The Journal of Nursing Research h VOL. 26, NO.
4, AUGUST 2018
Downloaded from http://journals.lww.com/jnr-twna by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 02/28/2022
ORIGINAL ARTICLE
Effects of a Psychoeducational Intervention in
Patients With Breast Cancer Undergoing
Chemotherapy
Pei-Hua WU1 & Shang-Wen CHEN2 & Wen-Tsung HUANG3 & Shu-Chan CHANG4
Mei-Chi HSU5*
ABSTRACT
Background: Compelling evidence has yet to be published
regarding the positive effect of psychoeducational interven-
tions (PEIs) on psychological distress in patients with breast
cancer. The impact of PEIs on self-efficacy, resilience, and
quality of life is also unclear.
Purpose: The aim of this study was to assess the effects of a
PEI on anxiety, depression, disease-specific care knowledge,
self-efficacy, resilience and quality of life in patients with breast
cancer during and after chemotherapy. The intervention was
administered before and during five rounds of chemotherapy
treatment.
Methods: A randomized controlled trial was conducted.
Patients with breast cancer (N = 40) were randomly assigned
to either the experimental or control group. The experimental
group participated in PEI, a brief and highly structured program
consisting of two parts: (a) an educational manual that
addressed depression, anxiety, disease-specific care knowl-
edge, self-efficacy, and resilience and (b) a self-assessment of
learning. The control group received only traditional pamphlet
education. Data were collected at four time points: before the
first chemotherapy session (T1), during the third chemother-
apy session (T2), during the fifth chemotherapy session (T3),
and at 2 weeks after the final chemotherapy session (T4).
Results: Anxiety, depression, resilience, and quality of life in
the experimental group showed significant differences at T4.
Significant differences became apparent at T2 for knowledge
and at T3 for self-efficacy. The effects of knowledge, resilience,
and quality of life remained significant when group and time
interactions were included in the model, showing a positive
relationship between PEI and the variables of knowledge,
resilience, and quality of life.
Conclusions/Implications for Practice: Face-to-face PEI for
patients with breast cancer is potentially effective in improving
knowledge, resilience, and quality of life during and after chemo-
therapy. In the current study, PEI significantly improved disease
care techniques, reduced chemotherapy-related discomfort, and
improved quality of life for participants in the experimental group.
KEY WORDS:
psychoeducational intervention, breast cancer, self-efficacy,
resilience, quality of life.
266
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Introduction
Cancer is an important global health issue. The World Health
Organization (WHO) has projected that new cancer cases will
reach 22 million globally by 2032 (WHO, 2014). Breast
cancer, in particular, is the most important disease affecting
women’s health worldwide (WHO, 2014) and is the fourth
leading cause of cancer death among women in Taiwan. A
recent report shows that the breast cancer mortality rate for
the period of 2006Y2010 is 54.79% higher for individuals
aged 20Y44 years and 149.78% higher for individuals aged
45Y64 years than for the period of 1971Y1975 (Ho, Hsiao,
Su, Chou, & Liaw, 2015).
Patients with cancer often experience specific perceived
stress as well as clinically significant symptoms and psycho-
logical distress (Huang & Hsu, 2013; Lai, 2016; Liao et al.,
2014). In patients with breast cancer, anxiety and depression
both after diagnosis and during treatment are common clinical
reactions that may lower the quality of life of patients (Hsu
& Tu, 2014; So et al., 2009). Indeed, patients with breast
cancer may experience anxiety during chemotherapy treat-
ment. Depression is also a common comorbidity that
requires careful management for Taiwanese breast cancer
survivors (Huang & Hsu, 2013; Liao et al., 2014). Both
anxiety and depression influence disease progression and
treatment compliance, and the more stressful the event that
is experienced by patients with breast cancer, the greater
the risk of experiencing chaotic emotions.
Promoting resilience mechanisms during cancer treat-
ment contributes to better adaptation and positive psy-
chosocial outcomes during and after treatment (Molina
et al., 2014). Women with breast cancer with higher self-
efficacy may be better able to control mood disturbances.
Thus, improving self-efficacy and resilience in patients
with cancer may lead to greater health-promoting behav-
iors such as adherence to treatment regimens. Women with
1
MSN, RN, Section Chief, Cancer Center, Chi Mei Medical Center,
Liouying & 2MD, Attending Physician, Department of Hematology
and Oncology, Chi Mei Medical Center, Liouying & 3MD, Director,
Cancer Center, Department of Hematology and Oncology, Chi Mei
Medical Center, Liouying & 4MSN, RN, Senior Administrator,
Cancer Center, Chi Mei Medical Center, Liouying & 5PhD, RN,
Associate Professor, Department of Nursing, I-Shou University.
Psychoeducational Intervention for Breast Cancer
breast cancer have reported improved resilience after psycho-
logical intervention (Victoria Cerezo, Ortiz-Tallo, Cardenal,
& De La Torre-Luque, 2014).
Psychoeducation is a process that provides information,
helps solve and discuss needs and problems, lowers stress,
manages symptoms, develops relaxation and adaptation
skills, guides emotional expression, and provides social sup-
port (Chiquelho, Neves, Mendes, Relvas, & Sousa, 2011;
Liao et al., 2014). Psychoeducation may help patients adjust
to changes in emotions and stress (Chiquelho et al., 2011;
Liao et al., 2014).
Many studies have examined the effects of psychoeducational
interventions (PEIs) in patients with cancer. Generally, the
psychoeducation process includes a health education man-
ual, one-on-one discussions, self-help groups, social support
groups, psychoeducation, cognitive behavioral therapy,
psychodynamic therapy, positive thinking training, and
telephone consultations. The design of different PEIs has
varied substantially in terms of delivery method, format,
frequency, timing, and disease- and treatment-related
content.
Depression and anxiety may influence the quality of life
of patients with breast cancer undergoing treatment with
chemotherapy (Taso et al., 2014). To date, no compelling
evidence has shown that PEIs are effective in addressing
the psychological distress of patients with breast cancer.
A number of randomized controlled trials have examined
the effects of PEI. No treatment effects were found for
quality of life, mood, symptoms, or psychological distress;
no postintervention treatment effects were found for per-
ceived stress, self-efficacy, quality of life, or mood; and no
treatment effects were found for quality of life or mood at
follow-up (Sandgren & McCaul, 2003, 2007). Moreover,
no significant differences in preYpost intervention change
scores were observed in terms of confidence with managing
fatigue, anxiety, depression, or quality of life (Yates et al.,
2005). Coleman et al. (2005) also found no significant dif-
ferences between groups in terms of mood or symptom out-
comes. However, two trials have suggested that PEIs may
have a positive effect on psychological distress (Chambers
et al., 2014), depression and anxiety levels, and quality of
life (Mahendran et al., 2015). Capozzo, Martinis, Pellis,
and Giraldi (2010) reported that women with breast can-
cer who participated in a 6-week structured supportiveY
expressive group psychotherapy intervention showed a
significant reduction in anxious preoccupation during the
early phase of adaptation to breast cancer. Similarly, Dastan
and Buzlu (2012) provided psychoeducational programs to
patients with Stage IYII breast cancer to improve their levels of
adjustment to cancer. Another study that utilized the Roy
adaptation model-based support and education intervention
was conducted over a 13-month period on 125 women with
early-stage breast cancer (Samarel, Tulman, & Fawcett,
2002). Results showed that the patients exhibited lower
levels of mood disturbance, less loneliness, and better rela-
tionships with a significant other after the intervention.
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 26, NO. 4, AUGUST 2018
Schofield et al. (2008) conducted an educational DVD
intervention for patients undergoing chemotherapy to assist
them to self-manage the side effects of the disease. They
found that providing chemotherapy patients with relevant
disease care knowledge increased patients’ understanding of
the disease, treatment, and side effects as well as their abil-
ity to care for themselves. Another study evaluated the effect
of providing a self-care manual and nursing instruction to
patients with breast cancer undergoing initial chemo-
therapy and found that the intervention reduced patient
uncertainty regarding the disease and treatment and en-
hanced the ability to care for themselves (Lien et al., 2010).
Similarly, a study of a community-based educational pro-
gram, which was a half-day patient education conference
implemented in accordance with the Patient Active Empow-
erment Model, was conducted to assess the effects on patient
and caregiver skills and knowledge related to disease
management and side effect treatment (Golant, Altman, &
Martin, 2003). Results showed that this program was
effective in patients with breast cancer, as shown by a
significant decrease in symptoms such as depression and
problems in work and daily life that were attributable to
psychological distress (Golant et al., 2003). In addition, Oh
and Kim (2010) designed a brief psychosocial intervention
that involved alleviating helplessness or hopelessness, anxi-
ety, and depression; enhancing fighting spirit; and improving
self-care behaviors by strengthening self-efficacy in patients
with cancer who were receiving adjuvant therapy. Although
no significant relief of patients’ helplessness or hopelessness,
anxiety, or depression was found, the fighting spirit and self-
care abilities of these patients improved significantly.
In Taiwan, two studies have described the degrees of
effectiveness of education and psychological support inter-
ventions for patients with breast cancer. Liao et al. (2014)
reported that patients with breast cancer who had partic-
ipated in an educational and psychological support inter-
vention experienced a significant decrease in state anxiety
and symptom distress and an improvement in terms of
unmet supportive care needs. In another study, Liu et al.
(2008) applied bodyYmindYspirit group therapy for partic-
ipants with breast cancer and found no apparent effects on
depression or well-being. Thus, more dedicated research on
PEIs is required in Taiwan. Furthermore, psychological
distress, self-efficacy, and resilience have been associated
with health status, although their specific influences and
impacts on quality of life among patients with breast cancer
are not yet sufficiently understood. These previous studies
have focused on reducing clinical psychological distress,
reducing patient distress, ameliorating treatment-related
concerns, and/or reducing the prevalence and severity of
distress caused by six chemotherapy side effects or by
anxiety and depression (Akechi et al., 2007; Aranda et al.,
2012). This study compares the longitudinal changes and
final outcomes of a PEI in terms of psychological and quality-
of-life variables in a population of patients with breast cancer
undergoing chemotherapy.
267
The Journal of Nursing Research
Conceptual Framework
The intervention protocol for this study was carefully con-
structed based on the findings of earlier research on breast
cancer and the Stress and Coping Model (Lazarus &
Folkman, 1984), which guided the development of the
PEI and outcome variables. According to the framework,
people who have been diagnosed with cancer may experi-
ence a combination of disease-related physical, emotional,
and stress effects (Lazarus & Folkman, 1984). Problem-
focused coping, emotional-focused coping, and stress
coping processes are widely accepted as important strate-
gies for individuals with cancer (Lazarus & Folkman, 1984).
This concept may be more practical for patients with breast
cancer whose situations are perceived as challenging and
who have the social support and health resources needed to
deal with the stressors. Accordingly, the most essential
components of the PEI in this study were to assist patients
with breast cancer to (a) maximize their physical and
emotional adjustments, (b) gain more adaptive and accu-
rate perspectives and knowledge to address health problems
and self-efficacy, and (c) build confidence and pro-
mote resilience to cope adequately with their specific sur-
vivorship concerns. Instruments that related directly to the
conceptual framework of the study were used to measure the
intervention effects over time.
The aim of this study was to evaluate the effects of the
PEI, which encompassed a broad range of activities, in-
cluding education and other activities addressing anxiety,
depression, disease-specific care knowledge, quality of life,
self-efficacy, and resilience in patients with breast cancer
undergoing chemotherapy. The hypothesis was that patients
receiving the PEI would experience significant reductions in
their levels of anxiety and depression and significant
improvements in terms of their disease care knowledge,
self-efficacy, resilience, and quality of life.
Methods
Design
This study was a randomized controlled trial and was
conducted in a cancer medical center located in southern
Taiwan. The PEI, a brief and highly structured program
that involves educational and support components, was
delivered individually. The PEI included interaction be-
tween healthcare professionals and patients, use of a self-
directed videotape, educational information and materials,
and an educational manual. After collecting baseline data
and assigning participants randomly into the two groups,
the PEI was conducted in six 60-minute sessions during
five chemotherapy treatments. Participants in the control
group were exposed only to the traditional pamphlet education
approach (consultation from nurses and information sheets)
in the outpatient department.
268
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Pei-Hua WU et al.
Participants
Inclusion criteria were (a) diagnosed with Stages IYIV of
breast cancer, (b) aged 20 years or older, (c) underwent a
modified radical mastectomy (MRM), (d) able to commu-
nicate in both Mandarin and Taiwanese, (e) currently re-
ceiving postoperative chemotherapy, and (f) willing to
participate. The exclusion criteria were having a major
psychiatric diagnosis or a serious medical condition with life-
threatening side effects or currently using antidepressant,
antianxiety, or other psychotropic medications.
Sample Size
An appropriate sample size was estimated using power
analysis to control for Type II error. This study used
Statistical Software Sample Power 2.0, with the power set
at 0.8 to limit the risk of a Type II error to 20%, the alpha
set at .05, and the covariate’s R2 set at .13. This was based
on the results of one study found in the literature; after a
6-week targeted, multiple intervention, researchers found
a mean difference in depression scores on the Hospital
Anxiety and Depression Scale (HADS) between the exper-
imental and control groups of 2.0, with a pooled standard
deviation of 3.6 (Oh & Kim, 2010). Therefore, the effect
size of the covariate adjustment in this study was set at
0.37, and the number of samples for each group was
calculated to be 20.
Randomization
Randomization of the study groups was carried out after the
eligibility of patients had been confirmed. All of the eligible
patients with breast cancer were randomly assigned to either
the experimental group or the control group using sealed
envelopes, in which the assigned method of treatment was
noted. Participants remained in the assigned experimental
and control groups throughout the study.
Intervention Programs
The experimental group received six sections of PEI during
chemotherapy, with each section lasting at least 1 hour. Each
session had defined goals and content. The arrangements of
the six sessions of PEI included informing the participants
of the medical aspects of their condition, informing them
about their treatments and symptoms, training them to care
for themselves and to respond to disease-related problems,
and teaching them activities to promote self-management of
their disease and related symptoms. These activities were
aimed to help patients identify the symptoms of their emotio-
nal responses, clarify interpretations of symptom-related
emotional changes, and learn about the related mechanisms.
The administrator of the training was a nurse with
experience in the management of patients with cancer.
Psychoeducational Intervention for Breast Cancer
The broad scope of the PEI was divided into two cate-
gories: (a) an educational manual that offered information
and activities related to depression, anxiety, disease-specific
care knowledge, self-efficacy, and resilience and (b) a self-
assessment of learning.
The educational manual provided a user-friendly guide.
For example, the section on disease-specific care knowl-
edge addressed a wide spectrum of knowledge, including
(a) suggestions on how to deal with special physical and
psychological conditions, (b) pharmacological treatments,
(c) an introduction to artificial blood vessels and methods
of self-care, (d) common chemotherapy side effects and
methods of self-care, (e) home dietary guidance, and (f)
uses of alternative treatments.
The contents of the activities consisted of six themes: (a)
relaxation techniques, (b) experience sharing, (c) adaptation
techniques, (d) emotional management, (e) scenarios, and (f)
forums. For example, relaxation techniques that focus on
modifying the breathing rate, relaxing the muscles through-
out the body, stopping negative thinking, and calming
emotions were taught to participants to reduce health risk
factors such as anxiety. A Hendrickson muscle relaxation
training session lasting for 15 minutes was used as the
relaxation technique in this study (Lee & Lee, 1993). This
technique achieves relaxation by using autosuggestion,
leading participants to harness their own inner feelings
while relaxed. The training was divided into 10 steps. For
example, muscle tension relaxation began with the facial
muscles and continued to the legs. Relaxation training for
peripheral muscle systems is designed to promote physical
and mental balance in combination with rhythmic breathing
and imagination. Self-assessments of learning used disease-
specific care knowledge scales to help patients evaluate their
own knowledge and skills.
Data Collection
This study was conducted in two phases. The content and
learning materials of the PEI were developed, and the validity
and reliability of these materials were established in Phase 1.
Content validity, an essential approach in the development of
the PEI, was evaluated by experts who identified the entire
domain of content relevant to the research and then evaluated
the instruments associated with the PEI. Feedback was
obtained from a panel of three nationally recognized mental
health experts who held positions in research, academia, and
clinical practice. Panel members were asked to determine the
quality of the content.
In Phase 2, before data collection commenced, the
hospital reviewed and approved this study. The investigators
explained the study objectives and methods to the relevant
doctors and hospital administrators and to the patients with
breast cancer who were anticipating chemotherapy. Before
the study began, all participants signed informed consent.
The chemotherapy regimens used for breast cancer chemo-
therapy after MRM included cyclophosphamide, metho-
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 26, NO. 4, AUGUST 2018
trexate, and 5-fluorouracil; cyclophosphamide, epirubicin,
and 5-fluorouracil; cyclophosphamide, doxorubicin, and
5-fluorouracil; and taxotere, Adriamycin, and cyclophos-
phamide. Chemotherapy was administered over a series of
six cycles (18 weeks). Data were collected at different time
points by the researchers in accordance with the partici-
pants’ treatment regimens, including just before the first
chemotherapy (T1), which was used as the baseline; during
the third (T2) and fifth (T3) chemotherapy sessions; and at
2 weeks after the final session (T4; Figure 1).
Two methods were applied in this study to avoid con-
tamination. One instructed the participants in the exper-
imental group not to share information with other patients.
Similarly, health professionals in the ward were requested
not to discuss this study with colleagues and patients who
might be involved in the control group. The second method
was to admit experimental and control group participants
into different cancer wards to provide geographic separation
between the two groups and reduce the likelihood of their
interacting and sharing information or materials.
Outcome Measures
The design of this study incorporates a number of outcome
measures to capture the effect of the intervention in participants
with breast cancer undergoing chemotherapy. Each measure
for each data collection time point is shown in Figure 1.
The HADS is primarily designed to test general clinical
patient symptoms of anxiety and depression and to assess the
severity of emotional impairment (Zigmond & Snaith, 1983).
The Chinese version of the HADS, which was translated by
Chen et al. (1999), was used in this study. The translated
version includes the anxiety and depression subscales, with
seven questions each. Each subscale uses a 4-point Likert
scale (0Y3 points) with total possible scores ranging between
0 and 21. A score below 7 indicates no anxiety or depression
problems, a score between 8 and 10 indicates the possible
presence of anxiety or depression problems, and a score
greater than 11 indicates a definite presence of anxiety or
depression problems. The Chinese version has shown
acceptable reliability (Chen et al., 1999).
This study used the disease-specific care knowledge
scale developed by Li (1990). This scale contains three
major parts, which respectively address treatment goals, side
effects, and self-care during treatment; each part consists of
16 questions. Correct answers are scored 1, and incorrect
answers are scored 0; higher total scores indicate greater
knowledge of chemotherapy. The scale has shown good
validity and reliability (Li, 1990).
Two different questionnaires (EORTC QLQ-C30 [European
Organization for Research and Treatment of Cancer Quality
of Life Questionnaire-Core 30] and EORTC QLQ-BR23
[European Organization for Research and Treatment of
Cancer Quality of Life Questionnaire-breast cancer mod-
ule 23]) were used in this study as disease-specific quality-
of-life questionnaires. This study employed the Chinese
269
The Journal of Nursing Research Pei-Hua WU et al.

Figure 1. Flow diagram of participant progress throughout the study. HADS = Hospital Anxiety and Depression Scale; EORTC
QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; BR23 = breast
cancer module 23.

version of the quality-of-life questionnaire for patients
with cancer, which was jointly translated by Chie, Chang,
Huang, and Kuo (2003) and the EORTC. This questionnaire,
abbreviated as the EORTC QLQ-C30, contains 30 questions
on global health status/quality of life, physical function, role
function, emotional function, cognitive function, social func-
tion, fatigue, pain, and nausea and vomiting. Quality of life is
assessed using a score ranging from 1 to 7 (extremely bad to
extremely good), whereas the rest of the questionnaire is
scored using a 4-point Likert scale, in which 1 represents
‘‘none’’ and 4 represents ‘‘many.’’
The EORTC QLQ-BR23 contains 23 questions covering
systemic therapy side effects (eight questions on chemotherapy
and hormone therapy), breast symptoms, arm symptoms, body

270

Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Psychoeducational Intervention for Breast Cancer
image, and sexual functions and single questions on perspec-
tives on the future, sexual enjoyment, and distress related
to hair loss. Scoring uses a 4-point Likert scale in which
1 represents ‘‘none’’ and 4 represents ‘‘many.’’ The EORTC
QLQ-C30 and EORTC QLQ-BR23 have shown acceptable
reliability and validity (Chie et al., 2003).
This study used the self-efficacy scale created by Cheng
(2000). The scale includes five questions on cancer patients’
physiology, physical functions, psychology, society, and
spirit. The scoring uses a 5-point Likert scale, with 1 =
expectations are never met, 2 = expectations are rarely met,
3 = expectations are sometimes met, 4 = expectations are
mostly met, and 5 = expectations are completely met. The
Cronbach’s " coefficient for this scale was .89 (Cheng, 2000).
Finally, this study used the resilience scale designed by
Wagnild and Young (1993). This scale contains 25 items and
is scored using a 7-point Likert scale, with 1 representing
strongly ‘‘disagree’’ and 7 representing ‘‘strongly agree.’’
Total possible scores range from 25 to 175, with scores
below 120 associated with poor resilience, scores between
121 and 146 associated with moderate resilience, and
scores over 147 associated with excellent resilience. The
Cronbach’s " coefficient for this scale was .91 (Wagnild &
Young, 1993).
Ethical Considerations
After the study protocol was reviewed and approved by
the institutional review board (File no. 10008-L07), the
investigators explained the objectives and methods to the
participants before the commencement of their chemo-
therapy. Participants were identified by number to protect
their anonymity. Participants were allowed to revoke their
consent at any time during the study and drop out for any
reason without negatively affecting their subsequent
medical care. Different scales were employed at different
time points during the study, reflecting considerations of
patients’ chemotherapy-related fatigue and the features of
outcomes. For example, the scales that were used to
measure resilience and quality of life required time and
effort to engage people to make changes and to develop
better strategies. Thus, data were collected for these scales
only at T1 and T4.
Statistical Analysis
IBM SPSS Statistics Version 22.0 (IBM, Inc., Armonk, NY,
USA) was used to analyze the data. Descriptive statistics
were used to characterize the sample, which was analyzed
using nonparametric techniques and Fisher’s exact test.
Differences between early and late interventions (T1YT4)
were analyzed using the MannYWhitney U test. Changes
between baseline and postintervention were assessed using
the Wilcoxon signed-rank test. Mixed model was used to
analyze the outcomes of nonnormal data distributions in
longitudinal designs (Cheng, Edwards, Maldonado-Molina,
Komro, & Muller, 2010). Nonparametric statistics has
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 26, NO. 4, AUGUST 2018
been applied as a powerful tool in smaller samples under
certain nonnormality conditions. A statistical significance
level of p G .05 was used for all of the comparisons.
Results
Participant Characteristics
The average age for the experimental group was 51.2
years, ranging from 30 to 70 years with an SD of 9.18
years, whereas the average age for the control group was
51.2 years, ranging from 31 to 76 years with an SD of
10.71 years (Table 1). Regarding the type of cancer,
invasive ductal carcinoma was the most common type of
cancer in the experimental group (n = 17), with one
participant each having invasive lobular carcinoma, medul-
lary carcinoma, and mucinous carcinoma. Similarly, invasive
ductal carcinoma was the most common type of cancer in the
control group (n = 19), with one participant having
mucinous carcinoma. Regarding the distribution of cancer
stages, Stage 2 (n = 8, 40%) was the most common stage in
the experimental group, and Stage 3 (n = 7, 35%) was the
most common stage in the control group, a statistically
significant intergroup difference between (p G .05). With
respect to the type of surgery, most in the experimental
group received MRM (n = 16), with two in this group
receiving breast conservative surgery and one each receiving
simple mastectomy and partial mastectomy. Similarly, most
in the control group received MRM (n = 14), with four in
this group receiving breast conservative surgery and two
receiving partial mastectomy. The patient compositions of
the two groups were comparable, as shown in Table 1.
Effects of the Psychoeducational
Intervention
The results in Table 2 show that the scores for anxiety and
depression were not significantly different between the
control and experimental groups at T1 and T2 (p 9 .05).
However, significant decreases were found in the experi-
mental group after the end of chemotherapy (T4; p G .05).
Before chemotherapy (T1), scores for disease-specific
care knowledge in the experimental group were slightly
higher than those in the control group (p = .048), and their
scores increased progressively over the course of the study.
As a result, the intergroup difference was even more striking
at the third administration of chemotherapy (T2; p = .001).
In terms of self-efficacy, whereas no significant differ-
ences were found between the control and experimental
groups before the start of chemotherapy (T1) or at T2 (p 9 .05),
significant differences were found starting at T3 (p = .021).
Similarly, the scores for resilience were not significantly
different between the two groups at T1 (p = .449). However,
the scores for the experimental group participants were
significantly higher than those in the control group at 2
weeks after the conclusion of chemotherapy (T4; p = .045;
Table 2).
271
The Journal of Nursing Research Pei-Hua WU et al.

TABLE 1.
Demographic and Clinical Data (N = 40)
Experimental Control
(n = 20) (n = 20) Total
Variable n % n % n % p

Age (mean, SD) 51.2 9.18 51.2 10.71 .725

Education .051
Illiterate 1 5.0 1 5.0 2 5.0
Elementary school 7 35.0 3 15.0 10 25.0
Middle school 6 30.0 4 20.0 10 25.0
High school 4 20.0 5 25.0 9 22.5
Junior college 1 5.0 4 20.0 5 12.5
College or above 1 5.0 3 15.0 4 10.0
Religion .173
None 8 40.0 4 20.0 12 30.0
Yes 12 60.0 16 80.0 28 70.0
Marital status .545
Single 2 10.0 2 10.0 4 10.0
Married 14 70.0 16 80.0 30 75.0
Divorced 3 15.0 1 5.0 4 10.0
Widowed 1 5.0 1 5.0 2 5.0
Number of children .318
0 2 10.0 3 15.0 5 12.5
1Y2 10 50.0 12 60.0 22 55.0
Q3 8 40.0 5 25.0 13 32.5
Occupation .294
Unemployed 16 80.0 13 65.0 29 72.5
Employed 4 20.0 7 35.0 11 27.5
Main caregiver .909
Self 5 25.0 6 30.0 11 27.5
Spouse 8 40.0 7 35.0 15 37.5
Child 7 35.0 4 20.0 11 27.5
Parent 0 0.0 3 15.0 3 7.5
Stage of cancer .019
1 7 35.0 2 10.0 9 22.5
2 8 40.0 6 30.0 14 35.0
3 3 15.0 7 35.0 10 25.0
4 2 10.0 5 25.0 7 17.5
Number of times of cancer (including this time) .594
1 18 90.0 19 95.0 37 92.5
2 2 10.0 0 0.0 2 5.0
Q3 0 0.0 1 5.0 1 2.5
Previous hospitalizations .107
Never 8 40.0 4 20.0 12 30.0
1Y2 times 8 40.0 8 40.0 16 40.0
Q 3 times 4 20.0 8 40.0 12 30.0
Previous surgeries .407
Never 8 40.0 5 25.0 13 32.5
1Y2 times 10 50.0 13 65.0 23 57.5
Q 3 times 2 10.0 2 10.0 4 10.0
Previous chemotherapy 1.000
Never 19 95.0 19 95.0 38 95.0
1Y2 times 1 5.0 1 5.0 2 5.0
(continues)

272

Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Psychoeducational Intervention for Breast Cancer VOL. 26, NO. 4, AUGUST 2018

TABLE 1.
Demographic and Clinical Data (N = 40), Continued
Experimental Control
(n = 20) (n = 20) Total
Variable n % n % n % p

Menstruation .327
Premenopause 9 45.0 5 25.0 14 35.0
Menopause 2 10.0 4 20.0 6 15.0
Postmenopause 9 45.0 11 55.0 20 50.0
Perceived severity .075
Mildly severe 6 30.0 3 15.0 9 22.5
Moderately severe 11 55.0 9 45.0 20 50.0
Severe 2 10.0 5 25.0 7 17.5
Extremely severe 1 5.0 3 15.0 4 10.0
Other treatments before chemotherapy .305
None 3 15.0 5 25.0 8 20.0
Surgery 16 85.0 15 75.0 31 77.5
Chinese medicine 1 5.0 0 0.0 1 2.5
Current other treatments .554
None 18 90.0 19 95.0 37 92.5
Radiation therapy 1 5.0 0 0.0 1 2.5
Hormone therapy 0 0.0 1 5.0 1 2.5
Chinese medicine 1 5.0 0 0.0 1 2.5

TABLE 2.
Comparison of Pretest and Posttest Anxiety, Depression, Disease-Care Specific
Knowledge, Self-Efficacy, and Resilience
Experimental (n = 20) Control (n = 20)
Variable Mean SD Mean SD p Value of Between Groups

Anxiety
T1 6.75 4.61 8.55 5.15 .248
T2 4.70 2.66 5.70 3.73 .470
T4 2.40 1.50 4.25 2.57 .004
Depression
T1 7.10 3.84 7.75 3.63 .523
T2 5.00 1.84 5.95 2.31 .298
T4 2.80 1.99 4.50 1.47 .002
Chemotherapy-specific knowledge
T1 11.35 2.41 9.80 2.35 .048
T2 12.65 1.09 10.60 2.09 .001
T4 14.65 0.99 11.55 1.64 G .001
Self-efficacy
T1 18.95 4.12 17.65 3.63 .333
T2 19.00 1.34 17.80 2.63 .058
T3 20.05 1.43 18.80 2.07 .021
T4 21.95 1.47 20.80 1.28 .003
Resilience
T1 116.85 22.00 119.90 14.96 .449
T4 131.90 16.20 122.15 13.12 .045

Note. T1 = before the first chemotherapy session; T2 = during the third chemotherapy session; T3 = during the fifth chemotherapy session; T4 = at 2 weeks
after the final chemotherapy session.

273

Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
The Journal of Nursing Research Pei-Hua WU et al.

TABLE 3.
Comparison of Pretest and Posttest Quality of Life
Experimental (n = 20) Control (n = 20)
Item Mean SD Mean SD p Value of Between Groups

EORTC QLQ-C30 (global health status)

Global health status/Quality of life
T1 67.50 17.08 61.25 11.56 .031
T4 88.75 8.24 70.00 10.26 G .001
EORTC QLQ-C30 (functional scales)
Physical function
T1 87.33 8.62 86.99 10.25 .900
T4 95.99 3.99 91.99 5.96 .025
Role function
T1 81.67 16.13 83.33 15.29 .774
T4 92.49 10.08 85.00 15.19 .118
Emotional function
T1 73.33 16.80 72.92 18.31 .967
T4 89.99 8.80 85.00 10.68 .122
Cognitive function
T1 85.83 14.58 78.33 15.39 .139
T4 99.17 3.73 90.83 10.08 .002
Social function
T1 74.99 25.07 84.99 15.20 .202
T4 94.17 11.18 93.33 12.56 .929
EORTC QLQ-C30 (symptom scales)
Fatigue
T1 22.78 13.23 23.33 12.95 .955
T4 9.44 8.28 15.55 14.15 .213
Nausea and vomiting
T1 4.17 9.17 8.33 12.68 .261
T4 0.00 0.00 5.00 9.52 .018
Pain
T1 16.67 10.81 20.00 16.75 .597
T4 3.33 6.84 7.50 10.08 .154
Dyspnea
T1 8.33 14.81 9.99 19.04 .928
T4 3.33 10.26 6.67 13.68 .382
Insomnia
T1 24.99 26.21 48.33 27.52 .006
T4 21.67 19.57 24.99 30.35 .988
Appetite loss
T1 18.33 17.01 19.99 16.75 .752
T4 3.33 10.26 6.67 13.68 .382
Constipation
T1 3.33 10.26 13.33 25.13 .111
T4 0.00 0.00 8.33 18.33 .038
Diarrhea
T1 6.67 13.68 5.00 16.31 .432
T4 0.00 0.00 1.67 7.45 .317
Financial problems
T1 9.99 15.67 3.33 10.26 .262
T4 1.67 7.45 3.33 10.26 .553
EORTC QLQ-BR23 (functional scales)
Body image
T1 73.34 22.56 74.58 18.23 1.000
T4 88.75 13.32 79.17 13.38 .037
(continues)

274

Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Psychoeducational Intervention for Breast Cancer VOL. 26, NO. 4, AUGUST 2018

TABLE 3.
Comparison of Pretest and Posttest Quality of Life, Continued
Experimental (n = 20) Control (n = 20)
Item Mean SD Mean SD p Value of Between Groups

Sexual functions
T1 96.67 8.72 98.33 7.45 .323
T4 92.50 11.44 94.99 9.52 .469
Sexual enjoyment
T1 129.99 14.91 129.99 14.91 1.000
T4 111.66 32.93 123.33 19.04 .323
Future perspective
T1 50.00 22.94 44.99 24.84 .373
T4 68.34 7.45 46.67 19.94 G .001
EORTC QLQ-BR23 (symptom scales)
Systemic therapy side effects
T1 14.05 8.67 11.19 8.50 .378
T4 12.38 7.63 12.38 7.31 .956
Breast symptoms
T1 16.25 11.30 17.08 18.43 .562
T4 4.17 4.27 9.17 8.51 .035
Arm symptoms
T1 21.11 11.34 19.99 23.80 .216
T4 3.89 5.44 7.22 14.09 .821
Upset by hair loss
T1 1.67 7.45 6.67 20.52 .515
T4 19.99 29.42 19.99 27.36 .879

Note. EORTC QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; T1 = before the first chemotherapy
session; T4 = at 2 weeks after the final chemotherapy session; BR23 = breast cancer module 23.

Table 3 shows no significant intergroup differences on the
EORTC QLQ-C30 and EORTC QLQ-BR23, except in the
insomnia and global health status subscales, at T1 (p 9 .05),
indicating that the baseline scores were similar in both groups
before chemotherapy. At T4, the experimental group scored
significantly higher than the control group on the EORTC
QLQ-C30 functional scales (physical function, cognitive
function) and symptom scales (nausea and vomiting, consti-
pation) and on the EORTC QLQ-BR23 functional scales (body
images, future perspective) and symptom scales (breast symp-
toms; see Table 3).
Results of the full model, including predictors, are displayed
in Table 4. The effects of knowledge (" = 0.52, SE = 0.22, p =
.022), resilience (" = 4.27, SE = 1.46, p = .006), and quality of
life (" = 4.18, SE = 1.33, p = .003) remained significant when
group and time interactions were included in the model. These
significant effects indicated a positive relationship between PEI
and the variables of knowledge, resilience, and quality of life.
The significant effects on these outcome measures indicate that
participants from the experimental group perceived higher
levels of knowledge, resilience, and quality of life than their
control group peers.
Discussion
The results of this study confirm that the PEI may be an
effective intervention for patients with breast cancer. The
PEI used in this study provided participants with information
about treatments, symptoms, and side effects; helped them
learn to manage their disease-related problems; taught them
how to relax as a way to reduce psychological distress; and
taught adaptive strategies for cancer. This study carefully
controlled the status of the participants in terms of having
the intervention run from beginning of the first cycle of
chemotherapy through the last cycle and considered the
dimensions of psychological distress, self-efficacy, resilience,
and quality of life. Data were collected at four time points,
allowing for the measurement of change over time.
The experimental group had relatively lower levels of
anxiety and depression than the control group. Whereas
the differences in the decrease in anxiety and depression
between the two groups were not statistically significant at
the third administration of chemotherapy, the differences
were significant 2 weeks after the end of chemotherapy (T4).
This finding is consistent with Dolbeault et al. (2009), who
conducted an 8-week psychoeducational group intervention
on 81 participants with early-stage breast cancer and found
that the intervention significantly decreased participant levels
of anxiety and depression. In this study, PEI significantly
lowered the levels of anxiety and depression in participants.
The PEI allowed them to learn more disease care techniques
and gave them emotional support, making them better
equipped to handle the stress of chemotherapy. This finding is

275

Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
The Journal of Nursing Research Pei-Hua WU et al.

TABLE 4. better prepared to manage care for their disease and its
Analysis of Anxiety and Depression, discomforts, to reduce treatment- and side-effect-related anxi-
Chemotherapy Knowledge, eties, and to increase their ability to adjust and improve their
Self-Efficacy, and Quality of Life quality of life (Chelf et al., 2002; So et al., 2009). Furthermore,
our findings were consistent with those of Lien et al. (2010),
Variable " SE p who showed that an intervention that included a self-care
manual and nursing instruction markedly improved the self-
Anxiety care abilities of patients with breast cancer undergoing initial
Group (experimental vs. control) j1.38 1.36 .315 chemotherapy. In this study, the self-care ability of partici-
Time: T4 vs. T1 j1.22 0.27 G .001
pants had clearly increased after the intervention. Lam,
Group  Time (experimental j1.41 0.38 .710
vs. control): T4 vs. T1 Shing, Bonanno, Mancini, and Fielding (2012) have
shown that the optimism and satisfaction that is felt by
Depression
patients who acquire necessary information may relate to
Group (experimental vs. control) j0.28 1.08 .795
Time: T4 vs. T1 j1.00 0.24 G .001
lower levels of distress both during treatment and even up to
Group  Time (experimental j0.36 0.35 .309 6 years after the completion of treatment.
vs. control): T4 vs. T1 Indeed, face-to-face discussion as a method of treatment
Knowledge has been proven to be successfully in resolving psychological
Group (experimental vs. control) 1.03 0.72 .155 distress and improving physical side effects (Park et al.,
Time: T4 vs. T1 0.56 0.16 G .001 2012; Sherman et al., 2012). Keller (2006) has suggested
Group  Time (experimental 0.52 0.22 .022 that, when nurses provide health education to patients before
vs. control): T4 vs. T1 chemotherapy, it increases chemotherapy-specific knowl-
Self-efficacy edge and improves their ability to handle side effects and
Group (experimental vs. control) 1.35 1.05 .203 implement appropriate adjustment strategies. In this study,
Time: T4 vs. T1 1.05 0.23 G .001 patients with breast cancer received PEI and a complete
Group  Time (experimental j0.05 0.32 .880 chemotherapy self-care manual. We found that this helped
vs. control): T4 vs. T1 patients gain more disease care knowledge and techniques to
Resilience handle chemotherapy.
Group (experimental vs. control) j7.31 6.09 .234 Although PEI had not significantly changed participant self-
Time: T4 vs. T1 0.75 1.03 .472 efficacy at the end of the third administration of chemotherapy
Group  Time (experimental 4.27 1.46 .006 (T2), significant improvement was observed at the fifth
vs. control): T4 vs. T1 administration (T3). Moreover, patient resilience had signifi-
Quality of life cantly increased at 2 weeks after the conclusion of chemother-
Group (experimental vs. control) 2.07 4.09 .661 apy (T4; Table 2). This result indicates that PEI may be
Time: T4 vs. T1 2.90 0.94 G .001 effective in enhancing self-efficacy for patients with breast
Group  Time (experimental 4.18 1.33 .003 cancer, which in turn may reduce their anxiety and depression.
vs. control): T4 vs. T1
PEIs have been developed to enhance patient resilience by
Note. T1 = before the first chemotherapy session; T4 = at 2 weeks after the helping patients with breast cancer promote more positive
final chemotherapy session. psychosocial outcomes before, during, and after cancer
treatment (Molina et al., 2014). Resilience may serve as a
similar to the results of Chelf et al. (2002) who showed that mechanism for positive adaptation, which increases positive
educational guidance and help could lower patients’ anxiety psychosocial functioning, protects against psychological
and increase their ability to adjust and improve their quality distress during cancer treatment, and protects quality of life
of life. Our finding is also in agreement with several other after completion of therapy in women with breast cancer.
studies showing that patients who received PEI experience Furthermore, PEIs may assist patients with breast cancer to
less psychological distress (Akechi et al., 2007; Park, Bae, cope with distressing emotions over time, as PEI has been
Jung, & Kim, 2012), less anxiety, higher treatment satisfac- shown to help patients undergoing cancer-related treatment
tion, and better self-care, which helps patients with cancer (Schou Bredal et al., 2014).
adjust to their disease (Akechi et al., 2007; Park et al., 2012; Quality of life is a multidimensional construct that
Sherman et al., 2012). consists of physical, psychological, and spiritual compo-
Newly diagnosed patients with breast cancer undergoing nents (Chie et al., 2003; Huang & Hsu, 2013). In this
treatment generally have insufficient knowledge of cancer and study, psychoeducation improved the psychological dis-
its treatment, physiological symptoms, and coping strategies. tress of patients and their adjustment to cancer. Conse-
This study found that disease-specific care knowledge had quently, overall better health status and quality of life
significantly improved by the third administration of chemo- were found at 2 weeks after the conclusion of chemo-
therapy in PEI patients. Patients with cancer who learn correct therapy. This finding is consistent with previous studies
and clear information through educational guidance may be (Dolbeault et al., 2009; Park et al., 2012), indicating that

276

Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Psychoeducational Intervention for Breast Cancer
psychoeducation and consultation indeed lower the inci-
dence of complications and the severity of side effects, thus
improving quality of life and decreasing the psychological-
symptom-related difficulties of patients with breast cancer
(Park et al., 2012).
Study Limitations
Limitations of our study include the small sample size,
which was drawn from a single institution and excluded
those with serious medical conditions. As the convenience
sampling approach that was used may limit the general-
ization of results, the findings reported in this study should
be interpreted cautiously. In addition, illness status (new
diagnosis or recurrence) and previous treatment received,
including treatment time, treatment modalities, and ad-
mission, may affect treatment outcomes. A further study
limitation is the significant difference in cancer stage
between the two groups at baseline, which may reduce
the power of our study to examine the effects of PEI.
Future investigation should include larger samples and
explore more deeply all of the relationships among the
clinical variables to obtain more conclusive claims regard-
ing the treatment mechanism, psychological- and quality-
of-life-related changes, and the efficacy of the evaluation.
A double-blind method may be a further important aspect
of future study on this issue because both psychoeducation
and relaxation are known to be helpful to patients.
Conclusions
Sharing critical disease care knowledge, symptoms, and
adaptation techniques with patients rather than providing
education that is focused on single symptoms or single
dimensions may improve the efficacy of cancer care. This
study provides evidence that PEI effectively increases disease
care knowledge, reduces anxiety and depression, and
improves treatment self-efficacy, resilience, and quality of
life in patients with breast cancer undergoing chemotherapy,
in addition to teaching progressive relaxation techniques to
patients. Nurses have an important role to play in the
application of PEI. Finally, it is recommended that future
studies on PEIs in Taiwanese patients with breast cancer use
more homogeneous samples and that interventions be
adapted to meet the needs of specific subgroups such as
patients at different stages of their disease.
Relevance to Clinical Practice
The results of this study indicate that PEI is a useful interven-
tion for patients with breast cancer. This study provides clinical
values for patient changes across several time points. We
suggest that PEI be implemented as a useful tool and be made
part of standard care to increase breast-cancer-specific knowl-
edge, to better understand treatment-related concerns, and
to enhance mental and physical health outcomes in patients
with breast cancer.
In addition, our study suggests that face-to-face psy-
choeducation in clinical oncology settings helps accelerate
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 26, NO. 4, AUGUST 2018
the positive adaptation of newly diagnosed and pre-
chemotherapy patients with breast cancer. During chemo-
therapy, patients with breast cancer often do not know how
to handle treatment or their disease. Thus, it is recommended
that PEI be given to patients before undergoing initial
chemotherapy. This will reduce the anxiety of patients and
enhance their confidence in coping with cancer, its treat-
ment, and its side effects. PEIs may also be applied to surgical
and radiation treatments to reduce the physiological and
psychological discomforts of treatment. The education of
patients by nurses may be helpful in the overall effective
management of cancer-related issues.
Accepted for publication: April 23, 2017
*Address correspondence to: Mei-Chi HSU, No. 8, Yida Rd.,
Jiaosu Village, Yanchao District, Kaohsiung City 82445,
Taiwan, ROC. Tel: +886-7-615-1100 ext. 7720;
E-mail: hsu88@isu.edu.tw
The authors declare no conflicts of interest.
Cite this article as:
Wu, P.H., Chen, S.W., Huang, W.T., Chang, S. C., & Hsu, M.C.
(2018). Effects of a psychoeducational intervention in patients
with breast cancer undergoing chemotherapy. The Journal of
Nursing Research, 26(4), 266Y279. https://doi.org/10.1097/
jnr.0000000000000252
References
Akechi, T., Taniguchi, K., Suzuki, S., Okamura, M., Minami, H.,
Okuyama, T., I Uchitomi, Y. (2007). Multifaceted psycho-
social intervention program for breast cancer patients after
first recurrence: Feasibility study. Psychooncology, 16(6), 517Y524.
https://doi.org/10.1002/pon.1101
Aranda, S., Jefford, M., Yates, P., Gough, K., Seymour, J.,
Francis, P., I Schofield, P. (2012). Impact of a novel nurse-led
prechemotherapy education intervention (ChemoEd) on patient
distress, symptom burden, and treatment-related information
and support needs: Results from a randomised, controlled trial.
Annals of Oncology, 23(1), 222Y231. https://doi.org/10.1093/
annonc/mdr042
Capozzo, M. A., Martinis, E., Pellis, G., & Giraldi, T. (2010). An
early structured psychoeducational intervention in patients
with breast cancer: Results from a feasibility study. Cancer
N u r s i n g , 3 3 ( 3 ) , 2 2 8Y2 34 . h t t ps : // do i. or g /1 0. 1 09 7 /
NCC.0b013e3181c1acd6
Chambers, S. K., Girgis, A., Occhipinti, S., Hutchison, S.,
Turner, J., McDowell, M., I Dunn, J. C. (2014). A random-
ized trial comparing two low-intensity psychological in-
terventions for distressed patients with cancer and their
caregivers. Oncology Nursing Forum, 41(4), E256YE266.
https://doi.org/10.1188/14.ONF.E256-E266
Chelf, J. H., Deshler, A. M., Thiemann, K. M., Dose, A. M.,
Quella, S. K., & Hillman, S. (2002). Learning and support
preferences of adult patients with cancer at a comprehen-
sive cancer center. Oncology Nursing Forum, 29(5),
863Y867. https://doi.org/10.1188/02.ONF.863-867
Chen, P. Y., See, L. C., Wang, C. H., Lai, Y. H., Chang, H. K., &
Chen, M. L. (1999). The impact of pain on the anxiety and
depression of cancer patients. Formosan Journal of Medicine,
277
The Journal of Nursing Research
3(4), 373Y382. https://doi.org/10.6320/FJM.1999.3(4).02 (Original
work published in Chinese)
Cheng, J., Edwards, L. J., Maldonado-Molina, M. M., Komro, K. A.,
& Muller, K. E. (2010). Real longitudinal data analysis for real
people: Building a good enough mixed model. Statistics in
Medicine, 29(4), 504Y520. https://doi.org/10.1002/sim.3775
Cheng, S. Y. (2000). A study of the association of symptom
distress, self efficacy, social support and quality of life
among breast cancer patients (Unpublished master’s thesis).
Taipei Medical University, Taiwan, ROC. (Original work
published in Chinese)
Chie, W. C., Chang, K. J., Huang, C. S., & Kuo, W. H. (2003).
Quality of life of breast cancer patients in Taiwan: Validation
of the Taiwan Chinese version of the EORTC QLQ-C30 and
EORTC QLQ-BR23. Psychooncology, 12(7), 729Y735. https://
doi.org/10.1002/pon.727
Chiquelho, R., Neves, S., Mendes, A., Relvas, A. P., & Sousa, L.
(2011). proFamilies: A psycho-educational multi-family
group intervention for cancer patients and their families.
European Journal of Cancer Care, 20(3), 337Y344. https://
doi.org/10.1111/j.1365-2354.2009.01154.x
Coleman, E. A., Tulman, L., Samarel, N., Wilmoth, M. C., Rickel,
L., Rickel, M., & Stewart, C. B. (2005). The effect of telephone
social support and education on adaptation to breast cancer
during the year following diagnosis. Oncology Nursing Forum,
32(4), 822Y829. https://doi.org/10.1188/05.ONF.822-829
Dastan, N. B., & Buzlu, S. (2012). Psychoeducation intervention
to improve adjustment to cancer among Turkish stage IYII
breast cancer patients: A randomized controlled trial. Asian
Pacific Journal of Cancer Prevention, 13(10), 5313Y5318.
https://doi.org/10.7314/APJCP.2012.13.10.5313
Dolbeault, S., Cayrou, S., Brédart, A., Viala, A. L., Desclaux, B.,
Saltel, P., I Dickes, P. (2009). The effectiveness of a psycho-
educational group after early-stage breast cancer treatment:
Results of a randomized French study. Psycho-Oncology,
18(6), 647Y656. https://doi.org/10.1002/pon.1440
Golant, M., Altman, T., & Martin, C. (2003). Managing cancer
side effects to improve quality of life: A cancer psychoeducation
program. Cancer Nursing, 26(1), 37Y44.
Ho, M. L., Hsiao, Y. H., Su, S. Y., Chou, M. C., & Liaw, Y. P.
(2015). Mortality of breast cancer in Taiwan, 1971Y2010:
Temporal changes and an age-period-cohort analysis.
Journal of Obstetrics and Gynaecology, 35(1), 60Y63.
https://doi.org/10.3109/01443615.2014.935717
Hsu, M. C., & Tu, C. H. (2014). Improving quality-of-life outcomes
for patients with cancer through mediating effects of depres-
sive symptoms and functional status: A three-path mediation
model. Journal of Clinical Nursing, 23(17Y18), 2461Y2472.
https://doi.org/10.1111/jocn.12399
Huang, C. Y., & Hsu, M. C. (2013). Social support as a moderator
between depressive symptoms and quality of life outcomes of
breast cancer survivors. European Journal of Oncology Nursing,
17(6), 767Y774. https://doi.org/10.1016/j.ejon.2013.03.011
Keller, J. S. (2006). Implementation of a prechemotherapy
educational intervention for women newly diagnosed with
breast cancer. Clinical Journal of Oncology Nursing, 10(1),
57Y60. https://doi.org/10.1188/06.CJON.57-60
Lai, Y. H. (2016). Perspectives on cancer survivorship: Care and
challenges. The Journal of Nursing Research, 24(2), 190Y192.
https://doi.org/10.1097/jnr.0000000000000163
278
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Pei-Hua WU et al.
Lam, W. W., Shing, Y. T., Bonanno, G. A., Mancini, A. D., &
Fielding, R. (2012). Distress trajectories at the first year
diagnosis of breast cancer in relation to 6 years survivorship.
Psychooncology, 21(1), 90Y99. https://doi.org/10.1002/pon.1876
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and
coping. New York, NY: Springer.
Lee, M. B., & Lee, Y. J. (1993). Behavior therapy for neurotic
disorders. Taipei City, Taiwan, ROC: Health World. (Original
work published in Chinese)
Li, R. M. (1990). A study of the cancer patients about their
knowledge, self-care behaviors and other related factors for
chemotherapy induced side effects of gastrointestinal tract
(Unpublished master’s thesis). National Defense Medical
Center, Taiwan, ROC. (Original work published in Chinese)
Liao, M. N., Chen, S. C., Lin, Y. C., Chen, M. F., Wang, C. H., &
Jane, S. W. (2014). Education and psychological support
meet the supportive care needs of Taiwanese women three
months after surgery for newly diagnosed breast cancer: A
non-randomised quasi-experimental study. International
Journal of Nursing Studies, 51(3), 390Y399. https://doi.org/
10.1016/j.ijnurstu.2013.07.007
Lien, C. Y., Chen, S. H., Tsai, P. P., Chen, K. M., Hsieh, Y. I., &
Liang, Y. (2010). Effectiveness of nursing instruction in
reducing uncertainty, anxiety and self-care in breast cancer
women undergoing initial chemotherapy. The Journal of
Nursing, 57(6), 51Y60. https://doi.org/10.6224/JN.57.6.51
(Original work published in Chinese)
Liu, C. J., Hsiung, P. C., Chang, K. J., Liu, Y. F., Wang, K. C.,
Hsiao, F. H., I Chan, C. L. (2008). A study on the efficacy of
bodyYmindYspirit group therapy for patients with breast
cancer. Journal of Clinical Nursing, 17(19), 2539Y2549.
https://doi.org/10.1111/j.1365-2702.2008.02296.x
Mahendran, R., Lim, H. A., Tan, J. Y., Chua, J., Lim, S. E., Ang,
E. N., & Kua, E. H. (2015). Efficacy of a brief nurse-led pilot
psychosocial intervention for newly diagnosed Asian cancer
patients. Supportive Care in Cancer, 23(8), 2203Y2206.
https://doi.org/10.1007/ s00520-015-2771-0
Molina, Y., Yi, J. C., Martinez-Gutierrez, J., Reding, K. W., Yi-
Frazier, J. P., & Rosenberg, A. R. (2014). Resilience among
patients across the cancer continuum: Diverse perspectives.
Clinical Journal of Oncology Nursing, 18(1), 93Y101. https://
doi.org/10.1188/14.CJON.93-101
Oh, P. J., & Kim, S. H. (2010). Effects of a brief psychosocial
intervention in patients with cancer receiving adjuvant
therapy. Oncology Nursing Forum, 37(2), E98YE104. https://
doi.org/10.1188/10.ONF.E98-E104
Park, J. H., Bae, S. H., Jung, Y. S., & Kim, K. S. (2012). Quality of
life and symptom experience in breast cancer survivors after
participating in a psychoeducational support program: A pilot
study. Cancer Nursing, 35(1), E34YE41. https://doi.org/10.1097/
NCC.0b013e318218266a
Samarel, N., Tulman, L., & Fawcett, J. (2002). Effects of two
types of social support and education on adaptation to
early-stage breast cancer. Research in Nursing & Health,
25(6), 459Y470. https://doi.org/10.1002/nur.10061
Sandgren, A. K., & McCaul, K. D. (2003). Short-term effects of
telephone therapy for breast cancer patients. Health Psy-
chology, 22(3), 310Y315.
Sandgren, A. K., & McCaul, K. D. (2007). Long-term telephone
therapy outcomes for breast cancer patients. Psycho-Oncology,
16(1), 38Y47. https://doi.org/10.1002/pon.1038
Psychoeducational Intervention for Breast Cancer
Schofield, P., Jefford, M., Carey, M., Thomson, K., Evans, M.,
Baravelli, C., & Aranda, S. (2008). Preparing patients for
threatening medical treatments: Effects of a chemotherapy
educational DVD on anxiety, unmet needs, and self-efficacy.
Supportive Care in Cancer, 16(1), 37Y45. https://doi.org/
10.1007/s00520-007-0273-4
Schou Bredal, I., Kåresen, R., Smeby, N. A., Espe, R., Sørensen,
E. M., Amundsen, M., I Ekeberg, Ä. (2014). Effects of a
psychoeducational versus a support group intervention in
patients with early-stage breast cancer: Results of a ran-
domized controlled trial. Cancer Nursing, 37(3), 198Y207.
https://doi.org/10.1097/NCC.0b013e31829879a3
Sherman, D. W., Haber, J., Hoskins, C. N., Budin, W. C., Maislin, G.,
Shukla, S., I Roth, A. (2012). The effects of psychoeducation
and telephone counseling on the adjustment of women with
early-stage breast cancer. Applied Nursing Research, 25(1),
3Y16. https://doi.org/10.1016/j.apnr.2009.10.003
So, W. K., Marsh, G., Ling, W. M., Leung, F. Y., Lo, J. C., Yeung,
M., & Li, G. K. (2009). The symptom cluster of fatigue, pain,
anxiety, and depression and the effect on the quality of life
of women receiving treatment for breast cancer: A multi-
center study. Oncology Nursing Forum, 36(4), E205YE214.
https://doi.org/10.1188/09.ONF.E205-E214
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 26, NO. 4, AUGUST 2018
Taso, C. J., Lin, H. S., Lin, W. L., Chen, S. M., Huang, W. T., &
Chen, S. W. (2014). The effect of yoga exercise on improving
depression, anxiety, and fatigue in women with breast cancer: A
randomized controlled trial. The Journal of Nursing Research,
22(3), 155Y164. https://doi.org/10.1097/jnr.0000000000000044
Victoria Cerezo, M., Ortiz-Tallo, M., Cardenal, V., & De La Torre-
Luque, A. (2014). Positive psychology group intervention for
breast cancer patients: A randomised trial. Psychological Reports,
115(1), 44Y64. https://doi.org/10.2466/15.20.PR0.115c17z7
Wagnild, G. M., & Young, H. M. (1993). Development and
psychometric evaluation of the resilience scale. Journal of
Nursing Measurement, 1(2), 165Y178.
World Health Organization. (2014). The world health report
2014. Geneva, Switzerland: Author.
Yates, P., Aranda, S., Hargraves, M., Mirolo, B., Clavarino, A.,
McLachlan, S., & Skerman, H. (2005). Randomized controlled
trial of an educational intervention for managing fatigue in
women receiving adjuvant chemotherapy for early-stage breast
cancer. Journal of Clinical Oncology, 23(25), 6027Y6036.
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and
depression scale. Acta Psychiatrica Scandinavica, 67(6),
361Y370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
279