Introduction

Cancer is a disease that originates from changes in the normal structure of cells due to genetic mutations. These abnormal cells proliferate uncontrollably, ignoring the usual rules of cell division, and through their aggressive behavior, they affect and alter body tissues (1). Approximately one-third of cancer-related deaths linked to five key lifestyle and dietary factors: high body mass index, insufficient consumption of fruits and vegetables, lack of physical activity, tobacco use, and alcohol consumption. Among these, tobacco is particularly significant, accounting for roughly 22% of cancer-related deaths. Infections contribute to 7% of cancer cases in developed countries, whereas in developing countries including Iran and other regions of the Eastern Mediterranean this figure rises to 29%. Moreover, lifestyle factors such as physical activity levels, diet type, and exposure to environmental chemicals also significantly influence cancer risk (2). Cancer is one of the major challenges facing healthcare systems worldwide and is recognized as the third leading cause of death and the second most common non-communicable chronic disease. Globally, it accounts for 12% of all deaths, and the increasing trend emphasizes the need for focused attention on prevention, early detection, and effective treatment (3). In Iran, cancer ranks as the third leading cause of death, with projections indicating a rising incidence rate. Studies suggest that over the next decade, the number of cancer cases may double. Among men, stomach cancer is most prevalent, followed by bladder and colorectal cancers, while among women, breast cancer is most common, followed by skin and stomach cancers. Nonetheless, stomach cancer remains the leading cause of cancer-related mortality in both sexes (4). According to statistics from the Iranian Ministry of Health and the World Health Organization, approximately 112,000 new cancer cases are diagnosed annually in Iran, equating to 177 cases per 100,000 men and 140 per 100,000 women. Projections indicate that within the next 15 years, cancer could account for 80% of deaths in Iran, highlighting the critical need for preventive strategies, public awareness, and improved diagnostic and therapeutic methods (5).

Resilience, defined as the ability to face adversity and adapt positively to challenging conditions, is a key psychological concept, especially relevant in the context of cancer, trauma, and complex life situations. Some approaches view resilience as a stable coping style that enables individuals to confront and overcome difficulties (6). For example, Ludolph et al. describe resilience as a stable, enduring psychological trait (7), whereas Min et al. conceptualize it as a dynamic process in which individuals demonstrate positive adaptation despite experiencing trauma or hardship (8). The concept of resilience was first introduced to nursing literature by Polk, who proposed the limited-domain resilience theory and developed a nursing model framing resilience as the ability to transform a catastrophic event into a constructive and progressive experience (9).

Masten identifies two criteria for resilience: exposure to risk, harm, or threat, and positive adaptation in response to these factors. The first criterion refers to experiences or events that can disrupt normal functioning and produce negative outcomes (10), known as risk factors (11). Miller defines risk factors as conditions that increase the likelihood of behavioral or emotional disorders compared to individuals randomly selected from the general population. Therefore, individuals not exposed to developmental disruption or not overcoming challenges are not considered resilient, even if they appear so (12).

Resilient individuals tend to have an analytical and critical perspective on their abilities and circumstances. They show flexibility when facing changing conditions and possess notable skill in generating diverse solutions to problems. They can realistically evaluate personal challenges and implement both immediate and long-term strategies for complex issues requiring time and reflection (13).

Cancer is widely regarded as one of life’s most stressful experiences. Individuals facing illness often encounter psychological challenges and attempt to endure hardships to overcome adverse conditions. This capacity to cope and adapt to difficulty is referred to in social sciences as "resilience" (14). Furthermore, cancer patients who enhance their resilience are better able to manage depression and stress associated with diagnosis and treatment. Evidence indicates that targeted psychological interventions following a cancer diagnosis significantly improve patients’ mental well-being. Resilience is generally defined as the ability to maintain or quickly restore mental health during or after stressful life events (15).

Macía et al. found that individuals with higher flexibility scored better in adaptive coping strategies, particularly acceptance and positive reappraisal. Regarding perceived quality of life, those with low resilience reported higher levels of pain and poorer general health, which were the most prevalent challenges in low-resilience groups. A significant relationship between resilience and adaptive coping was observed, correlating positively with the quality of life in cancer patients (16).

Lai et al. reported that higher resilience in patients reduced disease-related pain and directly affected symptoms of depression, anxiety, and sleep disturbances. Resilience also mediated the relationship between marital satisfaction and depression symptoms. It is closely linked with other psychological factors, and patients with inadequate resilience face greater difficulties (17).

Research consistently shows that patients with higher psychological resilience experience lower stress and better adapt to life-threatening challenges. They manage difficult conditions more effectively and follow treatment with a more positive attitude and consistent adherence (18). Consequently, interventions focused on relaxation and stress reduction are particularly beneficial for these patients (19).

Modern nursing emphasizes the effectiveness of care and educational interventions based on nursing models. One such model is the Collaborative Care Model, first developed by Mohammadi et al. in 2002 for managing hypertension in Babol County and later evaluated (20). In this model, the quality and nature of interaction between patients and healthcare providers are critical. Active patient participation in the treatment process is prioritized over independent actions. Collaboration between patients and healthcare professionals improves treatment outcomes, increases patient satisfaction, and enhances care quality (21). Moreover, using models aligned with patients’ cultural background significantly improves health outcomes and promotes effective patient-nurse communication (20,22).

The Collaborative Care Model represents the first application of participation theory in nursing in Iran. It integrates patient participation as a structural element, emphasizing that the effectiveness of care depends on the quality and nature of the caregiving relationship (21).

To achieve the model’s objectives, four structured stages are implemented:

ü  Motivation.

ü  Preparation.

ü  Engagement.

ü  Evaluation, each with defined practical programs (20).

The model’s impact on quality of life, social support, self-efficacy, and self-concept in patients has been demonstrated (20,23). However, no study has yet examined its effect on resilience in cancer patients. Therefore, the present study aims to investigate the impact of nursing interventions based on the Collaborative Care Model on the resilience of cancer patients.

 Methods

The present study is a quantitative, semi-experimental intervention with two groups: intervention and control. The study population consisted of cancer patients undergoing chemotherapy in the internal medicine and hematology-oncology wards for both men and women at Ayatollah Kashani and Hajar hospitals in Shahr-e Kord. Inclusion criteria were: diagnosis of cancer, absence of psychiatric disorders, absence of other physical illnesses, and age over 15 years. Exclusion criteria included: severe physical complications from the disease or its treatment that prevented the patient from continuing participation, and unwillingness to continue in the study. The sample size was calculated using the following formula, resulting in 25 participants per group (intervention and control). Considering a potential 20% dropout rate, the final sample size was adjusted to 30 participants per group, for a total of 60 participants.

In this study, sampling was initially performed using purposive sampling, and then participants were assigned to the intervention and control groups according to the random allocation rule. Data collection tools included a demographic questionnaire capturing information such as gender, age, occupation, marital status, educational level, and blood type. To assess resilience, the Connor-Davidson Resilience Scale (CD-RISC) was used, which was developed by Connor and Davidson. This questionnaire consists of 25 items rated on a Likert scale from 0 (not true at all) to 5 (true nearly all the time), yielding a total score range of 0 to 100. Higher scores indicate greater resilience. The questionnaire comprises five subscales: perception of personal competence, trust in instincts, tolerance of negative affect, positive acceptance of change and secure relationships, and spiritual influences (27). Connor and Davidson reported a Cronbach’s alpha of 0.89 for the CD-RISC (28), and test-retest reliability over a four-week interval was 0.87. The scale was standardized for use in Iran by Mohammadi, with a reported Cronbach’s alpha of 0.89 (29). In the present study, reliability was confirmed using Cronbach’s alpha, which was estimated at 0.79, indicating acceptable reliability.

The study was conducted with approval from the Research Deputy and Ethics Committee of Shahrekord University of Medical Sciences, obtaining the ethical code IR.SKUMS.REC.1400.100. Written introduction letters were provided to Hajar and Kashani teaching hospitals, and all ethical codes were strictly observed. With permission from the ward authorities, eligible patients were informed about the study objectives, procedures, and inclusion criteria. After obtaining informed consent and emphasizing confidentiality, participants were enrolled. At the pre-intervention stage, questionnaires were distributed to participants and collected after 48 hours. During the intervention, the experimental group attended nine weekly sessions, organized into groups of six to eight participants. The session content, as presented in Table 1, was delivered specifically to the intervention group.

Table 1. Content of Educational Sessions

At the end of the educational sessions, an instructional booklet was provided to participants in the intervention group. The booklet was developed by the researcher based on a review of existing books and resources and was validated by a psychologist. The control group, however, did not receive any training and were only monitored in the research units. Immediately after the completion of the sessions, the questionnaires were redistributed to participants in both groups and collected after a sufficient period (48 hours) to allow completion. Final data collection occurred two months after the intervention, at which point resilience levels in both the intervention and control groups were reassessed using the same questionnaire. To uphold ethical considerations, the educational booklet was provided to the control group at the conclusion of the study.

Data from the two groups, collected before, immediately after, and two months’ post-intervention, were analyzed using SPSS 24. Descriptive statistics (mean, standard deviation, interquartile range, etc.) and inferential statistics ncluding independent t-tests, Fisher’s exact test, Mann-Whitney test, and Friedman test were applied for analysis.

Results

A total of 60 participants were enrolled in the study and randomly assigned to two groups of 30 each (intervention and control). No participants were lost to follow-up, and all completed the educational sessions and questionnaires in full. The participants’ ages ranged from 33 to 65 years, with a mean of 49.45±8.45 years. The mean age in the control group was 47.40±1.27 years, and in the intervention group, it was 51.50±1.71 years. An independent t-test revealed no significant difference in age between the two groups (P=0.060).

Other demographic characteristics, including marital status, educational level, gender, blood type, and occupation, were also comparable between the two groups prior to the intervention. Chi-square and independent t-tests indicated no significant differences (P<0.05) (Table 2).

 Table 2. Distribution of Patients’ Demographic Characteristics in the Intervention and Control Groups

* Based on the Fisher Exact Test

The results of the resilience variable in cancer patients in the control and intervention groups during the study are presented in Table 3.

Table 3. Mean and Standard Deviation of Resilience Scores in Cancer Patients in the Control and Intervention Groups During the Study

*  Significance of the interaction effect of group and variable over time