Progress in research on the application of nursing models for breast cancer patients during the perioperative period

In 1971, the U.S. nursing scholar Orem proposed the self-care theory, which was introduced to China in 1983 by Shiai Lv and became an important model for clinical nursing in China.6 Orem believed that the nursing system is a behavioral system for developing openness and that the bases for selecting the nursing system are a patient’s self-care need and self-care ability. When self-care deficits are formed so that the patient is unable to either partially or completely unable to perform continuous and effective self-care, nursing staff are needed to provide care and assistance, and they are asked to provide wholly compensatory nursing, partly compensatory nursing, or supportive education to the patients – based on their specific situations – to meet patients’ self-care needs. Research has shown that in a nursing model under Orem’s self-care theory, the incidence of postoperative complications for breast cancer patients was significantly reduced, the patients’ limb function rehabilitation rate increased, and the awareness rate of health education knowledge was significantly higher than those of the conventional nursing group.7 Xu8 used postoperative breast cancer patients in the Henan Province region of China as a sample and divided that sample into control and conventional groups. A conventional surgical nursing model was used for the control group, while a nursing model from Orem’s self-care theory was used for the study group; in other words, based on whether the patients were in a lucid interval after surgery and their capacities for self-activity, a patient who was not lucid after surgery was listed as being in a wholly compensatory system, while one who was lucid after surgery and had the capacity for self-activity was listed as being in a partly compensatory system, with emphasis placed on penetrating the full course of the perioperative period with supportive education. Lu9 especially emphasized paying attention to unleashing the patients’ maximum self-care potential when applying this model, which requires the nurses to use their own wisdom in combination with the patients’ physiological and psychological conditions that have been brought to bear, posing higher requirements on clinical nurses. Zhang10 assigned patients to three major systems according to the patients’ postoperative chronology and believed that the wholly compensatory system–partly compensatory system–supportive education system is in a state of dynamic change, not isolated from each other; and the “self-care is a need of self-esteem” viewpoint was applied to the supportive education system. In a traditional nursing model, the patient passively accepts the help of the nursing staff, but in the self-care theory, the patient actively participates in decision-making regarding their health, with the objective of promoting self-care. It can be seen from this discussion that Orem’s self-care theory starts with self-care deficits in postoperative breast cancer patients based on changes in postoperative disease conditions. The nurses can use a self-care ability assessment table to perform assessments, lightening their workload while allowing for improved targeting of postoperative nursing issues. As a full-course system, the supportive education system seems to be especially important in the course of nursing breast cancer patients. Because the majority of the patients are women and surgery can greatly change the beauty of the woman’s original body shape, coupled with the great importance that women place on their own image, educating patients on psychological and physiological health throughout the process may promote postoperative rehabilitation and meet the demands of high-quality nursing care in modern times. However, Orem’s self-care theory is limited to existing nursing diagnosis and is relatively lacking in research on stimulating factors.

The PDCA cycle proposed by the U.S. quality management scholar Deming is a basic method used in quality management. This cycle performs quality management based on the sequence of plan, do, check, and act; the starting point for each cycle is raised to a new level, and the cycle continues without end.11 The four-in-one model is from the joint participation of the physicians, nurses, patients, and family members in formulating a functional exercise pathway table and in gradually implementing the proper sequence according to the table, while following scientific and systematic principles to enhance the relevance and purpose of rehabilitation training by fully mobilizing the patients’ initiative and enthusiasm. In particular, listening to other patients’ testimonials in the synchronous training for family members lets family members grasp the relevant rehabilitation training, which is favorable for supervising and increasing patient interest in functional exercises and their effects.11 Ding and Wang12 used breast cancer surgery patients as study subjects. A traditional method was used with the control group, i.e., the responsible nurse conducted rehabilitation knowledge education during the perioperative period, and the remainder of the time was devoted to random rehabilitation education, mostly in a lecture format to guide a single patient; the patient would practice on her own after being instructed. The PDCA cycle combined with the four-in-one model was implemented with the observation group by creating a PDCA functional exercise group, and the patients were educated on the drafted four-in-one format functional exercise clinical pathway table. Existing problems were reviewed and analyzed at each execution, and the problems were combined with reality to then revise the pathway table for reimplementation; the cycle was then repeated until the patients were rehabilitated. Research has shown that the PDCA cycle combined with the four-in-one model effectively solves the nurses’ “one-person platform” situation in traditional rehabilitation guidance, promotes exchange and cooperation between medical and nursing staff, increases enthusiasm in the patients and family members, and is able to continue to improve the quality of nursing, thereby effectively ensuring patient rehabilitation. Of course, this model also poses very high requirements on the nurses’ specialized knowledge; requires the nurses to have very good capabilities in analyzing, judging, summarizing, and applying knowledge; and may require them to play a leading role in this group of physicians, nurses, patients, and family members.

The peer support model is a type of nursing model that provides help to physically and psychologically healthy patients under treatment during the rehabilitation period.13 In other countries, two methods are used: face-to-face and virtual platforms. Research has shown that this model is able to effectively promote the psychological health of patients and to reduce adverse reactions during the perioperative period; sharing life experiences and professional lifestyles has been demonstrated to be able to reduce anxiety and a sense of loneliness in patients and to help improve their quality of life.5 Cao et al.14 divided 60 patients at different time periods at a hospital into control and study groups. Conventional nursing was implemented for the control group, while for the study group, a peer support model was used on the basis of conventional nursing to organize and guide volunteers and to provide help to patients during the preoperative and rehabilitation periods; the timing was once per week, and the contents were rehabilitation experience and emotional support.

While the breast cancer patients’ physical and psychological health parameters were effectively improved and postoperative complications were reduced through 2 months of intervention, there were also great savings in health-care human resources. Borkman15 proposed the “concept of being similar to this person.” This concept deems that empathy from patients who had similarly suffered and were subsequently rehabilitated from cancer using their firsthand experience and knowledge to provide support and help to patients with the same disease can make other patients look at the disease from a unique perspective and obtain social support. Dunn et al.16 also performed the same research and demonstrated that the peer support model could significantly reduce the sense of loneliness in patients and can provide patients with sufficient confidence to overcome their disease. However, the peer support model can only be an auxiliary nursing model for breast cancer patients during the perioperative period because the nursing staff are still playing the leading role in promoting patient rehabilitation.20 Moreover, the peer support model requires a hospital or an organization to establish standardized breast cancer volunteer institutions and also needs the regular input of medical staff for their training; only after they have met training standards can they enter the hospitals to help patients suffering from the same disease. Therefore, it is more suitable for use in urban areas where the volunteers are of higher quality and the level of medical treatment is developed and abundant. Patients will be limited in their participation in face-to-face peer support after they have completed treatment, recovered, and been discharged from the hospital. Emerging virtual platform services supplement face-to-face support, reduce the burden on the health-care system, and prevent patients and volunteers from rushing back and forth.17

The transcultural nursing theory was first proposed by the U.S. nursing scholar Madeleine Leininger and was introduced to China in 1995. The “Sunrise Nursing Mode” (SNM) is the core of the transcultural nursing theory. SNM deems nursing as providing differentiated care to patients with different ethnic and cultural backgrounds in a targeted manner within a relative framework, rather than a fixed model.18 Wang et al.18 implemented a nursing model guided by transcultural theory on 10 foreign breast cancer patients during their perioperative periods at the hospital.19 After the patients were admitted to the hospital, they were assessed in accordance with SNM’s three-level assessment method. The first level assessed the patients’ beliefs, educational backgrounds, languages, and personal economic status. The second level assessed the patients’ health, their caregivers, and medical expenses. The third level assessed the patients’ health needs, treatment needs, and nursing needs. Based on the assessment results, contents were formulated to compensate for the language communication barriers in nursing, psychological care, life care, and perioperative visit instructions, and specific nursing interventions were then performed. Research19 has shown that a nursing model guided by the transcultural theory avoids the occurrence of cultural coercion and culture shock due to cultural differences, improves the quality of nursing for foreign patients, carries forward the human-oriented spirit, and conforms to the world trend of global integration.

In recent years, an important medical diagnostic model has appeared internationally: the multidisciplinary team (MDT), which promotes the joint development of multiple disciplines mainly by optimizing diagnosis and treatment methods, reasonably allocating medical resources, and improving diagnosis and treatment results.21 The MDT is often a multidisciplinary and interdisciplinary approach that includes not only surgical and medical teams but also breast care nurses, physical therapists, expert peer support, consultants, and psychologists.22 This model centers on the breast cancer patient and uses a multidisciplinary approach to take care of them and their families and has always been recognized by physicians, nurses, allied health teams, and the women themselves.23 Zhang21 divided his hospital’s 120 breast cancer patients during their perioperative periods into observation and control groups. The hospital’s conventional nursing model was used for the control group, while an MDT was established for the observation group. The first-level members included a breast surgeon, a specialist nurse, and a bed nurse, and the second-level members included physicians from nutrition, psychology, rehabilitation, plastic surgery, imaging, pathology, traditional Chinese medicine, and other departments, wherein the specialist nurse assumed the duties as the team’s liaison officer. When the MDT was operating, there were two consultation meetings each week that first-level members must attend; second-level members may attend in accordance with the actual situation. The principles of coordination, mutual aid, and each giving full play to his/her strong points were followed, and on-the-spot assessment and analysis of the patients’ disease conditions and pathological test results were performed, helping the nurse to follow a systematic nursing program. Throughout the nursing process, the patients received the most convenient and effective medical services, and repeat appointments for visits by patients in various departments were avoided, thereby shortening the patients’ hospital stays. The results showed that the MDT nursing model is able to reduce the stress response of breast cancer patients during the perioperative period, reduce postoperative complications, and accelerate postoperative rehabilitation. Existing nursing issues for breast cancer patients during the perioperative period involve multiple disciplines; therefore, the use of a multidisciplinary cooperative nursing model can provide patients with the most professional medical resources. Moreover, the nursing staff who becomes the liaison officer not only must take part in the formulation of the nursing program but is also the main implementer of this program; the requirements for the nursing staff in terms of various capabilities are very high. For the physicians, two consultation meetings each week are also a challenge. At present, regular consultation meetings would be held for difficult illnesses in a grade A tertiary hospital, but regular consultation meetings for each breast cancer patient have not been implemented; moreover, nurses do not participate very much in consultation meetings,24 mainly due to the serious lack of domestic medical resources, the lack of manpower in terms of nurses, and fewer highly educated nurses.25

The KAP nursing model is an abbreviation of the factors knowledge (K), attitude (A), and practice (P). The KAP theory was first proposed by the team of a professor of Harvard University, Mayo et al., in the United States and was later further developed by researchers and successfully applied in promoting changes in people’s health behaviors.26 The KAP nursing model refers to enhancing the patients’ mastery of knowledge about the disease by educating patients on health, gradually forming healthy beliefs, with the objective of enabling the patients to form positive, beneficial health behaviors in daily life. Lv27 divided 58 breast cancer patients at her hospital into control and observation groups. Conventional nursing was implemented for the control group. The KAP nursing model was used on the basis of conventional nursing for the observation group. Educators for the KAP model were selected and trained to perform various forms of health education for breast cancer patients during the perioperative period. The contents mainly included explanation of the necessity of radical surgery and the postoperative rehabilitation process, making up for self-image disorders through breast reconstruction surgery, information on the inducing factors for breast cancer, and so on. Mapping breast cancer-related knowledge deeply into the minds of patients to gradually form beliefs exerts a subtle influence on the manifestation of favorable behavior for disease rehabilitation. Research27 has shown that as a method of continual health education, this model effectively increased the compliance of breast cancer patients during the perioperative period, thereby making them actively cooperate with treatment; the overall health assessment of the patients in the observation group was significantly higher than that of the control group. Compared with traditional health education, the KAP model emphasizes feedback from information recipients and whether the patients understand and are able to apply the knowledge transferred to them by the nurses and emphasizes the positive effects of health education on patient behavior;27 therefore, the model is worth promoting broadly in clinical use. However, the implementation effect of this model is related to the nurses’ education, experience, and professional attitude.

The safe management model refers to strict mastery of a variety of rules and regulations and operational procedures so that patients obtain physical and psychological safety during the perioperative period. Along with an increase in patient awareness of self-care and protection of rights, running the concept of the safe nursing management model throughout the perioperative period for patients has already become a requirement of clinical nursing. Tastan et al.28 strictly followed the clinical pathway in nursing patients after breast cancer surgery and found that under this model, the patients’ sense of anxiety was reduced, satisfaction was increased, and quality of life was better. Wu29 divided 120 breast cancer patients during the perioperative period at their hospital into a treatment group and a control group. Conventional nursing was used for the control group. A safe nursing management model was used for the treatment group. This model consisted of two parts, safe rehabilitation exercise and safe nursing quality management; the detailed description of safe rehabilitation exercises safely and effectively guided patients in postoperative rehabilitation training, and safe nursing quality management required the nursing staff to make work standardized and programmed. While the safe nursing model promotes the overall rehabilitation of patients, it also nurtures the nursing staff’s own safety awareness and service awareness.28

The case management model first appeared in social work management in the United States and was subsequently introduced to the medical and nursing fields in the United Kingdom and gained rapid development. In European and American regions, the breast cancer case management model is already quite mature.30 At present, China’s nursing staff have started to pay attention to the application of case management in breast cancer patients, but there are still few relevant studies. Peng31 implemented a case management model for 40 breast cancer patients accepted for treatment at her hospital and compared them to 40 cases for whom a primary nursing model was implemented. A case management team was formed, and a case manager with >8 years of seniority, a bachelor’s degree, and qualifying capabilities was selected. The contents of case management included recording patient information, formulating nursing plans, supervising and guiding patients by stage, and continuing nursing measures (telephone follow-up visits, establishing QQ group (a multiplayer communication service launched by Tencent), and announcing the case manager’s telephone). During the breast cancer perioperative period, one-on-one full-course nursing was implemented and combined with primary holistic nursing to ensure there were no gaps throughout the entire nursing process. In particular, the case manager was in close contact with patients until 6 months after the patients had been discharged from the hospital and accepted telephone consultation from patients thereafter. Research31 has shown that the case nursing model not only unleashes the strengths of capable nursing staff while optimizing nursing resource allocation but also, to a great extent, eliminates the breast cancer patients’ uncertainty in illness during the perioperative period, increasing patient satisfaction. However, there are also studies that have shown how reexaminations and follow-up visits would deepen the patients’ sense of anxiety due to worry about breast cancer relapse.32 Moreover, relapses are mostly found by the women themselves, and they believe that participation in follow-up visits is unable to provide them with better ways to adjust to postcancer life; even though the hospital provides them with prescription drugs, there is no prescription that can make them healthier.33