4.1 | Upper arm exercise self-efficacy among cancer patients with PICC
The aim of the study was to assess the level of upper arm exercise self-efficacy for cancer patients with PICC. To our knowledge, this study is the first that has assessed the level of upper arm exercise self-efficacy among cancer patients with PICC in china. This highlights the significance of our study, which will be a basis for the future studies and will add to the body of knowledge. The results of this study showed that the total self-efficacy score for upper arm exercise in cancer patients with PICC was (82.33±15.80), with a score of 71.16%, indicating that the self-efficacy for upper arm exercise in cancer patients with PICC was at an intermediate level, and that there was still a varying degree of need for upper arm exercise. After reviewing the literature, no studies have been reported on self-efficacy analyses of upper arm exercise in cancer patients with PICC, so the results of this study could not be compared with other literature.
Many patients find it difficult to perform physical activity during oncological treatment, and they are on average less physically active than the general population[33]. As a catalyst for maintaining motivation, exercise self-efficacy predicts an individual's choice of exercise style of exercise, how much effort they will put into exercise, and whether they will persevere when faced with obstacles[34]. Therefore, it is necessary to incorporate the management of upper arm exercise self-efficacy in cancer patients PICC into clinical nursing management. At the same time, nurses should pay timely attention to patients' exercise adherence in nursing practice, provide feasible health guidance in response to the problems that arise, and formulate corresponding measures to help patients exercise regularly.
4.2 | Factors that impacted upper arm exercise self-efficacy among cancer patients with PICC
4.2.1 Anxiety and depression influence upper arm exercise self-efficacy in cancer patients with PICC
Anxiety and depression are frequent symptoms in patients with cancer[35]. The results of the correlation analysis in this study showed that anxiety (r=-0.880, P<0.001) and depression (r= -0.897, P<0.001) were negatively correlated with upper arm exercise self-efficacy in cancer patients with PICC, indicating that the more severe the patient's anxiety and depressive symptoms, the lower the level of upper arm exercise self-efficacy. However, this study only found depression (β = -0.447, p < 0.001) to be an influential factor in upper arm exercise self-efficacy in cancer patients with PICC in multivariate linear regression analyses. Previous research has also pointed out that exercise maybe effective for mild to moderate depression, but less so for anxiety[36]. When patients are in a state of depression, they are prone to false expectations of competence, which will affect their beliefs about their ability to complete exercise. Therefore, medical professionals should incorporate early identification of depressive symptoms as a basic guideline when developing intervention strategies for upper arm movements, as well as enhancing psychological screening of cancer patients, and should encourage a warm atmosphere when attending to patients' needs and concerns.
4.2.2 PICC self-management competency influence upper arm exercise self-efficacy in cancer patients with PICC
Correlation analysis of this study have shown that upper arm motor self-efficacy is positively correlated with PICC self-management competency. Previous studies have also confirmed that patients with good self-management skills show a higher willingness to exercise. Their levels of exercise self-efficacy and adherence to exercise were also higher[37-40].
Self-management competency are a key variable in improving the health status and quality of life of cancer patients[41]. Multiple regression analysis in this study also found that PICC self-management competency (β= 0.169, p < 0.001) had a significant effect on upper arm exercise self-efficacy in cancer patients with PICC, higher self-management ability was associated with higher upper arm exercise self-efficacy. These findings will help us better understand the self-management competency and exercise self-efficacy of cancer patients with PICC. Importantly, in order to improve the level of patients' upper arm exercise self-efficacy, we now need to further investigate the mechanisms between self-management ability and upper arm exercise self-efficacy in cancer patients, to motivate patients to adopt positive self-management attitudes and uphold correct health beliefs and behaviours, and continuously improve their self-management competency so as to maintain good exercise status. Therefore, in the nursing process, nursing staff need to fully consider the influence of self-management competency on exercise self-efficacy, and can enhance patients' self-management competency through cognitive interventions or health education, so as to enhance patients' intrinsic willingness to exercise, improve their exercise self-efficacy, and further promote the physical and mental health of patients and improve their quality of life.
4.2.3 Perceived Social Support influence upper arm exercise self-efficacy in cancer patients with PICC
Social support in cancer care refers to the range of assistance and encouragement
provided by individuals or groups within a patient’s social network[42]. The results of the multiple regression analysis in this study showed that social support (β= 0.150, p<0.001) was positively related to upper arm exercise self-efficacy, indicating that friendly company and support can increase self-efficacy and provide a social model for undertaking and adhering to exercise. Previous findings have also found that social support can enhance physical activity through mechanisms such as providing information about expected behaviours, encouragement, and meeting contact needs. which may play an important role in cancer recovery[43-46].
Social support enables patients to experience that they are not alone, and when shared with others, the disease and treatment become easier to manage, facilitating access to resources from interpersonal interactions, and patients experience a sense of belonging and equality with others[47, 48]. Therefore, improving social support is of great significance to the physical and mental health of cancer patients with PICC placement. We suggest that healthcare professionals should strengthen communication with patients' families and friends so that families, hospitals and society can give more support, help and guidance to patients, and at the same time, fully mobilise and utilise the social support system to help patients to complete the exercise with a positive mindset, so as to improve the level of self-efficacy of their upper arm exercise.
4.2.4 Sociodemographic information influence upper arm exercise self-efficacy in cancer patients with PICC
In this study, we found that Exercise before illness, per capita monthly family income, duration of tube placement, and primary caregivers were statistically significantly associated with upper arm exercise self-efficacy in cancer patients with PICC.
The economic burden related to cancer treatment in society is substantial[49] 33.00% of the subjects in the survey for this study were freelancers with unstable jobs, and cancer and its treatment may lead to time away from work, limiting the patient's ability to work and reducing household income. In addition, patients receiving more intensive treatment may also have more severe or rapidly progressing disease, and greater intensity of treatment is often associated with higher out-of-pocket costs, which may increase the risk of financial hardship. This can also cause serious psychological and life distress to patients, making them spend little energy on upper limb activities, resulting in a low level of self-efficacy in upper arm exercise. Therefore, the government should gradually increase the financial support for cancer patients and adopt a more direct approach such as direct subsidies to more low-income groups or separate health insurance reimbursement policies for low-income groups, so as to achieve equity in the benefits of public health insurance, and these changes will enhance the confidence of cancer patients in fighting the disease.
In this study, patients who exercised more than three times in the week prior to illness had a significantly higher upper arm exercise self-efficacy score of 95.96 (2.65) than patients who did not exercise at all 60.01 (7.33). This indicates that the exercise habit before illness can bring patients a comfortable experience and a sense of inner enjoyment, because the upper arm exercise is similar to the previous exercise habit of most patients, so the patients' willingness to exercise is high. In addition, previous studies have reported that people with past exercise habits have greater exercise effects on subsequent re-exercise compared to those without past exercise habits[50] This leads patients to initiate action by subjectively judging that upper arm exercise can be beneficial and that it has a positive effect on promoting physical and mental health.
Linear regression analysis in this study found that patients' self-efficacy for upper arm exercise gradually decreased with the increase in catheterisation time (β = -0.053, p=0.042). Most of the patients changed their living habits after the tube was put in place and generally developed a sense of inferiority and reduced their social activities[51]. In addition, negative emotions such as fear of the disease and treatment, uncertainty about the future, and disappointment consumed the patients' energy. Resulting in the patient's inability to adhere to upper arm exercises. Our linear regression analysis also showed that patients' self-efficacy for upper arm movements was reduced when the primary caregiver was another loved one (β = -0.05, p = 0.024). Cancer patients tend to experience more frequent severe symptoms and a more severe decline in quality of life than other chronic diseases, and in order to effectively self-manage, patients need support, which often comes from family members or friends[52]. The role of the carer can affect the patient on a number of levels, and the expression of cancer-related emotions between couples gives the patient a sense of being understood, recognised and becared [53]. Higher intimacy between children and patients increases the patient's sense of security and self-confidence and leads to better outcomes[54]. Compared to spouses and children, patients may have less communication with other family members or may be reluctant to bother each other, resulting in patients not developing good behavioural effects and therefore low upper arm motor self-efficacy. In the future, a long-term longitudinal survey of cancer patients with PICC should be conducted based on the findings of this study to assess the dynamic level of upper arm motor self-efficacy and to provide a basis for further interventions.