Iran Journal of Nursing

Introduction
Cancer is one of the most important diseases of the century and the third leading cause of death in the world. Breast cancer is one of the most common types of cancer among women. Breast cancer accounts for one-third of all cancer cased in women and is the most common malignancy of women worldwide. The incidence of breast cancer in Iranian women is increasing. This disease endangers various aspects of physical and mental health in women. The patients with cancer have different behaviors when facing the disease and continuing the treatment process. Their belief that the breast cancer is a fatal disease and their lack of hope can lead to rumination in them. Rumination is one of the psychological problems that develop hopelessness in women with breast cancer. Rumination refers to obsessive thinking about an idea or situation; and are repeated without dependence on environmental demands. Rumination can increase the effects of negative mood on problem solving and motivation. Considering the psychological effects of cancer, the use of psychological treatments and training can be important in reducing the psychological effects of breast cancer. The present study aims to determine the effect of training based on hope therapy on the rumination of women with breast cancer.

Methods
This is a quasi-experimental study that was conducted in 2019. The study population consist of all women with breast cancer referred to chemotherapy departments of hospitals affiliated to Zahedan University of Medical Sciences. The sampling was done using a continuous method to select samples from among the patients who met the criteria. Then, the samples were divided into intervention (n=50) and control (n=50) groups randomly by lottery method. The inclusion criteria were: Completing a course of chemotherapy, not having a history of metastasis (according to the patient records), no mental disorders before the diagnosis of cancer according to the patient report, not suffering from other chronic physical diseases, not experiencing traumatic events in life such as divorce or the death of loved ones, the ability to participate in group therapy sessions, and not participating in other educational programs at the same time. Exclusion criteria were absence from more than one educational session and worsening of the patient’s condition during the intervention. The intervention was conducted at eight group sessions, twice a week. Education based on hope therapy is a therapeutic program designed based on Snyder’s theory of hope in order to increase hopeful thinking. In this program, the participants were first got familiar with the principles of hope theory and then they were taught how to apply these principles in their lives.
The data collection tools included a demographic form and the Ruminative Response Scale (RRS) designed by Nolen-Hoeksema which has 22 items rated on a Likert scale as: 1= almost never, 2= sometimes, 3= often, and 4= almost always. The total score ranges from 22 to 88. A higher score indicates higher rumination. The data were analyzed in SPSS software, version 16 using descriptive statistics (mean, standard deviation, percentage, frequency) and inferential statistics (independent t-test and paired t-test). The significance level was set at 0.05.

Results
The mean age of patients was 48.04 ± 6.82 years in the intervention group and 47.72±5.59 years in the control group. Most of the participants in both groups (68% in the intervention group and 72% in the control group) had no family history of breast cancer. In addition, 50% of women in the intervention group and 47% of women in the control group had undergone mastectomy. The mean score of rumination before the intervention was not significantly different between the two groups (P= 0.29). After the intervention, the difference between the two groups was significant (P=0.0001). The paired t-test results showed a significant difference in the mean score of rumination before and after the intervention in the intervention group (P=0.003), but there was no significant difference in the control group (P=0.89). 

Conclusion
The findings showed that education based on hope therapy can positively affect the rumination of women with breast cancer. By hope therapy-based intervention, the disturbing thoughts, which are mostly related to disease and despair can be reduced in women with breast cancer experiencing rumination. It is recommended that an educational intervention based on hope therapy be implemented in oncology departments. Considering that women with breast cancer suffer from extensive psychological problems and, on the other hand, their emotional conditions are very effective in improving their physical health, it is recommended that the nurses pay attention to mental health of these women who are involved in disturbing and obsessive thoughts, in addition to their physical health. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Zahedan University of Medical Sciences (Code: IR.ZAUMS.REC.1399.083). 

Funding
This study was extracted from a master thesis in Psychiatric Nursing. It was funded by Zahedan University of Medical Sciences.

Authors' contributions
The authors contributed equally to the preparation of this article.

Conflict of interest
The authors had no conflicts of interest.

Acknowledgments
The authors would like to thank all the women participated in this study for their contribution.


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