Nursing Intervention Essay
The effect of a nursing intervention on promoting self-care agency in breast cancer patients after breast surgery
INTRODUCTION
Breast cancer is a type of cancer, which is characterized by local uncontrolled cells growth and spread of abnormal cells in one or both breasts, which is the most common cancer in women around the world (Jemal et al., 2011). In Australia, over 12,614 (28%) women were diagnosed invasive breast cancer in 2006, and the number will keep on growing (AIHW, 2009). In 2006, a total of 2,618 women died from breast cancer; leading to the second cause of death for Australian women. However, the mortality rate of breast cancer had been decreasing since 1994 and the outcomes for breast cancer women have improved significantly …show more content…
(AIHW, 2009).
Quality of life means patients perceiving the physical, psychosocial, and emotional outcomes from healthcare treatments. Breast cancer is a potentially life-threatening, and its diagnosis and treatment can significantly impact the patient’s physical, psychological, social and financial aspects (Albert et al., 2004). A study showed that although women suffering from breast cancer had a better diagnosis and treatment than women with other cancers, they also had a lower quality of life, especially with more psychological problems than others (Engel et al., 2003). Recent studies have shown that currently the most effective way to treat breast cancer is surgical operation, which can significantly increase the survival rate of patients. However, breast surgery will significantly damage female body that may cause many complications and serious psychological trauma, which can directly affect their quality of marriage and social activities (Albert et al., 2004). As a result, a nursing strategy for breast cancer patients will be necessary to mitigate their poor quality of life and health problems.
Self-care refers to the individuals taking actions to care themselves or changing environmental conditions, in order to improve their own health through alleviation, elimination, or prevention of perceived problems (Orem, 1985). It depends on the individual ability to fill the self-care requirements. Because when people encounter health problems, the most important element is the self-health care that related to the further treatment and prognosis. Among this, self-care agency is becoming significant for human that is an integrated complex acquired capacity for individuals performing self-care activities, and is composed of belief, attitudes, skills, knowledge, and value motivation (Orem, 1985). And this ability can be improved through education, guidance and experiences of activities, but which is also influenced by culture, belief, health condition, economics, education, and life experiences. Therefore, it can adjust life processes, maintain or promote human integrity development, in order to promote well-being, which is one of the Orem self-care theory system concepts (Orem, 1985).
Recent research has indicated that the significance of self-care concept has been seen in many diseases and the effect of self-care agency on prognosis and quality of life has begun to be investigated.
A study showed that the prostatectomy patients who with high scores self-care agency would have higher level in quality of life than those who with lower scores (Kim, 2011). Another significant finding showed that greater self-care management related to greater self-care agency, leading to better glycemic control (Sousa et al., 2005). A study by Lev et al. (2001) stated that increased self-care perception increases treatment compliance and decreases physical and psychological symptoms, leading to the quality of life improvement (Lev et al., 2001). Therefore, how to promote patients’ self-care agency has become an important issue in nursing …show more content…
field.
In 1985, Orem asserted that the requirements of human limitations for self-health care conditions contribute to the requirement for nursing (Orem, 1985). It identified the self-care deficits and the needs of nurses’ actions performed after patients’ determination. A study showed that the prostatectomy patients who participated in the self-care agency promoting programme had higher scores in self-care ability than those who did not participate (Kim, 2011). As the importance of self-care agency for patients in enhancing quality of life, the nursing interventions to promote self-care agency has become significance for breast cancer patients. It is also the duty and responsibility of the nurse to educate and help them to promote their self-care agency; however, it would be a challenge for nurses. The significance of this study is to increase the knowledge on the subject of nursing intervention strategies which will enable patients with breast cancer through guided education to increase self-care agency result in improving quality of life.
Literature Review
Promoting the patients’ self-care agency is one way to improve the quality of life and make life better continuation. While quality of life is considered an essential issue in the prognosis for breast cancer women. After breast surgery, patients will face lots of conditions such as body image, drugs side-effect, and loss of part activities that is a hard time for patients both psychologically and physically. During this period it can easily occur for patients with poor adjustment and decreased quality of life that can be influenced by many factors (Frost et al., 2000; Schnipper, 2001). One study has reported that the level of education has an effect on quality of life and breast cancer patients in advanced stages had lower physical, psychological and social functioning than those in the early stages. And also, quality of life in patients with good economic situation is higher than the poor state of the economy (Gokgoz et al., 2011). Zhao revealed their findings that social support and breast cancer patients’ quality of life existed a positive correlation, especially the family support. The more support patients got from their families, the higher level that would be in patients’ quality of life (Zhao & Li, 2007). According to Lee et al. (2001) reported that among four independent variables (disease characteristics, individual characteristics, social support and psychological factors), the most influential factor affecting the quality of life for patients with breast cancer was the psychological factor (Lee et al., 2001).
In clinical, the nursing intervention in promoting self-care agency related quality of life among breast cancer patients is a neglected subject. Fewer researchers have discussed the effect of self-care agency on patients’ quality of life. Compared to some other surgical operation to treat acute illness, the level of self-care agency would be more significant for breast cancer patients in their future recovery and prognosis. One of the prior researches (Tastan et al., 2012) evaluated only a clinical pathway that affected on breast cancer patients undergoing breast surgery. This study indicates a positive effect on decreasing patient anxiety level, increasing patient satisfaction, and promoting quality of life (Tastan, et al., 2012). However, it did not consider about the care for breast cancer patients after discharging from hospital. Another study used a different self-care agency scale which was using to measure self-care agency in general, but not especially designed for patients with breast cancer (Duong, 1992) and the study used the self-care agency instrument only evaluate in terms of self-care skills and health knowledge. Therefore it can be said that these studies using the self-care agency instrument for evaluation of self-care agency for patients with breast cancer in a narrow sense.
However, in the previous data analysis Callaghan (2003) explored the relationship between self-care agency and self-care behaviors in humans. She found a strong relationship between psychological behaviors and self-care agency. Additionally, her findings revealed a need for nursing interventions promoting spiritual growth to improve self-care agency. Xie et al. (2011) suggested the use of health belief model based on self-care agency to examine the level of breast cancer patients’ self-care abilities. He recommended using such a model for breast cancer patients after surgery is the best guiding theory on improving self-care agency to promote rehabilitation of the disease (Xie, et al., 2011). And also, it indicated potential nursing interventions to investigate.
As a result, health care professionals must recognize the lack of patients in self-care and the importance of improving their self-care agency, besides their treatment in order to improve breast cancer patients’ health. The results of this study will help to fill gaps in the current limited knowledge and identify areas in which patients need additional support. Because it is obviously that many different factors can affect patients’ quality of life, health providers need to think about population variety focus on designing self-care skills and emotional interventions to improve patients’ self-care agency and quality of life. This will help patients’ adaptation to their disease, and physical and psychological well-being.
The purpose of this study is to determine the effect of a nursing intervention on promoting self-care agency in breast cancer patients who have had breast surgery, in order to provide a model for nursing care in assisting patients. The hypothesis is to be tested that participation in nursing intervention is associated with promoting self-care agency, as a result of improving quality of life.
Research questions:
1. What are the self-care agency and quality of life levels in Australian women with post-operative breast cancer?
2. What is the effect of a nurse-directed intervention on promoting self-care agency in patients who have had breast surgery?
3. What is the relationship between self-care agency and quality of life variables in Australian breast cancer patients?
Methodology
This study will be performed at the surgical ward for breast surgery of Westmead Hospital in NSW/Australia. A quasi-experimental and nonequivalent design (Borbasi & Jackson, 2011) is needed due to the study’s circumstances. 100 participants are to be into groups, each 50 participants will be allocated into the control group and the intervention group respectively. All of the followed patients will be interviewed to inform about the purpose of the study and participate voluntarily, and anonymity of study. A three-month intervention study will be conducted to analyze the effect of a nursing intervention on promoting self-care agency in patients who have had breast surgery. Time constraints can make a convenience sample necessary in order to obtain the appropriate number of participants.
An advantage to this design is that no other variables included confound the study. Based on the data collected from the demographic questionnaire statistical analysis can pinpoint whether there is a variation among this study. However, there would be some affect factors needed to be taken in to consideration like participant knowledge and post-operative time that may affect the patients’ self-care agency. Moreover, the ability to accurately report self-care agency scores possibly affects internal validity. In addition, participants involved in this study may have a pre-existing interest in self-care education to participating in the study. This may be a potential threat to internal validity.
As above stated, the sample included in this study should be adults who are post-breast surgery who have the ability to read, speak and hear in English. The age of participants will range from 18-80 years old. Trained RN working in the surgical area will be instructed and provide adaptable education for intervention group twice per week. Planned education programs can be providing verbal encouragement, introducing knowledge about disease and self-care skills and assisting patients to perform self-care. Assessment of patients’ self-care agency will be taken at the beginning of intervention, end of intervention, & 14 days after last intervention session.
Instruments
The questionnaires regarding the demographic characteristics and The Exercise of Self-care Agency (ESCA) Scale will be completed by the participants. The benefit of using questionnaires to collect data is words exact and patients have enough time to think of the answers.
Demographic questionnaire: There will be 8 items on the demographic questionnaire that includes age, educational level, marital status, whether fertility, occupation, economic condition, post-operative time and the knowledge about disease.
ESCA Scale: The ESCA Scale (Kearney & Fleischer, 1979) is a 43-item questionnaire measuring self-care agency. The tool is widely used in different populations for assessing self-care agency. This self- administered questionnaire incorporated 4 functional scales: self-care ability, self-care skills, self-care responsibility, and the level of health knowledge. All items will be scored on 5-point Likert Scale (Likert, 1932) ranging from 0 (not at all) to 4 (very much). As an exception, item 3, 6, 10, 16, 19, 22, 25, 28, 32, 34, and 39 in ESCA subscale are scored on a reverse score. All functional scales and individual item scores will be transformed to a 0-172 scale with higher values indicating a higher level in self-care agency.
References
Albert, U.S., Koller, M., Wagner, U., & Schulz, K.D. (2004). Survival chances and psychological aspects of quality of life in patients with localized early stage breast cancer. Inflammation Research. 53 (2), 136-141.
AIHW. (2009). Breast cancer in Australia: an overview, 2009. Cat. No. CAN 46. Canberra: AIHW. viewed from: http://www.aihw.gov.au/publication-detail/?id=6442468297. Borbasi, S., & Jackson, D. (2011). Navigating the maze of nursing research. Marrickville, NSW: Mosby Australia.
Callaghan, D.
M. (2003). Health-promoting self-care behaviors, self-care, self-efficacy, self-care agency. Nursing Science Quarterly, 16, 247-254.
Duong, D.N. (1992). Self-care in women with breast cancer. The University of Arizona, Service Branch: Air Force.
Engel, J., Kerri, J., Schlesinger-Raab, A., Eckel, R., Saucer, H., & Hobel, D. (2003). Comparison of breast and rectal cancer patients’ quality of life: results of a four year prospective field study. European Journal of Cancer Care. 12, 215-223.
Frost, M. H., Suman, V. J., & Rummans, T. A. (2000). Physical, psychological and social well-being of women with breast cancer: the influence of disease phase. Psychooncology. 9 (3), 221-231.
Gokgoz, S., Sadikoglu, G., Paksoy, E., Guneytepe, U., Ozcakir, A., Bayram. N., & Bilgel, N. (2011). Health related quality of life among breast cancer patients: a study from Turkey. Global Journal of Health Science. 3 (2), 140-152.
Jemal, A., Bray, F., Center, M.M., Ferlay, J., Ward, E., & Forman, D. (2011). Global Cancer Statistics. A Cancer Journal for Clinicians. 61, 69-90.
Kim, H.S. (2011). Development and evaluation of self-care agency promoting programme for prostatectomy patients. International Journal of Urological Nursing. 5 (1),
34-44.
Kearney, B. Y., & Fleischer, B. J. (1979). Development of an instrument to measure exercise of self-care agency. Research in Nursing and Health. 2(1), 25-34.
Likert, R. (1932). A Technique for the Measurement of Attitudes. Archives of Psychology. 140, 1–55.
Lev, E.L., Daley, K.M., Conner, N.E., Reith, M., Fernandez, G., & Quren, S. L. (2001). An intervention to increase quality of life and self-care self-efficacy and decrease symptoms in breast cancer patients. Scholarly Inquiry for Nursing Practice. 15 (3), 277-294.
Lee, H.L., Ku, N.P., Dow, W.J., & Pai, L. (2001). Factors related to quality of life in breast cancer patients receiving chemotherapy. J Nurs Res. 9 (3), 57-68.
Orem, D. (1985). Nursing: Concepts of Practice (3rd Ed.). New York, NY: McGraw-Hill.
Schnipper, H. H. (2001). Life after breast cancer. Journal of Clinical Oncology. 19, 3581-3584.
Sousa, V.D., Zauszniewski, J.A., Musil, C.M., Price-Lea, P.J., & Davis, S.A. (2005). Relationship among self-care agency, self-efficacy, self-care and Glycemic control. Research and Theory for Nursing Practice. 19 (3), 217-130.
Tastan, S.,Hatipoglu, S.,Lyigun, E., & Kilic, S. (2012). Implementation of a clinical pathway in breast cancer patients undergoing breast surgery. European Jounal of Oncology Nursing. 16, 368-374.
Xie, D., Zuo, P., & Lin, Y. (2011). Effective study on self-care ability of breast cancer patients after surgery by health belief model. Clinical Journal of Chinese Medicine. 3 (3), 21-22.
Zhao, J., & Li, Q. (2007). An analysis of the relationship between social support and breast cancer patients’quality of life. Modern Nursing. 2007. 13(19), 1787-1789.
INTRODUCTION
Breast cancer is a type of cancer, which is characterized by local uncontrolled cells growth and spread of abnormal cells in one or both breasts, which is the most common cancer in women around the world (Jemal et al., 2011). In Australia, over 12,614 (28%) women were diagnosed invasive breast cancer in 2006, and the number will keep on growing (AIHW, 2009). In 2006, a total of 2,618 women died from breast cancer; leading to the second cause of death for Australian women. However, the mortality rate of breast cancer had been decreasing since 1994 and the outcomes for breast cancer women have improved significantly …show more content…
(AIHW, 2009).
Quality of life means patients perceiving the physical, psychosocial, and emotional outcomes from healthcare treatments. Breast cancer is a potentially life-threatening, and its diagnosis and treatment can significantly impact the patient’s physical, psychological, social and financial aspects (Albert et al., 2004). A study showed that although women suffering from breast cancer had a better diagnosis and treatment than women with other cancers, they also had a lower quality of life, especially with more psychological problems than others (Engel et al., 2003). Recent studies have shown that currently the most effective way to treat breast cancer is surgical operation, which can significantly increase the survival rate of patients. However, breast surgery will significantly damage female body that may cause many complications and serious psychological trauma, which can directly affect their quality of marriage and social activities (Albert et al., 2004). As a result, a nursing strategy for breast cancer patients will be necessary to mitigate their poor quality of life and health problems.
Self-care refers to the individuals taking actions to care themselves or changing environmental conditions, in order to improve their own health through alleviation, elimination, or prevention of perceived problems (Orem, 1985). It depends on the individual ability to fill the self-care requirements. Because when people encounter health problems, the most important element is the self-health care that related to the further treatment and prognosis. Among this, self-care agency is becoming significant for human that is an integrated complex acquired capacity for individuals performing self-care activities, and is composed of belief, attitudes, skills, knowledge, and value motivation (Orem, 1985). And this ability can be improved through education, guidance and experiences of activities, but which is also influenced by culture, belief, health condition, economics, education, and life experiences. Therefore, it can adjust life processes, maintain or promote human integrity development, in order to promote well-being, which is one of the Orem self-care theory system concepts (Orem, 1985).
Recent research has indicated that the significance of self-care concept has been seen in many diseases and the effect of self-care agency on prognosis and quality of life has begun to be investigated.
A study showed that the prostatectomy patients who with high scores self-care agency would have higher level in quality of life than those who with lower scores (Kim, 2011). Another significant finding showed that greater self-care management related to greater self-care agency, leading to better glycemic control (Sousa et al., 2005). A study by Lev et al. (2001) stated that increased self-care perception increases treatment compliance and decreases physical and psychological symptoms, leading to the quality of life improvement (Lev et al., 2001). Therefore, how to promote patients’ self-care agency has become an important issue in nursing …show more content…
field.
In 1985, Orem asserted that the requirements of human limitations for self-health care conditions contribute to the requirement for nursing (Orem, 1985). It identified the self-care deficits and the needs of nurses’ actions performed after patients’ determination. A study showed that the prostatectomy patients who participated in the self-care agency promoting programme had higher scores in self-care ability than those who did not participate (Kim, 2011). As the importance of self-care agency for patients in enhancing quality of life, the nursing interventions to promote self-care agency has become significance for breast cancer patients. It is also the duty and responsibility of the nurse to educate and help them to promote their self-care agency; however, it would be a challenge for nurses. The significance of this study is to increase the knowledge on the subject of nursing intervention strategies which will enable patients with breast cancer through guided education to increase self-care agency result in improving quality of life.
Literature Review
Promoting the patients’ self-care agency is one way to improve the quality of life and make life better continuation. While quality of life is considered an essential issue in the prognosis for breast cancer women. After breast surgery, patients will face lots of conditions such as body image, drugs side-effect, and loss of part activities that is a hard time for patients both psychologically and physically. During this period it can easily occur for patients with poor adjustment and decreased quality of life that can be influenced by many factors (Frost et al., 2000; Schnipper, 2001). One study has reported that the level of education has an effect on quality of life and breast cancer patients in advanced stages had lower physical, psychological and social functioning than those in the early stages. And also, quality of life in patients with good economic situation is higher than the poor state of the economy (Gokgoz et al., 2011). Zhao revealed their findings that social support and breast cancer patients’ quality of life existed a positive correlation, especially the family support. The more support patients got from their families, the higher level that would be in patients’ quality of life (Zhao & Li, 2007). According to Lee et al. (2001) reported that among four independent variables (disease characteristics, individual characteristics, social support and psychological factors), the most influential factor affecting the quality of life for patients with breast cancer was the psychological factor (Lee et al., 2001).
In clinical, the nursing intervention in promoting self-care agency related quality of life among breast cancer patients is a neglected subject. Fewer researchers have discussed the effect of self-care agency on patients’ quality of life. Compared to some other surgical operation to treat acute illness, the level of self-care agency would be more significant for breast cancer patients in their future recovery and prognosis. One of the prior researches (Tastan et al., 2012) evaluated only a clinical pathway that affected on breast cancer patients undergoing breast surgery. This study indicates a positive effect on decreasing patient anxiety level, increasing patient satisfaction, and promoting quality of life (Tastan, et al., 2012). However, it did not consider about the care for breast cancer patients after discharging from hospital. Another study used a different self-care agency scale which was using to measure self-care agency in general, but not especially designed for patients with breast cancer (Duong, 1992) and the study used the self-care agency instrument only evaluate in terms of self-care skills and health knowledge. Therefore it can be said that these studies using the self-care agency instrument for evaluation of self-care agency for patients with breast cancer in a narrow sense.
However, in the previous data analysis Callaghan (2003) explored the relationship between self-care agency and self-care behaviors in humans. She found a strong relationship between psychological behaviors and self-care agency. Additionally, her findings revealed a need for nursing interventions promoting spiritual growth to improve self-care agency. Xie et al. (2011) suggested the use of health belief model based on self-care agency to examine the level of breast cancer patients’ self-care abilities. He recommended using such a model for breast cancer patients after surgery is the best guiding theory on improving self-care agency to promote rehabilitation of the disease (Xie, et al., 2011). And also, it indicated potential nursing interventions to investigate.
As a result, health care professionals must recognize the lack of patients in self-care and the importance of improving their self-care agency, besides their treatment in order to improve breast cancer patients’ health. The results of this study will help to fill gaps in the current limited knowledge and identify areas in which patients need additional support. Because it is obviously that many different factors can affect patients’ quality of life, health providers need to think about population variety focus on designing self-care skills and emotional interventions to improve patients’ self-care agency and quality of life. This will help patients’ adaptation to their disease, and physical and psychological well-being.
The purpose of this study is to determine the effect of a nursing intervention on promoting self-care agency in breast cancer patients who have had breast surgery, in order to provide a model for nursing care in assisting patients. The hypothesis is to be tested that participation in nursing intervention is associated with promoting self-care agency, as a result of improving quality of life.
Research questions:
1. What are the self-care agency and quality of life levels in Australian women with post-operative breast cancer?
2. What is the effect of a nurse-directed intervention on promoting self-care agency in patients who have had breast surgery?
3. What is the relationship between self-care agency and quality of life variables in Australian breast cancer patients?
Methodology
This study will be performed at the surgical ward for breast surgery of Westmead Hospital in NSW/Australia. A quasi-experimental and nonequivalent design (Borbasi & Jackson, 2011) is needed due to the study’s circumstances. 100 participants are to be into groups, each 50 participants will be allocated into the control group and the intervention group respectively. All of the followed patients will be interviewed to inform about the purpose of the study and participate voluntarily, and anonymity of study. A three-month intervention study will be conducted to analyze the effect of a nursing intervention on promoting self-care agency in patients who have had breast surgery. Time constraints can make a convenience sample necessary in order to obtain the appropriate number of participants.
An advantage to this design is that no other variables included confound the study. Based on the data collected from the demographic questionnaire statistical analysis can pinpoint whether there is a variation among this study. However, there would be some affect factors needed to be taken in to consideration like participant knowledge and post-operative time that may affect the patients’ self-care agency. Moreover, the ability to accurately report self-care agency scores possibly affects internal validity. In addition, participants involved in this study may have a pre-existing interest in self-care education to participating in the study. This may be a potential threat to internal validity.
As above stated, the sample included in this study should be adults who are post-breast surgery who have the ability to read, speak and hear in English. The age of participants will range from 18-80 years old. Trained RN working in the surgical area will be instructed and provide adaptable education for intervention group twice per week. Planned education programs can be providing verbal encouragement, introducing knowledge about disease and self-care skills and assisting patients to perform self-care. Assessment of patients’ self-care agency will be taken at the beginning of intervention, end of intervention, & 14 days after last intervention session.
Instruments
The questionnaires regarding the demographic characteristics and The Exercise of Self-care Agency (ESCA) Scale will be completed by the participants. The benefit of using questionnaires to collect data is words exact and patients have enough time to think of the answers.
Demographic questionnaire: There will be 8 items on the demographic questionnaire that includes age, educational level, marital status, whether fertility, occupation, economic condition, post-operative time and the knowledge about disease.
ESCA Scale: The ESCA Scale (Kearney & Fleischer, 1979) is a 43-item questionnaire measuring self-care agency. The tool is widely used in different populations for assessing self-care agency. This self- administered questionnaire incorporated 4 functional scales: self-care ability, self-care skills, self-care responsibility, and the level of health knowledge. All items will be scored on 5-point Likert Scale (Likert, 1932) ranging from 0 (not at all) to 4 (very much). As an exception, item 3, 6, 10, 16, 19, 22, 25, 28, 32, 34, and 39 in ESCA subscale are scored on a reverse score. All functional scales and individual item scores will be transformed to a 0-172 scale with higher values indicating a higher level in self-care agency.
References
Albert, U.S., Koller, M., Wagner, U., & Schulz, K.D. (2004). Survival chances and psychological aspects of quality of life in patients with localized early stage breast cancer. Inflammation Research. 53 (2), 136-141.
AIHW. (2009). Breast cancer in Australia: an overview, 2009. Cat. No. CAN 46. Canberra: AIHW. viewed from: http://www.aihw.gov.au/publication-detail/?id=6442468297. Borbasi, S., & Jackson, D. (2011). Navigating the maze of nursing research. Marrickville, NSW: Mosby Australia.
Callaghan, D.
M. (2003). Health-promoting self-care behaviors, self-care, self-efficacy, self-care agency. Nursing Science Quarterly, 16, 247-254.
Duong, D.N. (1992). Self-care in women with breast cancer. The University of Arizona, Service Branch: Air Force.
Engel, J., Kerri, J., Schlesinger-Raab, A., Eckel, R., Saucer, H., & Hobel, D. (2003). Comparison of breast and rectal cancer patients’ quality of life: results of a four year prospective field study. European Journal of Cancer Care. 12, 215-223.
Frost, M. H., Suman, V. J., & Rummans, T. A. (2000). Physical, psychological and social well-being of women with breast cancer: the influence of disease phase. Psychooncology. 9 (3), 221-231.
Gokgoz, S., Sadikoglu, G., Paksoy, E., Guneytepe, U., Ozcakir, A., Bayram. N., & Bilgel, N. (2011). Health related quality of life among breast cancer patients: a study from Turkey. Global Journal of Health Science. 3 (2), 140-152.
Jemal, A., Bray, F., Center, M.M., Ferlay, J., Ward, E., & Forman, D. (2011). Global Cancer Statistics. A Cancer Journal for Clinicians. 61, 69-90.
Kim, H.S. (2011). Development and evaluation of self-care agency promoting programme for prostatectomy patients. International Journal of Urological Nursing. 5 (1),
34-44.
Kearney, B. Y., & Fleischer, B. J. (1979). Development of an instrument to measure exercise of self-care agency. Research in Nursing and Health. 2(1), 25-34.
Likert, R. (1932). A Technique for the Measurement of Attitudes. Archives of Psychology. 140, 1–55.
Lev, E.L., Daley, K.M., Conner, N.E., Reith, M., Fernandez, G., & Quren, S. L. (2001). An intervention to increase quality of life and self-care self-efficacy and decrease symptoms in breast cancer patients. Scholarly Inquiry for Nursing Practice. 15 (3), 277-294.
Lee, H.L., Ku, N.P., Dow, W.J., & Pai, L. (2001). Factors related to quality of life in breast cancer patients receiving chemotherapy. J Nurs Res. 9 (3), 57-68.
Orem, D. (1985). Nursing: Concepts of Practice (3rd Ed.). New York, NY: McGraw-Hill.
Schnipper, H. H. (2001). Life after breast cancer. Journal of Clinical Oncology. 19, 3581-3584.
Sousa, V.D., Zauszniewski, J.A., Musil, C.M., Price-Lea, P.J., & Davis, S.A. (2005). Relationship among self-care agency, self-efficacy, self-care and Glycemic control. Research and Theory for Nursing Practice. 19 (3), 217-130.
Tastan, S.,Hatipoglu, S.,Lyigun, E., & Kilic, S. (2012). Implementation of a clinical pathway in breast cancer patients undergoing breast surgery. European Jounal of Oncology Nursing. 16, 368-374.
Xie, D., Zuo, P., & Lin, Y. (2011). Effective study on self-care ability of breast cancer patients after surgery by health belief model. Clinical Journal of Chinese Medicine. 3 (3), 21-22.
Zhao, J., & Li, Q. (2007). An analysis of the relationship between social support and breast cancer patients’quality of life. Modern Nursing. 2007. 13(19), 1787-1789.