Psychological capital in patients with cancer: A qualitative study based on cognitive adaptation theory

Abstract

Objective

Psychological capital (PsyCap) plays a critical role in facilitating psychological adaptation among patients with cancer. However, its constituent components in this population remain insufficiently understood. This study aimed to identify and define the components of PsyCap in patients with cancer and to develop a conceptual model grounded in cognitive adaptation theory.

Methods

A qualitative descriptive study was conducted using semi-structured interviews with 25 patients with cancer between November 2024 and February 2025. Data were analyzed using directed qualitative content analysis, supported by NVivo 14.0.

Results

Three main categories and nine subcategories were identified: (1) cognitive appraisal–oriented PsyCap (illness-related rational cognition, realistic optimism, and perceived positive meaning from the cancer experience); (2) control reestablishment–oriented PsyCap (hope within a limited future, active adjustment of physical and psychological states, self-efficacy in coping with illness, and perceived multidimensional support); and (3) self-esteem reinforcement–oriented PsyCap (sense of self-worth during the anticancer process and acceptance of post-illness physical and psychological changes).

Conclusions

This study delineates the core components of PsyCap in patients with cancer and proposes a theoretically informed conceptual model. The findings provide a foundation for developing PsyCap assessment tools and targeted interventions. Clinicians may use this model to identify patients with insufficient psychological resources and implement tailored strategies to enhance PsyCap and promote psychological adaptation.

Introduction

The global number of new cancer cases is projected to exceed 35 million by 2050, representing a 77% increase compared to 2022.¹ Data from the National Cancer Center of China indicates that there are about 4.82 million new cancer cases nationwide in 2022.² Due to changes in risk factors and an aging population, new cancer cases in China will continue to grow over the next decade.³ With the improvement of prevention and control systems and advancements in medical technology, cancer is increasingly being managed as a chronic disease.⁴ However, longer treatment duration, uncertain prognosis, and accompanying work-life imbalance, symptom burden, and financial strain collectively present patients with adaptive challenges they must confront.5, 6, 7, 8 Therefore, promoting patients' psychological adaptation is a consistently focused issue in psycho-oncology. Psychological adaptation is a dynamic and ongoing process through which individuals gradually achieve the optimal state of adaptation to their environment.⁹ Maladaptation often manifests as increased negative emotions, which significantly impact an individual's mental health and quality of life.10, 11, 12, 13

With the development of positive psychology, the protective role of individual stress resistance resources has increasingly gained attention.^14,15 Individual resources are crucial in buffering the negative effects of stressful events and promoting adaptive behavior.¹⁶ Research has indicated that patients possess psychological strengths that can be harnessed to help them restore mind-body balance in new circumstances.^17,18 Therefore, enhancing individual resources can promote patients’ psychological adaptation to the illness.

Psychological capital (PsyCap), a higher-order construct composed of positive psychological states,¹⁹ is widely regarded as a beneficial psychological resource for individuals to withstand adversity.20, 21, 22 Conservation of Resources (COR) theory states that individual resources function as resource caravans rather than in isolation.²³ In contrast to single constructs such as resilience and emotion regulation, PsyCap, as a set of positive psychological resources, can provide more comprehensive support for patients’ psychological adaptation through its multidimensional and synergistic structural features. Cultivating PsyCap systematically helps patients build a rich resource reserve, effectively enhancing their adaptive capacity to withstand cancer-related stressors. Previous studies have revealed a close relationship between PsyCap and outcomes of illness adaptation. Patients with high levels of PsyCap are more likely to actively accept their illness, proactively adopt coping strategies to adapt to life changes,²⁴ thereby achieving higher levels of subjective well-being, mental health, and quality of life.25, 26, 27

Initially, in positive organizational behavior, Luthans et al. integrated theoretical and empirical research to propose four components of PsyCap: optimism, hope, resilience, and self-efficacy.¹⁹ Additionally, they emphasized that PsyCap is a construct open to development and change.²⁸ Subsequently, researchers in other fields proposed specific conceptual connotations and components of PsyCap for various populations. Wang et al. collected data through literature analysis and semi-structured interviews to develop a framework of Chinese nurses’ PsyCap.²⁹ The framework comprises three first-order themes (task-oriented psychological capital, interpersonal relations-oriented psychological capital, and learning development-oriented psychological capital) and 15 second-order themes, such as work immersion, dedication, and learning to use. Xu et al. adopted grounded theory to construct a four-dimensional PsyCap model among college students with disabilities, including self-acceptance, hope, optimism, and resilience.³⁰ These findings suggested that individuals in different contexts have specificity in their PsyCap due to the distinct developmental or adaptive tasks they face. Compared with healthy people, patients with cancer face unique adaptive tasks such as existential threats, life imbalance, and identity crisis triggered by the illness. However, the structure of PsyCap in patients with cancer has not been explored. The classical four-factor PsyCap model was originally developed for employees and may not fully capture PsyCap components in the context of cancer. Thus, further investigation into the specific PsyCap structure for patients with cancer is warranted.

Based on a review of the relevant literature,^25,26,31,32 this study defined PsyCap in patients with cancer as the positive psychological states with plasticity and development, which can promote the process of psychological adaptation to the illness. According to the definition, this study focused on the psychological adaptation of patients with cancer to capture the PsyCap components they exhibited during this process. Cognitive Adaptation Theory (CAT) posits that when individuals encounter threatening events, they will respond with adaptive efforts to achieve a new dynamic balance with the environment.³³ The readjustment process focuses on three themes: (1) understanding the occurrence of the event and appraising its impacts and meaning; (2) in out-of-control situations, trying to reestablish control over the event and one's life; (3) attempting to restore self-esteem. CAT provides a clear, dynamic, and hierarchical path for our understanding of the complex psychological adaptation process of patients with cancer. Consequently, guided by CAT, this study employed in-depth interviews to explore new components that may transcend the classic four-factor PsyCap model. The findings can offer a theoretical foundation for assessing and enhancing PsyCap in patients with cancer.

Methods

Design

A descriptive qualitative design based on naturalism was used, which aims to describe the range of responses to a phenomenon, life event, or health and illness situation.³⁴ Consolidated Criteria for Reporting Qualitative Research (COREQ) ensured comprehensive reporting (Supplementary Table S1).³⁵

Participants

This study was conducted at a tertiary hospital in southern China between November 2024 and February 2025. Participants were recruited through face-to-face interviews using purposive sampling, guided by the study objectives and predefined inclusion criteria. Potential participants were initially screened through medical record review based on the eligibility criteria. Diagnosis awareness was then confirmed with primary nurses before finalizing the interview list. The researcher subsequently approached eligible patients, explained the study purpose, procedures, and confidentiality measures, and obtained written informed consent prior to participation.

Eligible participants were those who (1) were aged ≥ 18 years, (2) had been diagnosed with cancer for at least 3 months prior to recruitment, and (3) were aware of their diagnosis. Patients were excluded if they (1) were unable to communicate in Mandarin, (2) had a history of or current mental illness, or (3) had severe complications.

The restoration of psychological balance is typically accompanied by a reduction in negative affect and an enhancement of positive emotions.³⁶ Previous studies have shown that depressive symptoms in patients with cancer tend to peak shortly after diagnosis and decline significantly around 3 months post-diagnosis,³⁷ at which point positive psychological changes begin to emerge.³⁸ Accordingly, participants diagnosed at least 3 months prior to recruitment were included to ensure they had sufficient time to develop PsyCap.

A total of 25 individuals participated in the interviews, including 12 male and 13 female patients, with a mean age of 45.49 ± 11.97 years (range: 26–71 years). The sample included patients with nine different types of cancer. Regarding disease stage, 6 participants (24%) were diagnosed with stage I–II cancer, while 19 (76%) had stage III–IV disease. The time since diagnosis ranged from 3 to 62 months (mean = 16.8 months). Most participants had been diagnosed for 3–12 months (n= 16), whereas a smaller proportion had a longer disease duration (> 12 months, n= 9). Detailed participant characteristics are presented in Table 1.

Table 1.

Participant characteristics (N = 25).

ID	Sex	Age (years)	Diagnosis	Stage	Time since diagnosis (months)	Education level	Employment status	Marital status
P1	Female	49	Breast cancer	II	3	Junior college	Employed	Married
P2	Female	51	Breast cancer	I	3	Senior high school	Employed	Married
P3	Male	50	Rectal cancer	IV	36	Junior high school	Not employed	Married
P4	Female	53	Breast cancer	II	4	Bachelor's degree	Employed	Married
P5	Female	44	Breast cancer	III	6	Junior high school	Not employed	Married
P6	Female	29	Breast cancer	III	24	Bachelor's degree	Employed	Single
P7	Male	57	Nasopharyngeal cancer	III	3	Junior high school	Not employed	Married
P8	Male	35	Nasopharyngeal cancer	IV	4	Bachelor's degree	Employed	Married
P9	Female	26	Nasopharyngeal cancer	IV	4	Junior college	Not employed	Single
P10	Female	42	Cervical cancer	IV	7	Senior high school	Employed	Married
P11	Female	42	Lung cancer	IV	16	Junior high school	Not employed	Married
P12	Female	44	Breast cancer	I	4	Primary school	Self-employed	Married
P13	Female	35	Cervical cancer	III	62	Junior college	Self-employed	Married
P14	Female	32	Colon cancer	IV	43	Senior high school	Employed	Married
P15	Male	63	Lung cancer	III	13	Senior high school	Retired	Married
P16	Male	71	Lung cancer	IV	12	Master's degree	Retired	Married
P17	Male	56	Rectal cancer	III	5	Bachelor's degree	Employed	Married
P18	Female	50	Cervical cancer	IV	9	Junior college	Retired	Married
P19	Male	55	Lung cancer	IV	56	Junior high school	Retired	Married
P20	Male	39	Oral cancer	II	22	Junior college	Employed	Divorced
P21	Male	37	Colon cancer	III	21	Junior high school	Self-employed	Married
P22	Male	54	Oral cancer	II	5	Doctoral degree	Employed	Married
P23	Male	53	Esophageal cancer	III	3	Primary school	Not employed	Married
P24	Female	41	Colon cancer	IV	3	Junior high school	Self-employed	Married
P25	Male	41	Liver cancer	III	5	Junior college	Self-employed	Married

Data collection

The research team developed the initial interview guide based on CAT and integrated expertise in qualitative research. This was subsequently pilot tested through two interviews (Table 2).

Table 2.

Interview guide.

Sample questions
(1) Please briefly share your experience from diagnosis to treatment.
(2) What do you think are the causes of the illness? How do you understand the occurrence of the illness?
(3) How has your illness affected you? How do you see these effects?
(4) During your illness, how have you felt about your sense of control over your life and treatment? Could you share moments when you felt in control well, as well as times when it felt out of control or powerless? How did you adjust?
(5) During your illness, how have you viewed and evaluated yourself? Could you share moments when you felt good about yourself, or you felt less positive? How did you adjust?
(6) Is there anything else you want to share with me?

The semi-structured interviews were conducted by the first author, a female postgraduate student with a background in oncology nursing. Interviews were conducted on a one-to-one basis. All interviews took place either in a private consultation room or in quiet wards to ensure confidentiality and minimize interruptions. During the interviews, the researcher engaged in in-depth conversations with participants while observing and documenting their nonverbal cues, including facial expressions and tone of voice. Each interview lasted between 23 and 92 minutes, with a mean duration of 39 minutes. All interviews were audio-recorded and transcribed verbatim. Sampling continued until data saturation was achieved. After analysis of the initial 22 interviews, three additional interviews were conducted to confirm that no new themes or categories emerged, thereby ensuring data saturation. A total of 28 individuals were invited to participate in the study; however, three declined due to personal reasons.

Data analysis

The study used NVivo 14.0 and followed the three-step directed content analysis approach proposed by Elo and Kyngas to analyze the data based on CAT.³⁹ Data analysis was conducted independently by 2 researchers. The analysis proceeded in the following steps: (1) In the preparation step, every interview transcript was analyzed as a unit of analysis, and statements fitting the definition of PsyCap were potential meaning units. The coders read through all transcripts several times to gain a comprehensive understanding. To mitigate potential theoretical bias associated with the pre-specified CAT framework, all meaningful units were extracted and retained. (2) In the organizing step, three predetermined categories (main categories) were identified and defined based on CAT, including cognitive appraisal-oriented psychological capital, control reestablishment-oriented psychological capital, and self-esteem reinforcement-oriented psychological capital. A structured matrix of analysis was developed, and excerpts of the data that matched the predetermined categories were determined and coded. The definitions of the generic categories were identified through subcategories. After completing data analysis, 2 coders held a consensus meeting. Moreover, the other 3 researchers who were not engaged in coding reviewed the results to strengthen the rationality of coding classification and avoid prior theoretical filtering. (3) In the reporting step, the sampling process, the characteristics of the participants, data collection, data analysis, and each of the main classes were reported in detail in the results section.

Rigor and trustworthiness

We employed several strategies to ensure the rigor of this study, including credibility, dependability, transferability, and confirmability.⁴⁰ To ensure credibility, the interviewer, who was an intern nurse, provided care for participants and built a rapport with them to gain nuanced insights into their mental conditions. During data analysis, the research team held internal discussions to ensure a more objective stance. Dependability was ensured through a detailed audit trail documenting all research stages and decisions. Transferability was supported by maximum-variation sampling across personal and medical characteristics. Confirmability was verified by peer checking. We invited 5 oncology head nurses and 1 psychologist (with 17–27 years of working experience) to rate, on a 5-point Likert scale, the importance of the main and generic categories and to refine their definitions, leading to the final conceptual model.

Results

The codes extracted from the data were categorized under 28 subcategories, 9 generic categories, and 3 main categories (Table 3). Generic and main categories formed a second-order and three-factor structural model of PsyCap in patients with cancer (Fig. 1).

Table 3.

Main categories, generic categories, and subcategories.

Main categories	Generic categories	Subcategories
Cognitive appraisal-oriented psychological capital	Illness-related rational cognition	Combining lifestyle analysis with risk factors for the illness
		Viewing falling ill as a natural law
		Understanding treatment and condition prognosis based on objective evidence
	Realistic optimism	Maintaining a positive attitude toward life
		Viewing the difficulties caused by illness as temporary
	Perceived positive meaning from the cancer experience	Enhanced emotional connection with others
		Reshaped health concepts and behaviors
		Overcoming setbacks from illness to strengthen inner strength
Control reestablishment-oriented psychological capital	Hope within a limited future	The desire to live
		Looking forward to a bright future
		Hoping to continue spending time with family
	Active adjustment of physical and psychological states	Striving to restore physical functions
		Actively regulating negative emotions
		Relying on strong willpower to overcome the challenges of illness
	Self-efficacy in coping with illness	Believing that one can overcome the challenges of illness
		Believing that one's own strength plays an important role in coping with illness
	Perceived multidimensional support	Company and care of family
		Support from friends
		Mutual comfort among fellow patients
		Compassionate care of medical staff
		Assistance from social organizations
Self-esteem reinforcement-oriented psychological capital	Sense of self-worth during the anticancer process	Believing that one is still needed by one's family
		Feeling useful through altruistic behavior
		Gaining self-recognition through coping with illness
	Acceptance of post-illness physical and psychological changes	Accepting current physical condition
		Accepting current appearance
		Accepting negative emotions during the illness
		Accepting lifestyle adjustments

Fig. 1.

Conceptual model of psychological capital in patients with cancer.

Main category 1: cognitive appraisal-oriented psychological capital

Cognitive appraisal-oriented psychological capital refers to the positive psychological states that help patients to rationally understand the illness and positively appraise its impacts and meanings, including illness-related rational cognition, realistic optimism, and perceived positive meaning from the cancer experience.

Illness-related rational cognition

Illness-related rational cognition means that patients can correctly understand the occurrence, treatment, and prognosis of their illness based on objective evidence. Most participants attempted to figure out the cause of cancer from varied aspects, such as genetic factors, lifestyle habits, and work environment. This fact-based, rational analysis helped participants to make reasonable attributions about their illness and reduced their fear and anxiety.

“At first, just hearing the word ‘cancer’ was terrifying. However, after understanding the causes of the illness and my growing knowledge about it, I was not as fearful anymore; my anxiety lessened.” (P3)

At the same time, participants also recognized that the causes of cancer were complex and uncertain. They interpreted falling ill as a natural law, and they should respond positively rather than resist forcefully.

“Illness is unavoidable; it may happen to anyone. I didn’t complain about why this happened to me and not others. Instead, since I have been diagnosed, I should face and overcome it.” (P17)

Compared to other chronic diseases, cancer treatment is complex, and its progression is hard to predict. Many participants instinctively associated cancer with terminal illness during the initial post-diagnosis period. They described their reactions upon learning the diagnosis as “turning pale at the mention of a cancer diagnosis” (P25). However, objective understanding of treatment details and disease prognosis facilitated cognitive restructuring of their pre-existing perceptions and alleviated fear from uncertainty.

“Once I understood how the infusion port implant worked, I relaxed. If they had just told me they were inserting a tube, I would have been nervous and scared.” (P6)

“At first, I thought I was going to die immediately. Then I asked for information from my doctor … I have learned everything about my illness … I thought about the 5-year survival rate; for me, it is still acceptable, so I felt more at ease.” (P15)

Realistic optimism

Realistic optimism refers to patients being able to view the negative effects of the illness as temporary and limited. This optimism is based on trust in modern medical technology and ideal treatment results. The positive psychological state is reflected in two aspects: believing that the difficulties caused by the illness are temporary and maintaining a positive attitude toward life. On the one hand, the participants did not exaggerate the physical pain and daily inconvenience during the treatment period. Instead, they viewed these challenges as a “phased test”. Moreover, despite their original life plan being disrupted, the discrepancy between ideal and reality did not lead to pessimism, and they believed life would improve after the ordeal. The optimistic explanatory style alleviated their initial negative emotions.

“I think these effects are temporary. I feel that this illness is just a trial in life. After overcoming this challenge, I believe that my life will gradually get better.” (P7)

“I enjoy walking around. After retiring, I immediately bought a car to go on a road trip. But now I need to focus on treatment first. I am not being pessimistic. I told myself that if I can live with the tumor, then I will go out and explore the world. Thinking this way has made me feel more at ease.” (P15)

On the other hand, despite significant physical and mental trauma, it had not depleted participants’ love for life. They strived to avoid allowing the negative effects of the illness to permeate all aspects of their lives by maintaining a positive outlook, engaging in meaningful work, and enjoying their hobbies. This optimism is not blind, but a realistic choice based on illness adaptation.

“I have seen many people shouting or crying in pain, and it is not meaningful. There is no need to be so tense. It is better to focus on meaningful things, such as arranging my work for tomorrow and determining who will handle each task.” (P20)

Perceived positive meaning from the cancer experience

The positive meanings participants perceived from the cancer experience include personal growth, health awareness, and interpersonal relationships. Participants with a strong perception of positive meaning tended to identify beneficial changes in their lives after the illness through the reconstruction of meaning. Participants considered that the illness prompted them to live each day moving forward positively:

“Now I see this illness as a warning, a reminder to live life actively and take it seriously.” (P9)

Additionally, participants reported that cancer prompted them to reflect on their past unhealthy lifestyles. They shifted from neglecting their physical feelings to actively adopting healthier diets and more regular routines. This indicates that participants viewed their illness as an opportunity to pursue a healthy life.

“I used to enjoy spicy and barbecued foods, but now I realize they don’t benefit my health. So, I have learned to resist them now; I realized that taking care of myself is important.” (P14)

Some believed their cancer experience had strengthened their inner mental strength and shaped a more positive mindset for future life challenges. This perceived psychological growth reflects participants’ positive cognitive appraisal of the personal gain derived from overcoming illness-related setbacks.

“This experience is a test for me. This challenge will profoundly impact me because I have never faced significant hardships. Overcoming it will boost my self-confidence and courage.” (P8)

Participants also noted that this experience enhanced family cohesion. When cancer is viewed as “our illness,” the family becomes a highly coordinated response unit, jointly bearing the burden of treatment decisions and facing the risks of the illness.

“I found that after I got sick, the relationships between my siblings, my parents, and my partner seemed to become more harmonious and better than before. My children also became more sensible.” (P24)

Main category 2: control reestablishment-oriented psychological capital

Control reestablishment-oriented psychological capital refers to positive psychological states that drive patients to take proactive action and rebuild the sense of control over their illness and life, including hope within a limited future, active adjustment of physical and psychological states, self-efficacy in coping with illness, and perceived multidimensional support.

Hope within a limited future

Hope within a limited future refers to patients’ inner expectations that motivate them to take proactive measures to cope with the illness. The expectations involve three aspects: the desire to live, the expectation of a bright future, and the hope of continuing to accompany the family. Those who maintained a state of expectation usually showed strong belief and determination to conquer obstacles. When participants encountered the existential threat brought by cancer, they experienced a strong desire to live, which is the fundamental motivation for them to overcome the pain of treatment.

“People should have hope. With hope, I can see the direction and the goal, and have the courage to live on. The desire for life is the foundation of everything.” (P15)

Participants’ beautiful visions for the future inspired them to engage positively with treatment. Their visions often stemmed from a desire to realize individual plans and witness social development.

“I hope heaven grants me a few more years to see China’s reforms and prosperity—I have not seen enough of it yet.” (P23)

“Once my health is restored, I think I’ll seriously consider dating and starting a new chapter in my life.” (P20)

In the limited future perspective, family served as spiritual sustenance for participants during their cancer journey. Almost all participants who took on parental roles emphasized that they desired to be with their children and witness their growth, which drove them to confront the illness rather than escape it negatively. In addition, married participants hoped to spend their remaining years with their spouses, while those who were adult children wished to recover quickly to care for their aging parents.

“I need to be there for my parents as they grow old. They’ve worked hard for decades. They shouldn’t have to lose their daughter while they’re still young, right?” (P13)

“I would feel sorry if I could not witness my children grow up, get married. I am unwilling to accept it. This expectation is unbreakable. I want to witness them so that I can face cancer head-on.” (P18)

Active adjustment of physical and psychological states

Active adjustment of physical and psychological states refers to patients demonstrating strong willpower when facing challenges related to the illness and adopting adjustment strategies to restore stable physical and psychological function. Participants emphasized the crucial role of their strong will in trying to recover from unmanageable states: “A person's ability to fight against cancer is determined by their will. If you are mentally collapsing, then you are likely nearing death.” (P21). Side effects of treatment led to a series of bodily responses, and the rapid changes in physiological functions triggered a strong sense of loss of control and helplessness among participants. At this moment, participants' strong willpower encouraged them to adopt coping strategies.

“During my second chemotherapy session, I was exhausted and vomited after eating. It was the most helpless time … Then, I thought I couldn’t continue like this, so I contacted the doctor for a white blood cell injection. Afterwards, I had more strength and appetite, so I forced myself to exercise and eat, and overcame it.” (P11)

Participants also experienced many moments of emotional trough. In the face of negative emotions such as anxiety, loneliness, or despair, they actively regulated their emotions and restored their psychological balance by putting in work and listening to music.

“Sometimes I feel as if life has come to a standstill, and I feel a bit lonely. One’s mindset needs to be adjusted by oneself. I will engage in online work or read the news to make myself more fulfilled.” (P20)

Self-efficacy in coping with illness

Participants who believed that they played a vital role in illness management could think and execute self-management strategies positively, including developing and adhering to exercise plans, optimizing dietary structure, and maintaining a regular schedule.

“The road ahead (the journey against cancer) is still long, and many things require effort. A lot depends on me; I must manage my life and determine how to prevent or control the illness from worsening.” (P17)

“I exercise to keep my immune system strong and maintain enough energy to fight this illness. I usually climb a mountain in the morning and afternoon.” (P22)

“Of course, it's not like before—I will definitely fix my diet, including cutting out spicy food, anything irritating, and alcohol. And I definitely need to rest well, stay up late less often.” (P19)

Some reported that believing in themselves made them strong and motivated them to overcome the challenges. This state reinforced their initiative to respond to dilemmas. Moreover, the successful experience of each treatment cycle could be translated into greater confidence in their own tolerance and improve their sense of control over the subsequent treatment.

“I'm much more relaxed than at the beginning. I got through chemotherapy, which was so hard, got through the major surgery too. So if it’s just targeted therapy at the end, that’s totally manageable.” (P4)

“My self-confidence grows stronger, and when I am strong internally, these challenges are conquerable.” (P24)

Perceived multidimensional support

Perceived multidimensional support refers to patients' subjective perception of external support and their belief that these forces are helpful to their coping with the illness and rebuilding their lives. The ability to perceive support prompted patients to transform external assistance into internal strength, driving them to strive to regain control over the environment. The support came from family, friends, fellow patients, and medical staff. The meticulous care from family can be the participants’ fighting strength against cancer.

“When I first learned the diagnosis, I felt like I was slipping away from a normal life, heading toward death. Before I could succumb to despair, my family supported and comforted me during tough times. I was not fighting this battle alone.” (P5)

In addition to family, participants also reported that they perceived support from their friends. Economic and emotional support from friends emboldened the participants to cope with their illness.

“They (friends) all said, ‘You go ahead, I have money, don’t worry, when you need it, we will transfer it right away.’ Fortunately, they were there. It was their words that I dared to come to the hospital for treatment.” (P4)

For many participants, medical staff represented a reliable professional image. The medical information support and humanistic care they provided effectively reduced patients’ anxiety regarding the unfamiliar environment and worries about their condition.

“I'm like a child, and my attending doctor is the parent. What he says has a huge influence on me. When he told me, ‘Your condition has improved,’ that was the greatest encouragement for me.” (P7)

The similar illness experiences among patients created a unique emotional bond. Participants mentioned that they had formed online communication groups with fellow patients to share treatment experiences and encourage one another. This not only helped them gain a more comprehensive understanding of treatment but also enhanced their resolve to fight cancer.

“We chat together in a WeChat group and encourage each other. For example, people who’ve had surgery would talk about their experiences in the group, so we could better understand what it’s actually like.” (P2)

Main category 3: self-esteem reinforcement-oriented psychological capital

Self-esteem reinforcement-oriented psychological capital refers to positive psychological states that help patients maintain and improve their self-esteem, including a sense of self-worth during the anticancer process and acceptance of post-illness physical and psychological changes.

Sense of self-worth during the anticancer process

Sense of self-worth during the anticancer process refers to patients’ positive cognitive and subjective perceptions of their intrinsic value. Some participants viewed themselves as useless because they could no longer fulfill their previous social or family roles. However, when they engaged in social interactions in the role of a patient, the sense of self-worth derived from altruistic behaviors could enhance their diminished self-esteem.

“I saw the helpless and fearful expressions on their (fellow patients) faces and went to guide them with my own experiences … I realized I still had some use left.” (P6)

Some expressed that although they could not create social value equivalent to that before their illness, they could still feel their worth through their tenacity in battling cancer. This flexible shift in evaluative standards of value helped them strengthen their self-identity.

“Now that I can take good care of myself, I am very satisfied. I can prepare meals by myself at home, eat better, and recover faster, alleviating my family’s concerns.” (P14)

“Now, being able to endure so many rounds of chemotherapy without being a burden to others is my greatest value. I think I am strong.” (P2)

Within the family-centered cultural context of China, individuals highly value their contributions to the family. For participants, being able to provide financial support and perform daily household chores within their capacity fostered a strong sense of being “needed by the family.” This perception counteracted negative self-perceptions of uselessness and served as an important source of self-worth during their illness adjustment.

“I told my daughter, ‘I’m still getting treatment, so I can’t help much later. But I’ll give you the down payment if you buy a house.’ I think that’s what a father should do.” (P17)

“I try to do what I can for my family, like housework, grocery shopping, and cooking. Otherwise, if I just eat, sleep, and do nothing all day at home, I feel like a useless person.” (P9)

Acceptance of post-illness physical and psychological changes

Acceptance of post-illness physical and psychological changes refers to patients being able to embrace and accept their current physical and mental state, including changes in physical appearance and function, emotional fluctuations, and lifestyle adjustments caused by the illness. A participant who experienced hair loss due to chemotherapy side effects described that changes in physical appearance made her feel self-contemptuous: “Before, I used to dress up beautifully every day, but now I don't have the energy to do this, and all my hair fell out within a week. At that time, I could not accept it.” (P13). However, after accepting these changes tolerantly, the participant gradually regained an inner sense of balance and was ready to embrace a new life: “I should give it (the hair regrowth) some time, give myself some time to recover. If I am not feeling so weak, I will continue to pursue my hobbies, like flower arranging and making coffee myself.” (P13)

Participants could accept their negative emotions and vulnerability arising from stressful situations. Meanwhile, they also emphasized that they still possessed the courage to face difficulties.

“When you are sad, you cannot force yourself to be happy, so it is okay to cry when I am feeling down. Don’t force yourself to wear a “mask”. After crying, I can gather my courage to face illness again.” (P1)

Some were forced to detach from their original social roles, which led to varying degrees of crisis in their sense of value. However, accepting the current pace of life enabled participants to break free from self-deprecating struggles.

“Sometimes when I lie down, I feel a sense of emptiness, a lack of value … I tell myself not to overthink because only when I am healthy will I have the opportunity to continue striving.” (P10)

Discussion

Main findings

This study identified a set of positive psychological states that patients with cancer exhibited in the process of cognitive adaptation and proposed a second-order and three-factor conceptual model of PsyCap. To our knowledge, this was the first study to explore the specific structure of PsyCap in patients with cancer. This study utilized CAT as a framework to organize the conceptual structure and to identify the core components of PsyCap of patients with cancer from a holistic perspective, and defined these components based on participants’ experiences.

The conceptual model of PsyCap in patients with cancer developed in this study is both consistent with the classical PsyCap structure and provides targeted theoretical extensions. On the one hand, several dimensions in the model align closely with the four-factor structure of PsyCap.²⁸ Realistic optimism reflects the positive cognitive appraisal embodied in the optimism factor. Hope within a limited future corresponds to the connotation of hope in the classic framework. Self-efficacy in coping with illness corresponds to the essence of self-efficacy. Active adjustment of physical and psychological states accords with resilience, capturing the patient's psychological state of persisting through and recovering from cancer-related adversity. On the other hand, this study has identified several cancer-specific dimensions that broaden the applicability of PsyCap theory. Illness-related rational cognition serves as a context-specific cognitive adjustment dimension, addressing patients' unique needs to interpret their conditions and treatment information. Perceived positive meaning from the cancer experience represents a distinct meaning-making process for patients. Perceived multidimensional support enables patients to alleviate the dual psychological and financial burdens imposed by cancer during periods of physical and emotional vulnerability. Sense of self-worth during the anticancer process and acceptance of post-illness physical and psychological changes reflect a unique self-evaluation and adaptation shaped by role changes and physical-mental alterations. These cancer-specific dimensions underscore the significance of understanding PsyCap from patients' lived experiences.

The study suggested the PsyCap of patients with cancer differs from that of other groups. For instance, ease and content, gratitude and dedication, wisdom, and meaning in life are unique components of PsyCap in older people that help them successfully adapt to the developmental tasks of this age stage.⁴¹ In contrast, the PsyCap in patients with cancer is deeply shaped by life-threatening illness experiences and thus exhibits distinct characteristics. Patients with cancer demonstrate illness-related rational cognition, positive meaning-making from the cancer experiences, acceptance of post-illness physical and psychological changes, and reconstruction of multifaceted self-worth within the cancer context. These components correspond to challenges, including an unpredictable future, role transitions, and sharp declines in physical function. However, PsyCap in the general population focuses more on maintaining daily function and general emotional regulation, rather than the profound reconstruction of self-identity and life control under crisis.

Given these features of PsyCap in patients with cancer, it is critical to clarify how its components aid psychological adaptation. Early post-diagnosis, the primary adaptive challenge for patients is cognitive disorder, marked by rigid negative perceptions and catastrophic thinking about cancer. Cognitive appraisal-oriented psychological capital is vital for promoting adaptation during this period. Seeking the comprehensibility and meaning of stressful events is key to promoting individual psychological adaptation.³³ This study conceptualizes this process as the patients' cognitive appraisal of their illness. Rational cognition, optimism, and perceived positive meaning synergistically influence this process, promoting the restoration of psychological balance. Illness-related rational cognition helped buffer patients' fear and anxiety caused by the illness uncertainty. In this study, participants viewed life, aging, illness, and death as natural and universal processes. This attitude reflects the core thought of Chinese Taoism, which advocates respecting and complying with the natural laws of life.⁴² By internalizing this worldview, patients can understand the occurrence of cancer calmly and rationally, avoid the inner conflict of “why me”, and facilitate psychological adaptation. The ABC theory of emotion indicates that individual cognitive patterns dominate their emotions.⁴³ A cognitive-behavioral intervention study showed that helping patients identify and correct illness-related biases or unrealistic automatic thoughts can relieve their anxiety and depression.⁴⁴ Additionally, keeping realistic optimism helped participants flexibly shift their perspective on the losses caused by illness, thereby alleviating their negative emotions. The result is consistent with a previous study, which concluded that optimistic patients avoid catastrophic thinking by cognitively reappraising stressful events.⁴⁵ This positive psychological state can alleviate patients' negative emotions and help them maintain good physical health.⁴⁶ Perceived positive meaning from the cancer experience is a cognitive representation of participants' reconstruction and integration of their intrinsic values or attitudes toward life, which prompts them to accept the impacts of the illness on their lives. The meaning-making model explains this finding, suggesting that unexpected stressful events may disrupt an individual's overall systems of meaning, and discrepancies between situational meaning and global meaning can cause negative emotions.⁴⁷ Positively evaluating the impacts of illness is an important meaning-centered coping strategy that narrows this gap, thereby promoting the psychological adaptation to stressful events. An investigation by Zhu et al. also demonstrated that patients who perceive greater benefits from their illness exhibit lower levels of depression, anxiety, and distress.⁴⁸

During the cancer treatment stage, patients' main adaptive problem is losing control due to symptom burden, emotional breakdown, and financial pressure. Control reestablishment-oriented psychological capital emerges as an essential driving force for adaptation at this stage, motivating patients to confront the illness and take actions to regain control over their illness and lives. Snyder's theory of hope states that individuals in a state of hope can have their goals stimulate their path thinking and motivational thinking.⁴⁹ These two types of thinking are key to motivating patients to create pathways to overcome uncontrollable environments and maintain motivation. Research showed that patients with lower levels of hope tend to adopt passive coping strategies such as denial, self-blame, and behavioral disengagement.⁵⁰ Notably, in this study, although both realistic optimism and hope within a limited future involve positive expectations, they differ fundamentally. Realistic optimism reflects patients' positive cognitive style toward current and future circumstances, whereas hope within a limited future represents a concrete, goal-oriented motivational mechanism. Moreover, Self-efficacy in coping with illness is key to influencing patients to monitor and manage self-care,⁵¹ and is an important component to promote patient psychological adaptation. Believing in one's ability to manage symptoms, self-regulate, and overcome the illness was a powerful belief that drove participants to take active coping actions in the face of the illness. Patients who take practical personal actions can break through difficulties and regain a sense of control over new situations. The findings of the present study showed that active adjustment of physical and psychological states is a powerful force that motivates patients to continuously regulate their thoughts, emotions, and behaviors with a firm will to restore the stability of their physical and mental functions in uncontrollable situations. Consistent with the study by Qin, patients with high psychological rebound capacity tend to adopt confrontational coping strategies,⁵² which in turn influence outcomes related to their physical, psychological, and social functions.53, 54, 55 Additionally, perceived multidimensional support is a subjective feeling about the support received, focusing on the individual's psychological experience.⁵⁶ Participants in this study mentioned that feeling supported by others lifted their spirits in despair. A previous qualitative study conducted by Mokhtari also found that perceiving support from family, friends, relatives, and the medical teams was an important factor in motivating breast cancer patients to develop a fighting spirit and effectively adapt to their illness.⁵⁷ Within a collectivist cultural context, Chinese society emphasizes close interpersonal bonds, which is different from the individual autonomy pursued in Western individualistic culture.⁵⁸ Therefore, the reliance on interpersonal connections makes patients more likely to produce positive psychological responses upon receiving support from others, and further internalize it into individual PsyCap.

When a prolonged illness course prevents patients from fulfilling family responsibilities and pursuing personal goals for an extended period, triggering a self-identity crisis, self-esteem reinforcement-oriented psychological capital becomes a core resource for maintaining their self-esteem levels. Sense of self-worth during the anticancer process and acceptance of post-illness physical and psychological changes are two pillars of self-esteem reinforcement-oriented psychological capital. In this study, the core meanings of low self-esteem among participants were negative self-perceptions, which were related to a diminished sense of creative value, declining physical functions, and changes in appearance. However, regaining a sense of self-worth from different aspects was critical to reinforce participants' self-esteem, including providing illness-coping experiences for fellow patients, helping family with manageable tasks, or fighting against the illness. These findings indicated that the connotation of self-worth among Chinese patients with cancer is closely related to Confucian culture. Within the Confucian cultural pattern, individuals' self-understanding depends on family roles and social relationships, a characteristic of interdependent self-construal.⁵⁹ Therefore, contributing to the family and providing support to fellow patients serve as the main sources of self-worth and the foundation for enhancing self-esteem among participants in this study. The results of the study are consistent with previous research. In the dignity-conservation care model proposed by Xiao et al., sense of self-worth is one of the core elements of patients' self-esteem perception.⁶⁰ A study conducted on patients with blood cancer showed that deriving a sense of achievement and self-identity from altruistic behaviors is a motivator for patients to provide peer support for others.⁶¹ Another study suggested that returning to work made patients feel that they were still needed, which helped to overcome negative feelings of being “useless”.⁶² Moreover, this study found that accepting one's current physical and psychological state with an inclusive attitude can alleviate the feelings of dignity loss in patients with cancer due to changes in physical function and appearance, emotional fragility, and the interruption of the pace of life. Self-acceptance forms the foundation of self-esteem.⁶³ When the authentic and ideal selves are discrepant, acceptance demonstrates the compromises patients make in response to changes in their lives to maintain their dignity.⁶⁴ A similar investigation reported that individuals' unconditional acceptance of themselves is associated with higher self-esteem, positively impacting their mental health.⁶⁵

Implications for nursing practice and research

The findings contributed to in-depth insight into the characteristics of PsyCap in patients with cancer and highlighted how different components of PsyCap act to play a protective role during psychological adaptation. Within clinical practice, excavating and fostering these positive psychological states can lead to enhanced psychological nursing services tailored to the unique perspectives of patients with cancer. Furthermore, in nursing research, the identified positive attributes provide a solid foundation for the development of assessment tools and targeted interventions to promote PsyCap in patients with cancer, thereby enhancing their adaptability.

Limitations

First, potential selection bias was identified as a limitation of this study since all participants were recruited from one hospital. Second, the exploration of sample differential characteristics in this study needs to be strengthened: on the one hand, the study failed to investigate whether the dominant dimensions of PsyCap vary among patients with distinct clinical features (e.g., different disease stages and disease course durations), which may mask the clinical specificity of PsyCap; on the other hand, the current sample design lacks stratification based on patients' psychological adaptation levels. Future research can adopt a stratified sampling strategy, use quantitative tools to assess patients' psychological adaptation levels, screen participants with different adaptation statuses, and conduct subgroup analyses to comprehensively capture the PsyCap components in different patient groups. Third, in this study, the cognitive, emotional, and volitional states described by the participants were used to explain the positive psychological states they reflected. This in-depth interpretation could not separate the subjective bias of the data analysts. To address this limitation, the review team was established to increase the objectivity and confirm the accuracy of the findings. Finally, the CAT framework may have introduced a degree of analytical focus, underrepresenting potential patients’ psychological experiences unrelated to cognitive adaptation. Future research could adopt an atheoretical qualitative approach to explore PsyCap, expanding the findings of this study.

Conclusions

This study identified the positive psychological states exhibited by patients with cancer in the process of psychological adaptation and developed a conceptual model of PsyCap in patients with cancer. The findings of the study provided insights into the inner strength of patients with cancer and can inform the development of an assessment tool and intervention programs for PsyCap. We recommended developing integrated psychosocial interventions based on the results of this study to enhance patients’ personal psychological resources and improve their psychological adaptation to cancer.

CRediT authorship contribution statement

Wenwen Lu: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing - original draft. Qianlin Lai: Investigation, Data curation, Formal analysis, Writing - review & editing. Lin Xiao: Conceptualization, Methodology, Formal analysis, Writing - review & editing. Chang Gao: Formal analysis, Writing - review & editing. Peijuan Chen: Resources, Validation. Lili Zhang: Conceptualization, Methodology, Writing - review & editing, Funding acquisition, Supervision, Project administration. All authors have read and approved the final manuscript.

Ethics statement

The study was approved by the Medical Ethics Committee of Nanfang Hospital (Approval No. NFEC-2024-609) and was conducted in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants provided written informed consent.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author, LZ. The data are not publicly available due to their containing information that could compromise the privacy of research participants.

Declaration of generative AI and AI-assisted technologies in the writing process

No AI tools/services were used during the preparation of this work.

Funding

This study was supported by the Humanities and Social Science Research Project of the Ministry of Education (Grant No. 22YJA880084). The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

Declaration of competing interest

The authors declare no conflict of interest.

Appendix A. Supplementary data

The following is the Supplementary data to this article: