In this study, we explored the current landscape of family hardiness for breast cancer patients and investigated its influencing factors. The results revealed moderate family hardiness, with the main contributing factors being caregiver literacy, caregiver occupation, caregiver knowledge of patient disease. Family hardiness was positively predicted by caregiver readiness, but negatively predicted by intimate relationship experiences.
First,family hardiness is a characteristic and an attribute of a family. It describes how family members use their internal resources to adapt to a stressful environment and survive a crisis, protecting the family unit [15]. In this research, we used the Family Hardiness Index 20, which is a reliable and valid method [16, 17] for evaluating the internal advantages of family members. The adaptability assessment items in this survey included responsibility, control, and challenge aspects. As such, family hardiness can evaluate the ability of the main caregivers of breast cancer patients to assume responsibility (responsibility assumption), respond to challenges (actively meet challenges), and take control of the situation (control of negative events), in the face of such stressful circumstances.
In this study, the family hardiness score of breast cancer patient caregivers was 58.11 (SD = 5.67), which is consistent with the findings of Wang [18]. As expressed by crisis theory, negative life events can hinder fulfillment of the basic needs of family members, and can change family hardiness. If the family cannot face the harm brought by a negative event, it will appear imbalanced or disharmonious, resulting in family crisis or even collapse. When a family member is suffering from cancer, the whole family is impacted in various ways, leading to varying degrees of family crisis and seriously affecting the harmony of the whole family. This explains why the family hardiness score of cancer patients in this study was low, suggesting that nursing staff should pay attention to family hardiness when communicating with breast cancer patients and their families. This will enable each family to return to balance and harmony as soon as possible.
The main caregiver’s degree represents the level of education, which to a certain extent reflects the cultural environment of the whole family, and thus reflects the family’s ability to cope when faced with crisis events. A higher level of education indicates more mature and adaptable caregivers compared with lower education, independent access to disease-related knowledge, and more effective communication with the patient [19]. From their own point of view, highly educated caregivers can take responsibility and actively respond to negative events, so as to maintain a stable family state, control the development of the situation, and thereby improve the hardiness of the family. From the perspective of family members, highly educated caregivers can better maintain the stability of the family environment, deal with family conflicts and contradictions in a timely manner, and pay attention to the circumstances of patients’ lives. Therefore, when faced with crisis events, highly educated caregivers can better utilize their internal family resources to adapt to and deal with the stressful situation.
The extent to which caregivers know about the patient’s illness determines the level of stress on the family members, which laterally affects family hardiness. Due to the particularities of the disease, breast cancer patients may have a heavy psychological burden and emotional excitement, often accompanied by negative psychological experience [20]. Patients’ families with a greater understanding of the disease will have sufficient psychological preparation and a high degree of coordination with treatment, resulting in relatively less psychological pressure on both the patient and the main caregiver. However, families who lack understanding of the patient’s disease state will tend to overestimate or underestimate their condition, which has a certain impact on treatment effectiveness. At the same time, primary caregivers need to actively cooperate with adjuvant treatments, which places higher demands on them in terms of their hardiness and cognitive ability relating to the disease. This influences the psychological state and domestic environment of family members. Thus, the lower the level of caregivers’ knowledge of the patient’s disease, the lower the family hardiness will be.
In addition, care readiness (preparedness for caregiving) refers to the state of readiness to provide the necessary care to the patient, and is the evaluation indicator [21] used to predict the strain of the caregiving role. As the main support for and helper of the patient’s physical and mental needs, the caregiver’s own health may also be negatively affected after a long period of care. Furthermore, the physical and mental health of the caregiver will directly impact the effectiveness of the patient’s rehabilitation. We used the Caregiver Preparedness Scale, another methodology that has been proven reliable and valid, to assess the caregiver readiness of individuals supporting breast cancer patients. This scale has been validated for caregivers, and it is commonly used when researching this population.
We also used the Experiences in Close Relationships Inventory, another validated approach [22], to assess the status of family intimacy [23]. This is currently the most commonly used scale when assessing adult attachment, and it is also the most widely employed scale in research relating to caregiver attachment. When it is applied to family caregivers of cancer patients, some researchers consider that since cancer patients face life-threatening situations—and their caregivers genuinely worry about losing each other—this scale does not accurately reflect the caregiver’s attachment. However, the Cronbach’s alpha coefficients for the attachment anxiety and attachment avoidance subscales in the revised questionnaire were 0.88 and 0.86, respectively.
For the families of breast cancer patients, the main caregiver is the creator and maintainer of the family environment, and their psychological status is directly affected by caregiver readiness, as well as the level of intimate relationship experiences. If the primary caregivers suffer psychological problems themselves, they will be unable to maintain the original family environment, leading to uncoordinated family relations and tension in the family environment, thereby affecting the patient’s physical and mental progress [24]. Existing literature [25] shows that family stress felt by the main caregivers of breast cancer patients comes mostly from the family economic situation and the stress generated by the caring role. In the face of sudden crisis situations, family members with high levels of caregiver preparedness and intimacy have stronger coping skills, and can therefore have a positive impact on family hardiness.
This study found that caregiver readiness positively predicted family hardiness, whereas intimate relationship experiences negatively predicted it. Caregiver readiness measures caregivers’ level of preparedness for their upcoming responsibilities. The strength of the main caregivers’ abilities will have obvious impacts on treatment compliance and effectiveness. If the main caregiver is not prepared to deal with problems and emergencies in the process of taking care of the patient, it may lead them to experience inner anxiety and other emotions that will affect the tenacity of the family. Individuals with attachment anxiety are extremely sensitive in the face of setbacks or threats. They tend to overactivate their own emotional regulation strategies and their desire for excessive attention and support [26], but patients may ignore the psychological state of their caregivers due to their illness. This follows the findings of previous studies [27], and suggests that health care workers should strengthen their assessment of the attachment types of cancer patients’ caregivers, and guide them in adopting positive self-emotional regulation strategies. Meanwhile, targeted health education is also needed to promote caregiver readiness and improve the level of family hardiness among cancer caregivers.
In summary, in clinical nursing work, it is possible to provide the main caregivers of breast cancer patients with corresponding disease knowledge guidance and psychological counseling. This will improve the level of family hardiness, facilitate a good home environment, and promote disease rehabilitation of the patient. However, the sample size in this study is relatively limited, and sample collection should therefore be expanded in the future to test the reliability of the present results.
Table 1
General characteristics of the study subjects (N = 140).
Variable | N (%) | Family hardiness score (̄x ± SD) | T/F | P |
Sex | | | −1.900 | 0.060 |
Male | 79 (56.4) | 57.32 ± 5.44 | | |
Female | 60 (42.9) | 59.15 ± 5.88 | | |
Marital status | | | 2.305 | 0.023 |
With partner | 115 (82.1) | 57.60 ± 5.52 | | |
Without partner | 25 (17.9) | 60.44 ± 5.85 | | |
Education level | | | 5.062 | 0.002 |
Primary school and below | 7 (5.0) | 53.43 ± 1.90 | | |
Junior high school or junior college | 44 (31.4) | 56.57 ± 5.40 | | |
High school or junior college | 45 (32.1) | 58.31 ± 5.45 | | |
Bachelor’s degree or above | 44 (31.4) | 60.18 ± 5.78 | | |
Profession | | | 3.894 | 0.003 |
Unemployed | 17 (12.1) | 58.59 ± 4.68 | | |
Peasant | 32 (22.9) | 56.31 ± 6.16 | | |
Factory hand | 9 (6.4) | 55.33 ± 7.21 | | |
Office worker | 47 (33.6) | 60.55 ± 5.52 | | |
Individuality | 27 (19.3) | 57.67 ± 4.05 | | |
Self-employed | 8 (5.7) | 54.50 ± 4.31 | | |
Domicile | | | 1.961 | 0.052 |
Town | 76 (54.3) | 58.96 ± 5.59 | | |
Village | 64 (45.7) | 57.09 ± 5.63 | | |
Per capita monthly family income (RMB) | | | 4.013 | 0.004 |
< 1,000 | 14 (10.0) | 56.14 ± 4.70 | | |
1,000–2,999 | 24 (17.1) | 56.17 ± 5.61 | | |
3,000–4,999 | 52 (37.1) | 57.37 ± 5.51 | | |
5,000–10,000 | 32 (22.9) | 59.63 ± 4.51 | | |
> 10,000 | 18 (12.9) | 61.67 ± 6.88 | | |
Relationship to patient | | | 5.599 | 0.005 |
Offspring | 57 (40.7) | 59.32 ± 5.41 | | |
Spouse | 64 (45.7) | 56.44 ± 5.10 | | |
Other blood relative | 19 (13.6) | 60.11 ± 6.88 | | |
Self-perceived physical condition | | | 3.805 | 0.025 |
worse | 6 (4.3) | 57.00 ± 7.77 | | |
fair | 71 (50.7) | 56.93 ± 5.07 | | |
good | 63 (45.0) | 59.54 ± 5.86 | | |
Caregiving experience | | | 0.715 | 0.017 |
Yes | 59 (42.1) | 59.44 ± 5.79 | | |
No | 81 (57.9) | 57.14 ± 5.41 | | |
Others who need to care for | | | 1.066 | 0.288 |
Yes | 56 (40.0) | 57.48 ± 6.16 | | |
No | 84 (60.0) | 58.52 ± 5.32 | | |
Knowledge of the patient’s disease | | | 6.539 | 0.002 |
Incomprehension | 20 (14.3) | 54.35 ± 4.88 | | |
A little | 94 (67.1) | 58.36 ± 5.31 | | |
Very familiar | 26 (18.6) | 60.08 ± 6.34 | | |
Course of disease (months) | | | 0.051 | 0.985 |
≤ 6 | 101 (72.1) | 58.18 ± 5.35 | | |
7–12 | 23 (16.4) | 57.92 ± 6.13 | | |
13–24 | 7 (5.0) | 57.43 ± 8.18 | | |
≥ 24 | 9 (6.4) | 58.33 ± 6.82 | | |
Caring time per day (hours) | | | 0.150 | 0.861 |
4–8 | 61 (43.6) | 58.21 ± 5.12 | | |
8–12 | 39 (27.9) | 57.69 ± 6.16 | | |
≥ 12 | 40 (28.6) | 58.35 ± 6.09 | | |
Number of caregiving days per month | | | 3.017 | 0.052 |
7–14 | 64 (45.7) | 59.28 ± 5.89 | | |
15–30 | 18 (12.9) | 58.17 ± 5.23 | | |
30 | 58 (41.4) | 56.79 ± 5.35 | | |
Number of families to help care for | | | 0.681 | 0.565 |
0 | 51 (36.4) | 57.65 ± 5.23 | | |
1 | 47 (33.6) | 57.79 ± 6.18 | | |
2 | 32 (22.9) | 58.69 ± 5.74 | | |
≥ 3 | 10 (7.1) | 60.10 ± 5.30 | | |
Intimacy with the patient | | | 4.890 | 0.009 |
Commonly | 8 (5.7) | 52.75 ± 4.95 | | |
More intimate | 37 (26.4) | 57.41 ± 6.53 | | |
Very close | 95 (67.9) | 58.83 ± 5.12 | | |
Medical expenses payment method | | | 2.277 | 0.106 |
At own expense | 31 (22.1) | 56.29 ± 6.00 | | |
Hospitalization insurance | 54 (38.6) | 58.96 ± 5.28 | | |
Cooperative medical care | 55 (39.3) | 58.29 ± 5.72 | | |
Table 2
Family hardiness, and family adaptability, hardiness, and preparedness scores, for caregivers of breast cancer patients (N = 140).
Variable | Theoretical range of score | Range of actual score | Score (̄x ± SD) |
Family tenacity | 20–80 | 44–76 | 58.11 ± 5.67 |
Responsibility | 9–36 | 14–36 | 27.06 ± 3.46 |
Control | 6–24 | 10–23 | 16.71 ± 2.54 |
Challenge | 5–20 | 11–19 | 14.34 ± 1.48 |
Intimate relationship experiences | 36–252 | 49–184 | 121.7 ± 25.01 |
Attachment avoidance | 18–126 | 19–100 | 55.49 ± 14.50 |
Attachment anxiety | 18–126 | 29–110 | 66.18 ± 16.40 |
Caregiver readiness | 0–32 | 0–32 | 22.31 ± 5.69 |
Table 3
Correlation analysis (Pearson r) of family hardiness and parental stress among caregivers of patients with breast cancer.
Variable | Family hardiness |
Responsibility | Control | Challenge | Total |
Intimate relationship experiences | | | | |
Attachment avoidance | −0.400** | −0.247** | −0.406** | −0.461** |
Attachment anxiety | −0.092 | −0.432** | −0.261** | −0.318** |
Total | −0.292** | −0.428** | −0.407** | −0.476** |
Caregiver readiness | 0.368** | 0.106 | 0.369** | 0.369** |
** (e.g., P < 0.01).
Table 4
Multiple regression analysis of family hardiness of breast cancer patients’ caregivers.a
Variable | b | Sb | b’ | t | P |
(Constant) | 57.399 | 3.763 | – | 15.254 | 0.000 |
Total score of the intimate relationship experiences scale | −0.078 | 0.017 | −0.345 | −4.535 | 0.000 |
Total caregiver readiness score | 0.265 | 0.072 | 0.266 | 3.689 | 0.000 |
Educational background | 1.221 | 0.484 | 0.196 | 2.524 | 0.013 |
Occupation | −0.630 | 0.288 | −0.164 | −2.188 | 0.030 |
Knowledge of the patient’s disease | 1.445 | 0.714 | 0.146 | 2.023 | 0.045 |
aR2 = 0.334, F = 14.968.