Introduction

The demographic, epidemiological, and environmental transformations that society has been experimenting have brought about significant changes, mainly in the health-disease process of the populations. ⁽¹⁾ Aging, population growth, and adopting harmful habits have increased the incidence of malignant, non-transmissible chronic diseases. ^2,3 In this scenario, cancer constitutes one of the main challenges for healthcare systems around the world, given its high mortality rate and the impact it has on individual, family, and social levels. ⁴

Among the different types of cancer, breast cancer is of special concern due to its high prevalence and incidence in the world’s female population.⁵ The latest estimates published in 2020 by the International Agency for Research on Cancer reported 2,261,419 new cases and 684,996 deaths caused by this disease.⁶ In Latin America and the Caribbean there has been an increase in breast cancer with 462,000 new cases and close to 100,000 deaths. ⁷

In this context, breast cancer constitutes a global public health problem that has a major impact on women, their families and healthcare systems, given that it is a silent, complex, and extremely harmful disease.⁸ As a consequence, screening methods for early diagnosis and treatment are decisive in reducing this disease’s mortality, achieving a higher survival rate,⁸ promoting early psychosocial adaptation and improving the quality of life of affected women.⁹

Nowadays, a wide range of simple and combined cancer treatments are available that offer higher chances of recovery. However, these treatments cause multiple side effects that deteriorate body image, functional capacity, psychological state and social relationships, affecting the well-being of women and their families. ¹⁰

Although the prognosis and survival rate of women with breast cancer has dramatically improved in recent years, affected women experience problems in multiple aspects of their lives. ¹¹ The psychological impact generated by the diagnosis, treatment, and survival stages negatively impact women’s lives, given that they create uncertainty, anxiety, fear of death, loneliness, depression, pain, suffering throughout the disease process, feelings of loss of control over their lives, and gradual loss of self-esteem and their personal coping resources. ^10-12

These feelings and perceptions are associated with diagnosis, the lack of knowledge of the disease process, treatments and uncertainty about the future. ¹²⁾ Uncertainty has been identified as a factor that causes high levels of psychological stress, and it is regarded as the most influential variable during the process of adaptation to the disease, ¹⁴ generating ambiguities that hinder the understanding of the disease and its treatment, which can have an impact on the timely initiation of treatment, the degree of adherence to treatment and the patient’s adaptation to their new health condition. ³

Health-related quality of life (HRQoL) is regarded by multiple authors as a multidimensional and dynamic concept. ^{(15, 16)} Shumaker and Naughton (1995) defined HRQoL as “the subjective assessment of the influence of current health status, and health care on the individual´s ability to maintain a level of functioning and their general well-being. Where social, physical and cognitive functioning; mobility and self-care; and emotional well-being converge”. ¹⁵ It is thus deduced that the quality of life of women with breast cancer is greatly affected not only in physical aspects, but also in psychological, social, and spiritual factors due to the changes in their physical image which deteriorate their self-esteem, self-management skills, feelings, attitudes, mood and social relationships, ¹⁷ all of which affect their psyche. ¹⁸

Quality of life has become a necessary criterion within oncological care for breast cancer, as it should lead to an improvement in the overall well-being of affected women. In this regard, one of the variables that has shown a positive influence on the well-being of people with chronic diseases is self-efficacy, ¹⁹ which plays a mediating role between personal skills and human behavior, which determines their motivation and well-being. ²⁰

The construct of self-efficacy was introduced by ^{Bandura (1977)} as a key point of the Social Cognitive Theory, acknowledging that individuals possess a self-system that allows them to control their thoughts, feelings, emotions and regulate their behavior in potentially stressful situations. ²¹ Among women with breast cancer, self-efficacy is regarded as an essential abilityin order to cope with the difficulties, high levels of stress, anxiety, uncertainty, and depression associated with the disease process and its treatments, ²² enhancing a series of strategies such as having a positive mindset and a fighting spirit, which in turn, lead to a better quality of life.²³

Consequently, to inquire about the possible intervention of self-efficacy to improve quality of life and reduce uncertainty, would allow to explore in greater depth the impact of these variables on the experience of women with breast cancer, which could contribute with various orientations to the health team, for the design of future care interventions with a holistic approach, focused on the development of coping strategies that facilitate the process of adaptation to the disease. ²⁴ In addition to contributing evidence to healthcare practice in the field of nursing care.

Therefore, the objective of this study is to determine the influence self-efficacy has on uncertainty and quality of life of women with breast cancer through the review of published scientific literature, which will identify the care needs of affected women. Moreover, this study aims to be a contribution to clinical practice and to disciplinary knowledge in the area, allowing healthcare and nursing professionals to apply the existing knowledge and evidence to promote the implementation of interventions that help to improve the quality of life of the women affected by this disease and their families.

Materials and method

This review is carried out in the context of Evidence-Based Nursing, which promotes the application of research findings in clinical nursing practice as a key element to achieve a higher quality of care. ²⁵ This research followed the methodology for integrative reviews proposed by Mendes et al., ²⁶ which allows to gather the best evidence in the selected field of study, whose stages are: definition of the problem and formulation of the review question, establishment of inclusion and exclusion criteria for the studies, search identification of the relevant studies in the scientific databases, selection and categorization of studies, evaluation of the studies included in the review, interpretation of results and synthesis of knowledge. In addition, PRISMA quality criteria for integrative reviews were considered.²⁷

The PIO strategy ²⁵ was used to formulate the question guiding this study, which was defined as follows: What influence does self-efficacy have on uncertainty and quality of life of women with breast cancer?

A review of the scientific literature was conducted to answer the question posed using the databases: Scielo, Pubmed, Scopus, Bvs and Medline and Web of Science. The following DeCS and MeSH descriptors were considered: “breast cancer”, “uncertainty”, “quality of life” and “self-efficacy” in Spanish, English, and Portuguese. Finally, the research was carried out using a combination of the descriptors “cáncer de mama AND incertidumbre”, “cáncer de mama AND calidad de vida” and “cáncer de mama AND autoeficacia”, in Spanish; “breast cancer and uncertainty”, “breast cancer and quality of life”, “breast cancer and self-efficacy”, in English, conjugated using the Boolean Operator AND due to the characteristics of this research study.

The inclusion criteria allowed for public access primary quantitative research studies published in English, Spanish and Portuguese between 2015 and 2020 who preferably had a nurse as first or corresponding author, to enhance the development of Nursing care; and whose sample included women with a breast cancer diagnosis. The exclusion criteria included secondary studies such as meta-analyses, systematic reviews, integrative reviews, and studies whose full texts were not available online.

Initially, 134 articles were identified, 20 of which met the inclusion criteria. Quality assessment was carried out using the Effective Public Health Practice Project (EPHPP) tool, which assesses the risk of bias and classifies the methodological quality of the studies into low, moderate, and strong. ²⁸

Finally, a critical reading was carried out to assess the validity, reliability, relevance, and pertinence of the selected articles. The review complied with the ethical principles by respecting copyrights, using proper citation, and crediting the reviewed authors. Figure 1

Figure 1: Flowchart of the identification, selection, and inclusion of studies 

Results

With a baseline of 20 articles that addressed the subject and met the proposed criteria, we proceeded to synthesize and analyze them. The articles that make up the corpus of analysis are presented in Table 1 and are arranged according to the relationship between the studied variables.

Table 1: Results of the influence of self-efficacy on uncertainty and quality of life of women with breast cancer according to the selected articles 

^Source: Own elaboration (2021).

The time frame considered for the article search was 5 years, finding one article published in 2020; ²⁹ nine in 2018;^{5,30,31,35-37,38,44} four in 2017; ^{32,39,40,45,46} and three in 2016 ^(33,41,42 and 2015. ^34,43,47 Regarding the research design, 100% of the studies had a quantitative approach, 84.2% were cross-sectional and 15.3% were longitudinal. Eight were correlational studies;^{30,31,34,37,42,45-47} seven were observational;^{29,33,35,36,39,41,43} three were analytical ^5,38,44 and two were exploratory. ^32,40 Considering the EPHPP scores,²⁸ nine articles had moderate quality^{5,29,31,36,38,41,43,45,46} and eleven reached a strong quality. ^{30,32-35,37,39,40,42,44,47}

Regarding the geographical area of the selected studies, seven took place in Asia; ^{30,32,37,40,42,44,45} ten in the Americas ^{29,31,33-36,38,41,43,46)} and three in Europe, ^5,39,47 evidencing that the majority were carried out in the Americas. 25% of them took place in Brazil, ^{35,36,38,41,43} 15% in Colombia, ^29,31,34 10% in Iran ^44,45 and Korea ^30,32 and 5% were carried out in the United States, ³³ Croatia, ⁵ Indonesia, ³⁷ Spain, ⁽³⁹⁾ Malaysia, ⁴² Mexico ⁴⁶ and the United Kingdom. ⁴⁷ The studies were published in English (10= 52.6%), Portuguese (5= 26.3%) and Spanish (4= 21%).

The articles made use of a wide variety of scales and questionnaires to collect data in accordance with the objectives of each study, as shown in Table 2.

Table 2: Main Self-Efficacy, Uncertainty and Quality of Life Scales used in the reviewed studies 

^Source: Own elaboration (2021).

The most significant contribution of these studies is the description of each variable in relation to breast cancer and the influence that may exist between them, which shows the priorities that need to be addressed in healthcare, an example of this are the deterioration in Quality of life of women due to breast cancer and its treatments ^{5,32,35,36,39}, uncertainty as a psychological stressor that affects quality of life^30,31,34,40) and Self-efficacy as a facilitating factor for well-being and coping. ^45-47

Discussion

The study of health-related quality of life of women with breast cancer continues to be a challenge for healthcare professionals, especially in nursing, due to its high complexity and that, in fact, the quality of life is a result of the interaction of women and their families with the disease, its evolution, cancer treatments and their side-effects, as well as the changes produced in their physical, psychological, and social domains due to the disease. Even so, studying the quality of life of patients with breast cancer has enabled a shift from the traditional concept of health and purely physical well-being into a more comprehensive concept of well-being. ⁴⁹

The analysis of the obtained results clearly evidences that women with a breast cancer diagnosis undergo multiple changes in their clinical, psychological, family, social, functional, sexual, and work spheres that negatively impact their quality of life. ^5,29,37,39) The affected women have low levels of overall quality of life, ⁴⁰ due to the alterations arising from the disease and its treatments, which cause a loss of balance between the physical, emotional, and social functions. As a result, the study of psychological, social, and spiritual aspects has become more relevant in recent years, as they offer a more comprehensive approach, which is necessary in the field of nursing in relation to quality of life. ⁵⁰

Women and their families who must coexist with breast cancer feel lack of security, fear and uncertainty regarding future prospects and require the influence of a constant positive attitude as a predictor of a better understanding of the disease and managing stress, anxiety, and depression; this motivational support and assistance to maintain a positive attitude may be given and stimulated by the healthcare team, especially by nurses caring for patients in oncology units supported by the interdisciplinary team that treats women, facilitating the development of coping strategies that allow affected women to adapt to their new health condition. ⁴⁵ As a consequence, self-efficacy is regarded as an important predictor that influences women’s behavior against breast cancer and constitutes a facilitating factor for well-being, as shown by the obtained results.

The reviewed studies placed uncertainty as a variable that generated high levels of stress, distress, anxiety, depression, and hopelessness, all of which negatively affect the quality of life of women with breast cancer and their families, their level of satisfaction with healthcare services and self-efficacy. ³⁰ These situations make women feel unable to confront the disease and its challenges. Therefore, care strategies targeted toward women with breast cancer should incorporate clinical and psychological elements and the perspective of the affected patients, thus having a more meaningful impact on their well-being and quality of life.

Uncertainty is a cognitive factor that accompanies women and their families throughout the development of the disease, as living with a chronic disease such as breast cancer means living with a constant feeling of worry and lack of security. ³¹ Lack of information may lead to uncertainty ³⁸ and it may also create a feeling of discomfort due to the patient’s inability to determine the meaning of the facts; a subjective interpretation of their disease puts them in an unfavorable position that may alter their psychological well-being and responsiveness.

A revealing fact is that uncertainty increases in patients with a low socioeconomic level,³⁴ which could be a determinant factor derived from difficult access to healthcare services, delays in the initiation of treatment and needing to fulfill a great number of requirements.

Women’s self-esteem is damaged during the course of the disease, altering their well-being and damaging their self-efficacy.⁴⁶ After suffering changes in their body image due to cancer treatments, women show higher levels of anxiety and depression, which could lead to lower self-efficacy and self-concept. Studies show a negative linear relationship between self-efficacy and uncertainty in the face of the disease, given that uncertainty may create emotional discomfort, increase difficulty to predict symptoms, a gradual loss of motivation and a lower coping capacity, ⁵¹ which negatively relate to quality of life and well-being.

Although scientific literature shows little evidence regarding the influence of self-efficacy on quality of life and uncertainty in women with breast cancer, it was determined that self-efficacy regarding symptom management and an optimistic outlook on life were positively correlated with coping with breast cancer. Furthermore, there is a significant negative correlation between uncertainty and maintenance of activity and independence, seeking and understanding medical information, stress management, coping with treatment-related side-effects, accepting cancer and maintaining a positive attitude, affective regulation and seeking support. Maintaining a positive attitude is related to higher levels of behavior against cancer and a high level of education is related to higher levels of self-efficacy.

In view of this, it is deeply important in nursing to achieve a holistic approach regarding oncological care, as it highlights the need to design care interventions that incorporate biological, psychological, emotional, spiritual, and social factors, also to identify the sociocultural determinants of each context due to the nature of the recipient of nursing care: the human being. This should be done so that the diverse care, help and support needs of women with breast cancer can be met.

Conclusions

As an answer for the objective, it was determined that self-efficacy is a predictor of a better quality of life in women with breast cancer, given that self-efficacy has a positive relationship with well-being and the development of disease coping strategies. Uncertainty proved to be a psychological stressor that damages the overall well-being of affected women, and it negatively influences the psychological, functional, social, and physical domains. However, this variable may be mediated by enhancing self-efficacy as a powerful cognitive factor that has an effect on behavior and responsiveness to existential crisis created by the disease and its treatments.

The quality of the information provided by the healthcare team, especially by nurses, represents a key point in the care of sick women and their families. Uncertainty rises if the information is ambiguous, so nursing care calls for the development of relevant, empathetic, sensitive, and humane educational programs. In this regard, it is recommended that nurses carry out care interventions starting from the moment of diagnosis and throughout the course of the disease in order to reduce doubts and possible emotional effects.

Education is a useful tool to lower uncertainty toward the disease during care interventions if it is reliable and concise, provided by a credible source and given through clear and assertive communication means. This would help people to understand the disease process, allowing for the development of coping strategies that ease the adaptation to the new health condition. Uncertainty toward the disease should be addressed during the different stages of the disease: moment of diagnosis, treatment, and care. Reliable information and nursing care will reduce uncertainty in each phase of the disease.

Based on the results, self-efficacy is a determinant of well-being when faced with different health conditions. Moreover, applying this psychological tool during nursing interventions may help improve self-perception, increase the patient’s self-confidence, and give them a positive attitude to effectively manage crisis.

This analysis found that breast cancer creates high levels of stress, suffering, uncertainty, and distress from the moment of diagnosis and throughout the disease and treatments processes, as well as during recovery, up until remission. This drastically damages the quality of life of affected women. This study showed that self-efficacy is a cognitive-behavioral factor of self-protection, allowing women with breast cancer to accept and/or handle difficulties and threats that may hinder their biopsychosocial well-being.

Future research should consider using a qualitative approach to analyze the relationship between self-efficacy and uncertainty in women with breast cancer.

One of the limitations of the present study was the difficulty finding studies that analyzed the influence of self-efficacy on uncertainty and quality of life in breast cancer patients.