Enhancing Supportive-Educative Nursing Systems to Reduce Risk of Post-Breast Cancer Lymphedema

Abstract

This study describes the use of data regarding self-care agency to enhance a supportive-educative nursing system for breast cancer survivors to reduce the risk of developing lymphedema post surgery. Impetus for this study came from the analysis of participant feedback from a parent study (Lance Armstrong Foundation pilot study) that sought to plan an educational program for nurses that will improve their supportive-educative nursing system when working with breast cancer survivors. The goal is to enable these women to reduce the risk of lymphedema post surgery. The parent study examined a bundled behavioral-educative intervention, which included standard lymphedema education coupled with Modified Manual Lymph Drainage (MMLD) to reduce the risk of developing lymphedema in newly-diagnosed breast cancer survivors. Based upon the feedback received from the parent study, the research team recognized that many of the participants were not fully following the recommendations of the intervention protocol. In order for nurses to help patients develop self-care agency (SCA) (Orem, 2001) to engage in actions that addressed the self-care requisites associated with post-breast cancer surgery, these nurses needed to refine their intervention skills. Prior to the development of a program for the nurses, the research team conducted a study to explore the state of power related to SCA of the study participants. The information obtained from this was then used in the development of an educational program for bundled intervention. Both motivational interviewing (Miller & Rollnick, 2002) and solution-focused therapy (Berg & DeJong, 1996) were incorporated into the educational program for the research nurse team to strengthen and improve supportive-educative nursing systems. Supportive-educative systems of care that integrate self-care deficit nursing theory, motivational interviewing, and solution-focused therapy can assist patients to develop and sustain self-care agency.

Introduction

Lymphedema (LE) is the accumulation of lymph in the interstitial spaces caused by the failure of the lymph-conducting system to accept and/or conduct lymph back to the blood circulation system (Browse, Bernand, & Mortimer, 2003). Breast cancer-related LE results from treatment such as axillary node dissection and radiation therapy, and manifests itself as chronic and distressing upper limb swelling due to accumulation of protein-rich interstitial fluid. Although typically less than half of breast cancer survivors develop LE, even using conservative estimates, the number of survivors affected or potentially affected by breast cancer-related LE is staggering, comprising potentially 1 to 5 million people worldwide (ACS, 2006; Armer & Stewart, 2005).

Worldwide, 10 million breast cancer survivors are at life-time risk of developing lymphedema (LE) (American Cancer Society (ACS), 2007; Ferlay, Bray, Pisani, & Parkin, 2004). Once manifested in breast cancer survivors, lymphedema is considered to be a chronic and life-long condition. However, there are self-care activities that may reduce the risk of developing LE, such as avoiding body weight gain and obesity, avoiding limb infections on the affected side, and reducing high levels of hand use (Soran et al., 2006). The simple act of providing lymphedema education information to breast cancer survivors has been shown to increase the practice of risk-reduction behaviors, thus preventing LE in many survivors. (Fu, Axelrod, & Haber, 2008).

Once an individual develops lymphedema, the standard of care focus is on improving lymph function through various manual techniques administered both by a trained therapist in a clinic setting and by the individual at home (Mayrovitz, 2009). Manual lymph drainage, designed to move lymph fluid out of affected areas to healthy regions, is one component of this treatment. This process is initiated by a therapist and continued by the individual. However, these treatments usually occur after lymphedema has developed, and have rarely been reported to be used to reduce the risk of developing LE.

A Lance Armstrong Foundation-funded pilot study (referred hereto after as the parent study) examined a bundled intervention combining standard lymphedema education plus Modified Manual Lymph Drainage (MMLD; referred hereto after as the bundled intervention) designed to reduce the risk of developing lymphedema in newly-diagnosed post-surgery breast cancer survivors. The intervention of MMLD is a behavioral-educative self-care action consisting of deep breathing, abdominal massage, axillary clearance, and gentle lymphatic manipulation of the limb, coupled with standard LE education. The education component included information about the appropriate use of compression garments, skin care and avoiding injury to the skin, lifestyle modification, and caution about limb constriction. Increasing self-care agency through motivational interviewing and solution-focused therapy via the supportive-educative nursing system may help patients engage in self-care actions to reduce the risk of developing LE.

Power and Self-Care Agency (SCA)

Self-care agency, which is the power to engage in self-care, develops through the spontaneous process of learning. Its development is aided by intellectual curiosity, instruction, and supervision of others and by experience in performing self-care measures (Orem, 2001). The Nursing Development Conference Group (NDCG) (1979) identified 10 power components or specific enabling capabilities essential for performing estimative, transitional, and productive operations of SCA (Table 1). The NDCG (p. 205) also identified themes for the degrees of development of SCA as underdeveloped, developing; developed but not stabilized; developed and stabilized; and developed but declining. If nurses are to be effective in helping patients to develop self-care agency, they need to understand the elements and principles of self-care, particularly patient capabilities and limitations.

Table 1.

Power Components of Self-Care Agency

Ability to maintain attention and exercise requisite vigilance with respect to self as self-care agent and internal and external conditions and factors significant for self-care Controlled use of available physical energy that is sufficient for the initiation of the movements required to initiation and completion of self-care operations Ability to control the position of the body and its parts in the execution of the movements required for the initiation and completion of self-care operations. Ability to reason within a self-care frame of reference Motivation (i.e. goal orientations for self-care that are in accord with its characteristics and its meaning for life, health, and well-being) Ability to make decisions about care of self and to operationalize these decisions Ability to acquire technical knowledge about self-care from authoritative sources, to retain it, and to operationalize it A repertoire of cognitive, perceptual, manipulative, communication, and interpersonal skills adapted to the performance of self-care operations Ability to order discrete self-care actions or action systems into relationship with prior and subsequent actions toward the final achievement of regulatory goals of self-care Ability to consistently perform self-care operations, integrating them with relevant aspects of personal, family, and community living.

[Table adapted from Nursing Development Conference Group (1979), Concept Formalization in Nursing: Process and Product (2nd Ed). D.E.Orem, Editor. Boston: Little Brown, 195-196.]

At various time points during the parent study, data from field notes on return visits and telephone contacts indicated patients were not routinely performing self-care measures as instructed in the bundled nursing intervention. The research team recognized the need to refine the bundled intervention to assist patients in developing self-care agency to engage in self-care actions that addressed the self-care requisites associated with post-breast cancer surgery.

Helping patients develop self-care agency requires a supportive-educative (developmental type) nursing system. In order to enhance self-care agency, the team developed an educational program (referred hereto after as supportive-educative nursing system) incorporating motivational interviewing and solution-focused therapy to be taught to and piloted by the research nurse team working with the study participants.

Motivational interviewing

Motivational interviewing has been used successfully with patients experiencing health care deviations who require self-care behavior change such as smoking cessation, lifestyle changes in hypertension, and dietary changes (Burke et al., 2003). Motivational interviewing is a specific approach directed toward helping patients. Miller (1983) devised a model that includes five general principles: 1) express empathy, 2) develop discrepancies, 3) avoid arguments, 4) roll with resistance, and 5) support self-efficacy. In addition, motivational interviewing can be adapted using a three-step framework that includes: 1) build rapport with the patient, 2) perform the usual assessment, and 3) summarize and reconnect with patient to develop awareness of discrepancies, explore pros and cons of self-care actions, and set self-care goals (Martino et al., 2006).

Effective motivational interviewing requires a change in perspective from the nurse being the expert in charge and responsible for patient compliance to a focus on giving the patient charge of daily self-care management. This method stresses collaboration between nurse and patient (Moyers, Miller, & Hendrickson, 2005). The role of the nurse is to provide information, expertise, and on-going support to empower the patient. This change in perspective also requires that nurses discontinue the use of words such as adherence, compliance, and non-compliance and replace them with words such as impact, self-care choices, self-management, quality of life, and consequences of care.

Solution-focused therapy

Solution-focused therapy is an approach which guides the interviewer/interventionist to focus on what clients want to achieve rather than on the problem(s) that brought them to seek health care. This method, developed by Berg and de Shazer and at the Family Therapy Center in Milwaukee, WI (Berg & De Jong, 1996) invites patients to envision a preferred future and the small or large changes that they might make to achieve this future vision. This method assumes that change is constant and by helping people to identify the things they wish to change and also to attend to what is currently happening in their life, patients can move toward the preferred future.

Methods

Study Design

Twenty-seven newly-diagnosed breast cancer survivors scheduled for surgery were recruited in the parent study where limb volume measurements and symptoms were assessed prior to and following surgery at periodic intervals (pre-op, post-op, and every six months through 18 months after surgery). The bundled intervention of individual education on lymphedema risk-reduction and MMLD was provided by the nurse researchers at the post-op visit and reinforced as appropriate thereafter.

As the parent study progressed, data from field notes on return visits and telephone contacts indicated patients were not routinely performing self-care measures as instructed in the nursing intervention. These findings were elicited from conversations with and observations of patients in the study by the research nurses. Participants reported low energy, fatigue, and lack of motivation as some of the reasons for not performing self-care measures. Many patients were not keeping diaries or not bringing them with them to return visits.

Based on these findings, the research team recognized the need to refine the bundled intervention to assist patients in developing self-care agency to engage in self-care actions that addressed the self-care requisites associated with post-breast cancer surgery. The research team engaged a doctorally prepared nurse with expertise teaching motivational interviewing . This expert had previously worked to enhance the skills of nurses and registered dieticians working with patients experiencing diabetes. These patients reported barriers to self-care management similar to those experienced by the participants in the parent study (Brooks C., personal communication, November 20, 2007).

A questionnaire was developed through consensus by the investigators based on Orem’s power components (2001). This guide consisted of 19 open-ended interview questions to explore the essential capabilities of study participants to engage in self-care actions related to health care deviation requisites specific to risk-reduction of lymphedema. These questions were designed to elicit inferences to patient power/capabilities to perform self-care. Examples of open-ended questions included: How would you describe the level of energy you have to perform self-care activities on a continuous basis to reduce risk for or decrease lymphedema? How do you fit the self-care practices of specialized lymphatic massage, deep breathing, and other self-care measures into your daily routine of your over-all self-care?

The questionnaires were mailed to the 27 participants currently enrolled in or who had recently completed the 18-month parent study. Mail-back envelopes were enclosed with the survey, and telephone interviews were conducted by the study research nurse or a trained graduate student for those who did not return the survey by mail. A total of 14 participants returned the surveys by mail or participated in a telephone interview. Respondent age ranged from 35 to 81 years with a mean of 60 years. The average participant was 13 months beyond breast cancer surgery at the point of the completion of the survey.

Data Analysis

Survey data were recorded from phone interviews and hand-written return surveys. Data were analyzed and categorized using Crabtree and Miller’s (1999) template guidelines for qualitative data analysis and categorized as related to the power components described by Orem (1979, p.205; 2001, p. 265) in Table 1. Each participant statement was compared to Orem’s description of the power components. The themes, initially identified by the fourth author and confirmed by the research team, emerged from comparison of these statements to the power component definitions. For example: Comparing the power component of “the ability to consistently perform self-care operations, integrating them with relevant aspects of personal, family and community living” to the statement “family helps me make time to do it” indicates that self-care capability is present and consistent with the support of others. The focus of this analysis was to explore the state of power related to self-care agency in this population. Since the goal was to elicit general information for developing the educational program to enhance the supportive educative nursing intervention, data were not analyzed specific to each participant but in the aggregate.

Results/Findings

The survey data revealed that study participants were experiencing the most difficulty in four selected power components. These power components included: 1) ability to maintain attention and exercise requisite vigilance with respect to self as self-care agent, internal and external conditions, and factors significant for self-care; 2) ability to reason within a self-care frame of reference; 3) motivation; and 4) ability to consistently perform self-care operations, integrating them with relevant aspects of personal, family, and community living. Table 2 presents the results of the analysis, with data categorized by power component and theme.

Table 2.

Themes of Selected Power Components

First Power Component: ability to maintain attention and exercise requisite vigilance with respect to self as self-care agent, internal and external conditions, and factors significant for self-care
Theme:	Example:
Fully developed power	“Nothing gets in the way.”
Intermittent power	“Get bored with same routine.” “Easier to pay attention when not distracted with life events.”
Absence of power	“I lack focus.”
Second Power Component: ability to reason within a self-care frame of reference
Theme:	Example:
Recognizing the risk of lymphedema	“I believe I am at risk for lymphedema based on information.”
Expressing values and beliefs about self-care related to lymphedema	“I believe self care can prevent or reduce lymphedema;” “I don’t do any of self-care measures except deep breathing outside, [there is a] heavy smoker in the house and [I] think [it is] better to breathe fresh air.”
Recognizing the importance of self-care in risk	“I think it [self-care] is important, I can tell the difference in flexibility in daily activities and [self-care] reduces stress.”
Third Power Component: motivation
Theme:	Example:
Motivated with specific goals	“[My]goals are to lose weight, massage, exercise daily, meditation, and take known precautions (e.g. wearing [compression] sleeves on arms when flying, wearing gloves for chores, taking blood pressure in leg rather than affected arms).”
Motivated with broad goals	“Already doing everything to prevent it.” “Keep [lymphedema] at minimum, try to avoid excessive swelling.”
Motivated with a desire but no specific goal	“I have desire to prevent it [lymphedema]” “Desire to do what it takes.” “I’d like to prevent it [lymphedema].”
Not motivated with no goals established	“Nothing, they never told me to do anything, I haven’t done anything.”
Fourth Power Component: ability to consistently perform self-care operations, integrating them with relevant aspects of personal, family, and community living
Theme:	Example:
Consistent power	“Take care of self, others, yard, drive car and boat, and keep my appointments.” “Do MMLD every morning when I get up.”
Struggling with consistency of power	“Still trying to get into a routine.” “Some days I can.” “Ability now, if things get worse would need assistance.”
Power consistent with support of others	“I don’t see any family much.” “Good emotional support, talk on phone a lot.” “Encourages me to exercise.” “Family helps me make time to do it.” “Family members remind me.”
Inconsistent power	Competing commitments of: “Just daily living, my husband and pets. I think you take care of everyone else first.” “Between the office and keeping up with house work I don’t seem to have enough time.”

Discussion of findings

The following discussion relates the themes from the selected power components to Orem’s degrees of development of SCA (1979, p. 205). The themes emerging from the data (Table 2) reflect a range of self-care capabilities from undeveloped to developed and stabilized self-care agency (Orem, 1979).

Un-developed self-care agency

Undeveloped power is noted in the theme of absence of power. This is reflected in the statement “I lack focus.” This statement may also indicate undeveloped power in the second and fourth power components.

Developing self-care agency

The statements in the three themes of power component two, ability to reason within a self-care frame of reference, (Table 2) reflect developing or possibly developed SCA. Statement one indicates the patient is aware of the risk of lymphedema. Statement two reflects partial development as this patient is performing the deep breathing exercises, but does not see the importance of engaging in the other self-care measures such as MMLD. Statement three indicates the patient recognizes risk, believes self-care is important, and notices the impact of completing self-care measures. The statement in the third power component theme, motivated with desire but no specific goal, also reflects developing SCA.

Developing SCA is also indicated in the fourth power component theme, inconsistent power. These patient statements indicate these patients are likely to be capable of performing self-care actions, but competing commitments hinder the patient’s ability to consistently practice MMLD.

Developed but not stabilized

Developed but not stabilized SCA is observed in the theme of intermittent power and is reflected in the statement “Easier to pay attention when not distracted with life events. The statements in the fourth power component theme, power consistent with support of others, is an example reflecting SCA that is developed but sustained with the support of significant others. Self-care actions for this patient are developed. However the operability of self-care (Orem, 1976), is dependent upon the support of others.

Developed and stabilized self-care agency

The statement “Nothing gets in the way” in power component one, theme fully developed, is an example reflecting developed and stabilized power in maintaining attention and exercising requisite vigilance with respect to self as self-care agent, internal and external conditions, and factors significant for self-care. This statement may also be an indication of developed and stabilized power in motivation for self-care (power component three) and ability to consistently perform self-care operations, integrating them with relevant aspects of personal, family and community living (power component four).

These findings demonstrate that post-breast cancer surgery patients experience a range of self-care capabilities in performing the bundled intervention actions to reduce the risk of lymphedema.

This reinforces the need for individualized supportive-educative systems of care.

These findings also suggest persons strong in one area of power may also be strong in other areas. For example: One participant stated that (MMLD) “fits with my schedule, convenience, practical and not complicated to perform, time efficient.” This statement indicates developed and sustained power in the component of ability to consistently perform self-care operations, integrating them with relevant aspects of personal, family, and community living. This same participant considered her physical capabilities in performing MMLD as excellent. Strengthening one area may leverage capacity in another. The findings in this study also indicate that statements made by patients may overlap in describing the strengths and limitations of patients in performing self-care actions related to multiple power components. This information is helpful in designing supportive-educative systems of care. For example, helping a patient who perceives lack of focus as the problem in performing self-care to regain that focus may increase the patient’s SCA in several power component areas. These areas could include ability to reason within a self-care frame of reference and consistently perform self-care operations, integrating them with relevant aspects of personal, family, and community living. These areas could also include the power component of ability to maintain attention and exercise requisite vigilance with respect to self as self-care agent, internal and external conditions, and factors significant for self-care.

Implementation

Development of the Educational Program to Enhance Supportive/Educative Nursing System

Nurses help patients to develop and sustain SCA in undeveloped and underdeveloped areas through supportive-educative nursing systems. Motivational interviewing integrated with solution-focused therapy is one method to help nurses provide more effective supportive-educative interventions. This supportive-educative system approach is patient focused and individualized; key factors in self-management programs (Coster & Norman, 2009).

The supportive-educative nursing system was developed by the fourth author, an advanced practice nurse in adult psychiatric nursing who is expert in motivational interviewing, to enhance nurse agency in the supportive-educative role system. The educational model consisted of five components (see Table 3).

Table 3.

Educational Model to Enhance Supportive-educative Nursing Systems

Overview of Orem (2001) concepts Introduction to motivational interviewing (Emmons & Rollnick, 2001; Miller & Rollnick, 2002: Resnicow, Dilorio, Soet, Borreli, Hecht, & Ernst, 2002) and solution-focused therapy (Berg & De Jong 1996) concepts and their application to nursing Review of a video on motivational interviewing techniques (Miller, 2000) and discussion of the application to the interpersonal role of nursing Integration of components of solution-focused therapy with motivational interviewing techniques Review of a case study developed by the second author specific to the study population and example questions based on limitations of self-care agency as identified in the survey assessment of SCA power components.

The questionnaire provided data subsequently used to teach the research nurses involved with the bundled intervention motivational interviewing and counseling skills to help patients develop their self-care agency. This supportive-educative nursing system furthers the development of nursing methods of guiding or supporting to help patients enhance their self-care agency in performing the bundled intervention including MMLD (including deep breathing, abdominal massage, axillary clearance, and gentle lymphatic manipulation of the affected limb) and self-care practices of skin care (avoidance of constriction, burns, and muscle strain; care of cuts, scratches, or burns).

Operating in the supportive-educative nursing system in order to enhance self-care actions is a basic premise of Orem’s (2001) self-care deficit nursing theory. Using motivational interviewing (Miller & Rollnick, 2002) and the solution-focused therapy developed by Berg and de Shazer (Berg & De Jong, 1996) as methods to enhance the supportive-educative nursing system are considered promising interventions for helping patients to develop new self-care abilities related to health care deviation requisites and to change ineffective health care behaviors (Burke, Arkowitz, & Menchola, 2003; Keller & White, 1997; Shinitzky & Kub, 2001).

Motivational interviewing can be adapted using a three-step framework that includes: 1) build rapport with the patient, 2) perform the usual assessment (review patient diary, take arm measurements), and 3) summarize and reconnect with patient to develop awareness of discrepancies, explore pros and cons of self-care actions, and set self-care goals (for performing MMLD and other self-care practices related to post-breast cancer surgery) (Martino et al., 2006).

Solution-focused therapy can be applied through scaling questions to motivate clients to change behavior. For example, the nurse might ask, “On a scale of 1-10, how motivated are you to do MMLD on the days you work?” If the patient says, “My motivation is about 5,” then the nurse’s next question might be, “What could you do that might move you from a 5 to an 8 on that scale?” This patient might then move forward in planning and making changes in her self-care behaviors to manage her risk for lymphedema. This series of questions helps the patient to consider how she might incorporate MMLD into her self-care. Exception-seeking questions are also used such as, “On a day that you were able to complete the MMLD, what was going on for you that made that possible?” Another format of questions used in this method are coping questions such as, “I am intrigued that you are able to work each day and care for your grandchild several evenings a week. How do you do that?” This type of question helps patients to recognize their own coping skills. Another key component of solution-focused therapy is helping clients identify self-care capabilities, external resources, and external support (e.g. family support). For example, the nurse might ask the patient “Can you identify the people who might support you in making a change to incorporate MMLD into your self-care strategies?”

Example scenarios and questions for nurses to use with patients were extrapolated from the data of this study, and one case is provided in Box 1.

Box 1. Motivational Interview Using Data from Power Component Assessment Survey.

Scenerio:

Mrs. X comes to see the nurse for her first follow-up clinic appointment. Mrs. X was previously seen at an initial clinic visit to enroll in a pilot study behavioral education program to reduce the risk of lymphedema. On her initial visit, Mrs. X was taught self-care management that included performing MMLD (including deep breathing, abdominal massage, axillary clearance, and gentle lymphatic massage of the affected limb) and self-care practices of skin care (avoidance of constriction, burns, and muscle strain; care of cuts, scratches, or burns). Mrs. X’s follow-up visit to the clinic is to receive arm measurements as part of the lymphedema study and to assess her self-care status related to the behavioral-educational intervention.

The nurse begins by building rapport

Nurse: “Welcome to the clinic. Glad you could come in all this rain” (an affirmation statement lets the patient know the nurse values her).

Patient: “I’m glad I can be part of the study. I just hope I can learn all this.”

Nurse: “Sounds like you are a little concerned about what you want to learn. You might find the information a little overwhelming at first” (lets the patient know the nurse has empathy).

The nurse then performs the usual assessment

Nurse: “Let’s take a look at where you are now. Would that be Ok with you?” (asking permission affirms the decision-making skills of the patient).

Patient: “Sure.”

The nurse performs the usual assessment including arm measurements, review of diary, open-ended questions to determine the patient’s perspective of current health status and self-care management status.

Nurse: “So now that we have your arm measured, tell me how things are going for you in your self-care management activities.”

Patient: “I’m still trying to get into a routine. I don’t do any of the self-care measures except deep breathing outside because there is a heavy smoker in the house. I think it is better to breathe fresh air.”

Nurse: “Good, you’re doing deep breathing outside in the fresh air. You’re not doing other self-care measures. I wonder what you’re thinking about these other self-care activities.”

Patient: “I have the desire to prevent it [lymphedema].”

Nurse: “It seems important for you to keep lymphedema from happening. What other self-care measures are you considering or taking to reach that goal?”

Patient: “My family encourages me to exercise and some days I can.”

Nurse: “It sounds like your family supports you and there are times you can do exercise. What concerns do you have about the other self-care management activities?”

Patient: “Well, I tried the MMLD things you showed me, but I didn’t keep doing them. I’m not sure if I can do them right and I don’t have access to a physical therapist to help me.”

Summarize, Awareness of Discrepancies, Pros and Cons, Goals

Nurse: “Let’s summarize where you are right now. It sounds like you are doing some of the self-care measures such as deep breathing, some exercise, and skin care. It also seems like performing the lymph massage is a real challenge for you. If you would like to work on that, there are several things we can do that might help. Would you like me go over those with you?” (use of “we” demonstrates nurse-partnership; leaves option open for patient to make a choice about learning MMLD).

Patient: “Yes, I would like to work on that. I just don’t know how to do it right.”

Nurse: “Ok, let’s look at some options. I can give you a DVD that demonstrates the procedure. We can go over your handout again. I can demonstrate the procedure. You could perform the procedure and I can coach you in doing it correctly. What do you think might work best for you?” (providing choices affirms patient decision-making).

Patient: “Well, I think it would help if I do it and you coach me and then give me the DVD to review at home if I get stuck.”

Nurse: “That sounds fine.”

The nurse coaches the patient in performing MMLD.

Patient: “I think I can do this now. I feel better about doing it if I know I can do it right.”

Nurse: “Good, you did this very well. Remember, you can call me if you have questions or get stuck between now and your next clinic visit.”

The nurse reassures patient, affirms her self-care skills, and offers on-going support as needed, using the word stuck as the patient used in an earlier statement. The use of the patient’s language demonstrates empathy and understanding by the nurse. As in standard motivational counseling, the nurse is guided to close the patient encounter with an affirmation. This can be a comment on any area in which the patient has made progress, even if it is only in keeping the appointment.

The nurse research team has incorporated the supportive-educative nursing system into the parent study. The next steps under consideration by the research team include further coaching and education through case conferencing of patient situations, discussion of articles on self-care and motivational interviewing, coaching of nurses involved with the parent study on motivational interviewing techniques, and further exploration of health care deviation requisites of post-breast cancer surgery patients. The development of future study components to evaluate the use of these supportive educative nursing interventions is the logical next step.

Implications/Recommendations

Recommendations for the future include a more extensive review of how power components are measured and the development of questions that are more specific to measuring the constructs of the power components. The development of more specific tools that measure self-care agency related to specific health care requisites is needed. Further exploration to determine how increasing self –care capabilities in one area impacts on other areas is warranted.

Upon reflecting about insights gained from this preliminary work, some of these findings may have broader application. For example, it is important to provide support throughout the educational program. Orem (2001) describes supportive-educative systems as consisting of helping actions that include combinations of support, guidance, provision of developmental environment and teaching. Much of the current literature indicates a focus on education to help persons develop self-management abilities. (Coster & Norman, 2009) Unfortunately, education can overshadow support; it is important to remember that education alone may be insufficient. Support may be the essential component in developing self-care agency.

Nurses are the largest group in the health care workforce with the knowledge and skills to assist persons with self-care management (Astin & Closs, 2007). They have the opportunity to change the face of health care by helping patients to develop self-care agency both to meet self-care requisites related to post-breast cancer surgery and other health conditions and to develop self-care abilities to prevent injury and disease. Supportive-educative systems of care that integrate self-care deficit nursing theory, motivational interviewing, and solution-focused therapy can assist patients to develop and sustain self-care agency. Caring for patients with chronic disease is an increasing burden on health care delivery services worldwide (Coster & Norman, 2009). It is imperative for nurses to strengthen the supportive-educative system of care as they work with this growing population.