Exploring the usefulness of collaborative reflective practice in fostering generative actions among breast cancer survivors: A reviewed literature

Exploring the usefulness of collaborative reflective practice in fostering generative actions among breast cancer survivors: A reviewed literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Exploring the usefulness of collaborative reflective practice in fostering generative actions among breast cancer survivors: A reviewed literature Dr Motlalepule Lekeka This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5550232/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Erikson’s theory provides a broad framework from which to view development throughout the entire lifespan. For instance, with specific reference to Erickson's theory’s in stage 7, namely, generative versus stagnation stage. It is a stage in which individuals are focused on creating or nurturing ideas and projects that may contribute to building a legacy. However, when one fails to become generative, one may emerge with a sense of inadequacy and become stagnant in that aspect of development. For example, those adults who are confronted with life-threatening diseases such as breast cancer may fall short in fulfilling the requirements of stage 7 of the Erikson model due to the illness. Breast cancer can pose a conflict on one’s development, and cause a disruption that may lead to stagnation. However, through engaging in collaborative reflective practice, breast cancer can become a catalyst for one to gain momentum to successfully transition into another stage of development. This review paper sought to explore the usefulness of collaborative reflective practice in fostering generative actions and increasing the quality of life among breast cancer survivors. The Prisma framework was utilized to select studies that suggest that the experience of breast cancer can foster generative behaviors and actions among cancer survivors. 20 Studies were analyzed using thematic analysis. Collaborative reflection can create newness as self-agency, increased productivity, and actualized goals for the survivors to lead meaningful lives. The collaborative reflective practice can develop a sense of trust in the survivors to gain control of their illness and develop an ability to act in an empowered manner. Psychology breast cancer psychosocial interventions collaborative reflective practice external dialogue transformation generative actions renewed goals and the quality of life among breast cancer survivors. Figures Figure 1 Figure 2 Introduction Studies have shown that ill health as a result of cancer experiences can be a period of loneliness, with feelings of isolation because of their otherliness caused by the disease. A high prevalence of depression and anxiety disorders has been reported following breast cancer diagnosis and treatment, which is associated with body image dissatisfaction among women (Kagee, 2018; van Oers, 2017; Patel, 2013; Schlebush & van Oers, 1999). Benson's (2019) study uncovered the emerging reality of the high prevalence of depression (84.2%) and anxiety (92.5%) significantly higher among women who underwent breast removal. In particular, disfigurement, pain, scars, and alopecia may lead to loss of femininity, including sexuality and intimacy (Akkaya et al., 2011; Benson, 2019; Cipolleta, 2019; Harris, 2019; Helms et al., 2008; Lambert et al., 2020; Schain, 1988; Travado, 2013). Breast cancer disease has a profound impact on the mental health of patients, leading many to experience stagnation as depicted in the Erickson (1982)’s stage 7 of the model. The psychosocial reactions of women who are diagnosed and treated for breast cancer can develop a sense of stagnation. The stage 7 of Erickson's model, addresses generative versus stagnation experiences in individuals’ development. Generative experiences are manifested in those individuals are focused on creating or nurturing ideas and projects that may contribute to building a legacy. An experience of generative as explained in Ericksons (1982)’s model resonates with Jung's (1963) concept of rebirth in the theory of individuation. The focus of Jung's (1963) theory of individuation is to discover one's meaning and purpose in order to improve one's life. The rebirth experience as a process of adopting a new perspective in one’s psychic condition, arising from the critical examination of the unconscious (Jung, 1974). According to Robin (2006), rebirth experience is associated with wholeness, positive outlook, and a life-affirming character. The generative-renewed individual can live beyond self, and become productive in actualizing goals and success that would outlive them. However, for an individual who is confronted with a life-threatening disease, and experiencing deterioration of physical abilities to perform their roles, it would be impossible to become generative-renewed. In contrast to generative-renewed experience, the individuals who are diagnosed and treated for breast cancer may present with a stagnant-near death experience. An experience of stagnation as explained in Erickson (1982)’s model resonates with Jung's (1963) concept of the death-like experience that signify the ego disintegration, characterized by suffering, losses, confusion, despondency, and uncertainty. Jung’s description of the death-experience stage of the individuation theory have resonance with the initial onset of symptoms of breast cancer illness prior to and subsequent to the diagnosis and during treatment. A stagnant-near death experience can be characterized with isolation, negative rumination as the individual faces the end of life. However, research indicates that the prognosis for individuals who are diagnosed and treated for breast cancer significantly relies on their participation and engagement in psychosocial interventions (Claasen et al., 2007; Serlin, 1996; Cipolletta, 2019; Spiegel et al., 1981). Participation in the cancer group therapy intervention can create a space for individuals to voice out their emotions, and question the underlying assumptions and can become a catalyst for women to successfully transition from a stagnant-near death experience into a generative-renewed experience. Participation in the cancer group therapy intervention that provides the sick person with an opportunity to engage in collaborative reflective dialogue (Anderson, 1995), has potential to cause a change from a stagnant-near death experience into a generative-renewed experience. According to Anderson (1995), when one enters into a conversation that may allow one to define ones’ dilemmas, and present own narrative concerning the challenge. As a result of such engagement, the individual may develop new competencies and acquire new narratives that can provide solutions (Anderson, 1995). In this paper, I argue that cancer support groups that adopt a collaborative reflective inquiry may provide those who are sick with an opportunity to co-create a new reality with a restored focus and strength to handle dilemmas differently. As a result, the breast cancer survivors may engage in generative-renewed experiences, in order build the legacy and have positive quality of life. The main aim of the review The main aim of this review paper was to examine the impact of collaborative reflective in fostering generative actions among breast cancer survivors. The review focused on those interventions that incorporate a collaborative reflective practice among breast cancer survivors during the survivorship period. In addition, the review was centered on the impact of breast cancer within the context of the theory of Erickson on adult lifespan, and explored cancer experiences in relation to stagnation and generative behavior. The review sought to identify those studies that implemented intervention that incorporated collaborative reflective inquiry, and how such engagement can instigate generative actions among cancer survivors. Review Procedures A comprehensive database search was conducted to identify relevant studies. The various databases searched included Psych INFO, Google Search, and PubMed, as well as ProQuest databases. Both published articles in peer-reviewed journals and unpublished articles (doctoral dissertations) were utilized. The search terms included breast cancer interventions, reflection practice in breast cancer psychosocial intervention, critical reflection, and the quality of life among breast cancer survivors. Data Availability There are limited studies that view breast cancer diagnosis and treatment from a strength-based perspective. Studies have identified interventions that can build strength for one to cope with the challenges of chronic illness. Such studies incorporated internalized reflective practices such creative writing (Gripsrud et al., 2016), dreaming and dream work (Goelitz, 2001; Goelitz 2007; DeCicco, et al, 2010) and spiritually inspired rituals (Becker, 2006; Struthers & Eschiti, 2004; Hodge et al., 1996; Ristevski et al, 2020). Other studies incorporated collaborative reflective practice based on externalized dialogue during the group process (Brooks, 2009; Bonsui et al, 2019; Chu et al, 2020; Dominic et al, 2017; Hvidt, 2017; Martino et al, 2022; Mcwilliam, et al., 1999; Nunstedt et al., 2017; Nzuza, 2016; Park et al, 2009; Santiparp et al., 2014; Serlin, 1996; Tranchenberg, 2012). In addition, studies that shared internalized reflective practice among breast cancer survivors (Ginter and Braun, 2019; Mahommadi et al., 2018) was also included. The inclusion criteria The inclusion criteria of the identified studies required participants to have had breast cancer diagnosis and treatment. The study specifically includes middle-aged adult breast cancer survivors aged between 30 to 60 years old, spanning from a few months to over five years post-treatment breast cancer experiences. The review encompasses qualitative studies employing focus group processes and individual open-ended interviews during 1999 to date. Erickson’s model was utilized as a strategy to select studies that would address the research question in the review. The reviewed studies focused on the psychosocial interventions that incorporated collaborative reflective practices (implemented through psychosocial interventions). The review emphasizes people's lived experiences and their interpretations as they encounter reality. Interventions that empower participants to derive meaning from their lived realities align with reflection, a fundamental aspect of qualitative research. The exclusion criteria The exclusion criteria used covered several aspects such as those studies that implemented psychosocial interventions that were rooted in the biomedical framework, utilized a top-down approach of care, that denied multiple knowledge, limited emotional disclosure, dismissed the importance of contextual factors, minimized participants’ownership of the process, and overlooked the importance of collaborative inquiry principles were excluded (Harris, 2019; Ohaeri et al. 1998; Spiegel & Bloom, 1983; Spiegel et al., 1989; Caruso, 2017). Theoretical Framework Erikson (1982)’s model of human development provides a broad framework from which to view development throughout the entire lifespan. Erikson's (1982) psychosocial development theory introduces the seventh stage as generativity versus stagnation. Throughout this stage, adults experience a compelling urge to create or nurture entities that will outlast their existence. This might involve raising children, instigating positive change through their work and career, and contributing substantially to society. Those who are unable to attain these skills experience stagnation, may experience feelings of unproductiveness and detachment from the world. Generative experiences Generativity can be defined as a stage encompassing creativity, productivity, and generative behavior (Newman & Newman, 2018, p. 498, as cited in Moyer et al, 2020). Erikson's model acknowledges that certain individuals invest themselves in the broader community (Rubinstein et al, 2015). The theme of generativity emphasizes communal growth, involving qualities like caring, dialogue, sharing, and connections beyond the self (Bauer & McAdams, 2004). This might involve raising children, instigating positive change through their work and career, and contributing substantially to society. In adulthood, individuals demonstrate a desire to engage in community activities and nurture intimate, productive, creative, and caring relationships. In these cases, individuals engage in role-related activities by effecting positive changes that benefit others through their work, careers, and contributions to society. Boyle et al. (2017) describe generativity as an outward-looking care for others and future generations, particularly during adulthood. Generative actions may involve active participation in community activities and the creation of positive changes that benefit others (Moyer et al., 2020). Ackerman et al. (2000) attest that individuals who display generative actions are concerned with creating or producing something that will impact others and leave a legacy for future generations. Generativity involves those individuals who impact others and leave a legacy for future generations through active participation in community activities and the creation of positive changes that benefit others (Moyer et al, 2020). For instance, Bauer & McAdams (2004) coined the term generative action to refer to the degree to which the person put the concern into action by engaging in behaviors that are thought to be generative in nature. For example, the impact of cancer experience may serve as a catalyst for cancer survivors to develop high levels of adaptation, psychological functioning, or life awareness (Bellizzi, 2004). Contemporary perspectives have spurred research to advocate an alternative viewpoint on breast cancer survivorship. For example, Mystakidou et al. (2006) affirmed that certain breast cancer patients may embrace the impact of their experiences by actively employing coping strategies that enhance their circumstances. For example, Mystakidou et al (2006)’s study involved a group process with breast cancer survivors. During the group process, the cancer survivors developed increased altruistic behaviors (e.g., acting as mentors to others) and some women made decisions to return to work after their cancer experience with a changed outlook on their current professional career. Ackerman et al. (2000) proposed that individuals who grappled with trauma (such as a breast cancer diagnosis) created experiences that resonated with others to leave a legacy for future generations. For example, some breast cancer survivors may be transformed by the cancer journey, by channeling a dilemma into an opportunity to empower others through education and early detection. However, such the accounts of women who have grown and reinvented themselves as a consequence of breast cancer diagnosis and treatment remain largely unexplored. Stagnation experiences In contrast to the generative experiences, stagnation experiences emerge when adults experience failure to actualize their goals. McAdams and de St. Aubin (1992) introduced the concept of "generative concern" as an experience among those who are grappling with stagnation caused by a life-threatening chronic disease from their thirties onward. Generative concern can result from the kind of internal dialogue as the person engages internally with thoughts related to the cancer diagnosis. For example, the psychosocial reactions of women who have been diagnosed with breast cancer may elicit experiences of generative concern in their cancer journey. The generative concern fosters role reversals, can lead to disruption caused by breast cancer experiences, and potentially a sense of failure to actualize goal attainment. The inward-focused rumination poses a risk of creating an inherent negative narrative that can lead to a generative concern. For instance, studies focusing on breast cancer survivorship (Bellizzi, 2004; de Souza et al., 2021; Keesing et al., 2018; Klaeson & Beterton, 2016; Knaul et al., 2020; Muzzatti et al., 2020; Perlman, 2003) underscore cancer illness as an obstruction to the realization of generative experiences among those diagnosed during adulthood. Notably, Perlman's (2003) study indicates that adults diagnosed with cancer face heightened risks of disruptions and difficulties while striving to accomplish critical developmental tasks. In his conclusion, Perlman (2003) believed that most adult breast cancer survivors exhibit a weakened resolution of the generativity versus stagnation stage. Diagnosis of breast cancer illness was seen as a primary disruptor leading to stagnation and emotional distress. Consequently, this negatively affects women's vocational aspirations, impairs their physical and mental well-being, hampers social interactions, and diminishes overall quality of life. In their investigation, Muzzatti et al. (2020) revealed that treatment side effects, both immediately following and one year after breast cancer surgery, triggered psychological distress that significantly impacted participants' quality of life. Physical health impairments and limitations curtailed engagement in work and other role-related activities. Mental functioning post-surgery experienced a decline, characterized by prevalent emotional issues like anxiety and nervousness, which detrimentally affected daily life and work-related functions. The persistent psychological consequences of treatment and medication including anxiety, mood swings, depression, poor concentration, and lack of motivation, impacted their success in resuming previous daily routines and activities and participation in meaningful roles, including employment (Keesing et al, 2018). To such an extent that women who went through mastectomy experiences in the study (Mahommadi, et al, 2018) resigned from their employment because they felt unprepared to face the stress of adjusting to the career demands post-cancer treatment, they were not ready to handle the role pressure that comes with such role activities. Through such an experience, one can develop an internal dialogue consisting of negative thoughts and ideas (Anderson, 1995). As a result, one’s quality of life functioning can become entwined with a sense of losing control over work self-efficacy and skills, and lead to interpersonal challenges that can hinder connections both within and outside of the workplace. The transition from a stagnant-near death individual into a renewed- generative individual: Collaborative external dialogical conversation involves people engage with others in an external dialogical conversation. According to Anderson (1995), collaborative reflective dialogue takes place when each participant enters the conversation, not knowing what is best for the other person, but acknowledges that each person is an expert on their circumstances and can provide their solutions. Participants define their dilemmas, each participant listens actively to the narrative being presented, and creates possibilities for addressing them. As each participant presents the narrative concerning the illness challenges, reveals what is significant. Those who are listening may ask conversational questions in a manner that encourages the talker to say more about the subject being discussed. Listeners may clarify the sharer’s narrative in a manner that enhances the dialogue. This model may become beneficial to use when working with an individual who is confronted with stagnant-near death experiences. During the cancer support group intervention, collaborative reflection may open the minds of those who are ill, and empower them to gain mastery to make new changes (Mcwilliam, et al 1999 Nunstedt et al, 2017). The evolution of expanding meanings and understandings unfolds through dialogue (Anderson, 1995). When one who is afflicted by the disease can participate in a collaborative reflection process during cancer support group intervention with others that share similar experiences, one can partake in the process of co-construction of a new reality. Strength can be restored to handle dilemmas competently, and new narratives can emerge (Anderson, 1995). Collaborative reflection enabled them to move beyond the generative concern stage, transcend their cancer experience, and engage in generative behaviors (Bellizzi, 2004). For instance, Sears et al (2002) have found that 83% of women diagnosed with breast cancer, saw cancer experiences in a positive manner. As a result of collaborative reflection, survivors developed enhanced life appreciation, improved relationships with others, and influenced the development of positive changes in self-concept (as cited in Mystakidou et al, 2006). Similar results were shared in Hvidt’s (2017) study in which breast cancer survivors reframed the illness experiences in a positive light. For example, the women reported several changes in their identities as a result of cancer but made a choice to lead happy, joyful, and authentic lives as a result cancer journey (Hvidt 2017). Such reflections allowed women to acknowledge that they have turned into different people, and they are grateful that they could choose whom they wanted to become and spend time with in the future and therefore have attained inner peace in their lives. These findings confirmed the importance of reflection process can embrace painful conversations and place more emphasis on affective ways of knowing through dialogue (Taylor, 2009). The collaborative reflection may create new possibilities to emerge, and newness as self-agency; the ability to act, or to feel that we are capable of acting (Anderson, 1993). The collaborative reflection may influence the generative behaviors and activities among cancer survivors by identifying interventions that could have catalyzed and nurtured such generative behaviors and actions, ultimately enhancing their quality of life. For example, within the context of breast cancer interventions, researchers (Brooks, 2009; de Souza et al., 2021; Mcwilliam, et al 1999; Nunstedt et al, 2017) found that women’s sense of agency increased, and desire to help others in the same situation also increased. In this instance, reflection seems to influence generative behaviors and actions. There is little in the literature that shows how breast cancer survivors can transcend the boundaries of their disease to reshape their roles and continue to lead fulfilling lives across the adult lifespan. Few studies attempted to look at the transformative effects of breast cancer to prompt survivors to reauthor their life stories. Few studies have identified the breast cancer survivors’ needs and are limited to discovering steps required for women to re-chart the course of their self-growth. For example, survivors also acquired the value of compassion and become altruistic, sensitive, empathetic, and willing to help others. Participants reported that cancer experiences represented a point of reflection and growth that resulted in an increased desire to be supportive of others. One of the participants said: “I am more sensitive, I feel the pain of others more deeply and therefore tend to have the need to do good deeds, to concretely help others if they need help, to do good deeds towards those in need, because now I know what it means” (Martino, 2022, pp. 34). In her study, Brooks (2009) observed that women's generative actions manifested in their involvement in facilitating support group interventions for recently diagnosed individuals in the early stages of treatment. Cancer survivors expressed their willingness to actively support others, providing a listening ear and raising awareness while connecting with those in need. For instance, Andrea Ivory, a breast cancer survivor of nearly two decades, transformed her cancer experience into an opportunity to assist individuals less privileged due to their socioeconomic status (Miller, et al, 2020). She extended her hand to others, focusing on promoting preventative care, including early screening and addressing risky behaviors. Data Analysis A reflexive thematic analysis was employed to analyze and interpret the data gathered from the reviewed studies. Braun and Clarke’s (2019), reflexive thematic analysis was chosen as the method to uncover and report themes and patterns within the collected dataset. This analytical approach proved invaluable in recognizing both shared traits and variations in the phenomenon under investigation (Braun & Clarke, 2019). The themes were subsequently identified and scrutinized in alignment with the objectives of the review. The main four themes were: an emergence of new awareness, a platform for emotional disclosure, a creation of new shifts or changes in perspectives, and discovery the diversity of individual perceptions and points of views. An Illustration of studies reviewed on the role of collaborative reflective inquiry: (1). The collaborative reflective inquiry led to the emergence of new awareness among breast cancer survivors: Collaborative reflective inquiry can allow each participant to experience and think about ill-health dilemmas differently. Through participation, survivors were able to analyze their experiences and their thinking processes, leading them to create a new construction of meaning from their experiences. In the context of illness, for example, Mcwilliam, et al (1999) study showed that collaborative reflection heightened awareness of health and life and brought resolution of emotional and rational conflicts among those who were sick. Miller's (2020) study showed that breast cancer survivors who underwent a shift in their mental perspectives through engagement in collaborative reflective practices, enabled them to process their thoughts about changes that precipitated by the illness. Collaborative reflection serves as a cognitive function that adopts a systematic approach to information processing (Anderson, 1993). Collaborative reflection can empower participants and offer insights to examine specific issues that require change, ultimately leading to emancipation and desired improvements (Mezirow, 1991). Collaborative reflection can generate new knowledge and actions by challenging established perceptions of cancer to empower individuals (Vince, 2002). In their study, Gripsrud et al (2016) utilized expressive writing intervention to improve quality of life, and post-traumatic stress among breast cancer patients across cultures. The qualitative research on exploring the experience of women following mastectomy increased awareness of the psychosocial impact of breast cancer. After conducting semi-structured interviews data was analyzed and the most distinct theme that emerged was the participants’ desire to use writing as a means to empower others. Reflection practice (through creative writing) increased an altruistic motivation to benefit future patients among breast cancer survivors. Collaborative reflection emphasizes the role of language in empowering individuals to effect change. In Hvidt's (2017) study, women reported the acquisition of a new language that reflects their relationship with life and death in their daily lives. The women came to terms with life's inherent conditions such as death. They concluded that they had conquered death and gained a power they never knew was possible, leading to courageous lives. They changed their language and acted differently in response to cancer's intentions to enhance their lives. Through collaborative reflection, participants can cultivate critical awareness to comprehend and adopt the new values that breast cancer intends to undermine. For instance, research has shown that reflective practice can influence breast cancer survivors to reconsider their career aspirations. Bauer and McAdams (2004) found that individuals who interpret life transitions as opportunities for growth experience higher satisfaction with those transitions. For example, in Mystakidou et al.'s (2006) study, some women developed increased altruistic behaviors, such as acting as mentors to others, while some decided to return to work after their cancer experiences with a changed perspective on their current careers. Studies that utilized reflective practices interventions, through creative writing (Gripsrud et al., 2016), dreaming (Goelitz, 2001; Goelitz 2007; DeCisso et al, 2010) spiritually inspired rituals (Becker, 2006; Struthers & Eschiti, 2004 ; Haozous et al., 2010; Hodge et al., 1996; Ristevski et al, 2020) showed that reflection can enable participants to expand their consciousness by understanding the meaning of their own lives and health. Collaborative reflection can empower participants and provide them with insights to scrutinize specific issues requiring changes for the advancement of emancipation, thus facilitating desired changes (Mezirow, 1991). Collaborative reflection heightens awareness of health and life. Such that patients' reflection about their illness influenced their thinking, and resulted in empowerment (Nunstedt et al., 2017). According to Mcwilliam, et al (1999), power can be gained through understanding the meaning of an illness experience, and can strengthen skills and resources to make new changes. A positive mindset towards life, health, and self can also contribute to improving the quality of life. (2) The collaborative reflective inquiry became a platform for emotional disclosure: Dialogue can facilitate change in the individual’s frame of reference so that one can implement plans that bring about new ways of defining their worlds (Santiparp et al, 2014). For example, in Santiparp et al (2014) study results showed that the participation of women in guided reflective dialogue made a possible acquisition of understanding that altered women’s perceptions related to their experience of an illness. Through dialogue, individuals can evaluate and alter their thought processes to gain new insights. The storytelling approach provided a safe space for women to listen sympathetically to one another and explore the emotional responses associated with cancer experiences (Lechner, et al 2012). In addition, Dominic et al (2018), piloted the Malaysian psychosocial intervention with women who were diagnosed with breast cancer and assisted them in shifting cancer patients’ locus of control from external to internal. Through collaborative reflection, the researcher was able to attain the goal of developing an internal locus of control among cancer survivors, enhancing an improved quality of life and reducing their depression and anxiety. For example, Serlin et al (1996) adapted supportive expressive group therapy into a journal program for breast cancer survivors in the rural settings, and to help the women receive immediate and continuing emotional support and gain insights. The community-based, interactive workbook-journal approach embraced supportive narratives of the personal experiences of women with breast cancer who live in rural communities, and journal space allowed the women to include their own thoughts and questions. In the cancer support group, women may critically examine their dilemmas and status quo through dialogue, they can evaluate and alter their thought processes. For example, de Souza et al. (2021) found that breast cancer survivors required time and space to process their emotions to manage the shock upon receiving their diagnoses. In Brooks' (2009) study, participants were allowed to reflect on their breast cancer experiences. Collaborative reflective processes allow individuals to analyze their experiences and their thought processes, leading to the construction of meaning from these experiences. Through reflective dialogue during the group process, the women developed insights to come to terms with life and its inherent conditions such as death and reported a new realization of their own potential and possibilities in life (Hvidt, 2017). (3) The collaborative reflective inquiry facilitated new shifts or changes in perspectives: Collaborative reflection opens the minds of those who are ill and empowers them to gain mastery through strengthening skills and resources in order to make new changes (Mcwilliam, et al., 1999, Nunstedt et al., 2017). Within this perspective, collaborative reflection may develop new experiences for change to emerge, enhance a fresh and positive mindset towards life, health, and self and may improve the quality of life. In their study, Nunstedt et al (2017) found that reflection practice can heighten women’s understanding of breast cancer illness and develop trust in themselves as they gain control of their illness. Breast cancer survivors shared their experiences to foster the co-construction of knowledge and understanding. In Brooks' (2009) study, participants were given the opportunity to reflect on their breast cancer experiences. Through collaborative reflection, participants developed resilience and deepened their connections to life and relationships throughout their cancer journeys, resulting in a renewed perspective that viewed the cancer experience as a transformative blessing. In Targ &Levine’s (2013) study, researchers found that collaborative reflection incorporated meditation, affirmation, imagery, and rituals to enhance spiritual integration. Participants were 181 women with breast cancer who participated in the randomized study positioned within a primary care setting. The women shared descriptions of their lived experiences during the group process in a safe, positive, and equal atmosphere. In Struthers & Eschiti (2004)’s case study, the native women who were diagnosed with breast cancer participated in the indigenous traditional healing practices to prepare and improve their levels of readiness while awaiting biomedical treatment (including surgery). The women participated in the sweat lodge ceremony, sang the songs and prayed, in order to regain strength and power to heal, and provided spiritual support. The process of collaborative reflection can facilitate emotional disclosure (Fook, 2007; Vince, 2002). It can uncover participants' authentic feelings (Barge & Oliver, 2003). Mezirow (2000) argues that all emotions play a crucial role in driving change. Furthermore, the reflective process can encompass challenging conversations and prioritize effective ways of knowing through dialogue (Taylor, 2009). For instance, the women in the study reported numerous shifts in their identities due to breast cancer. In Trachtenberg's (2012) study, mothers with young children identified the importance of becoming more focused on their children. Women shared that the experience of cancer increased their awareness of the fragility of life and the value of their lives, loved ones, family, and friends (Trachtenberg, 2012). For example, some women expressed appreciation for the second chance: “hoped to live until her children are grown” and “realized that [living until the children are grown] is not a given.” Another 45-year-old cancer survivor stated, “It’s made me more aware of health issues and the fact that our time is limited so make the most of it.” (de Souza et al, 2021). Some women, on the other hand, redirected their attention towards living each day to the fullest by prioritizing the things that mattered most to them, such as engaging in more frequent conversations with their children, family, and friends (Bellizzi, 2004). Park et al (2009) argued that living through cancer involves developing a survivor identity that may strongly influence well-being. A survivor's identity is related to living through cancer by integrating the cancer experience to enhance a sense of agency in managing self. In the study, Park et al (2009) found that the survivor identity correlated with better psychological well-being and post-traumatic growth, and was associated with active involvement. This implies that the survivor identity was perceived as demonstrating generative actions such as contributing money to cancer causes and participating in cancer-related events to promote the empowerment of those with cancer. A survivor's identity is also related to consciously choosing to lead a joyful, authentic life as a result of their cancer journey (Hvidt, 2017). In Hvidt's (2017) study, the women acknowledged undergoing transformative change and expressed gratitude for the ability to choose their future selves, thereby attaining inner peace. Through the process of collaborative reflective practice, the survivors developed a sense of self-acceptance, and self-appreciation, and a more balanced view of the world (Murray et al., 2021). Roger (1951) defines appreciation as encompassing all aspects, and acknowledging them even when conflicts or value differences exist. Appreciation aims to facilitate the emergence of fresh and novel experiences for fostering change. Bosnak's (1989) embodied imagination approach in her work with cancer patients, enabling them to reconnect with their bodies and acknowledge their symptoms. She recognized that her clients often grappled with severe physical pain and a sense of disconnection from their bodies (Goelitz, 2007). She incorporated a body-centered intervention that addressed the physical needs of cancer patients. Throughout her dream work process, she aimed to explore the wisdom embedded in the dreams within their bodies, guiding them through meditative exercises to heighten body awareness. She encouraged patients to re-experience dreams, focusing on feelings and bodily sensations. Engaging with dream images allowed patients to expand their imagination, gaining fresh perspectives and insights to modify dysfunctional patterns that hindered their mental and physical well-being. (4) The collaborative reflection process facilitates the diversity of individual perceptions and points of view: Lambert et al. (2020) revealed that participation in peer support groups allowed women to reflect, develop courage, and find strength in the positive accounts of those who had successfully battled breast cancer. In addition, Gripsrud et al (2016)’s study, breast cancer survivors viewed creative writing as a means to reach out to a total stranger, in order to pass their knowledge to other women with breast cancer. Interestingly, researchers also found that as women’s sense of agency increased, women expressed the desire to help others in the same situation that they were in. In this instance, reflection seems to influence generative behaviors and actions. Recent research attributed positive outcomes collaborative reflective practices among breast cancer survivors (Mystakidou et al, 2006). For example, women in Hvidt (2017)’s study reported also reported that they have acquired a new language that reflects in their relationships to life and death in their day-to-day lives. The women concluded that they overcame death and gained power that they never knew was possible, and were living a courageous life. They changed their language and acted differently to improve their lives. The impact of collaborative reflection to activate generative behaviours and actions from others who are closely related to the survivors became evident. For example, the family members, co-workers, and community leaders who demonstrated altruistic values to nurture and care for the sick among them.Nzuza's (2016) study emphasized the significance of social support from families, with family members being responsible for all treatment decisions. In Mohammadi et al.'s (2018) study, survivors' family members took on the responsibilities of the ill women and cared for their young children to shield them from experiencing depression or academic failure. These family members assisted with the children's school work, transportation to school, feeding, and all other related caregiving activities. Breast cancer management is increasingly transitioning to outpatient care in community settings, with family members often assuming the role of primary caregivers (Gabriel, 2017). For example, Ristevski et al (2020) employed yarning to collect data on breast cancer survivorship experiences and incorporated families of the survivors in the study. The outcome of the study yielded positive results by including the families of the survivors and showing appreciation since they are involved in the daily struggles of the breast cancer experience. Moreover, Becker (2006) and Hodge et al. (1996) made adaptations to the use of yarning circles, by also involving family members to capture the stories of individuals diagnosed with cancer, both from patients and their families. Researchers observed an increased sense of bonding and empathy among participants, including both family members and patients heightened feelings of acceptance, self-worth, and connection when family members participated in these circles. In the research conducted by Ginter and Braun (2019), it was revealed that the work environment has the potential to alleviate the stress experienced by breast cancer patients through support mechanisms. Among the twenty individual participants interviewed, positive experiences with co-workers and management support throughout their cancer journeys were reported. For instance, some participants' colleagues offered various forms of instrumental support. This included donating sick days to their sick colleagues, with co-workers even approaching the union leader to request approval for such donations. Additionally, co-workers took on certain tasks and created gift baskets for their ill colleagues. Furthermore, participants highlighted acts of kindness from their colleagues, who continued to call and visit them throughout their post-diagnosis and post-treatment journey. In some instances, the sick colleague received their full salary during their absence from work for an entire year to aid in their recovery, and colleagues sometimes even purchased groceries for them when visiting (Bonsiu et al., 2016). Summary of Findings and Conclusion Studies have shown that stagnant-near death experience characterized with isolation, negative rumination as explained in Erickson (1982)’s model may be triggered by cancer experiences (Bellizzi, 2004; de Souza et al., 2021; Keesing et al., 2018; Klaeson & Beterton, 2016; Knaul et al., 2020; Lambert et al., 2020; Muzzatti et al., 2020; Perlman, 2003). Such experiences underscore cancer illness as an obstruction to the realization of generative experiences among those diagnosed during adulthood. A sense of stagnation can be undesirable to the quality of life of the survivors, since it poses a risk of developing a generative concern, by focusing on the disruptions caused by breast cancer experiences. However, the alternative approach that is grounded in a strength-based perspective, provided a new way of building strength for survivors to cope with the challenges of chronic illness. For example, the collaborative reflective inquiry model (Anderson, 1995), can facilitate a transition from a stagnant - death like experience into a renewed - generative individual experience among the survivor (Bonsui et al, 2019; Brooks, 2009; Chu et al, 2020; DeCicco, et al, 2010; Dominic et al, 2017; Goelitz, 2001; Goelitz 2007; Hvidt, 2017; Hodge et al., 1996; Ginter and Braun, 2019; Gripsrud et al., 2016; Mahommadi et al., 2018; Martino et al, 2022; Mcwilliam, et al., 1999; Nunstedt et al., 2017; Nzuza, 2016; Park et al, 2009; Santiparp et al., 2014; Serlin, 1996; Struthers & Eschiti, 2004; Ristevski et al, 2020; Tranchenberg, 2012). This contemporary perspective presents an alternative viewpoint of the impact of breast cancer as a catalyst to foster generative behaviors and actions. The collaborative reflective inquiry led to an emergence of new awareness, provided a platform for emotional disclosure, harnessed a creation of new shifts or changes in perspectives, and embraced the diversity of individual perceptions and points of views. Research has shown that through participation in collaborative reflective inquiry, women developed positive growth-like outcomes (Brooks, 2009; Chu et al, 2020; Dominic et al, 2018). The creative writing intervention and shared reading (Nunstedt et al., 2017; Gripsrud et al., 2016; Santiparp et al., 2014) and dreaming and group dream work (Goelitz, 2001; Goelitz 2007; DeCicco, et al, 2010) helped women to shift their focus to live each day to its fullest by enjoying the things that were the most important to them, such as spending time to talk to their children, family, and friends more often (Bellizzi, 2004; Lechner, et al 2012; Goelitz, 2001, 2007; Targ &Levine, 2013). For instance, in her study (Hvidt, 2017) found that breast cancer survivors described their cancer trajectory as a transformative process that led to a new way of being in the world of the living. Within this perspective, the collaborative reflective practice showed the potential to create new possibilities (Nunstedt et al., 2017; Mcwilliam, et al., 1999; Santiparp et al., 2014; Serlin, 1996). The collaborative reflective practice created newness as self-agency, increased productivity, and actualized goals for the survivors to lead a meaningful life (Nunstedt et al., 2017; Mcwilliam, et al., 1999; Santiparp et al., 2014). In their study, Nunstedt et al (2017) found that collaborative reflective practice can heighten women’s understanding of breast cancer illness and develop trust in themselves as they gain control of their illness, and develop an ability to act in an empowered manner (Gripsrud et al., 2016). The collaborative reflective practice could inspire generative actions among survivors, from survivors’ families, co-workers, and communities (Becker, 2006; Bonsiu et al., 2016; Ginter & Braun, 2019; Haozous et al., 2010; Hodge et al., 1996; Mohammadi et al., 2018; Ristevski et al., 2020). The collaborative reflective practice could develop a sense of appreciation among survivors and those connected to them (Gripsrud et al., 2016; Goelitz, 2001; Goelitz 2007; Lyons & Pannier, 2014; Struthers & Eschiti, 2004; Brooks, 2009; Hvidt, 2017; Martino et al, 2022; Mcwilliam, et al., 1999). Even though there is a small scale of research, its contribution is compelling enough not be dismissed. The growth orientation is still at its infancy level, however, there is potential room for growth, and can improve the quality of life, by enhancing productivity and generative actions among breast cancer survivors. What is missing from the review is the limited amount of research from psychological literature on the use of collaborative reflective practices as interventions in cancer survivorship. Studies that incorporated dreaming, and journaling (Goelitz, 2001; Goelitz 2007; DeCisso et al, 2010; Serlin, 1996) were the only studies from a psychological perspective, and were grounded on humanistic existential orientation within the psychological field (Goelitz, 2001; Goelitz 2007; DeCicco, et al, 2010). The majority of studies on collaborative reflective inquiry in breast cancer were conducted within the field of nursing. For example, studies on creative writing, reflective dialogue (group processes), and the quality of life (Nunstedt et al., 2017; Mcwilliam, et al., 1999; Santiparp et al., 2014; Mahommadi et al. 2018).) were conducted from the medical and healthcare perspective. Implications and future recommendation Research has shown that breast cancer survivors may live longer when they experience a renewed self-agency, have gained control over their lives and their abilities to act has been restored in an empowered manner. The collaborative reflective practice can create new possibilities for the survivors to live afresh. The main themes identified in the literature showed that collaborative reflective practice can inspire generative actions among survivors, from survivors’ families, co-workers, and communities. The collaborative reflective practice can unleash hidden power, can serve as an outlet of emotional disclosure, and can develop a sense of appreciation among survivors and those connected to them. Based on the findings of the review, it is recommended that clinicians should consider developing psychosocial interventions for breast cancer survivors from a growth-based orientation. When serving a multi-ethnic population group in non-western cultures, the collaborative reflective practice can address their unique needs and allow them to identify solutions that are relevant to their contextual backgrounds. Declarations Ethics approval and consent to participate The need for ethics approval and consent was waived. Consent for publication The manuscript contained secondary information from the primary research and therefore consent for publication was waived. Availability of data and materials The manuscript includes secondary data since it is a review, and data availability was stated in the manuscript. Competing interests The author declares no conflicts of interest regarding the publication of this paper. Acknowledgement and Funding This work is based on research supported by the National Institute for the Humanities and Social Sciences. Authors' contributions Dr M. 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Cape Town: Oxford University Press; 2005. Hodge F, Cadogan M, Itty TL, Williams A, Finney A. (2016). Culture-broker and medical decoder: contributions of American Indian cancer caregivers in cancer pain management. J Community Support Oncol 2016; 14(5):221-228 Additional Declarations The authors declare no competing interests. Supplementary Files PrismaandCollaborativeReflectivePractice.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5550232","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":384356983,"identity":"12f7f55e-777d-4203-9aaa-46d5ecf636df","order_by":0,"name":"Dr Motlalepule Lekeka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIie3RoQrCQBzH8d8hnOXQ+l/ZXmHDrq+yMfCSb2AYCLciWvUtZjEPhLNs7AGuzDKrFsEiWi2eNsN98v/LL/wBx/lDIThYBvgQvyaj35Mk+z7pq+S0me9lUR27FvMxgry0JEIfokKbWVFnMoROwZaxJSGpvJa/kgaawEv0YEuCc35vH0aGDVOERwk+bG0rXLOdMnFYLzgxVUKQbUVMU2+7MtG20pySVSqILCuTXEfX5c0Eg0p2dLmN/WBtWXn3Ov76PY7jOM4HTwXxQnl5gx8xAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0006-5411-9455","institution":"University of Kwazulu-Natal","correspondingAuthor":true,"prefix":"Dr","firstName":"Motlalepule","middleName":"","lastName":"Lekeka","suffix":""}],"badges":[],"createdAt":"2024-11-29 15:33:36","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5550232/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5550232/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70586638,"identity":"5e35e002-6cfe-4876-a515-ad4fe83381c3","added_by":"auto","created_at":"2024-12-04 16:00:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55429,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Review Procedures section.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5550232/v1/9572253bb74103e9aba8f84f.png"},{"id":70586637,"identity":"d6e48b23-25aa-4c99-ae16-065a9ec069af","added_by":"auto","created_at":"2024-12-04 16:00:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57604,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Review Procedures section.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5550232/v1/2191f65b61f62b0fa3b3fa3e.png"},{"id":70588205,"identity":"66307257-bd01-4971-b709-45bda86d74ab","added_by":"auto","created_at":"2024-12-04 16:16:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":609053,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5550232/v1/a1aba00b-842d-4991-b090-a5869503a13d.pdf"},{"id":70586639,"identity":"53b453e5-1707-4b7c-827a-1f780587772e","added_by":"auto","created_at":"2024-12-04 16:00:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":43174,"visible":true,"origin":"","legend":"","description":"","filename":"PrismaandCollaborativeReflectivePractice.docx","url":"https://assets-eu.researchsquare.com/files/rs-5550232/v1/66926b715cc9f6b4b734124c.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eExploring the usefulness of collaborative reflective practice in fostering generative actions among breast cancer survivors: A reviewed literature\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStudies have shown that ill health as a result of cancer experiences can be a period of loneliness, with feelings of isolation because of their otherliness caused by the disease. A high prevalence of depression and anxiety disorders has been reported following breast cancer diagnosis and treatment, which is associated with body image dissatisfaction among women (Kagee, 2018; van Oers, 2017; Patel, 2013; Schlebush \u0026amp; van Oers, 1999). Benson's (2019) study uncovered the emerging reality of the high prevalence of depression (84.2%) and anxiety (92.5%) significantly higher among women who underwent breast removal. In particular, disfigurement, pain, scars, and alopecia may lead to loss of femininity, including sexuality and intimacy (Akkaya et al., 2011; Benson, 2019; Cipolleta, 2019; Harris, 2019; Helms et al., 2008; Lambert et al., 2020; Schain, 1988; Travado, 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBreast cancer disease has a profound impact on the mental health of patients, leading many to experience stagnation as depicted in the Erickson (1982)’s stage 7 of the model. The psychosocial reactions of women who are diagnosed and treated for breast cancer can develop a sense of stagnation. The stage 7 of Erickson's model, addresses generative versus stagnation experiences in individuals’ development. Generative experiences are manifested in those individuals are focused on creating or nurturing ideas and projects that may contribute to building a legacy. An experience of generative as explained in Ericksons (1982)’s model resonates with Jung's (1963) concept of rebirth in the theory of individuation. The focus of Jung's (1963) theory of individuation is to discover one's meaning and purpose in order to improve one's life. The rebirth experience as a process of adopting a new perspective in one’s psychic condition, arising from the critical examination of the unconscious (Jung, 1974). According to Robin (2006), rebirth experience is associated with wholeness, positive outlook, and a life-affirming character. The generative-renewed individual can live beyond self, and become productive in actualizing goals and success that would outlive them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, for an individual who is confronted with a life-threatening disease, and experiencing deterioration of physical abilities to perform their roles, it would be impossible to become generative-renewed. In contrast to generative-renewed experience, the individuals who are diagnosed and treated for breast cancer may present with a stagnant-near death experience. An experience of stagnation as explained in Erickson (1982)’s model resonates with Jung's (1963) concept of the death-like experience that signify the ego disintegration, characterized by suffering, losses, confusion, despondency, and uncertainty. Jung’s description of the death-experience stage of the individuation theory have resonance with the initial onset of symptoms of breast cancer illness prior to and subsequent to the diagnosis and during treatment. A stagnant-near death experience can be characterized with isolation, negative rumination as the individual faces the end of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, research indicates that the prognosis for individuals who are diagnosed and treated for breast cancer significantly relies on their participation and engagement in psychosocial interventions (Claasen et al., 2007; Serlin, 1996; Cipolletta, 2019; Spiegel et al., 1981). Participation in the cancer group therapy intervention can create a space for individuals to voice out their emotions, and question the underlying assumptions and can become a catalyst for women to successfully transition from a stagnant-near death experience into a generative-renewed experience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipation in the cancer group therapy intervention that provides the sick person with an opportunity to engage in collaborative reflective dialogue (Anderson, 1995), has potential to cause a change from a stagnant-near death experience into a generative-renewed experience. According to Anderson (1995), when one enters into a conversation that may allow one to define ones’ dilemmas, and present own narrative concerning the challenge. As a result of such engagement, the individual may develop new competencies and acquire new narratives that can provide solutions (Anderson, 1995). In this paper, I argue that cancer support groups that adopt a collaborative reflective inquiry may provide those who are sick with an opportunity to co-create a new reality with a restored focus and strength to handle dilemmas differently. As a result, the breast cancer survivors may engage in generative-renewed experiences, in order build the legacy and have positive quality of life.\u003c/p\u003e\n\u003ch3\u003eThe main aim of the review\u003c/h3\u003e\n\u003cp\u003eThe main aim of this review paper was to examine the impact of collaborative reflective in fostering generative actions among breast cancer survivors. The review focused on those interventions that incorporate a collaborative reflective practice among breast cancer survivors during the survivorship period. In addition, the review was centered on the impact of breast cancer within the context of the theory of Erickson on adult lifespan, and explored cancer experiences in relation to stagnation and generative behavior. The review sought to identify those studies that implemented intervention that incorporated collaborative reflective inquiry, and how such engagement can instigate generative actions among cancer survivors. \u0026nbsp;\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n"},{"header":"Review Procedures ","content":"\u003cp\u003eA comprehensive database search was conducted to identify relevant studies. The various databases searched included Psych INFO, Google Search, and PubMed, as well as ProQuest databases. Both published articles in peer-reviewed journals and unpublished articles (doctoral dissertations) were utilized. The search terms included breast cancer interventions, reflection practice in breast cancer psychosocial intervention, critical reflection, and the quality of life among breast cancer survivors.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThere are limited studies that view breast cancer diagnosis and treatment from a strength-based perspective. Studies have identified interventions that can build strength for one to cope with the challenges of chronic illness. Such studies incorporated internalized reflective practices such creative writing (Gripsrud et al., 2016), dreaming and dream work (Goelitz, 2001; Goelitz 2007; DeCicco, et al, 2010) and spiritually inspired rituals (Becker, 2006; Struthers \u0026amp; Eschiti, 2004; Hodge et al., 1996; Ristevski et al, 2020).\u0026nbsp;\u003c/p\u003e\u003cp\u003eOther studies incorporated collaborative reflective practice based on externalized dialogue during the group process (Brooks, 2009; Bonsui et al, 2019; Chu et al, 2020; Dominic et al, 2017; Hvidt, 2017; Martino et al, 2022; Mcwilliam, et al., 1999; Nunstedt et al., 2017; Nzuza, 2016; Park et al, 2009; Santiparp et al., 2014; Serlin, 1996; Tranchenberg, 2012). In addition, studies that shared internalized reflective practice among breast cancer survivors (Ginter and Braun, 2019; Mahommadi et al., 2018) was also included.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eThe inclusion criteria\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe inclusion criteria of the identified studies required participants to have had breast cancer diagnosis and treatment. The study specifically includes middle-aged adult breast cancer survivors aged between 30 to 60 years old, spanning from a few months to over five years post-treatment breast cancer experiences. The review encompasses qualitative studies employing focus group processes and individual open-ended interviews during 1999 to date. Erickson’s model was utilized as a strategy to select studies that would address the research question in the review.\u003c/p\u003e\u003cp\u003eThe reviewed studies focused on the psychosocial interventions that incorporated collaborative reflective practices (implemented through psychosocial interventions). The review emphasizes people's lived experiences and their interpretations as they encounter reality. Interventions that empower participants to derive meaning from their lived realities align with reflection, a fundamental aspect of qualitative research.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eThe exclusion criteria\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe exclusion criteria used covered several aspects such as those studies that implemented psychosocial interventions that were rooted in the biomedical framework, utilized a top-down approach of care, that denied multiple knowledge, limited emotional disclosure, dismissed the importance of contextual factors, minimized participants’ownership of the process, and overlooked the importance of collaborative inquiry principles were excluded (Harris, 2019; Ohaeri et al. 1998; Spiegel \u0026amp; Bloom, 1983; Spiegel et al., 1989; Caruso, 2017).\u0026nbsp;\u003c/p\u003e"},{"header":"Theoretical Framework","content":"\u003cp\u003eErikson (1982)’s model of human development provides a broad framework from which to view development throughout the entire lifespan. Erikson's (1982) psychosocial development theory introduces the seventh stage as generativity versus stagnation. Throughout this stage, adults experience a compelling urge to create or nurture entities that will outlast their existence. This might involve raising children, instigating positive change through their work and career, and contributing substantially to society. Those who are unable to attain these skills experience stagnation, may experience feelings of unproductiveness and detachment from the world.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eGenerative experiences\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eGenerativity can be defined as a stage encompassing creativity, productivity, and generative behavior (Newman \u0026amp; Newman, 2018, p. 498, as cited in Moyer et al, 2020). Erikson's model acknowledges that certain individuals invest themselves in the broader community (Rubinstein et al, 2015). The theme of generativity emphasizes communal growth, involving qualities like caring, dialogue, sharing, and connections beyond the self (Bauer \u0026amp; McAdams, 2004). This might involve raising children, instigating positive change through their work and career, and contributing substantially to society. In adulthood, individuals demonstrate a desire to engage in community activities and nurture intimate, productive, creative, and caring relationships. In these cases, individuals engage in role-related activities by effecting positive changes that benefit others through their work, careers, and contributions to society. Boyle et al. (2017) describe generativity as an outward-looking care for others and future generations, particularly during adulthood. Generative actions may involve active participation in community activities and the creation of positive changes that benefit others (Moyer et al., 2020). Ackerman et al. (2000) attest that individuals who display generative actions are concerned with creating or producing something that will impact others and leave a legacy for future generations. Generativity involves those individuals who impact others and leave a legacy for future generations through active participation in community activities and the creation of positive changes that benefit others (Moyer et al, 2020). For instance, Bauer \u0026amp; McAdams (2004) coined the term generative action to refer to the degree to which the person put the concern into action by engaging in behaviors that are thought to be generative in nature.\u0026nbsp;\u003c/p\u003e\u003cp\u003eFor example, the impact of cancer experience may serve as a catalyst for cancer survivors to develop high levels of adaptation, psychological functioning, or life awareness (Bellizzi, 2004). Contemporary perspectives have spurred research to advocate an alternative viewpoint on breast cancer survivorship. For example, Mystakidou et al. (2006) affirmed that certain breast cancer patients may embrace the impact of their experiences by actively employing coping strategies that enhance their circumstances. For example, Mystakidou et al (2006)’s study involved a group process with breast cancer survivors. During the group process, the cancer survivors developed increased altruistic behaviors (e.g., acting as mentors to others) and some women made decisions to return to work after their cancer experience with a changed outlook on their current professional career. Ackerman et al. (2000) proposed that individuals who grappled with trauma (such as a breast cancer diagnosis) created experiences that resonated with others to leave a legacy for future generations. For example, some breast cancer survivors may be transformed by the cancer journey, by channeling a dilemma into an opportunity to empower others through education and early detection. \u0026nbsp;However, such the accounts of women who have grown and reinvented themselves as a consequence of breast cancer diagnosis and treatment remain largely unexplored.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStagnation experiences\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eIn contrast to the generative experiences, stagnation experiences emerge when adults experience failure to actualize their goals. McAdams and de St. Aubin (1992) introduced the concept of \"generative concern\" as an experience among those who are grappling with stagnation caused by a life-threatening chronic disease from their thirties onward. Generative concern can result from the kind of internal dialogue as the person engages internally with thoughts related to the cancer diagnosis. For example, the psychosocial reactions of women who have been diagnosed with breast cancer may elicit experiences of generative concern in their cancer journey. The generative concern fosters role reversals, can lead to disruption caused by breast cancer experiences, and potentially a sense of failure to actualize goal attainment.\u0026nbsp;\u003c/p\u003e\u003cp\u003eThe inward-focused rumination poses a risk of creating an inherent negative narrative that can lead to a generative concern. For instance, studies focusing on breast cancer survivorship (Bellizzi, 2004; de Souza et al., 2021; Keesing et al., 2018; Klaeson \u0026amp; Beterton, 2016; Knaul et al., 2020; Muzzatti et al., 2020; Perlman, 2003) underscore cancer illness as an obstruction to the realization of generative experiences among those diagnosed during adulthood. Notably, Perlman's (2003) study indicates that adults diagnosed with cancer face heightened risks of disruptions and difficulties while striving to accomplish critical developmental tasks. In his conclusion, Perlman (2003) believed that most adult breast cancer survivors exhibit a weakened resolution of the generativity versus stagnation stage. Diagnosis of breast cancer illness was seen as a primary disruptor leading to stagnation and emotional distress. \u0026nbsp;Consequently, this negatively affects women's vocational aspirations, impairs their physical and mental well-being, hampers social interactions, and diminishes overall quality of life.\u003c/p\u003e\u003cp\u003eIn their investigation, Muzzatti et al. (2020) revealed that treatment side effects, both immediately following and one year after breast cancer surgery, triggered psychological distress that significantly impacted participants' quality of life. Physical health impairments and limitations curtailed engagement in work and other role-related activities. Mental functioning post-surgery experienced a decline, characterized by prevalent emotional issues like anxiety and nervousness, which detrimentally affected daily life and work-related functions. The persistent psychological consequences of treatment and medication including anxiety, mood swings, depression, poor concentration, and lack of motivation, impacted their success in resuming previous daily routines and activities and participation in meaningful roles, including employment (Keesing et al, 2018). To such an extent that women who went through mastectomy experiences in the study (Mahommadi, et al, 2018) resigned from their employment because they felt unprepared to face the stress of adjusting to the career demands post-cancer treatment, they were not ready to handle the role pressure that comes with such role activities. Through such an experience, one can develop an internal dialogue consisting of negative thoughts and ideas (Anderson, 1995). As a result, one’s quality of life functioning can become entwined with a sense of losing control over work self-efficacy and skills, and lead to interpersonal challenges that can hinder connections both within and outside of the workplace.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eThe transition from a stagnant-near death individual into a renewed- generative individual:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eCollaborative external dialogical conversation involves people engage with others in an external dialogical conversation. According to Anderson (1995), collaborative reflective dialogue takes place when each participant enters the conversation, not knowing what is best for the other person, but acknowledges that each person is an expert on their circumstances and can provide their solutions. Participants define their dilemmas, each participant listens actively to the narrative being presented, and creates possibilities for addressing them. As each participant presents the narrative concerning the illness challenges, reveals what is significant. Those who are listening may ask conversational questions in a manner that encourages the talker to say more about the subject being discussed. Listeners may clarify the sharer’s narrative in a manner that enhances the dialogue. This model may become beneficial to use when working with an individual who is confronted with stagnant-near death experiences. During the cancer support group intervention, collaborative reflection may open the minds of those who are ill, and empower them to gain mastery to make new changes (Mcwilliam, et al 1999 Nunstedt et al, 2017). The evolution of expanding meanings and understandings unfolds through dialogue (Anderson, 1995). When one who is afflicted by the disease can participate in a collaborative reflection process during cancer support group intervention with others that share similar experiences, one can partake in the process of co-construction of a new reality. Strength can be restored to handle dilemmas competently, and new narratives can emerge (Anderson, 1995).\u0026nbsp;\u003c/p\u003e\u003cp\u003eCollaborative reflection enabled them to move beyond the generative concern stage, transcend their cancer experience, and engage in generative behaviors (Bellizzi, 2004). For instance, Sears et al (2002) have found that 83% of women diagnosed with breast cancer, saw cancer experiences in a positive manner. \u0026nbsp;As a result of collaborative reflection, survivors developed enhanced life appreciation, improved relationships with others, and influenced the development of positive changes in self-concept (as cited in Mystakidou et al, 2006). Similar results were shared in Hvidt’s (2017) study in which breast cancer survivors reframed the illness experiences in a positive light. For example, the women reported several changes in their identities as a result of cancer but made a choice to lead happy, joyful, and authentic lives as a result cancer journey (Hvidt 2017). Such reflections allowed women to acknowledge that they have turned into different people, and they are grateful that they could choose whom they wanted to become and spend time with in the future and therefore have attained inner peace in their lives. These findings confirmed the importance of reflection process can embrace painful conversations and place more emphasis on affective ways of knowing through dialogue (Taylor, 2009).\u003c/p\u003e\u003cp\u003eThe collaborative reflection may create new possibilities to emerge, and newness as self-agency; the ability to act, or to feel that we are capable of acting (Anderson, 1993). The collaborative reflection may influence the generative behaviors and activities among cancer survivors by identifying interventions that could have catalyzed and nurtured such generative behaviors and actions, ultimately enhancing their quality of life. For example, within the context of breast cancer interventions, researchers (Brooks, 2009; de Souza et al., 2021; Mcwilliam, et al 1999; Nunstedt et al, 2017) found that women’s sense of agency increased, and desire to help others in the same situation also increased. In this instance, reflection seems to influence generative behaviors and actions. There is little in the literature that shows how breast cancer survivors can transcend the boundaries of their disease to reshape their roles and continue to lead fulfilling lives across the adult lifespan. Few studies attempted to look at the transformative effects of breast cancer to prompt survivors to reauthor their life stories. Few studies have identified the breast cancer survivors’ needs and are limited to discovering steps required for women to re-chart the course of their self-growth. For example, survivors also acquired the value of compassion and become altruistic, sensitive, empathetic, and willing to help others. Participants reported that cancer experiences represented a point of reflection and growth that resulted in an increased desire to be supportive of others.\u003c/p\u003e\u003cp\u003eOne of the participants said:\u003c/p\u003e\u003cp\u003e“I am more sensitive, I feel the pain of others more deeply and therefore tend to have the need to do good deeds, to concretely help others if they need help, to do good deeds towards those in need, because now I know what it means” (Martino, 2022, pp. 34).\u003c/p\u003e\u003cp\u003eIn her study, Brooks (2009) observed that women's generative actions manifested in their involvement in facilitating support group interventions for recently diagnosed individuals in the early stages of treatment. Cancer survivors expressed their willingness to actively support others, providing a listening ear and raising awareness while connecting with those in need. For instance, Andrea Ivory, a breast cancer survivor of nearly two decades, transformed her cancer experience into an opportunity to assist individuals less privileged due to their socioeconomic status (Miller, et al, 2020). She extended her hand to others, focusing on promoting preventative care, including early screening and addressing risky behaviors.\u003c/p\u003e"},{"header":"Data Analysis","content":"\u003cp\u003eA reflexive thematic analysis was employed to analyze and interpret the data gathered from the reviewed studies. Braun and Clarke’s (2019), reflexive thematic analysis was chosen as the method to uncover and report themes and patterns within the collected dataset. This analytical approach proved invaluable in recognizing both shared traits and variations in the phenomenon under investigation (Braun \u0026amp; Clarke, 2019). The themes were subsequently identified and scrutinized in alignment with the objectives of the review. The main four themes were: an emergence of new awareness, a platform for emotional disclosure, a creation of new shifts or changes in perspectives, and discovery the diversity of individual perceptions and points of views.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAn Illustration of studies reviewed on the role of collaborative reflective inquiry:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e(1). The collaborative reflective inquiry led to the\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eemergence of new awareness\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eamong breast cancer survivors:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eCollaborative reflective inquiry can allow each participant to experience and think about ill-health dilemmas differently. Through participation, survivors were able to analyze their experiences and their thinking processes, leading them to create a new construction of meaning from their experiences. In the context of illness, for example, Mcwilliam, et al (1999) study showed that collaborative reflection heightened awareness of health and life and brought resolution of emotional and rational conflicts among those who were sick. Miller's (2020) study showed that breast cancer survivors who underwent a shift in their mental perspectives through engagement in collaborative reflective practices, enabled them to process their thoughts about changes that precipitated by the illness. Collaborative reflection serves as a cognitive function that adopts a systematic approach to information processing (Anderson, 1993). Collaborative reflection can empower participants and offer insights to examine specific issues that require change, ultimately leading to emancipation and desired improvements (Mezirow, 1991).\u0026nbsp;\u003c/p\u003e\u003cp\u003eCollaborative reflection can generate new knowledge and actions by challenging established perceptions of cancer to empower individuals (Vince, 2002). In their study, Gripsrud et al (2016) utilized expressive writing intervention to improve quality of life, and post-traumatic stress among breast cancer patients across cultures. The qualitative research on exploring the experience of women following mastectomy increased awareness of the psychosocial impact of breast cancer. After conducting semi-structured interviews data was analyzed and the most distinct theme that emerged was the participants’ desire to use writing as a means to empower others. Reflection practice (through creative writing) increased an altruistic motivation to benefit future patients among breast cancer survivors.\u003c/p\u003e\u003cp\u003eCollaborative reflection emphasizes the role of language in empowering individuals to effect change. In Hvidt's (2017) study, women reported the acquisition of a new language that reflects their relationship with life and death in their daily lives. The women came to terms with life's inherent conditions such as death. They concluded that they had conquered death and gained a power they never knew was possible, leading to courageous lives. They changed their language and acted differently in response to cancer's intentions to enhance their lives.\u003c/p\u003e\u003cp\u003eThrough collaborative reflection, participants can cultivate critical awareness to comprehend and adopt the new values that breast cancer intends to undermine. For instance, research has shown that reflective practice can influence breast cancer survivors to reconsider their career aspirations. Bauer and McAdams (2004) found that individuals who interpret life transitions as opportunities for growth experience higher satisfaction with those transitions. For example, in Mystakidou et al.'s (2006) study, some women developed increased altruistic behaviors, such as acting as mentors to others, while some decided to return to work after their cancer experiences with a changed perspective on their current careers. Studies that utilized reflective practices interventions, through creative writing (Gripsrud et al., 2016), dreaming (Goelitz, 2001; Goelitz 2007; DeCisso et al, 2010) spiritually inspired rituals (Becker, 2006; Struthers \u0026amp; Eschiti, 2004\u003c/p\u003e\u003cp\u003e; Haozous et al., 2010; Hodge et al., 1996; Ristevski et al, 2020) showed that reflection can enable participants to expand their consciousness by understanding the meaning of their own lives and health.\u0026nbsp;\u003c/p\u003e\u003cp\u003eCollaborative reflection can empower participants and provide them with insights to scrutinize specific issues requiring changes for the advancement of emancipation, thus facilitating desired changes (Mezirow, 1991). Collaborative reflection heightens awareness of health and life. Such that patients' reflection about their illness influenced their thinking, and resulted in empowerment (Nunstedt et al., 2017). \u0026nbsp;According to Mcwilliam, et al (1999), power can be gained through understanding the meaning of an illness experience, and can strengthen skills and resources to make new changes. A positive mindset towards life, health, and self can also contribute to improving the quality of life.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e(2) The collaborative reflective inquiry became a platform for emotional disclosure:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eDialogue can facilitate change in the individual’s frame of reference so that one can implement plans that bring about new ways of defining their worlds (Santiparp et al, 2014). For example, in Santiparp et al (2014) study results showed that the participation of women in guided reflective dialogue made a possible acquisition of understanding that altered women’s perceptions related to their experience of an illness. Through dialogue, individuals can evaluate and alter their thought processes to gain new insights. The storytelling approach provided a safe space for women to listen sympathetically to one another and explore the emotional responses associated with cancer experiences (Lechner, et al 2012). In addition, Dominic et al (2018), piloted the Malaysian psychosocial intervention with women who were diagnosed with breast cancer and assisted them in shifting cancer patients’ locus of control from external to internal. Through collaborative reflection, the researcher was able to attain the goal of developing an internal locus of control among cancer survivors, enhancing an improved quality of life and reducing their depression and anxiety.\u0026nbsp;\u003c/p\u003e\u003cp\u003eFor example, Serlin et al (1996) adapted supportive expressive group therapy into a journal program for breast cancer survivors in the rural settings, and to help the women receive immediate and continuing emotional support and gain insights. The community-based, interactive workbook-journal approach embraced supportive narratives of the personal experiences of women with breast cancer who live in rural communities, and journal space allowed the women to include their own thoughts and questions.\u0026nbsp;\u003c/p\u003e\u003cp\u003eIn the cancer support group, women may critically examine their dilemmas and status quo through dialogue, they can evaluate and alter their thought processes. For example, de Souza et al. (2021) found that breast cancer survivors required time and space to process their emotions to manage the shock upon receiving their diagnoses. In Brooks' (2009) study, participants were allowed to reflect on their breast cancer experiences. Collaborative reflective processes allow individuals to analyze their experiences and their thought processes, leading to the construction of meaning from these experiences. Through reflective dialogue during the group process, the women developed insights to come to terms with life and its inherent conditions such as death and reported a new realization of their own potential and possibilities in life (Hvidt, 2017).\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e(3) The collaborative reflective inquiry facilitated new shifts or changes in perspectives:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u0026nbsp;Collaborative reflection opens the minds of those who are ill and empowers them to gain mastery through strengthening skills and resources in order to make new changes (Mcwilliam, et al., 1999, Nunstedt et al., 2017). Within this perspective, collaborative reflection may develop new experiences for change to emerge, enhance a fresh and positive mindset towards life, health, and self and may improve the quality of life. In their study, Nunstedt et al (2017) found that reflection practice can heighten women’s understanding of breast cancer illness and develop trust in themselves as they gain control of their illness. Breast cancer survivors shared their experiences to foster the co-construction of knowledge and understanding. In Brooks' (2009) study, participants were given the opportunity to reflect on their breast cancer experiences. Through collaborative reflection, participants developed resilience and deepened their connections to life and relationships throughout their cancer journeys, resulting in a renewed perspective that viewed the cancer experience as a transformative blessing.\u003c/p\u003e\u003cp\u003eIn Targ \u0026amp;Levine’s (2013) study, researchers found that collaborative reflection incorporated meditation, affirmation, imagery, and rituals to enhance spiritual integration. Participants were 181 women with breast cancer who participated in the randomized study positioned within a primary care setting. The women shared descriptions of their lived experiences during the group process in a safe, positive, and equal atmosphere. In Struthers \u0026amp; Eschiti (2004)’s case study, the native women who were diagnosed with breast cancer participated in the indigenous traditional healing practices to prepare and improve their levels of readiness while awaiting biomedical treatment (including surgery). The women participated in the sweat lodge ceremony, sang the songs and prayed, in order to regain strength and power to heal, and provided spiritual support.\u003c/p\u003e\u003cp\u003eThe process of collaborative reflection can facilitate emotional disclosure (Fook, 2007; Vince, 2002). It can uncover participants' authentic feelings (Barge \u0026amp; Oliver, 2003). Mezirow (2000) argues that all emotions play a crucial role in driving change. Furthermore, the reflective process can encompass challenging conversations and prioritize effective ways of knowing through dialogue (Taylor, 2009).\u0026nbsp;\u003c/p\u003e\u003cp\u003eFor instance, the women in the study reported numerous shifts in their identities due to breast cancer. In Trachtenberg's (2012) study, mothers with young children identified the importance of becoming more focused on their children. Women shared that the experience of cancer increased their awareness of the fragility of life and the value of their lives, loved ones, family, and friends (Trachtenberg, 2012).\u003c/p\u003e\u003cp\u003eFor example, some women expressed appreciation for the second chance:\u003c/p\u003e\u003cp\u003e“hoped to live until her children are grown” and “realized that [living until the children are grown] is not a given.” Another 45-year-old cancer survivor stated, “It’s made me more aware of health issues and the fact that our time is limited so make the most of it.” (de Souza et al, 2021).\u003c/p\u003e\u003cp\u003eSome women, on the other hand, redirected their attention towards living each day to the fullest by prioritizing the things that mattered most to them, such as engaging in more frequent conversations with their children, family, and friends (Bellizzi, 2004).\u0026nbsp;\u003c/p\u003e\u003cp\u003ePark et al (2009) argued that living through cancer involves developing a survivor identity that may strongly influence well-being. A survivor's identity is related to living through cancer by integrating the cancer experience to enhance a sense of agency in managing self. In the study, Park et al (2009) found that the survivor identity correlated with better psychological well-being and post-traumatic growth, and was associated with active involvement. This implies that the survivor identity was perceived as demonstrating generative actions such as contributing money to cancer causes and participating in cancer-related events to promote the empowerment of those with cancer.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u0026nbsp;A survivor's identity is also related to consciously choosing to lead a joyful, authentic life as a result of their cancer journey (Hvidt, 2017). In Hvidt's (2017) study, the women acknowledged undergoing transformative change and expressed gratitude for the ability to choose their future selves, thereby attaining inner peace.\u003c/p\u003e\u003cp\u003eThrough the process of collaborative reflective practice, the survivors developed a sense of self-acceptance, and self-appreciation, and a more balanced view of the world (Murray et al., 2021). Roger (1951) defines appreciation as encompassing all aspects, and acknowledging them even when conflicts or value differences exist. Appreciation aims to facilitate the emergence of fresh and novel experiences for fostering change.\u0026nbsp;\u003c/p\u003e\u003cp\u003eBosnak's (1989) embodied imagination approach in her work with cancer patients, enabling them to reconnect with their bodies and acknowledge their symptoms. She recognized that her clients often grappled with severe physical pain and a sense of disconnection from their bodies (Goelitz, 2007). She incorporated a body-centered intervention that addressed the physical needs of cancer patients. Throughout her dream work process, she aimed to explore the wisdom embedded in the dreams within their bodies, guiding them through meditative exercises to heighten body awareness. She encouraged patients to re-experience dreams, focusing on feelings and bodily sensations. Engaging with dream images allowed patients to expand their imagination, gaining fresh perspectives and insights to modify dysfunctional patterns that hindered their mental and physical well-being.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e(4)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The collaborative reflection process facilitates the diversity of individual perceptions and points of view:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u0026nbsp;Lambert et al. (2020) revealed that participation in peer support groups allowed women to reflect, develop courage, and find strength in the positive accounts of those who had successfully battled breast cancer. In addition, Gripsrud et al (2016)’s study, breast cancer survivors viewed creative writing as a means to reach out to a total stranger, in order to pass their knowledge to other women with breast cancer. Interestingly, researchers also found that as women’s sense of agency increased, women expressed the desire to help others in the same situation that they were in. In this instance, reflection seems to influence generative behaviors and actions.\u0026nbsp;\u003c/p\u003e\u003cp\u003eRecent research attributed positive outcomes collaborative reflective practices among breast cancer survivors (Mystakidou et al, 2006). For example, women in Hvidt (2017)’s study reported also reported that they have acquired a new language that reflects in their relationships to life and death in their day-to-day lives. The women concluded that they overcame death and gained power that they never knew was possible, and were living a courageous life. They changed their language and acted differently to improve their lives.\u0026nbsp;\u003c/p\u003e\u003cp\u003eThe impact of collaborative reflection to activate generative behaviours and actions from others who are closely related to the survivors became evident. For example, the family members, co-workers, and community leaders who demonstrated altruistic values to nurture and care for the sick among them.Nzuza's (2016) study emphasized the significance of social support from families, with family members being responsible for all treatment decisions.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u0026nbsp;In Mohammadi et al.'s (2018) study, survivors' family members took on the responsibilities of the ill women and cared for their young children to shield them from experiencing depression or academic failure. These family members assisted with the children's school work, transportation to school, feeding, and all other related caregiving activities.\u0026nbsp;\u003c/p\u003e\u003cp\u003eBreast cancer management is increasingly transitioning to outpatient care in community settings, with family members often assuming the role of primary caregivers (Gabriel, 2017). For example, Ristevski et al (2020) employed yarning to collect data on breast cancer survivorship experiences and incorporated families of the survivors in the study. The outcome of the study yielded positive results by including the families of the survivors and showing appreciation since they are involved in the daily struggles of the breast cancer experience.\u003c/p\u003e\u003cp\u003eMoreover, Becker (2006) and Hodge et al. (1996) made adaptations to the use of yarning circles, by also involving family members to capture the stories of individuals diagnosed with cancer, both from patients and their families. Researchers observed an increased sense of bonding and empathy among participants, including both family members and patients heightened feelings of acceptance, self-worth, and connection when family members participated in these circles.\u0026nbsp;\u003c/p\u003e\u003cp\u003eIn the research conducted by Ginter and Braun (2019), it was revealed that the work environment has the potential to alleviate the stress experienced by breast cancer patients through support mechanisms. Among the twenty individual participants interviewed, positive experiences with co-workers and management support throughout their cancer journeys were reported. For instance, some participants' colleagues offered various forms of instrumental support. This included donating sick days to their sick colleagues, with co-workers even approaching the union leader to request approval for such donations. Additionally, co-workers took on certain tasks and created gift baskets for their ill colleagues.\u003c/p\u003e\u003cp\u003eFurthermore, participants highlighted acts of kindness from their colleagues, who continued to call and visit them throughout their post-diagnosis and post-treatment journey. In some instances, the sick colleague received their full salary during their absence from work for an entire year to aid in their recovery, and colleagues sometimes even purchased groceries for them when visiting (Bonsiu et al., 2016).\u003c/p\u003e"},{"header":" Summary of Findings and Conclusion","content":"\u003cp\u003eStudies have shown that stagnant-near death experience characterized with isolation, negative rumination as explained in Erickson (1982)’s model may be triggered by cancer experiences (Bellizzi, 2004; de Souza et al., 2021; Keesing et al., 2018; Klaeson \u0026amp; Beterton, 2016; Knaul et al., 2020; Lambert et al., 2020; Muzzatti et al., 2020; Perlman, 2003). Such experiences underscore cancer illness as an obstruction to the realization of generative experiences among those diagnosed during adulthood. A sense of stagnation can be undesirable to the quality of life of the survivors, since it poses a risk of developing a generative concern, by focusing on the disruptions caused by breast cancer experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the alternative approach that is grounded in a strength-based perspective, provided a new way of building strength for survivors to cope with the challenges of chronic illness. For example, the collaborative reflective inquiry model (Anderson, 1995), can facilitate a transition from a stagnant - death like experience into a renewed - generative individual experience among the survivor (Bonsui et al, 2019; Brooks, 2009; Chu et al, 2020; DeCicco, et al, 2010; Dominic et al, 2017; Goelitz, 2001; Goelitz 2007; Hvidt, 2017; Hodge et al., 1996; Ginter and Braun, 2019; Gripsrud et al., 2016; Mahommadi et al., 2018; Martino et al, 2022; Mcwilliam, et al., 1999; Nunstedt et al., 2017; Nzuza, 2016; Park et al, 2009; Santiparp et al., 2014; Serlin, 1996; Struthers \u0026amp; Eschiti, 2004; Ristevski et al, 2020; Tranchenberg, 2012).\u003c/p\u003e\n\u003cp\u003eThis contemporary perspective presents an alternative viewpoint of the impact of breast cancer as a catalyst to foster generative behaviors and actions. The collaborative reflective inquiry led to an emergence of new awareness, provided a platform for emotional disclosure, harnessed a creation of new shifts or changes in perspectives, and embraced the diversity of individual perceptions and points of views. Research has shown that through participation in collaborative reflective inquiry, women developed positive growth-like outcomes (Brooks, 2009; Chu et al, 2020;\u0026nbsp;Dominic et al, 2018). The creative writing intervention and shared reading (Nunstedt et al., 2017; Gripsrud et al., 2016; Santiparp et al., 2014) and dreaming and group dream work (Goelitz, 2001; Goelitz 2007; DeCicco, et al, 2010) helped women to shift their focus to live each day to its fullest by enjoying the things that were the most important to them, such as spending time to talk to their children, family, and friends more often (Bellizzi, 2004; Lechner, et al 2012; Goelitz, 2001, 2007; Targ \u0026amp;Levine, 2013). For instance, in her study (Hvidt, 2017) found that breast cancer survivors described their cancer trajectory as a transformative process that led to a new way of being in the world of the living. Within this perspective, the collaborative reflective practice showed the potential to create new possibilities (Nunstedt et al., 2017; Mcwilliam, et al., 1999; Santiparp et al., 2014; Serlin, 1996).\u003c/p\u003e\n\u003cp\u003eThe collaborative reflective practice created newness as self-agency, increased productivity, and actualized goals for the survivors to lead a meaningful life (Nunstedt et al., 2017; Mcwilliam, et al., 1999; Santiparp et al., 2014). In their study, Nunstedt et al (2017) found that collaborative reflective practice can heighten women’s understanding of breast cancer illness and develop trust in themselves as they gain control of their illness, and develop an ability to act in an empowered manner (Gripsrud et al., 2016).\u003c/p\u003e\n\u003cp\u003eThe collaborative reflective practice could inspire generative actions among survivors, from survivors’ families, co-workers, and communities (Becker, 2006; Bonsiu et al., 2016; Ginter \u0026amp; Braun, 2019; Haozous et al., 2010; Hodge et al., 1996; Mohammadi et al., 2018; Ristevski et al., 2020). The collaborative reflective practice could develop a sense of appreciation among survivors and those connected to them (Gripsrud et al., 2016; Goelitz, 2001; Goelitz 2007; Lyons \u0026amp; Pannier, 2014; Struthers \u0026amp; Eschiti, 2004; Brooks, 2009; Hvidt, 2017; Martino et al, 2022; Mcwilliam, et al., 1999).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEven though there is a small scale of research, its contribution is compelling enough not be dismissed. The growth orientation is still at its infancy level, however, there is potential room for growth, and can improve the quality of life, by enhancing productivity and generative actions among breast cancer survivors. What is missing from the review is the limited amount of research from\u0026nbsp;psychological literature on the use of collaborative reflective practices as interventions in cancer survivorship. Studies that incorporated dreaming, and journaling (Goelitz, 2001; Goelitz 2007; DeCisso et al, 2010; Serlin, 1996) were the only studies from a psychological perspective, and were grounded on humanistic existential orientation within the psychological field (Goelitz, 2001; Goelitz 2007; DeCicco, et al, 2010).\u003c/p\u003e\n\u003cp\u003eThe majority of studies on collaborative reflective inquiry in breast cancer were conducted within the field of nursing. For example, studies on creative writing, reflective dialogue (group processes), and the quality of life (Nunstedt et al., 2017; Mcwilliam, et al., 1999; Santiparp et al., 2014;\u0026nbsp;Mahommadi et al. 2018).) were conducted from the medical and healthcare perspective.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications and future recommendation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch has shown that breast cancer survivors may live longer when they experience a renewed self-agency, have gained control over their lives and their abilities to act has been restored in an empowered manner. The collaborative reflective practice can create new possibilities for the survivors to live afresh. The main themes identified in the literature showed that collaborative reflective practice can inspire generative actions among survivors, from survivors’ families, co-workers, and communities. The collaborative reflective practice can unleash hidden power, can serve as an outlet of emotional disclosure, and can develop a sense of appreciation among survivors and those connected to them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on the findings of the review, it is recommended that clinicians should consider developing psychosocial interventions for breast cancer survivors from a growth-based orientation. When serving a multi-ethnic population group in non-western cultures, the collaborative reflective practice can address their unique needs and allow them to identify solutions that are relevant to their contextual backgrounds.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe need for ethics approval and consent was waived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe manuscript contained secondary information from the primary research and therefore consent for publication was waived.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe manuscript includes secondary data since it is a review, and data availability was stated in the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no conflicts of interest regarding the publication of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work is based on research supported by the National Institute for the Humanities and Social Sciences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr M. Lekeka was the major contributor in writing the manuscript, she read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAkkaya, N., Atalay, N.S., Selcuk, S.T., Akkaya, S. and Ardı\u0026ccedil;, F. (2011) Impact of Body Image on Quality of Life and Mood in Mastectomized Patients and Amputees in Turkey. Asian Pacific Journal of Cancer Prevention, 12, 2669-2673.\u003c/li\u003e\n \u003cli\u003eAndersen, T. (1995). Reflecting processes: Act of informing and forming: You can borrow my eyes, but you must not take them away from me. In S. Friedman (Ed.), The Reflecting Team in Action: Collaborative Practice in Theory (pp. 11-37). New York: Guilford Press.\u003c/li\u003e\n \u003cli\u003eBoyle, C.C., Stanton, A.L., Ganz, P.A., \u0026amp; Bower, J.E. (2017). Posttraumatic growth in breast cancer survivors: Does age matter. Psychooncology. 26(6): 800\u0026ndash;807. doi:10.1002/pon.4091\u003c/li\u003e\n \u003cli\u003eHvidt, E. H. 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London, UK: Constable.\u003c/li\u003e\n \u003cli\u003ePerlman, M. I. (1998). Age, developmental stage, and psychological distress in breast cancer patients. Unpublished doctoral dissertation. Northwestern University, IL\u003c/li\u003e\n \u003cli\u003eKeesing, S., Rosenwax, L., \u0026amp; McNamara, B. (2018) The implications of women\u0026rsquo;s activity limitations and role disruptions during breast cancer survivorship. Women\u0026rsquo;s Health. Volume 14: 1\u0026ndash;11. DOI: 10.1177/1745505718756381\u003c/li\u003e\n \u003cli\u003eBecker L. Working with groups. Cape Town: Oxford University Press; 2005.\u003c/li\u003e\n \u003cli\u003eHodge F, Cadogan M, Itty TL, Williams A, Finney A. (2016). Culture-broker and medical decoder: contributions of American Indian cancer caregivers in cancer pain management. J Community Support Oncol 2016; 14(5):221-228\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"breast cancer psychosocial interventions, collaborative reflective practice, external dialogue, transformation, generative actions, renewed goals, and the quality of life among breast cancer survivors. ","lastPublishedDoi":"10.21203/rs.3.rs-5550232/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5550232/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eErikson\u0026rsquo;s theory provides a broad framework from which to view development throughout the entire lifespan. For instance, with specific reference to Erickson's theory\u0026rsquo;s in stage 7, namely, generative versus stagnation stage. It is a stage in which individuals are focused on creating or nurturing ideas and projects that may contribute to building a legacy. However, when one fails to become generative, one may emerge with a sense of inadequacy and become stagnant in that aspect of development. For example, those adults who are confronted with life-threatening diseases such as breast cancer may fall short in fulfilling the requirements of stage 7 of the Erikson model due to the illness.\u003c/p\u003e \u003cp\u003eBreast cancer can pose a conflict on one\u0026rsquo;s development, and cause a disruption that may lead to stagnation. However, through engaging in collaborative reflective practice, breast cancer can become a catalyst for one to gain momentum to successfully transition into another stage of development. This review paper sought to explore the usefulness of collaborative reflective practice in fostering generative actions and increasing the quality of life among breast cancer survivors.\u003c/p\u003e \u003cp\u003eThe Prisma framework was utilized to select studies that suggest that the experience of breast cancer can foster generative behaviors and actions among cancer survivors. 20 Studies were analyzed using thematic analysis.\u003c/p\u003e \u003cp\u003eCollaborative reflection can create newness as self-agency, increased productivity, and actualized goals for the survivors to lead meaningful lives. The collaborative reflective practice can develop a sense of trust in the survivors to gain control of their illness and develop an ability to act in an empowered manner.\u003c/p\u003e","manuscriptTitle":"Exploring the usefulness of collaborative reflective practice in fostering generative actions among breast cancer survivors: A reviewed literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-04 16:00:37","doi":"10.21203/rs.3.rs-5550232/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f0fd8bbb-5f31-460c-a713-ce7cd58f73cb","owner":[],"postedDate":"December 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":41122060,"name":"Psychology"}],"tags":[],"updatedAt":"2024-12-04T16:00:37+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-04 16:00:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5550232","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5550232","identity":"rs-5550232","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}