ISSN 0120—5552 eISSN 2011—7531 Vol. 34, N° 2, 2018 Fecha de recepción: 23 de julio de 2017 Fecha de aceptación: 30 de septiembre de 2017 DOI: http://dx.doi.org/10.14482/sun.34.2.616.99

artículo de revisión / review article

Yeis Miguel Borré—Ortiz¹, Sandra Prada—Reyes², Audit Arrieta—Paternina³, Yuranis De la Hoz—Pantoja³, Yurisney Jimenez—Maury³, Cristian Santos—Puello³

¹Enfermero. Magíster en Enfermería. Magister en Investigación. Docente—Investigador, Universidad Metropolitana.

²Enfermera. Especialista en Cuidado al paciente en Estado Crítico. Especialista en Gerencia de la Calidad y Auditoria en Salud. Magister en Educación. Docente Programa de Enfermería, Universidad Metropolitana.

³Enfermeros. Programa de Enfermería, Universidad Metropolitana.

Correspondencia: Yeis Miguel Borré—Ortiz. Calle 76 No. 42—78 Universidad Metropolitana de Barraquilla. Colombia. yeismiguel@gmail.co

Abstract

Objective: To demonstrate the importance of nursing care in patients with breast cancer. Materials and Methods: Narrative review of the literature, which analyzed 34 studies that were selected from 5 databases, taking into account the recommendations of the report Preferred Reporting Items for Systematic Reviews and Meta—Analyzes (PRISMA) during the search strategy, keeping the Methodological rigor.

Results: In addition to the descriptive aspects found in the 34 studies, two major categories were identified that allow to describe the importance of nursing care in patients with breast cancer. The categories are: Aspects valued by nurses and approach to nursing care.

Conclusion: The importance of nursing care is evident through the humanized, dignified and palliative treatment that this type of patients require. The literature continues to show the need for nursing care to be comprehensive and strengthened in the light of interdisciplinarity. Key words: breast cancer, oncology, nursing, care, palliative care. (Source: MeSH).

Resumen

Objetivo: Mostrar la importancia de los cuidados de enfermería en pacientes con cáncer de mama.

Materiales y métodos: Revisión narrativa de la literatura, en la que se analizaron 34 estudios que fueron seleccionados de 5 bases de datos, teniendo en cuenta las recomendaciones del informe Preferred Reporting Items for Systematic reviews and Meta—Analyses (PRISMA) durante la estrategia de búsqueda, guardando el rigor metodológico correspondiente.

Resultados: Adicional a los aspectos descriptivos encontrados en los 34 estudios, se identificaron dos grandes categorías que permiten describir la importancia del cuidado de enfermería en pacientes con cáncer de mama. Las categorías son: Aspectos valorados por los enfermeros y enfoque de los cuidados de enfermería.

Conclusión: La importancia del cuidado de enfermería es evidente a través del trato humanizado, digno y paliativo que requiere este tipo de pacientes. La literatura sigue mostrando la necesidad de que los cuidados de enfermería sean integrales y se fortalezcan a la luz de la interdisciplinariedad.

Palabras clave: cáncer de mama, oncología, enfermería, cuidado, cuidados paliativos. (Fuente: DeCS).

INTRODUCTION

Cancer continues to be one of the leading causes of death in the world (1). It is estimated that its incidence will continue to increase and that 22 million deaths will be recorded in the next two decades (2,3). This indicates that cancer mortality will increase by more than 45% between 2007 and 2030, caused in part by demographic growth and the aging of the population (4). However, its incidence, prevalence and mortality vary in each region and country, and therefore, it is considered a major public health problem worldwide (5).

In 2012 there were about 14 million new cases and 8.2 million deaths related to cancer. The cancers most frequently diagnosed in man were those of lung, prostate, colon and rectum, stomach and liver, in women were breast, colon and rectum, lung, cervix and stomach. More than 60% of the world's new total annual cases occur in Africa, Asia, Central and South America. These regions represent 70% of cancer deaths in the world (6).

The World Health Organization (WHO) reports that the incidence rate of breast cancer increased by 20% between 2008 and 2012, with 1.67 million new cases diagnosed in 2011, which makes it the second type of cancer more common in the world and more frequent among women. The mortality of this type of cancer increased in those 4 years by 14%, with a total of 522.000 deaths in 2012 (7).

A statement issued by the Pan American Health Organization (PAHO) in 2012, revealed that in Latin America and the Caribbean there are 27% of new cases of cancer and 15% of these cases were due to breast cancer. In North America, 30% of new cases and 15% of cancer deaths in women were the result of breast cancer. Taking into account this behavior, it is estimated that by the year 2030 there will be more than 596.000 new cases and more than 142.100 deaths from breast cancer (8).

In Colombia, breast cancer is one of the chronic non—communicable diseases that has claimed the most lives. The Ministry of Health and Social Protection says that from 1998 to 2013, the number of women who died of this type of cancer increased by 93.37%. This indicates that around 8.686 cases are detected each year; Most of these are registered in Bogota, Medellin, Cali, Barranquilla, Cartagena, Bucaramanga, Santa Marta and the island of San Andrés (9).

In the Department of Atlántico (Colombia), according to statistics from the National Cancer Institute and the Ministry of Health and Social Protection, the cancer incidence rate between 2007 and 2011 was 481 new cases, the estimated prevalence rate was 1.825 cases, and the observed mortality rate of 12.1% of people diagnosed with breast cancer, with a mortality of 41.5% (10).

The American Cancer Society considers that breast cancer originates when the cells of the breast begin to grow uncontrollably. These cells usually form a tumor that can often be seen on an x—ray or can be felt as a lump. The tumor is malignant (cancerous) if the cells can grow by penetrating (invading) the surrounding tissues or spreading (metastasizing) to distant areas of the body (11).

According to Cano et al. (12) cancer is cataloged as a disease that affects the person at the physiological, psychological and social level; it brings with it the idea of suffering and death. Thus, when a person is diagnosed with cancer, she goes through a series of changes and situational crises that break her biopsychosocial balance. In response, the person performs adaptive behaviors that allow her to adapt, overcome and regain her balance again.

Currently, an effective cure for breast cancer has not been found, which implies that patients suffering from this type of disease tend to require interdisciplinary and long—term care, commonly known as palliative care. The nursing professional plays an important role in the management of these patients, because nursing care is the epicenter on which the entire care and the discipline responsible for care revolves during the health and illness experiences of the people (13).

Law 911 of 2004 (Code of Ethics of Nursing in Colombia) highlights that the essence of the Nursing profession is the care of health and life, and that this is based on communication and humanized interpersonal relationships between the professional nursing and the human being, family and/or social group, in the different stages of life course, health situation and the environment (14).

This indicates the importance of nursing care in patients with breast cancer, their family and their immediate social environment. For this reason, the present study aimed to show the importance of nursing care in patients with breast cancer in light of the publications reported in the scientific literature.

METHODOLOGY

A narrative review of the literature was developed in order to achieve the stated objective.

Dixon—Woods et al. (15) affirm that the narrative approach is characterized by the selection, chronicle and sequential and contingent order of a certain topic or phenomenon. Mays et al. (16) state that the purpose of narrative reviews is to summarize, explain and interpret data on a specific topic or question, an aspect that distinguishes it from a systematic review, insofar as it does not emphasize the search, evaluation and intensive criticism of publications through a rigorous technical protocol, but try to select a certain number of articles, group them according to their results and discuss their approach in light of the methodological characteristics of each to generate general conclusions (17).

Search strategy

Five databases were reviewed: CINAHL, Pubmed, Ovid nursing, Google Scholar and The Cochrane Library, in the period January —April 2017. The key words used were: “breast cancer”, “nursing care”, “palliative care” and “oncology” which were combined in English and Spanish taking into account the Boolean operators “AND”, “OR” and “NOT” and their different synonyms; truncating the terms with (* y $) to specify the search. The established limits were: clinical cases, research and /or revisions published between 2005 and 2017, in English and/or Spanish, and which would have been developed by nursing at home, in oncology or palliative care units.

Search results

During the literature search, 12,800 works were identified. After the revision of titles and abstracts resulted 11,600, after the application of selection criteria and elimination of duplicates resulted in 54 documents, of which 20 were eliminated for not having access to the full text. Additionally, the snowballing technique was applied and 15 studies were obtained, but they were eliminated in duplicates. Therefore, the total of studies selected for this review was 34 works. (Fig. 1)

The information of the 34 studies included in this work was organized chronologically and synthesized, in order to have an amplified panorama for its interpretation. (Table 2)

RESULTS

During the review it was observed that of the 34 selected studies, 1 was carried out in Chile (18), 11 in Spain (19—29), 8 in Mexico (30—37), 6 in Brazil (38—43), 4 in Cuba (44—47), 3 in Colombia (48—50) and 1 in Peru (51).

It was identified that 9 studies used theoretical—conceptual foundations of nursing, such as: the theory of transpersonal care (37) and human care of Jean Watson (50), the theory of the end of life of Ruland and Moore (51), the psychodynamic theory of Hildegard Peplau (30), Swanson's Theory of informed care (49), Saunders total pain theory (46), Henderson's theory of 14 basic needs (21), the Adaptation model by Callista Roy (33), the self—care deficit theory Dorothea Orem (31). Additionally, the use of the natural systems theory of Murray Bowen was found (45), although it is a theoretical construct of Psychology, this author cites it frequently in her studies on palliative care in nursing and quality of family life. (45,52).

The remaining 24 studies did not prove to have been guided by any theoretical—conceptual model of reference. When distributing the studies according to the year of publication, it was found that 8 studies were published between 2005 and 2008 (18—20,30,38,39,44,48), 15 were published between 2010 and 2013 (21— 25,31—34,40—42,45,46,49), and 11 were published between 2014 and 2016 (26—29,3537,43,47,50,51).

It is important to highlight that in addition to the findings found with respect to the theoretical framework of reference, 7 studies were framed in the use of the nursing process under the approach of the North American Nursing Diagnosis Association (NANDA), the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC) (20, 21, 25, 31, 33, 35, 37). Of the 7 studies, 1 combined the standard language with the functional patterns of Marjorie Gordon (20), and 1 with the 10 processes of Watson's care (37). On the other hand, 1 study showed not having used the nursing process and the Nanda—Noc—Nic taxonomy, but took as a reference the Nursing Care Plan for patients with breast cancer, approved by the Junta of Andalucía in Spain (29).

7 studies were oriented under a qualitative research methodology (33, 34, 37, 40, 42, 48, 51), 9 used quantitative methodology (23, 24, 30, 32, 36, 38, 39, 43, 47), 7 were reports of successful experiences and clinical cases (19, 20, 21, 25, 35, 49, 50), 10 were bibliographic reviews (18, 22, 26—29, 31, 41, 44, 46), and only 1 developed a mixed—type quasi—experimental study; that is, it combined quantitative and qualitative methodology concomitantly (45).

Identified Categories

From the critical and exploratory review carried out to the 34 selected studies, using colorimetric technique, two large categories emerged that allowed to identify and describe the importance of nursing care in patients with breast cancer. The categories are: a) Aspects assessed by nurses, and b) Approach to nursing care.

Category 1: Aspects assessed by nurses

A total of 7 subcategories were identified as fundamental aspects valued by nurses during the care experience given to patients with breast cancer, these subcategories are listed in Table 1.

The studies reviewed highlight the important role of nurses in providing social, psychological, emotional and family support required by patients who have been diagnosed or have breast cancer, whether in the early, middle or late stages of the disease (18—20,22,28,29,38,48).

Below are some descriptive fragments for the identification of subcategories:

Self—care and the proactive attitude of women with breast cancer is an aspect addressed by nursing professionals, because it helps in the process of cancer recovery and improvement of well—being, as well as the reduction of costs and institutional expenses (18,20,30,31).

It is important to emphasize that in order to achieve self—care behavior and a proactive attitude, it is necessary that nurses provide information and education to the patient and evaluate each stage of the process (19,23,35).

Taking into account that breast cancer involves a set of emotional and psychological affectations in the patient, the nursing professionals see it necessary and pertinent to evaluate the level of coping, stress and degree of adaptation that the patients may acquire (29,33).

Another important aspect identified in the studies is related to the assessment of spiritual well—being and the interpersonal relationships of the patient who experiences the disease (30,31,34,37,49). Therefore, some of the studies reviewed highlight the work of nursing in the approach to the spiritual dimension of the person.

Most studies are focused on the management and control of unpleasant signs and symptoms derived from breast cancer, as well as the proportion of education to the patient and caregivers about how to control them. Among the clinical manifestations, the most approached are the control and relief of physical signs and symptoms (20,21,22,2528,33,35,46,50,51), the psychosocial symptoms (21,22,24, 27,28,30,46,50,51), and alterations in the skin (25,26,39).

Category 2: Approach to nursing care

For the identification of the approach, a classification of the studies according to the nursing approach was made to the sick person of breast cancer and the main family caregiver as the immediate context of the affected person. In this sense, it was found that of the 34 studies analyzed, 26 are aimed at people with the health problem (18—28,30,31,3335,37—39,41—42,44,46,48—50), 3 are aimed at family caregivers (32,45,47), 4 were directed towards the nursing staff (29,36,40,43), and only 1 approached patients, primary caregivers and nursing staff concomitantly (51). It is important to highlight that those studies in which the patient was approached, was done from clinical perspectives. However, it is striking that the approaches of the studies do not include the family.

DISCUSSION

Cancer, and specifically breast cancer, is a process of great emotional impact both for the disease itself and for the physical and emotional consequences that it entails (24). The literature shows that breast cancer is the most common cancer pathology among women worldwide, and is increasing especially in developing countries (23,22,31). That is why early detection, in order to improve prognosis and survival, continues to be the cornerstone of the fight against this type of cancer (23,22). This has turned professional care into an important social requirement, as well as an ethical imperative for health professionals (20,31); especially, Nursing professionals, who stay longer and establish greater contact with this type of patients (54—57), besides being the most numerous within the health institutions (58,59). This situation makes these professionals have the need to look for new and better mechanisms of approach that allow them to achieve their objective: to take care of health and life (53). In this sense, Argüelles and Fernández (26) affirm that it is important that nursing care be provided with the best possible quality, in order to avoid complications derived from the disease However, to provide quality care, the nursing professional requires extensive knowledge about comprehensive palliative care (36,43).

According to Muñoz—Torres et al. (31) the complexity of the physical, psychological and social changes that breast cancer encompasses requires that Nursing personnel have the capacity to meet all these needs in order to help the individual maintain their independence in the evolutionary process of his illness and in turn, strengthen his biopsychosocial and spiritual health.

Olea et al. (34) with words of Jean Watson, affirm that the nursing professional must adopt the perspectives of human care to better approach the patient, and Urra et al. (60) state that in the care of this type of patients it is fundamental to preserve the human essence and reposition the care within the health systems. This is because the psychological impact that women experience as a result of the diagnosis and treatment of breast cancer is not ephemeral (22).

According to Almeida et al. (40) another important aspect that should be strengthened in the practice of palliative care is the therapeutic communication between the nursing professional, patients and the family. This interrelation must be configured in a nursing situation, in which the flow of experiences and shared life allows transforming the meaning of nursing care in the context of the disease.

Some authors affirm that nursing professionals give meaning to their practice in the light of other theoretical contexts and conceptual frameworks that are not nursing (61). However, this review shows that when nursing care is provided under theoretical foundations of reference and systematic methodological frameworks, the results could have a greater impact on the health of patients with breast cancer. In this regard, Hernández (49,50) affirms that the process of care, based on a nursing theory, makes it possible to articulate science and technology, and also allows the integration of the emotional and social dimension with the biological, leading to personal and professional growth in the nurses.

The use of nursing methodology has been a subject on which the effectiveness of care has been demonstrated. Authors such as Ortega et al. (35) affirm that the application of the Nursing Care Process allows nurses to provide care in a rational, logical and systematic way. However, these methodologies would have greater impact, if family caregivers and the family in general were included. Ostiguin et al. (32) assert that it is necessary to recognize the primary caregiver as an important figure in the health system, by accepting their potential and limitations to assume responsibilities in the care task in the health institution as well as in the home.

Borré—Ortiz et al. (62) maintain that the care of the sick person in the home is provided by a primary caregiver or the family, but that in turn, the family requires educational, psychological, spiritual, emotional and social support systems that allow it to maintain its stability, balance and potentiality; confirming what was expressed by Canga et al. (63) and Vivar (64) who affirm that it is important that health professionals have a systemic vision of the family and be considered as a unit of care.

In addition to the psychological, emotional and spiritual aspects valued by nurses, this review found a strong tendency towards the care of physical symptoms. This is consistent with what is expressed by Expósito, who affirms that adequate control of symptoms is part of the essence of Palliative Care. (45).

Lafaurie et al. (48) recommend that educational processes should be focused on the greater understanding of cancer by women with breast cancer, in addition to guiding them to know self—care strategies that help them to minimize their symptoms and the effects of their treatments. In this same sense, Carvalho (41) proposes that the actions necessary to achieve effective palliative care are related to health education, in which the nurse should encourage the participation of the female user of the health service, encouraging selfcare in performing the clinical examination of the breasts ; considering that nursing has a preponderant role in the development of actions with the population, since the focus of their work is humanized care, focused on the prevention of grievances and the promotion of health.

CONCLUSION

Nursing care in patients with breast cancer continues to be a permanent challenge that requires nursing professionals not only to have clinical competencies for the management of symptoms, but also demand competencies for the educational, emotional, family, psychosocial and spiritual approach. Additionally, this approach represents a challenge in the use of disciplinary knowledge to be able to demonstrate the usefulness it has in the improvement of the nursing care process.

On the other hand, the literature continues to demonstrate the importance of the human, dignified and palliative nursing care required by breast cancer patients. Therefore, it is necessary that nursing care be more comprehensive and strengthened in the light of interdisciplinarity. However, it is suggested to continue developing the body of scientific knowledge, increasing research in this field, to improve the quality of care offered to patients diagnosed with breast cancer and, therefore, their quality of life, satisfaction and well—being; both individually and familiar.

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