Feelings and Spiritual Practices of Patients with Mastectomy : A Qualitative Study from Turkey

Purpose: This study was conducted to describe feelings and spiritual practices of patients with mastectomy. Method: The study was employed a qualitative design at a private university hospital oncology unit in Ankara, Turkey. Interviews were performed with 20 mastectomized women. Results: The findings indicated that commonly used in several spiritual practices; prayer was used by 96%, of the patients, and 94% requested that others pray for their health, the practice to positive reframing (76%), the practice to planning for family-friends activities (74%), visiting mosque-shrine (73%), and the practice to reading Quran (71%). The categorization of the data led to identification of three thematic units. The first we described as “Experiencing the consequences of illness as a disorder”. The second was “Restoring a sense of order to life”, and the third was “Living with the new condition”. Conclusion: We concluded that a having mastectomy was difficult for the subjects. In this respect, nurses’ role is vital to help women with breast cancer in such a difficult and modifying process as breast removal.


Introduction
Breast cancer is the most common cancer of women, comprising 23% of all female cancers around the globe.Breast cancer incidence has been increased three times in last decades in Turkey, incidence in western part of Turkey (50/100,000) is more than two times in eastern part of Turkey (20/100,000) due to "Westernizing life" (increased early menarche, late menopause, first birth > 30 years, smoking, alcohol consumption, oral contraceptive usage, use of hormone replacement therapy for 5 years or more, having miscarriages, aware of breast screeningearlier diagnosis, less breast feeding leads to higher the incidence in western part of Turkey), and other related factors [1].The physical and psychological results of a breast cancer diagnosis can result in many changes in quality of life [2].Mastectomy is a common treatment for breast cancer and deeply influence the perception of women's sexuality, body image and femininity [3,4].
Spirituality involve feelings of hope, love, connection, inner peace, power greater than self, a value system, God, cosmic consciousness, comfort and support [5].For some people, their spiritual practices act as a source of comfort and strength in dealing with life's difficulties.Especially people living with the illness may find it through a connection to nature, through music and the arts, through a set of principles [6].These are reflected in the quality of an individual's inner resources.In recovery from illness, spiritual applications can be helpful and powerful coping mechanism in the prevention of illness including decreased tension-depression, and negative physical outcomes [5,7].
In this sense, spirituality has been identified as factors that contribute to management of chronic illnesses and has become an increasingly popular concept among the health-related literature, is regarded as part of nursing practice [8,9].Nurses consider spirituality as an important component of holistic care [10,11].Although interest in the concept of spirituality and, especially spiritual needs in people with cancer has increased, limited research has targeted women who had undergone mastectomy [12][13][14][15].

Objective
The purpose of the study was to describe feelings and spiritual practices with women breast cancer.

Sample and Setting
Qualitative descriptive study conducted to describe the spiritual practices experienced in living with mastectomy from the perspective of patients with breast cancer from January to December of 2010.Data were collected from a convenience sample of 20 mastectomy patients participated voluntarily at Baskent University Oncology Unit in Ankara-Turkey.

Data Collection
A total of 20 mastectomized women at least 4 months previously, had completed adjuvant cancer treatment and had not experienced metastasis.In-depth semistructured interviews using open-ended questions were carried out, tape-recorded, and transcribed verbatim.The approximate duration of each interview was of about an hour and a half.Data collection and inductive analysis occurred concurrently.The research project was approved by the Ethics in Research Committee of the Hospital of Baskent University.Written consent was obtained from all participants and the anonymity and privacy of the participants were guaranteed.

Research Questions
In this paper, research question was as follows: cancer experienced, feeling about the removal of your breast, difficult times, meaning of spirituality, deeper own spiritality, recognition of needs, spiritual coping strategies and practices, and interventions to respond to spiritual needs, frequent use of spiritual behaviors or practices.

Results
In all, 38% of the patients were premenopausal and <50 years (their ages varied from 36 to 70 years of age); 77.4% were married, 64.5% were housewives, 38.1% were graduates of a basic education school, 68.8% had children, 65.8% lived at home with her spouse and children, and 60.4% had average incomes.The time since mastectomy surgery varied between 4 months and 25 months.A majority (72%) had been diagnosed for more than six months.
The categorization of the data led to identification of three thematic units.The first we described as "experiencing the consequences of illness as a disorder".The second was "restoring a sense of order to life", and the third was "living with the new condition".Patients conveyed positive spiritual changes as a result of their experience with breast cancer, and the women counted on their spirituality to help them cope and derive meaning from their disease experience.Most women (87%) believed that spirituality was an important part of their cancer treatment.
The findings indicated that several coping strategies; prayer was used by 96% of the patients, and 94% requested that others pray for their health, the practice to positive reframing (76%), the practice to planning for family-friends activities (74%), visiting mosque-shrine (73%), the practice to reading Quran (71%), the practice to go to a quite place (68%), the practice to use of instrumental support/helping others (66%), the practice to listening to or playing music (65%), the practice to do exercises (44%), meditation and yoga (13%).Complementary and alternative medicine (CAM) was used by nearly half of women (48%) after being diagnosed with breast cancer.The most commonly used CAM practices were herbal (94%), relaxation techniques (35%), and vitamin and minerals (67%).

Looking at the Three Thematic Units
1) Experiencing the consequences of illness as a disorder; losing a breast, feelings of shame, rejection and inferiority, a component and essential element of individuality.Self-image was mentioned by all subjects as the most important change.Psychological reactions related to mastectomy and the subsequent functional losses suffered have been noted.When confronted with breast cancer, experience of women was very difficult and they mostly felt grief.This behavior can be understood and justified in our society we live in.
One respondent stated, "…Initially, I was in shock.When I heard it first, I got rude awakening.I was so anxious and afraid of dying.The doctor and nurse convinced me to think positively.I knew that things were not going to be the same anymore.I felt reducing the sense of control on me.I thought about my children, how are they going to handle this, then I thought that I need to be stronger for them.I tried to look at this situation in other perspectives, but of course it is not an easy experience for me".
Another respondent stated, "…The truth is, nothing is like the way they were used to be before.Being not able to change this situation makes me feel desperate.And this feeling is too much for me to handle.Whenever I go outside, I feel naked and ugly.I feel like people are staring at me.So, I started to spend most of my time at home.I prefer not to talk about it.My family were the only ones who knew about my problem".
Another respondent stated, "…It really changed my life.I used to love doing make up.But I can't do it anymore because of my disorder.After mastectomy, I started to avoid to look at the mirror for several weeks.I couldn't feel like a women.I thought that no man would ever like me again.I used to love to swim, but now I feel shame of that because I scared to get negative reaction from others.So, I gave up doing it".
Another respondent stated, "…I used to find myself beautiful and positive.But I can't see these sides of me anymore.I don't feel special as a person.I become a shy person after mastectomy, even when I'm with my husband.This had never happened to me before.I'm afraid my husband divorcing me.I feel that my husbands' thoughts has been changed since (she began to cry)".
2) Restoring a sense of order to life; this section illustrates and demonstrates through the statements of the participants being able to restore their lives.
One participant described, "…When it comes to health care, I think it's better for me to remove the breast instead of remaining the cancer.So, I prepared myself to lose my breast.After that operation, I thanked God for helping met o get rid of cancer.My family and my friends had supported me a lot.In the main time, I have started to go to work.Now I am using breast prosthesis.I feel much better now".
Another participant described, "…I was nervous when I heard that my breast is going to removed.But now, I am okay with it.I've just started to see the good sides of things".
Another participant described, "…I passed experience discomfort due to pain, fatigue sleep disturbance, and nausea etc.But, I am still strong, so I think I can handle this problem.Of course it'll be hard for me to lose my breast but I can move on".
3) Living with the new condition; the participants of the study, express clearly that the beginning was difficult for them to accept their new condition.
One participant described, "…In the beginning it was very difficult.I have been bothered because the cancer and/or treatments have interfered with my ability to perform activities.But in time I had some experiences and now it is not that hard anymore.I learned lots of things after mastectomy.My life has been more meaningful".
Another participant described, "…I thought my life was ruined.Because mastectomy affected my body image in negative ways.My breasts were not equal so I couldn't wore light clothes a while.But then I started to fill my bra and made them look normal.Now I don't think that my life is over".

Conclusion and Recommendation
The results of this study concluded that a having mastectomy was difficult for the women, and their perception of functioning is closely related to emotional state.In general, very few women believed in the possibility of recovering and getting back to a normal life.They concerned about their partner's and public's reaction.The most common feeling is anxiety, fear, disappointment, alters patients' body image and self esteem, impaired sexual functioning, decreased social activities, withdrawal and shame.Hence, nurses should physically, emotionally and socially support these women and her family before mastectomy for the adaptation process.Also, nursing education should enhance nurses' understanding and awareness of spiritual issues as part of their daily routines.Future research could expand the research to include a larger, more diverse group of women of all ages who had underwent mastectomy with breast cancer.