Resilience-related Breast Cancer: A Concept Analysis

Background: Breast cancer-related adversity can result in severe psychological issues. However, some patients were able to demonstrate resilience, while others were not. Therefore, the concept of resilience in breast cancer patients requires further clarification


Introduction
Breast cancer is the most frequent malignancy among women and the second most significant cause of cancer-related death.A breast cancer diagnosis potentially leads to a traumatic event, with both physical and psychological consequences, that occurs in late response after the end of medical treatment (Martino et al., 2019).The fifth edition of the diagnostic and statistical manual of mental disorders (APA, 2013) classifies a cancer diagnosis as a sort of trauma that brings a slew of issues (Romeo et al., 2019).Because of the difficulty in recognizing a unique stressful event, breast cancer has a distinct and special nature of the disease.The risk of life crisis and bodily integrity are frequently high, and the agony, damage, and loss of social and occupational roles could cause overwhelming emotion in a significant minority of patients.Lack of control, impairment, and the diagnosis' swiftness will cause acute fear, hopelessness, terror, anxiety, and melancholy (Quattropani et al., 2016).Some people who have been traumatized may have serious issues, whereas others (who may have been subjected to the same traumatic event) may only have little or no trouble recovering.This condition is known as resilience.In general, "resilience" refers to regaining normal function following hardship, sustaining the regular part of life, or successfully adapting to stressful experiences in life (Johnston et al., 2015).The ability to successfully adjust to adversity, difficult life experiences, major threat, or trauma is characterized widely as resilience.Recent research indicates that resilience is an "active process" rather than simply reversing pathological mechanisms (Feder et al., 2019).The ability to adapt to life circumstances positively is referred to as resilience.The process of dynamism involves a form of adaptable functioning that enables

The uses of the concept
The word resilience derives from the participle of the Latin verb resilire, meaning "to jump back" or "to recoil".Resilience can be defined as the ability to effectively adapt to challenging life experiences, which involves the capacity to exhibit mental, emotional, and behavioral flexibility in response to both internal and external demands (VandenBos, 2007).
Resilience refers to the capacity to adjust the changes in life circumstances.It involves a dynamic process and requires a particular sort of adaptive functioning to deal with the obstacles in life by regaining initial equilibrium or bouncing back to growth (Sisto et al., 2019).Resilience is intrinsically linked to mental health as a protective factor against psychological distress.All aspects, such as biological (e.g., gene-environment interaction), personal (e.g., feeling of coherence, optimism, hope), and social (e.g., social support, acceptance) aspects, contribute to the resilience of cancer patients.Thus, it is primarily favorable to psychological and treatment-related outcomes (Seiler & Jenewein, 2019).Psychological resilience enables people to overcome challenges by preserving and increasing their resources to the point where personal strength and a positive restructuring of their biographical history are achieved.As a result, adopting resilient attitudes allows one to construct and reconstruct one's life path, re-establish a new balance by bringing about change in oneself, and responding constructively to challenges, turning them into chances for progress (Sisto et al., 2019;Yi et al., 2020).

Defining attributes
Identification of the defining attributes of a concept is the heart of concept analysis.Protective factors refer to distinct characteristics or circumstances that are essential for the manifestation of resilience.Several attributes of the concept of resilience in breast cancer patients were identified, including; 1) satisfaction with social support, 2) ability to cope with the disease and cancer treatment, and 3) optimism (see Table 1, Figure 2).
The first antecedent is the ability to cope with the disease and treatment.The term coping refers to the ongoing cognitive and behavioral strategies employed by individuals to manage internal or external stressors that may be overwhelming or beyond their capacity to handle (Lazarus & Folkman, 1984).The diagnosis and treatment of cancer can elicit significant and enduring distress.The empirical data suggests that the patients' level of engagement with the treatment was correlated with their capacity to manage the stress and burden associated with their illness and treatment.The association between positive thinking and improved mental and physical health is linked to the employment of adaptive coping strategies (Carver et al., 2005).Emotional intelligence and resilience are essential for people to deal with difficult situations, including patients with breast cancer.This ability to cope with the crisis is modifiable through support and training.Patients who could enhance resilience and have better emotional intelligence are associated with better clinical outcomes (Edward & Warelow, 2005).
The second attribute is satisfaction with social support.The concept of social support pertains to an individual's subjective evaluation of their level of contentment with social interactions.There is a prevalent belief that it plays a crucial role in mitigating both psychological and physical stress responses (Cohen & Wills, 1985).The moderating influence of social support on genetic and environmental vulnerabilities for mental illness may be attributed to its impact on various psychosocial factors, including the promotion of effective coping strategies and the modulation of multiple neurobiological factors.The provision of social support appears to play a significant role in endowing individuals with the ability to withstand and recover from the negative effects of stress (Pérez et al., 2016).Stress can occur in patients with breast cancer from diagnosis to recovery, necessitating social support from the surrounding environment.Social support is critical for developing resilience and an increase in the quality of life of breast cancer patients.Health practitioners should establish appropriate recommendations to assist patients in obtaining adequate assistance and building resilience to improve their quality of life following breast cancer (Zhang et al., 2017).
The level of contentment with social support indicates that such contentment may serve as a mediator or moderator in relation to health outcomes.Furthermore, the contentment pertaining to the origins and varieties of aid, the ability to recover from adversity, and a hopeful outlook demonstrate a favorable standard of living (Simancas Fernandez et al., 2021).A study by Razurel and Kaiser (2015) found that satisfaction with social support, primarily from the spouse, will reduce psychological disorders, depressive symptoms, and anxiety and increase self-efficacy.
The third attribute is optimism.Optimism refers to a widespread expectation of favorable outcomes (Scheier & Carver, 1985).Breast cancer patients who had a higher level of optimism reported more significant social and mental health issues (Colby & Shifren, 2013).Optimism can be characterized as a set of protective factors that facilitate emotional well-being, mitigate anxiety, promote adaptive health behaviors, and yield improved physical health results (Gallagher et al., 2019).Breast cancer patients who encounter substantial stressors and negative or cognitive processes are at an increased risk of developing anxiety and other emotional disorders.At this point, optimism promotes resilience and healthy coping (Gallagher et al., 2019).

Model Case
A model case demonstrates all its defining attributes and thus helps better articulate the concept's meaning (Walker & Avant, 2018)  Based on the above case, Angela demonstrates all attributes, satisfaction with social support (breast cancer support group), coping (reducing her pain with medication and yoga), and optimism (believing that her disease is treatable).

Borderline, related, and contrary cases 3.4.1 Borderline case
A borderline case exhibits a majority of the defining characteristics of a given concept, albeit not all of the attributes that are encompassed within the concept.
Clara, 37 years old, was diagnosed with breast cancer stage 2. Clara is known as a tough person in the face of life's problems.Despite the illness she experienced, she still looked cheerful and excited, undergoing a series of cancer therapies.She told the nurse in charge that she could be a survivorship woman for her disease, and she was optimistic that her condition would be better.Although she has not received much support from her husband, she believes to has positive outcomes from treatment.
In this case, Clara only experienced one attribute, namely optimism (believing that her condition would be better).

Related case
A comparable scenario exemplifies instances of apprehension that indicate the concept under investigation yet lacks all of its defining attributes.The concept in question exhibits resemblances to the primary point of interest as observed in analogous scenarios; however, it is important to note that the two concepts are separate and distinct.
Brunette, 34 years old, has come to the hospital for a medical check-up, and she recently received a breast cancer diagnosis.She is severely impacted by having breast cancer and the chemotherapy effects at such a young age, and she wishes to give up.However, she tries to undertake the treatment.Brunette is satisfied with the hospital's services because her illness can be diagnosed early.The hospital also has complete treatment facilities so that her disease is not too late for treatment.
In this case, Brunette's complaint relates to the concept or attribute, but the causes are different.She is satisfied with the hospital's services, not because of social support related to her disease.

Contrary case
In a contrary case, none of the attributes of the concept is present.
A famous photo model, Dorothy, 30 years old, was diagnosed with breast cancer stage III B. When she came to the clinic, her doctor said that she required a total mastectomy before getting worse.She was very frustrated and depressed since she could not continue her carrier due to her cancer.She felt hopeless and thought that her body could not be normal even if the cancer was taken out.Thus, she felt sad and unsatisfied with the doctor's Nurse Media Journal of Nursing, 13(1), 2023, 36 Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811 treatment plan.Because she is an orphan, she lives alone and has no more support from her significant, resulting in her blue feeling and inability to deal with his illness.
In this case, Dorothy shows the opposite symptom of the attribute.She experienced psychological distress, an inability to cope, and was unable to be resilient to her illness.

Antecedents and consequences 3.5.1 Antecedents
Antecedents are factors, events, or situations before or preceding the concept (Walker & Avant, 2018).The occurrences of traumatic or negative events were identified to be necessary for developing resilience throughout the literature.The events will threaten an individual's ability to cope with the disease and impact the personal response to the life crisis (Garcia-Dia et al., 2013).The available literature indicated that the antecedent of resilience in breast cancer (Figure 2) are body image issues after mastectomy, symptoms of distress, cancer-related stigma, and fear of cancer recurrence (Izydorczyk et al., 2018;Koral & Cirak, 2021;Lee & Kim, 2018;Ocel, 2017).
The surgical intervention utilized in the management of breast cancer has the potential to adversely impact a woman's perception of her physical appearance and self-concept (Koçan & Gürsoy, 2016).We can see this body image issue as a trauma for breast cancer that will trigger resilience in breast cancer patients.Aside from body image disturbance, they will develop symptom distress.The experience of symptom distress has the potential to lead to physical dysfunction and emotional disturbances.This is especially true for upper-arm problems, sleep disturbance, fatigue, and body image disturbance, which may manifest as long-term side effects over time (Boehmke, 2004).Patients with higher distress will have a lower resilience level (Matzka et al., 2016).
Cancer patients are often subjected to social stigma in numerous nations.Stigmatization is linked to diverse clinical outcomes and social ramifications (Fujisawa & Hagiwara, 2015).People who are stigmatized frequently face prejudice and social exclusion.As was previously said, it is not unexpected that cancer stigma deters many people from getting medical care (Matthews et al., 2002).Resilience will moderate stigmatization in breast cancer patients through a higher level of psychological well-being (Ocel, 2017).
The phenomenon of fear of cancer recurrence is characterized by an individual's apprehension, anxiety, or unease regarding the potential for cancer to reoccur or advance.This ailment is frequently encountered by individuals who have undergone therapy for cancer (Ozakinci et al., 2014).Patients with a lower fear of recurrence will have a higher resilience score.Increased resilience can potentially decrease the level of anxiety associated with the possibility of a future occurrence.Individuals possessing a high degree of resilience are anticipated to exhibit a greater capacity for managing stressors encountered throughout their lifespan (Koral & Cirak, 2021).

Consequences
Consequences are the end-points that occur due to the critical components of the concept (Windle, 2011).Consequences aim to recognize or measure the essential characteristics or attributes of the resilience concept.The end-points of resilience in breast cancer patients (see Figure 2) are quality of life and post-traumatic growth (Celik et al., 2021;Edward et al., 2019;Li et al., 2020).Quality of life refers to personal perception of their current expectation regarding their life with breast cancer.Breast cancer is associated with reducing health-related QoL (Lidgren et al., 2007).The experience of a life crisis that arises during the diagnosis and/or treatment of breast cancer has the potential to foster personal resilience, ultimately impacting the individual's quality of life.Patients who exhibit greater resilience tend to experience a notably higher quality of life across a wide range of quality of life domains (Ristevska-Dimitrovska et al., 2015).
Post-traumatic growth (PTG) refers to the positive psychological transformation that individuals undergo as a result of coping with highly challenging life circumstances.PTG emerges in a relatively short period of time following a diagnosis of breast cancer and is linked to the level of illness intrusiveness at the outset, as well as to subsequent increases in social support, spirituality, active-adaptive coping strategies, and mental health (Danhauer et al., 2013).PTG can present itself in diverse forms, such as an augmented sense of gratitude towards life, deeper and more significant connections with others, enhanced personal resilience, altered priorities, and a more profound existential or spiritual perspective on the existence (Pat-Horenczyk et al., 2015).Insufficient levels of resilience have a direct and indirect impact on post-traumatic growth, as well as the utilization of maladaptive coping mechanisms, and may result in avoidance behaviors that hinder comprehensive processing of the traumatic event (Gori et al., 2021).The presence of PTG has been found to be correlated with decreased levels of psychological distress and increased resilience.Enhancing resilience among breast cancer patients is crucial, as it is widely acknowledged that resilience plays a pivotal role in determining an individual's quality of life and post-traumatic growth (Pat-Horenczyk et al., 2015).

Empirical Referents
Empirical referents pertain to factual data that can be subjected to testing, replication, and validation (Walker & Avant, 2011).Several studies have utilized the available instrument to identify resilience among breast cancer patients.The most common tools are the Connor-Davidson Resilience Scale (CD-RISC) (Connor & Davidson, 2003) followed by the Resilience Scale (RS) (Wagnild & Young, 1993), and the Resilience Scale for Adults (RSA) (Friborg et al., 2003).Besides those standard tools, two instruments precisely measure the cancer patient's resilience: The Breast Cancer Survivor Resilience Scale and the Resilience Scale Specific to Cancer (RS-SC).
The CD-RISC consists of 25 items with the 5-point Likert scale from not all true (0) to true nearly all the time (4).The tool encompasses five distinct domains, namely personal competence, high standards and tenacity, trust in one's instincts, tolerance of negative affect and strengthening effects of stress, positive acceptance of change and secure relationships, control, and spiritual influences.A positive correlation exists between higher scores and increased resilience among the patient population (Connor & Davidson, 2003).
The Resilience Scale exists with 25 items, divided into five essential characteristics: meaningful (or purpose) life, perseverance, self-reliance, equanimity, and existential aloneness.The responses are available on a 7-point scale from 1, disagree, to 7, agree.Possible scores range from 25 to 175, reflecting higher resilience scores (Wagnild & Young, 1993).The third tool, the Resilience Scale for Adults, consists of six protective dimensions of resilience in adult patients.The aforementioned constructs include self-perception, future planning, social competence, familial cohesion, social resources, and a structured approach.The Resilience Scale for Adults (RSA) comprises 33 items, with response options ranging from 1 to 7. The scores obtained from the RSA are indicative of the degree of protective factors associated with resilience, with higher scores indicating greater levels of resilience (Friborg et al., 2003).Most of the included studies used the CD-RISC as the measurement tool to identify resilience among breast cancer patients.It makes sense since the critical characteristics of resilience in breast cancer patients are covered by this tool, making it more suitable and applicable to identifying resilience in breast cancer.The ability to cope with cancer is related to personal competence; satisfaction with social support includes a secure relationship, and optimism has tenacity.
The Breast Cancer Survivor's Resilience Scale (BCRS) was originated in Japan.The instrument in question was specifically designed for the purpose of assessing the resilience levels of individuals who have survived breast cancer.The BCRS scale is deemed to possess a considerable degree of validity and reliability due to its incorporation of both individual and social factors.Healthcare professionals may contemplate implementing resilience interventions for breast cancer survivors based on personal and social perspectives, as indicated by the scale (Kim et al., 2020).
The Resilience Scale Specific to Cancer Instrument (RS-SC) comprises five domains, namely generic element, benefit finding, support and coping, hope for the future, and meaning for existence.The scale is designed to measure resilience levels, with higher scores indicating greater resilience.There exist two distinct variations of RS-SC, namely the 25-item and 10-item versions.The psychometric properties of RS-SC-25 are favorable, indicating its potential utility in determining an asymptomatic threshold for informing the implementation of psychosocial or pharmacological intervention.A brief 10-item version (RS-SC-10) has been created utilizing multidimensional item response theory (MIRT) to enhance item discrimination and alleviate the scale burden on patients.This abbreviated version has been employed for patients receiving care in outpatient wards (Ye et al., 2020).

Discussion
The objective of this analysis was to conduct a comprehensive examination of resilience in individuals diagnosed with breast cancer, including an assessment of its defining characteristics, precursors, outcomes, and empirical evidence.The resilience of breast cancer patients is noteworthy, given the potentially traumatic nature of the diagnosis and treatment of breast cancer, which can result in both physical and psychological challenges (Martino et al., 2019).Although a cancer diagnosis and treatment can cause considerable distress, a considerable number of cancer patients exhibit remarkable resilience.Regrettably, not all breast cancer patients exhibit a favorable response to adversity, and certain individuals experience a decline in their condition in response to the life crisis associated with breast cancer (Seiler & Jenewein, 2019).Thus, this paper delivered the redefining of resilience among breast cancer patients.
This study identified four antecedents in breast cancer resilience: body image issues after mastectomy, symptoms of distress, cancer-related stigma, and fear of cancer recurrence.Mastectomy is a surgical procedure aimed at the complete removal of breast tissue in order to address or prevent the onset of breast cancer.The mastectomy procedure is commonly regarded as a distressing occurrence that induces psychological strain and, in certain instances, psychological complications (such as anxiety and depressive symptoms, low self-regard, body image concerns, and others).The body image includes the symbolic meaning and importance of her breasts.Changes in body image after mastectomy will affect positive or negative adaptation or resilience (Izydorczyk et al., 2018).Some studies reported mastectomy hurts body image (Ruiz-Rodríguez et al., 2022;Tü k & Yı z, 8).This is because mastectomy will change the appearance and women's perception that the cancer experience threatens their womanhood and make them feel less like a woman (Tü k & Yı z, 8).On the contrary, an alternative investigation demonstrated that certain women experienced heightened strength and selfassurance subsequent to undergoing surgery.These women refused to conform to conventional beauty standards and expressed a sense of pride in the scars resulting from their mastectomy (Grogan & Mechan, 2016).
Symptoms of distress can affect the resilience of breast cancer patients.The prevalent symptoms encountered by patients undergoing chemotherapy are pain, nausea, and vomiting.(Booth et al., 2007;Maida et al., 2009).The pain was a significant problem for many women with breast cancer, and this was generally poorly managed.Physical pain caused by cancer wounds is a complex phenomenon and seriously impacts patients' quality of life (Maida et al., 2009).The pain may be attributed to various factors such as the expanding neoplasm, compression of adjacent anatomical structures, edema arising from compromised lymphatic and capillary drainage, wound infection, contact with cutaneous nerve endings, or manipulation during dressing alterations (Probst et al., 2012).Wound-related problems were often uncontrollable and unpredictable, as they could appear at any time during the day or night, despite strategies to control the issues.It slowly became more and more of a challenge for the women to contain and disguise odor and exudate (Probst et al., 2012).In addition, the rates of prevalence for nausea or vomiting were recorded as 37% and 13% after 24 hours and 70% and 15% during days 2-5 (Booth et al., 2007).Therefore, the patient must have an excellent coping ability to survive the disease and the side effects of therapy.
Attributes are crucial features that assist in distinguishing one concept from others and clarifying its meaning.The search results revealed several resilience attributes in breast cancer patients, including coping with the disease and cancer treatment, satisfaction with social support, " external and/or internal demands that are appraised as taxing or exceeding the person' " (Lazarus, 1993).Coping strategies used during the diagnostic phases of breast cancer are indicators of psychological adjustment after surgery (Drageset et al., 2010).A patient who has good psychological adjustment would solve the problem and seek support as their coping mechanism (Werdani & Silab, 2020).Early intervention could assist patients in controlling cancer-related stress through effective coping mechanisms that could boost their resilience (Borgi et al., 2020).
Social support provided by social engagement initiatives has the ability to improve coping mechanisms, resilience, and social connectedness, as well as have positive benefits on both physical and mental health (Steptoe & Fancourt, 2019).According to Lam et al. (2010), there exists a positive correlation between optimism and resilience among individuals diagnosed with Nurse Media Journal of Nursing, 13(1), 2023, 39 Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811 cancer.According to Seiler and Jenewein's (2019) study, a positive outlook and positive initial treatment outcomes were indicative of resilience and reduced distress in female breast cancer patients.According to Stewart and Yuen (2011), resilience will be achieved when individuals manage to maintain or regain their mentality in significant difficulties or risks.Therefore, those three-concept play a vital role in developing resilience, especially in breast cancer patients.
The results or ramifications manifest as the level of well-being and the positive psychological changes following a traumatic event.The concept of quality of life, specifically pertaining to health, has been operationalized as the subjective evaluation of breast cancer patients regarding their physical, mental, and social well-being, which is impacted by factors such as diagnosis, treatment, post-treatment, and survivorship.This evaluation is typically conducted using rigorously validated instruments (Mokhatri-Hesari & Montazeri, 2020).The impact of psychological resilience on various domains of health-related quality of life is noteworthy.Patients who exhibit greater resilience tend to experience a notably higher quality of life across a wide range of dimensions pertaining to their overall well-being (Ristevska-Dimitrovska et al., 2015).Post-traumatic growth is a phenomenon that is observed when an individual is able to derive positive meaning from a traumatic event that has caused significant distress.This implies that the extent of the trauma experienced by the survivor is a crucial factor in determining the likelihood of post-traumatic growth.Individuals who exhibit high levels of resilience may have a decreased tendency to perceive threats to their personal or ideological beliefs.Consequently, individuals who possess greater resilience are better equipped to mitigate the impact of such events, thereby highlighting the necessity of providing education (Jannat et al., 2022;Levine et al., 2009).

Implications and limitations
This concept analysis of resilience in breast cancer patients helps nurses develop holistic patient-centered nursing interventions to enhance the resilience of breast cancer patients.Nurses working with breast cancer patients may find resilience and its attributes for the assessment and implement the nursing intervention.This study suggests that resilience is an important concept in improving the quality of life and post-traumatic growth in breast cancer patients.Despite its universal approach, the current concept analysis also has its limitation.As our literature search was based on mostly English-language academic databases, our perspective might be biased toward non-English academic literature.

Conclusion
This concept analysis provides in-depth insights into resilience among breast cancer patients.Resilience reduces adversity and facilitates transition after a life crisis.Identification from the literature reveals that significant characteristics of resilience in breast cancer patients include coping with the disease and treatment, optimism, and satisfaction with social support.Furthermore, the body image issue after mastectomy, symptoms of distress, cancer-related stigma, and fear of cancer recurrence are identified as antecedents, and quality of life and posttraumatic growth are consequences of breast cancer patients' resilience.The CD-RISC, RS, and RSA are the referent tools to measure resilience among breast cancer patients.Identifying attributes, antecedents, consequences, and empirical referents of resilience makes further research and clinical service clearer.

Quantitative
The study participants exhibited superior coping strategies for managing setbacks and adverse emotional states, indicating a heightened capacity for disengagement from challenging circumstances and alterations in their physical appearance.

Antecedent, Consequences
Nurse Media Journal of Nursing, 13(1), 2023, 48 Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811 The study found a significant positive correlation between psychological resilience and health-related quality of life (HRQoL) among Swedish women who were recently diagnosed with breast cancer.No modifying factor was detected in this relationship.

Consequences
Nurse Media Journal of Nursing, 13(1), 2023, 50 Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811 The independent contribution of resilience to a decreased level of anxiety and depression, as well as an increased level of quality of life, has been observed in breast cancer patients prior to neoadjuvant chemotherapy.
Antecedent, Consequences 24.The effects of personality traits and resilience on quality of life in breast cancer survivors Song et al. (2021) Quantitative The association between quality of life and personality profiles was moderated by resilience.The levels of post-traumatic growth were found to be higher among survivors of breast cancer, and this was observed to be linked with a reduction in psychological distress and an increase in resilience.

Figure 1 .
Figure 1.PRISMA flowchart . The following are examples of model cases.In this model, patients experience all attributes.
Angela, 44 years old, has been diagnosed with breast cancer stage 3 in the last two years.She is a gorgeous, successful businesswoman who has a wonderful family with her husband and two children before her illness.Angela has already been unable to work following her cancer treatment due to the side effects of chemotherapy and the tremendous pain she endured.She always tries to cope with her illness and treatment by following yoga and some traditional herbs to reduce the pain.Angela also attends a breast cancer awareness program led by nurses in the hospital where she is receiving treatment.

Table 1 .
Description of the articles and their contributions to the concept analysis

Table 1 .
ContinuedFriborg et al. (2005)QuantitativeThe treatment objectives for breast cancer patients with regards to their psychological resilience involve facilitating the acquisition of novel coping mechanisms to alleviate stress, augmenting their personal and social aptitude, and promoting the utilization of existing social support systems.Additionally, the goals include improving family cohesion, fostering optimism and enhancing the quality of life.Furthermore, the treatment aims to assist patients in developing new values and priorities that align with their present and future life circumstances.Quantitative The positive impact of physical exercise of moderate intensity, self-efficacy, family hardiness, and social support on the promotion of disease rehabilitation and improvement of quality of life is wellestablished.Specifically, these factors have been found to have a positive effect on PR.

Table 1 .
Continued He would never let me just give up": Communicatively Constructing Dyadic Resilience in the Experience of Breast Cancer Lillie et al. (2018) Qualitative The findings indicate that the communication between couples has a dual effect on resilience, as it can both facilitate and impede it.