Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

Yingzi Zhang, MS
Kristine Kwekkeboom, PhD, RN
Marcia Petrini, PhD, RN

Uncertainty, Self-efficacy, and Self-care

Behavior in Patients With Breast Cancer
Undergoing Chemotherapy in China
K E Y W O R D S Background: Treatment for breast cancer causes uncertainty in the face of new and
Breast cancer distressing experiences and often results in the need for self-care. Identifying how
Chemotherapy uncertainty influences self-care behavior is essential to design interventions that enhance
Self-care behavior self-care capacity and improve patient outcomes. Objectives: The aims of this
Self-efficacy study were to describe the levels of uncertainty, self-efficacy, and self-care behavior in
Uncertainty Chinese women receiving chemotherapy for breast cancer and to determine if
self-efficacy mediates the relationship between uncertainty and self-care behavior.
Methods: A cross-sectional descriptive correlational design was used. Ninety-seven
participants completed the Generalized Self-efficacy Scale, the Mishel Uncertainty
in Illness Scale, and the Appraisal of Self-care Agency ScaleYRevised. Descriptive
statistics were used to analyze the levels of uncertainty, self-efficacy, and self-care
behaviors in the sample. Multiple regression was used to test the mediating effect
of self-efficacy in the relationship between uncertainty and self-care behavior.
Results: Mean ratings of uncertainty (76.70), self-efficacy (27.15), and self-care
behavior (53.96) all fell in the moderate range. Both uncertainty and self-efficacy
independently predicted self-care behavior, explaining 18.2% of the variance, but
self-efficacy did not mediate the relationship between uncertainty and self-care behavior.
Conclusions: Research is needed to further evaluate the proposed relationships
using instruments specific to/related to cancer and evaluate change over time. Self-care
interventions that have been efficacious in Western populations could be revised to
assist Chinese women to reduce uncertainty and enhance self-efficacy in coping with

Author Affiliations: School of Nursing, Wuhan University, Wuhan, Hubei, Correspondence: Yingzi Zhang, MS, School of Nursing, University of
China (Ms Zhang and Dr Petrini); and School of Nursing, University of Wisconsin- Wisconsin-Madison, K6/117 Clinical Science Center, 600 Highland Ave, Madison,
Madison (Ms Zhang and Dr Kwekkeboom). WI 53792 ([email protected]).
This work was completed to fulfill the requirements of the master’s thesis and Accepted for publication April 13, 2014.
was supported by Wuhan University School of Nursing. DOI: 10.1097/NCC.0000000000000165
The authors have no conflicts of interest to disclose.

Uncertainty, Self-efficacy and Self-care in Breast Cancer Cancer NursingTM, Vol. 38, No. 3, 2015 n E19

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 breast cancer. Implications for Practice: Self-care intervention programs should
include strategies to reduce uncertainty and enhance self-efficacy in coping with breast
cancer treatment.

powerful cognitive mediator of action.16 Gist and Mitchell17 de-

n Literature Review scribe uncertainty as an important component in the formation
of self-efficacy beliefs. They describe uncertainty as a component
Breast cancer is the second most common cancer, with an estimated in assessing task complexity, which provides an external informa-
1.67 million new cancer cases diagnosed in 2012 worldwide.1 tional cue that contributes to one’s estimate of his/her ability to
The estimated annual incidence of breast cancer in Chinese women perform the task.17 With high levels of uncertainty, patients may
is 187 213, with an incidence rate of 15.1%.1 Chemotherapy is feel less confident to make accurate judgments, identify appropriate
widely used in the treatment of breast cancer and causes many actions, and engage in coping behaviors.11,18
adverse effects, such as hair loss, vomiting, nausea, anorexia, fa- In previous research, uncertainty has been shown to negatively
tigue, anxiety, and sleep disturbance.2,3 Women diagnosed with correlate with self-efficacy. For example, in pregnant women, un-
breast cancer are challenged to learn to manage these distressing certainty in the experience of pregnancy was negatively correlated
adverse effects and also to participate in complex treatment reg- with self-efficacy for responding to novel or difficult fetal health
imens and cope with a life-threatening diagnosis. The breast can- situations.19 Moreover, in a study of Taiwanese patients who had
cer experience can cause significant psychological burden and received percutaneous coronary intervention 3 to 6 months before,
put heavy self-care demands on these patients.4Y6 illness-related uncertainty was negatively correlated with self-
Self-care behavior has been defined as the range of voluntary efficacy for physical activity.20 Several studies have demonstrated
activities that an individual uses to maintain life, health, and a positive relationship between self-efficacy and self-care behavior
well-being. It is learned behavior and is performed by individuals across a range of chronic conditions. A positive correlation was
on their own behalf.7 Some self-care behaviors may be intuitive, found between self-efficacy and self-care activities in patients with
for example, resting when feeling fatigued. More complex and hypertension,21 type 2 diabetes,22 arthritis,23 heart failure,24 and
systematic self-care behaviors may be taught by nurses to help cancer.25 Only 1 study was located that tested the mediating role
patients cope with the anticipated effects of chemotherapy treat- of self-efficacy in the relationship between uncertainty and self-
ment. Several studies have examined self-care interventions to im- care behavior. Using baseline data from an intervention study of
prove coping in patients with breast cancer, demonstrating beneficial adults with chronic idiopathic pain, LeFort26 demonstrated that
effects of strategies such as written materials about self-care skills,8 self-efficacy mediated the relationship between uncertainty and
audiotapes of cognitive-behavioral coping techniques,6,9 and a self-care. Patients with greater uncertainty about their pain con-
self-help training program including uncertainty management.2 dition reported less self-efficacy for pain control behaviors and
Two nurse investigators, Braden and Mishel, have developed fewer self-care activities.26 Although cancer was the focus in only
frameworks and conducted a series of studies demonstrating the a few of these studies, chronic illnesses like hypertension, diabetes,
impact of uncertainty and the role of self-care behavior in coping and heart failure bear similarities to cancer in that they are chronic
with and adjusting to chronic illnesses, including cancer.10Y13 and potentially life-limiting and all require significant patient in-
They postulated that disease and treatment adverse effects, when volvement in long-term monitoring and management of the health
recognized as unfamiliar and in the absence of supportive struc- condition and frequent adjustment to changing illness and treat-
ture, can lead to feelings of uncertainty.10 Mishel11 defined un- ment trajectories. However, more research is necessary to deter-
certainty as the inability to determine the meaning of events. She mine if self-efficacy indeed mediates the effect of uncertainty on
suggested that uncertainty occurs in situations where the decision self-care, particularly in patients with cancer.
maker is unable to assign definite values to objects and events or One study27 reported that uncertainty correlated with self-
unable to accurately predict outcomes.11 In women with breast care behavior in Chinese patients with coronary heart disease,
cancer undergoing treatment, lack of information about the dis- and Wen28 demonstrated a correlation between self-efficacy and
ease, treatment, and expected adverse effects may contribute to self-care behavior in Chinese patients with breast cancer under-
high levels of uncertainty.10,14 Braden’s Self-help Model suggests going adjuvant chemotherapy. Apart from these 2 studies, much
that uncertainty may diminish resourcefulness and ultimately un- of the research on uncertainty, self-efficacy, and self-care in women
dermine self-care behavior.12,13 Indeed, studies document the with breast cancer has been conducted in Western populations. It is
relationship between uncertainty and self-care behavior and that likely that the experiences of Chinese women with breast cancer
interventions designed to reduce uncertainty lead to improvements may be different from that of Western women related to factors
in self-care.12,13 such as sociodemographic and cultural differences, differences in
Neither Mishel’s Uncertainty in Illness theory nor Braden’s healthcare systems, and differences in availability of supportive
Self-help Model specifically addresses the concept of self-efficacy, services. For example, most Chinese patients with cancer receive
although it is arguably a logical and useful concept in explicating chemotherapy entirely as an inpatient, not outpatient, procedure.
the relationship between uncertainty and self-care. Wood and This practice may foster the belief that care is the responsibility
Bandura15 described self-efficacy as one’s capacity and confidence of others (eg, family and healthcare professionals) and leave Chinese
to carry out a task or behavior and theorized that such belief is a women largely unprepared for self-care when receiving chemotherapy.

E20 n Cancer NursingTM, Vol. 38, No. 3, 2015 Zhang et al

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Cultural differences in self-efficacy have also been demonstrated, within 1 year were excluded because these could substantially
with Chinese samples, particularly women, reporting lower self- influence self-efficacy, uncertainty, and self-care behavior.
efficacy than either men or women in German and Spanish sam-
ples.29 In the presence of low self-efficacy, Chinese women may
experience many unmet needs related to cancer management that
Instruments
result in poor quality of life30 and greater psychological distress.31 Demographic and medical information were collected directly
Thus, it is critical to evaluate self-efficacy and its relationships from patients. Participants reported their age, family income,
with uncertainty and self-care in Chinese women. financial resources, educational level, marital status, employment
The aims of this study were as follows: status, religious beliefs, stage of cancer, type of treatment, chemo-
therapy cycle length, and comorbidities.
1. To describe the levels of self-efficacy, uncertainty, and self-
Uncertainty was measured using the Mishel Uncertainty in
care behaviors in Chinese women receiving chemotherapy
Illness Scale for Adults (MUIS-A).32 The MUIS-A has 2 factors,
for breast cancer.
which are ambiguity and complexity. The 16-item ambiguity
2. To test the mediating effect of self-efficacy in the relation-
subscale measures the perception that cues about the state of the
ship between uncertainty and self-care behavior (Figure 1).
illness are vague and indistinct and tend to blur and overlap.
We hypothesize that, after controlling for demographic and Twelve items on the complexity subscale measure the perception
medical factors: that cues about treatment and the system of care are multiple,
intricate, and varied. Items are measured on 5-point Likert scales
1. Uncertainty will be negatively correlated with self-care behavior.
from 1 (strongly disagree) to 5 (strongly agree), with responses
2. Uncertainty will be negatively correlated with self-efficacy.
summed across all items to create the total scale score. The pos-
3. Self-efficacy will be positively correlated with self-care be-
sible range of scores is 28 to 140, with higher scores indicating
havior, controlling for the effect of uncertainty.
greater levels of uncertainty. In previous research, the Cronbach’s !
ranged from .90 to .94 for the total scale.32 The scale was trans-
n Methods lated into Chinese for this study. The first author (Y.Z.) translated
the English scale to Chinese, it was then back translated into
English by an English teacher, and the back-translated version
Design and Sample was evaluated for consistency of meaning by the third author
A cross-sectional descriptive correlational design was used. In the (M.P.). The translated version demonstrated good internal consis-
timeframe allotted for study completion, a convenience sample tency reliability, with a total scale Cronbach’s ! of .87.
of 97 women receiving chemotherapy for a new diagnosis of Self-efficacy was measured using the Chinese version of the
breast cancer were recruited from 3 university-affiliated govern- General Self-efficacy Scale (GSE).29 It consists of 10 items de-
ment hospitals in central south China. In China, persons with signed to assess beliefs about confidence in one’s personal ability
cancer are typically hospitalized for the course of chemotherapy. to cope with a variety of difficult life situations. Items are rated
Participants had to be 1 month or more post mastectomy or on a 4-point scale with the anchors 1 (not at all true) to 4 (exactly
lumpectomy, currently receiving inpatient chemotherapy (any true). The potential range of total scores is 10 to 40. Higher scores
cycle number in the initial course of treatment), and able to com- indicate greater levels of self-efficacy. The Chinese version of the
municate verbally and read and write in Chinese. Women who GSE has demonstrated a Cronbach’s ! of .91 in previous re-
were newly diagnosed with a recurrence of cancer, newly diag- search.29 In this study, a Cronbach’s ! of .82 was obtained.
nosed with any disease other than breast cancer within the pre- The Appraisal of Self-Care Agency ScaleYRevised (ASAS-R)
vious 3 months, and with terminal illness expected to cause death scale was used to measure self-care.33 It is a 15-item scale that

Figure 1 n Conceptual framework.

Uncertainty, Self-efficacy and Self-care in Breast Cancer Cancer NursingTM, Vol. 38, No. 3, 2015 n E21

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

measures one’s general and specific capabilities to engage in self- 2. Determine if uncertainty is associated with self-efficacy (GSE)
care (eg, I am able to get the information I need) as well as self- by regressing the GSE score on the MUIS-A score.
care behaviors (eg, I have changed some of my old habits in 3. Determine if self-efficacy mediates the effect of uncertainty
order to improve my health). Items use a 5-point Likert type scale on self-care behavior by regressing the ASAS-R score on the
ranging from 1 (totally disagree) to 5 (totally agree), with sum- MUIS-A and GSE scores, together. Mediation is present if
mated scores ranging from 15 to 75 and higher scores indicating the association between uncertainty and self-care behavior is
greater self-care. The scale was translated into Chinese for this either no longer statistically significant or reduced significantly.
study as described above for the MUIS-A. The overall ASAS-R
All regressions were conducted controlling for demographic
had a Cronbach’s ! of .89 in previous research.33 The trans-
and medical factors shown in previous research to be related to
lated ASAS-R had a Cronbach’s ! of .75 in this study.
uncertainty, self-efficacy, and self-care. These variables included
age, family income, financial resources, educational level, marital
Procedure status, employment status, religious beliefs, stage of cancer, type
The study was approved by the ethics committees of Wuhan
University and the 3 hospitals where patients were recruited. Table 1 & Demographic Characteristics and
Patients who met the inclusion criteria were identified by a re- Medical Characteristics of the
search nurse and invited to participate in the study. The research Sample (N = 97)
nurse explained the study purpose and informed patients that Characteristics Category n %
their participation was completely voluntary and they may with-
draw from the study at any time. The consent form included a Age, y 20Y40 7 7.2
statement that the patients’ medical care would not be affected 40Y60 75 77.3
by their decision to participate or withdraw from the study. After Q60 15 15.5
Educational level Illiterate 5 5.2
obtaining informed consent, the research nurse explained the in-
Primary school 7 7.2
structions for answering questions. Participants completed the
Middle school 26 26.8
questionnaires at the time of recruitment, while the women were High school 41 42.3
hospitalized for chemotherapy. The research nurse was present College 18 18.6
to clarify any items that were confusing. Approximately 15 to Marital status Without a partner 7 7.2
20 minutes was required to complete the questionnaires. No com- Have a spouse 90 92.8
pensation was provided. or partner
Employment Unemployed 32 33.0
Employed 65 67.0
Data Analysis Financial resource Themselves 69 71.1
Data were screened for missing items. Only 7 items were found (who paid for healthcare)
to be missing, and these were imputed using item-mean substitution Spouse 23 23.7
across the sample. Total scale scores (not subscales) were com- Children 5 5.2
puted for measures of self-efficacy, uncertainty, and self-care be- Family income, Yuan/mo G2000 34 35.1
2000Y4000 41 42.3
havior, and all were analyzed as continuous variables. Descriptive
94000 22 22.7
statistics (eg, frequency, percentage, mean, and standard deviation)
Religious belief None 83 85.6
were computed to describe the demographic and medical charac- Buddhism 7 7.2
teristics of participants and their levels of self-efficacy, uncertainty, Christian 4 4.1
and self-care. Bivariate correlations among all study variables were Folk beliefs 3 3.1
computed for descriptive purposes. The Pearson correlation coeffi- Stage of cancer I 17 17.5
cient was used for continuous and interval variables (age, cycle II 59 60.8
length, stage of cancer, uncertainty, self-efficacy, and self-care) III 19 19.6
and Spearman > for ordinal and dichotomous categorical variables. IV 2 2.1
Multiple regression was used to explore the mediating effect Type of therapy Chemotherapy 59 60.8
of self-efficacy in the relationship between uncertainty and self- Chemotherapy and 38 39.2
radiation therapy
care. Regression assumptions of normality, homoscedasticity, and
Chemotherapy cycle length 2 wk 15 15.5
multicollinearity were tested by examining histograms and scatter- 3 wk 54 55.7
plots of the standardized residuals, normal probability plots, and 4 wk 28 28.9
variance inflation factors. The assumptions were not violated and Comorbidity None 78 80.4
multicollinearity was not a problem. Mediation was tested using Diabetes 4 4.1
the procedure described by Baron and Kenny,34 which includes Hypertension 13 13.4
the following 3 steps. Diabetes and 1 1.0
hypertension
1. Determine if uncertainty (MUIS-A) is associated with self- Hypertension and 1 1.0
care behavior (ASAS-R) by regressing the ASAS-R score on heart disease
the MUIS-A score.

E22 n Cancer NursingTM, Vol. 38, No. 3, 2015 Zhang et al

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

of treatment, chemotherapy cycle length, and comorbidities.10,35Y42

14

1
One-tailed tests were used to explore the hypothesized directional
relationships among uncertainty, self-efficacy, and self-care. A

0.283b
threshold of significance for all tests was set at .05. All analyses

13
were performed using SPSS 20.0 (IBM Inc, Armonk, New York).

1
j0.314b
0.019
Results

12
n

1
Characteristics of the Sample

j0.247a
0.111
0.084
11
A total of 97 women agreed to participate in this study. Table 1

1
presents patients’ demographic and medical characteristics. All
of the patients were women with children. The mean (SD) age

0.058 j0.115
0.100 j0.079
0.073
0.169
10
was 51.76 (9.016) years. About half of them completed high

1
school education (42.3%). Most of the women were married
(92.8%) and employed (67%). For most (77.4%), their family

0.005

0.082
j0.039 j0.065
9
income each month was below 4000 Yuan (US$658, €479). Most

1
of the women (71.1%) financed their healthcare for themselves.
Most (80.4%) had the diagnosis of stage II breast cancer without

0.359b

0.294b
j0.054
0.083

j0.008
any comorbidity. All were receiving chemotherapy or chemo-

1
therapy with radiotherapy. For approximately half (55.7%), the
chemotherapy cycle length was 3 weeks.

0.003

0.017
j0.077
j0.034
j0.076

j0.071

j0.163
7

1
Levels of Uncertainty, Self-efficacy, and
Self-care Behavior

j0.321b

0.292b
j0.201a

0.243a
j0.032
j0.050
j0.040
0.040
The levels of uncertainty, self-efficacy, and self-care behaviors in
6

1
women receiving chemotherapy for breast cancer are presented
in Table 2. Mean (SD) uncertainty was 76.70 (13.55) on a scale of
28 to 140, mean (SD) self-efficacy was 27.15 (5.67) on a scale j0.318b

j0.237a
j0.083

j0.026
j0.150

j0.047
0.046
0.121

0.066
of 10 to 40, and mean (SD) self-care was 53.96 (6.08) on a scale
5

of 15 to 75. Bivariate correlations among study variables are re-

Table 3 & Correlation Matrix of Research Variables (N = 97)

ported in Table 3.
j0.659b
0.479b

0.207a
j0.073
j0.021
j0.085

j0.175
0.046
0.125

0.181
4

Mediating Effect of Self-efficacy

1

Mediation analysis was conducted as planned to test the spe-

cified hypotheses. Results are presented in Table 4 and Figure 2.
0.231a

0.224a
0.059
0.068

j0.096

0.021
j0.014
j0.063
j0.026
0.046
0.125
3

In step 1, uncertainty was a significant predictor of self-care (" =

1

j.192, P = .047). In step 2, the relationship between uncertainty

and self-efficacy was not statistically significant (" = .205, P =
0.537b
j0.340b
0.523b

0.241a
0.218a
0.103

j0.099
j0.047
j0.155
j0.028
j0.069
j0.169

.960). In step 3, both uncertainty (" = j.247, P = .015) and

2

self-efficacy (" = .266, P = .006) independently predicted self-

care behavior. Because uncertainty was not significantly related
to self-efficacy, and because self-efficacy did not reduce the effect
0.350b

0.367b
j0.280b
j0.211a

j0.222a

0.203a

0.232a
j0.080

j0.007
0.071
0.015

0.143

0.035

of uncertainty on self-care behavior in the analysis, self-efficacy

1
1

Table 2 & Self-efficacy, Uncertainty, Self-care

Behavior Scores (N = 97)
Financial resource

Type of therapy
Religious beliefs

Stage of cancer
Family income
Marital status
Employment

Comorbidity

Possible Obtained
Cycle length

Uncertainty
Self-efficacy
Education

Variable Mean SD Range Range !

Self-care

Uncertainty 76.70 13.550 28Y140 44Y115 .87

Age

P G .05.
P G.01.

Self-efficacy 27.15 5.672 10Y40 10Y38 .82

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Self-care behavior 53.96 6.076 15Y75 34Y69 .75

b
a

Uncertainty, Self-efficacy and Self-care in Breast Cancer Cancer NursingTM, Vol. 38, No. 3, 2015 n E23

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 Table 4 & Mediating Effects of Self-efficacy With Covariates of Demographic and Medical Variables (N = 97)
Model Summary Coefficients

R2 P Independent Dependent " SE Standardized " P

Model 1 0.225 .031 Uncertainty SCB j.086 .051 j.192 .047
Model 2 0.189 .099 Uncertainty Self-efficacy .086 .049 .205 .960
Model 3 0.283 .006 Uncertainty SCB j.111 .050 j.247 .015
Self-efficacy .285 .111 .266 .006
Abbreviation: SCB, self-care behavior.

did not mediate the effects of uncertainty on self-care behavior. population given that the study participants were currently receiv-
The total variance explained by all variables combined was 28.3%. ing chemotherapy and experiencing its adverse effects. It is pos-
Excluding the effect of covariates, uncertainty and self-efficacy sible that women were unaware of self-care strategies to cope with
explained 18.2% of the variance in self-care. chemotherapy-related challenges or symptoms. It may also have
been that others were providing care for these women at the time
of assessment. Unlike most Western countries where chemotherapy
is administered on an outpatient basis, these Chinese patients were
n Discussion hospitalized for the duration of their chemotherapy cycles. Being
hospitalized may have resulted in less of a demand for self-care, as
The current study found moderate levels of uncertainty, self-
hospital staff and family members were present to provide assis-
efficacy, and self-care among the Chinese women sampled. Ob- tance and support for the women with breast cancer. Other poten-
served responses reflected nearly the full range of possible scores, tial explanations may be related to the measure of self-care used
indicating an array of individual differences on all 3 variables.
in this study. The ASAS-R is a measure of general, not cancer-
The average level of uncertainty in our sample (76.70) was higher
specific, self-care. Engagement in typical daily self-care may not
than that reported in previous studies using the MUIS-A 28-item
have changed, while other less common (cancer-specific) self-care
scale, which reported scores ranging from 63.76 to 65.30 in a
needs may have been considerably different. In addition, the
sample of Western patients with breast cancer.42 Women in the
ASAS-R items measure both actual self-care behavior and ca-
current sample were recently diagnosed and had few comorbidities.
pacity to engage in self-care behavior. Participants may have
They would be expected to have more uncertainty because they reported low scores on capacity items while hospitalized and re-
lack any experiential frame of reference to define illness-related ceiving chemotherapy.
events.43 In addition, the low educational level of the sample in
Evidence in this study partially supported our research hy-
this study may have contributed to greater uncertainty35; less than
potheses. We demonstrated that uncertainty was negatively cor-
20% of our sample had more than a high school education.
related with self-care behavior, suggesting that the higher the
Moreover, many of our participants (77.4%) had family income
level of uncertainty that patients feel, the less self-care they per-
of less than 4000 Yuan per month (US$658, €479), which is far
form to cope with effects of the disease.12 Patients without suf-
below the average medical expense for inpatients in third-level
ficient information or knowledge cannot interpret illness situations
hospitals (10 442.4 Yuan in 2010).44 Families spend almost easily and are restricted in presenting satisfying and appropriate
50% of their household income for healthcare expenses when a self-care behavior when the breast cancer or its treatment is per-
family member has cancer.45 The economic pressure combined
ceived as complex and difficult to predict. Therefore, providing
with complex cancer treatment and limited illness experience
uncertainty management is an essential component in self-care
and education may have led to greater feelings of uncertainty in
interventions for patients with breast cancer.9
this sample.
The mean score for perceived self-efficacy found in this study
(27.15) was similar to or slightly lower than those reported by
other investigators, ranging from 27.4 to 31.91 for Western pa-
tients with cancer37,46,47 and 29.63 for Chinese women with
breast cancer.48 Participants in the current sample were relatively
young and most did not have a college education, factors that
correlated with lower self-efficacy in previous studies.37,38 Ac-
cording to Bandura,49 past mastery experiences are an important
resource in promoting self-efficacy beliefs, and patients who are
young and without any disease history may be less confident in
their coping ability.
The level of self-care behavior reported in the current sample
(53.96) is consistent with a previous study reporting a mean self-
care behavior score of 54.5 in the general population.33 We had
expected to observe higher levels of self-care relative to the general Figure 2 n Observed relationships. *P G .05; **P G .01.

E24 n Cancer NursingTM, Vol. 38, No. 3, 2015 Zhang et al

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 Our study also demonstrated that self-efficacy was positively (cancer) specific, which may have weakened our ability to detect
correlated with self-care behavior, controlling for the effect of mediation in this sample. Moreover, the self-care measure in-
uncertainty. This finding is consistent with Bandura’s Self- cluded items that measured both actual behavior and perceived
efficacy theory,50 which indicates that individuals need to believe behavioral ability. Fourth, the instruments used in the study were
that they can put self-care activities into practice to exert suffi- developed in the Western culture, and although all had good
cient effort and be able to perform self-care behavior. In other reliability, some (MUIS and ASAS-R) have not been validated
words, their self-efficacy facilitates the achievement of self-care for use with a Chinese mainland population. Fifth, an a priori
goals and adaptation to illness.36 Thus, a second essential com- power analysis was not done to determine sample size. Post hoc
ponent of self-care interventions is strategies to enhance patients’ analysis indicated a power of 0.52 to 0.75 for observed relation-
confidence and ability to engage in self-care activities. ships. However, we do not know if these observed effect sizes
Not all of the research hypotheses were supported by the data. accurately estimate the true population effect sizes. Our sample
We hypothesized a negative relationship between uncertainty and of 97 participants is sufficient if the true effect sizes of the me-
self-efficacy, with greater levels of uncertainty eroding one’s confi- diation pathways are large (> = 0.50, N = 26) or medium (> =
dence for coping with the challenge. Conversely, we found a 0.30, N = 82), but a larger sample size would be needed if the
positive relationship between uncertainty and self-efficacy, although true effect sizes are small (> = 0.10, N = 779). Finally, we did
not statistically significant. The direction of the relationship suggests not collect information about the exact length of time since diag-
that patients with higher levels of illness uncertainty tended to nosis or chemotherapy cycle number. Observed responses may
report greater confidence in their ability to manage difficult life have been influenced by how ‘‘new’’ chemotherapy was to the
situations. A similar relationship was demonstrated in spouse’s patient (ie, how much treatment women had already had), although
psychological adaptation to wives’ breast cancer diagnosis. Spouses previous studies have demonstrated consistently greater uncertainty
who reported more uncertainty had greater confidence to emo- levels during the treatment period compared with posttreatment.3
tionally support their wives and manage the impact of breast
cancer.51 Although the sources of uncertainty and personal im-
pact of cancer are different between women with breast cancer
and their spouses, both may share a similar spirit of ‘‘rising to the
n Conclusion
challenge’’ and being positive and hopeful in the face of a life-
Despite the limitations, the findings suggest some potential im-
threatening diagnosis. How people with cancer appraise an un-
plications for clinical practice. Our results underscore the impor-
certain situation is continually fluctuating. Future longitudinal
tant roles that uncertainty and self-efficacy play in self-care
evaluation may be useful to detect changes in uncertainty over
behavior. Health professionals need to assess patients’ knowledge
time and how uncertainty influences self-efficacy at different points
and information needs when facing a new cancer diagnosis and
in the breast cancer trajectory.
new treatment regimens with expected adverse effects. Nurses can
The mediating role of self-efficacy in the relationship between
help patients manage uncertainty by providing education and
uncertainty and self-care behavior was also not supported. One
assisting patients to anticipate and correctly make sense of cancer-
explanation may be the selection of a generalized self-efficacy
related experiences. Nurses also need to build or restore patients’
scale, rather than a cancer-specific self-efficacy scale. The GSE
confidence in their ability to successfully cope with these new chal-
measures global confidence in one’s coping ability across all stress-
lenges and help them to actively engage in self-care tasks. Inter-
ful situations, which may be perceived as a trait-like variable in this
vention programs for women with breast cancer should emphasize
study. Illness uncertainty occurs when a specific cancer-related
tailored ways to reduce uncertainty and enhance perceptions of
situation is complex, ambiguous, and unpredictable or when the
self-efficacy and controllability of unfamiliar experiences. Some
patient lacks information about a specific cancer stressor, which
uncertainty and self-efficacy interventions have demonstrated
is a more state-like variable.12 It is presumed that illness (cancer-
efficacy in Western samples of patients with cancer. Given the
related) self-efficacy may be a stronger mediator of the relation-
disparities in culture and economic status, these interventions
ship between uncertainty and self-care and that cancer-related
could be revised and tested to meet the unique needs of Chinese
self-efficacy may also be negatively rather than positively cor-
women with breast cancer.
related with illness uncertainty.
There are some limitations of this study that need to be taken ACKNOWLEDGMENTS
into consideration. First, the results of this study were obtained
from a convenience sample of women who all received chemo- The authors express their appreciation to Ms Xiaoxing Wen
therapy during an inpatient stay at a university-affiliated hos- for her assistance in back-translation of study questionnaires and
pital. They may not be representative of all Chinese women with to the patients and nursing staff in the Department of Oncology
breast cancer, particularly those who cannot access or afford of the 3 hospitals for identifying participants in the process of
third-level hospital care. Second, the study was cross-sectional data collection. The authors thank the Kwekkeboom research
and cannot account for temporal order of effects. In the current group for feedback on earlier versions of the manuscript.
analysis, we cannot be sure that uncertainty and self-efficacy led
to specific self-care activity. It is possible that successful self-care References
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