivors in adapting
to the adversity and provides better understanding of processes of resilience. This study was based
on the social ecosystem theory and results suggested that nurses should not ignore the effect of
individual resource in survivors. Nurses should understand cultural or religious differences
between their patients and get to know their physiological and psychological need in their
nursing work in a timely manner. More importantly, this study also suggested that the social eco-
system theory is helpful for fully assessing patients’ individual resource. Further study in this area
is required to develop a comprehensive evaluation system that can help clinical nurses assess
patients and promote better adaption to breast cancer. Identifying other resilient factors from
mezzo and macro systems of social environment facilitate understanding of the mechanisms
underlying resilience in breast cancer patients.

Acknowledgments
We would like to thank the breast cancer patients and medical staff who supported this study.

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Appendix 1. Interview checklist

Topic questions/follow-up questions

1 Would you please share your experiences of breast cancer with me ?

- Outlook on breast cancer
- Feelings toward the process of treatment

2 Which of your individual resources helped you adapt to the disease ?

- Physiological resources
- Psychological resources
- Material resources
- Age and gender

3 What are your perceptions on life?

- Previous perceptions on life
- Present perceptions on life
- Have these perceptions changed? What is the reason for these change?