Navigating emotional and professional challenges: Israeli nurses' experiences in breast cancer surgery preparation.

Background
Breast cancer (BC) is a prevalent disease among women, often accompanied by significant distress, notably prior to breast surgery [1–3]. Although nurses are well positioned to deliver interventions that reduce preoperative anxiety and improve patient outcomes, their specific role in this context remains informal and unstandardized, especially in Israel [4–6]. As this area has received limited research attention, a qualitative exploration of Israeli nurses’ experiences in preparing patients for BC surgery is essential for improving training, clinical practices, and patient outcomes, as well as addressing nurses’ professional and emotional needs.

Breast cancer
Cancer is a complex and often life-threatening disease that affects millions of people worldwide. Particularly, BC is one of the most common cancers worldwide, affecting one in eight women [1]. In 2022, approximately 5500 new cases of BC were diagnosed in Israel, and about 1100 women died from the disease, accounting for around 18% of all cancer-related deaths among Israeli women [7].
Although approximately 40% of women with early-stage BC eventually develop metastatic disease [8], advances in early detection and treatment have significantly improved survival rates [9, 10]. These advancements have enabled more effective management of early-stage BC, which is typically treated with localized therapies, such as radiation and surgery, in 90% of women diagnosed with the disease (Trayes and Cokenakes [3]).

Breast surgery and preoperative distress
Breast surgery plays a central role in the management of early-stage BC, typically involving either a lumpectomy – removal of the tumor and some surrounding tissue – or a mastectomy, which involves removal of the entire breast [3]. The surgical choice is influenced by factors such as tumor size, location, and patient preference, with the multifaceted goal of removing cancerous tissue while preserving the patient’s quality of life. As it is highly recommended that surgery be scheduled within weeks following BC diagnosis to avoid delays that could compromise survival [11, 12], many women find themselves grappling with the emotional distress triggered by both the diagnosis and the implications of breast surgery [2].
BC surgeries are particularly associated with significant preoperative anxiety, which can persist into the early postoperative period [13]. This anxiety is often accompanied by fear, uncertainty, demoralization, a sense of loss of control, and concerns about the potential impact of the disease and surgery on well-being, recovery, and survival [14]. Breast surgery tends to heighten emotional distress among women with BC and is associated with additional concerns about body image, loss of femininity, and the implications for intimate relationships [15, 16]. Consistent with this, a study in Turkey found that women after mastectomy experienced higher levels of depression, sexual problems, and relationship difficulties compared to those who had a hysterectomy – the surgical removal of the uterus [17].
Although low to moderate levels of anxiety can help patients cope effectively with anticipated surgery, high levels of preoperative anxiety may have detrimental effects on both mental and physical health [18]. Elevated stress levels have been associated with various physiological responses, including neuroendocrine, immune, and inflammatory responses, that may hinder recovery and have been linked in some studies to cancer progression and metastasis [19, 20]. Furthermore, these stress-associated responses have been linked to increased anesthetic requirements, prolonged hospitalization, and intensified postoperative pain and medication use [18].

Breast cancer nursing in the perioperative period

Evolution of oncology nursing
Oncology nurses play a vital role across the cancer care continuum, from screening and education to symptom management and end-of-life care, especially as care shifts increasingly to outpatient settings [21–23]. Their role has become more specialized across various types of cancer, including involvement in clinical trials and diverse care environments [24].
The evolution in BC care, in particular, has led to the emergence of the breast cancer nurse (BCN) role, first introduced in the UK in the 1980s and later adopted in countries like Sweden, the Netherlands, Australia, and the USA, though definitions vary [25]. Initially focused on emotional support, the BCN role has expanded to include integrated clinical and coordination responsibilities, along with patient education, psychosocial counseling, and participation in BC-related multidisciplinary teams [26]. In contrast, Dopelt et al. [6] highlighted the lack of a clearly defined role for oncology clinical nurses in Israel, including BCNs, pointing to status conflicts between professional unions that hinder effective collaboration and negatively impact patient outcomes.

Breast cancer nursing in Israel
While international studies provide valuable perspectives, Israeli BCNs’ experiences in preparing women for breast surgery remain unexplored. Cultural contexts shape patient experiences and the need for psychological support. Hebi et al. [27] found cultural differences between Arab and Jewish Israeli BC survivors, with Arab participants reporting higher depression, fatigue, and pain levels, along with stronger conservative values and coping styles shaped by collectivist and religious norms. These findings point to the value of culturally tailored psychosocial interventions, particularly in a society marked by significant ethnic diversity and demographic change [28]. However, capturing this diversity requires samples that include participants from varied cultural and demographic backgrounds.
Given conservative cultural values prevalent in some populations within the Israeli society and BC’s connection to identity, body image, and sexuality, the predominantly female nursing workforce [29] may offer advantages in helping female patients feel comfortable during intimate care [30, 31]. At the same time, the increased BC risk among female nurses [32–34] has been associated with stronger emotional identification with patients and greater vulnerability.

Challenges in oncology and perioperative nursing
Oncology nurses are increasingly facing growing demands, staff shortages, burnout, emotional labor, and compassion fatigue, which negatively impact their well-being and work-life balance [35–38]. Qualitative studies worldwide identity challenges including time pressure [39], burnout and emotional distancing [40], feelings of guilt [41], and loneliness [42].
Research from other perioperative nursing contexts also provides key observations. Gonçalves et al. [43] found that Portuguese nurses preparing patients for elective surgery experienced significant systematic and emotional challenges, with psychological needs often overlooked due to time constraints and lack protocols. Lekens et al. [44] showed how nurse anesthetists navigate tensions between clinical efficiency and empathetic presence, leading to moral distress when institutional demands conflict with human-centered approaches.
While qualitative research has shed light on nurses’ challenges, its applicability to BCNs’ preoperative role remains limited. To date, only one study has explored BCNs’ preoperative experiences. Curak Sagdıç et al. [45] interviewed Turkish nurses caring for mastectomy patients who described emotional distress related to patients’ anxiety, fear, and vulnerability, particularly among younger women and mother concerned about body image. They often felt inadequate in addressing these emotional and psychosocial needs, with stress from anticipating postoperative complications and managing staffing shortages further complicating the provision of holistic preoperative care.
This limited research reveals the complex emotional and professional challenges that BCNs face when preparing patients for breast surgery, emphasizing the need to better understand their experiences to develop appropriate support and training programs.

The critical role of breast cancer nurses
In perioperative care, breast cancer nurses (BCNs) play a critical role by providing both clinical and emotional support throughout the surgical journey, with evidence showing that they effectively deliver psychological interventions through empathetic, person-centered care [5]. Despite the lack of global standardization, the core competencies of BCNs are well-recognized, with evidence showing that their support is associated with improved patient satisfaction, well-being, and quality of life, achieving outcomes comparable to those of mental health professionals [4, 46–48].
Understanding Israeli BCNs’ current practices and challenges in preparing patients for breast surgery may inform the design of effective preoperative nursing interventions, and may contribute to improving training, clinical practices, and patient care, while also addressing nurses’ professional and emotional needs. The complex emotional and psychological demands reported by these nurses, combined with the unique cultural context of Israeli healthcare, call for a deeper understanding of their lived experiences. Given the limited research on Israeli BCNs’ experiences in preoperative breast surgery preparation, this study employed a qualitative phenomenological approach to explore and understand these experiences. The methodology was designed to capture the depth and complexity of nurses’ lived experiences, providing insights that could inform future practice improvements, psychological support for nurses, and training programs that address both clinical competencies and emotional resilience.

Methods

Participants
We conducted a qualitative study exploring the experiences of oncological breast surgery coordinating nurses. Participants were recruited using snowball sampling, a nonprobability chain-referral technique suitable for accessing hard to reach professional populations. Initial recruitment was facilitated through the professional network of the fourth author, a breast surgeon and medical doctor. To mitigate potential power dynamics and perceived bias, we implemented several safeguards: The fourth author had no managerial or supervisory authority over any participants and did not approach nurses directly and was not involved in the interview process, data collection, or any direct interaction with participants. Initial contact was made solely through professional nursing networks, with potential participants receiving detailed information sheets. Nurses interested in participating were explicitly invited to contact the first and second authors directly, both medical psychologists with no clinical authority over participants, ensuring a clear separation between the recruiting surgeon and the research process. Participation was entirely voluntary, with explicit assurance of anonymity and no professional consequences for declining. Informed consent emphasized participants’ right to withdraw at any stage, and the snowball approach allowed participants to choose whether to refer colleagues, further reducing any sense of obligation.
We acknowledge that recruitment through a professional network introduces potential for selection bias and social desirability. However, the safeguards described above, combined with the diversity of hospitals represented (five major medical institutions) and the candid nature of participants’ accounts, including descriptions of challenges, uncertainties, and emotional strain, suggest that nurses felt comfortable sharing authentic experiences.
Each participant was interviewed and then asked to recommend one or two colleagues who met the inclusion criteria. Referred individuals who agreed to participate were subsequently interviewed. This process continued in iterative “waves” through four waves of recruitment until data saturation was reached after 11 interviews, defined operationally as the point at which no new themes or substantive insights emerged from additional interviews. At each wave, participants were requested to share the researchers’ contact information with colleagues who had relevant experience. This variant corresponds to linear or exponential discriminative snowball sampling, depending on whether seeds referred only one or multiple eligible participants per wave.
Prior to participation, potential participants were provided with information regarding the study once their compatibility with the inclusion criteria was confirmed. The inclusion criteria were (1) Israeli and Hebrew-speaking; (2) registered nurse; (3) currently employed in a breast cancer surgical unit at a hospital in Israel; and (4) with experience in preparing patients for breast cancer surgery.
Eleven female nurses, working in five different major hospitals, all married, ranging in age from 40 to 77 years (average age, 54) and meeting the inclusion criteria, were interviewed (see Table 1 for participant characteristics). All participants identified as Jewish Israelis based on self-identification during recruitment screening. To ensure anonymity, identifying information was excluded from the transcripts. Participants are identified throughout the manuscript using numerical codes (P1–P11) that correspond to Table 1. Quotes were translated from Hebrew into English by the last author, a native speaker of Hebrew with proficiency in English. All translations were reviewed and approved by all authors, who are native Hebrew speakers and proficient in English, through collaborative discussions to ensure meaning preservation. Where necessary, bracketed clarifications were added to maintain cultural and contextual nuances. Back-translation was not performed; instead, the bilingual research team employed consensus-based verification to minimize meaning loss.

Data collection
Participants were interviewed by the second author, a female graduate student in medical psychology with experience in conducting and analyzing qualitative interviews. The interviews were semi-structured and took place between April and July 2024 (see Table 2 for interview guide). The interviews were conducted by the second author one-on-one via the Zoom video-conferencing platform to accommodate participants’ schedules and ensure their comfort. All interviews were audio-recorded with participants’ permission. Interviews ranged from 45 to 70 minutes (50 minutes in average). A general opening question was used at the start of each interview regarding their training as a nurse. Subsequent questions included follow-up, exploratory, and open-ended questions, such as: “Tell me about your experience when preparing a patient for a mastectomy or lumpectomy?” and “Are there specific topics that you feel are important to address during the preparation meeting?”.

Data analysis
Data analysis was performed by the first, second, and last authors using Braun and Clarke’s method for reflexive thematic analysis [49, 50]. This method is well-established for the analysis of qualitative data and consists of six iterative steps: (1) becoming familiar with the data; (2) generating codes; (3) generating themes; (4) reviewing themes; (5) defining themes; and (6) choosing exemplars [49]. While these steps offer structure, the depth of the analysis stems from reflexive engagement with the data, focusing on identifying patterns of meaning that capture significant aspects of participants’ experiences, rather than aiming for thematic consensus or representativeness [50].
The interviews were transcribed by the second author within 48 hours of each interview. Following transcription, the first, second, and last authors engaged in repeated readings of the transcripts to become deeply familiar with the content. Initial coding was performed independently by each researcher for each transcript, generating descriptive codes that captured semantic and latent meaning within participants’ accounts. For example, when participants described learning their role without formal preparation, codes such as “self-taught,” “learning by doing,” “no training,” and “creating materials” were generated. Codes were subsequently compared and discussed in team meetings before being organized into broader conceptual categories. For instance, the codes mentioned above, along with “building the role” and “no protocol”, were grouped into the broader category of “informal role development,” which ultimately contributed to the theme “Lack of Protocol”.
The coding process was collaborative and iterative, with the research team engaging in regular discussions to compare interpretations, refine codes, and build shared understanding through reflexive dialogue. Throughout analysis, team members engaged in regular discussions documenting emerging patterns, interpretive decisions, and questions arising from the data.
Candidate themes were iteratively refined through multiple rounds of review, during which the team assessed whether themes were internally coherent (i.e., data within each theme fit together meaningfully) and externally distinct (i.e., themes were clearly differentiated from one another). This process involved returning to raw data to verify that interpretations remained grounded in participants’ accounts and checking theme coherence by examining whether the narrative within each theme told a convincing story. These categories served as the foundation for developing candidate themes. The analytical process was iterative and reflexive, with regular team discussions aimed at critically examining interpretations, refining theme definitions, and challenging underlying assumptions. This collaborative reflexivity was central to ensuring a nuanced and theoretically informed interpretation of the data. The final analysis yielded a set of themes and sub-themes, accompanied by detailed descriptions and representative data extracts that exemplify each sub-theme.

Researcher reflexivity
Following Braun and Clarke’s [50] perspective, we recognize that meaning in qualitative research is actively constructed through interpretation rather than simply discovered within the data. This process is inherently contextual and subjective, shaped by researchers’ backgrounds and experiences. To enhance the rigor of our findings, we applied principles of trustworthiness, including credibility, transferability, and dependability.
The research team comprises individuals with diverse but complementary expertise. The first and last authors (TH-M, AG-L) are experienced medical psychologists with extensive backgrounds in qualitative research and clinical work with cancer patients. The second author (SB), a graduate student in medical psychology, conducted all interviews. The third author (TM), a graduate student in medical psychology at the time of the study, contributed to data validation and manuscript preparation. The fourth author (SW) is a breast surgeon contributed to the visualization and conceptualization form her experience working with both breast cancer patients and nurses in general and her perceptions of the nurses’ roles.
We were particularly attentive to the power dynamics inherent in having a graduate student conducting interviews with experienced clinical specialists. We recognized that this dynamic could influence the depth and nature of participants’ responses, potentially leading them to simplify explanations or modify their accounts. To mitigate this, the interviewer emphasized at the outset of each interview that she was there to learn from participants’ expertise, positioned herself as genuinely curious about their experiences, and used follow-up questions to encourage indepth and elaboration. The collaborative analytical process, involving senior researchers with extensive clinical experience, helped ensure that interpretations honored the complexity of participants’ accounts and that the graduate student’s relative lack of clinical experience did not limit analytical depth.
Throughout the research process, the team engaged in reflexive practice through regular analytical meetings where interpretations were discussed, challenged, and refined. We remained mindful that our collective experience with cancer patients, while providing valuable context, could also introduce interpretive assumptions, and we actively worked to ground our analysis in participants’ own words and meanings.

Findings
Four interconnected themes emerged that characterize the nurses’ experiences in preparing patients for breast surgery. These themes reveal the complex nature of their role, highlighting both professional challenges and sources of meaning in their work.

First theme: lack of protocol
This first theme emerged from participants’ repeated descriptions of entering their roles without formal preparation, creating their own materials, and learning through trial and error. Through all interviews, nurses consistently emphasized the absence of standardized protocols and institutional guidance, framing this as a defining characteristic of their professional experience.
Most participants described entering their roles without formal training beyond basic nursing education, learning instead through direct patient interaction, peer consultation, and self-directed study. As P1 explained: “I must mention that I had no formal preparation or training … I learned it on my own, from our social worker … I began to understand the experience of the women, got to know the patients, and asked them, ‘What is important for you to know? What is right for you to know?’” Several participants emphasized their role in independently creating the structure and materials for their position. P4 described: “I was the one who created the pre-surgery process, I developed the explanatory handouts, the post-surgery follow-up phone calls, and even organized screening exams for the staff … learning the field as I go. Before I came, this position didn’t exist.” Even the one participant who received formal oncology training emphasized that “most of the learning comes from the patients themselves” (P7).
The nurses’ accounts reflect their perception that they needed to create educational materials and define and give meaning to a role that, in many cases they reported, did not exist before their arrival. Even the participant who received more structured training emphasized the importance of informal learning through peer collaboration and patient interaction.
Across participants’ accounts, this absence of formal preparation emerges as a defining feature of their experience, one that created both challenges and opportunities. While nurses described uncertainty and the burden of self-teaching, they also valued the flexibility to develop approaches tailored to individual patients’ needs. This tension between institutional absence and individual agency runs through their descriptions of role development.

Second theme: dual role perception
This theme was derived from participants’ consistent descriptions of navigating two distinct but interrelated responsibilities. Analysis revealed a pattern in which nurses described moving fluidly between technical information delivery and emotional assessment, with the latter often taking precedence in their decision-making about what and how much information to share. The interviewees’ accounts revealed a dual perception of their role: providing patients with medical and technical information, while also assessing and addressing emotional needs and reducing anxiety.
Information management: Tailoring information for each patient. While participants reported that they rely on structured materials and standardized medical information to guide preoperative consultations, they described consistently adapting their approach to meet each woman’s unique emotional state, questions, and coping style. Participants described this balance between delivering essential clinical content and responding sensitively to a patient’s psychological needs reflecting the complexity of the role.
Most participants described using structured “handouts” and standardized information to cover essential medical content, while simultaneously adapting their approach to each patient’s emotional state and questions. “It’s important to me that a woman leaves knowing exactly what will be done.”, says P7, referring to the “technical part” – the medical preparation for the surgery, hospitalization, procedures. However, participants emphasized tailoring their delivery to individual needs, as P8 described: “there isn’t a single fixed script that I follow … I really tailor it to the patient who is in front me and what is most functional for her, adapting the meeting to the individual patient.”
Emotional requirements: Emotional assessment of patient state of mind. The interviews highlight participants’ emphasis on emotionally attuned care, where they described constantly switching between providing essential information and responding to the need to protect patients from emotional overwhelm.
P5 outlines the dual nature of her job: “The experience is divided into a technical part and an emotional part. The technical part involves covering what to do before surgery and during surgery. The emotional part is truly about listening. The preparation depends heavily on how the woman responds”. Subsequently, she describes what this emotional part means to her: “I pay close attention to her body language, notice every sign, and then I might pause, ask again, or if she starts crying, I give her space for that”. P4’s description was similar, emphasizing balancing the “technical side” with what the women are “capable of hearing”. P3, P7, P8, and P10, spoke of how they “observe” and “make an assessment” during the conversation with each woman, and described deciding accordingly how much information to give based on their judgment of the patient’s emotional capacity. P11 summarized her approach by saying: “I absolutely do not overload them with information.”
While they reported recognizing the need to provide medical information, participants described feeling felt they should make accommodations according to their subjective assessment of the patient’s emotional state of mind. Participants described how their duty to give information was mediated by their sense of duty to relieve and ease the patients emotionally.
The goal is to avoid overwhelming: A strong need to reduce anxiety and provide reassurances and support. Beyond their clinical responsibilities, the nurses emphasized an underlying goal they identified as central to their practice: a guiding principle they described in their work was to avoid emotional overload of the patient. They described a range of intuitive strategies they perceived as intuitive – managing and simplifying information or, in their judgment, sometimes withholding it altogether when they felt it was necessary for the patient’s emotional well-being – to help each woman feel less overwhelmed.
Participants consistently described their intention to ease patients’ emotional burden and create a sense of reassurance. This was evident in sentences like: “I really do everything I can to somehow ease her burden, that’s my intention.” (P5); “To lighten the atmosphere, to show them that it’s not all dark and not all terrible.” (P10); “I try to focus on the positive side.” “The goal is to create a sense of optimism in the room” (P2). This focus on reducing anxiety and maintaining hope was a central principle across participants’ accounts.
These accounts reveal participants’ experiences of the emotional and professional complexity of the role, which they described as requiring them to assess each patient’s psychological state, filter and tailor essential medical information accordingly, and offer individualized support, all without having received adequate training in emotional care, which they reported often left them feeling unprepared and mentally burdened, as will be described in the following themes.
The nurses’ descriptions demonstrate a consistent pattern: medical information delivery was consistently mediated by their subjective assessment of each patient’s emotional capacity. While participants framed this as patient-centered care, their accounts also reveal the substantial discretionary power they exercised in determining what information patients received and when - decisions made without standardized guidelines or training in psychological assessment.

Third theme: deep personal engagement
This theme emerged from participants’ frequent and often unprompted references to personal experiences with illness, caregiving, and loss. The analysis identified a pattern in which nurses explicitly connected their professional approaches to their personal histories, describing how these experiences informed their empathy and shaped their interactions with patients. A central theme emerging from the interviews is the deep personal engagement participants described bringing to their role, which they reported was shaped by both past experiences and emotional identification with their patients.
Relying on personal experience. Many participants drew upon significant personal experiences - such as caring for relatives with breast cancer, facing their own illness, or navigating other life crises - as sources of empathy and connection with patients. Some openly shared these experiences with patients to offer comfort.
P1, who was diagnosed with breast cancer herself, described using self-disclose: “I’ve been there. Sometimes I even share that with patients, like “I once had a patient …”, and then I bring up something from my own experience.” P7 also noted on the impact of personal sharing: “The moment I shared that I had also been through it, you wouldn’t believe the relief it brought to the patient.”
Identification. Many participants expressed a strong sense of identification with their patients, both professionally and as women sharing similar concerns. Participants described how they identified with each patient’s pain, anxiety, or hopes. They reported that for some, this identification was instinctive and emotional, while for others, it was conscious and deliberate.
P3 described a recurrent notion, several over participants shared: “But, overall, I strongly identify with the patients, first and foremost.” Some stated they identified with the patients as women, as P4 noted: “For a woman, it’s our body image, it’s our aesthetics, it’s our sexuality. It’s hard – very hard.” This gendered identification sometimes extended to specific patients, with one participant describing how she felt the same urgency as a patient awaiting surgery.
Some described specific patients they personally identified with. P7 spoke of a woman whose disease was progressed and described identifying with her: “I felt that I wanted the surgery to happen already, just like the patient did, I felt the same way.”
Together, these accounts demonstrate participants’ descriptions of how personal history and emotional resonance become an integral part of their caregiving, blurring the boundaries between the professional and what they perceive as the personal, thereby shaping the nature of the support they offered.
Participants’ reliance on personal experience and identification with patients appeared to serve dual functions in their accounts: it deepened empathy and connection, while also potentially intensifying emotional vulnerability. The boundary blurring they described - between their own experiences and those of their patients - emerged as both a source of therapeutic connection and a potential risk factor for emotional burden, particularly in the absence of formal support structures to help them process these identifications.

Fourth theme: role impact, emotional toll, and a sense of meaning
This final theme was constructed from participants’ accounts of the consequences of their deep engagement with patients. Analysis revealed a tension between the emotional burden nurses experienced - manifested in difficulty maintaining boundaries, carrying work home, and experiencing vicarious trauma - and the profound meaning they derived from supporting women through a vulnerable time. This duality appeared consistently across interviews, suggesting it is integral to the BCN experience. The participants described the effects of the emotional aspects and intensity of their role, highlighting both its personal cost and deep sense of purpose.
Emotional toll due to identification and reactivation of personal trauma. Many participants described the emotional strain they experienced when their work evoked personal memories or triggers deep identification with patients. Specifically, when they reported that encounters with young women stirred strong emotional reactions, sometimes leading to reactivation of past trauma or personal loss. P5 explained being “sensitive to” younger women “because they often have young families with small children.” Some participants described how specific encounters reactivated personal trauma: As P4 shared: “My mother passed away from cancer … So, yes, I think this is where I’m somewhat involved, but also keeping a certain distance” (P4).
Emotional toll due to blurring of boundaries: At work and between work and home. Participants described the mental toll they experienced from transitioning quickly between emotionally charged meetings, the difficulty they reported of “switching off” after intense sessions, and the way they perceived that their care responsibilities extended beyond formal working hours. Whether by taking calls late at night, offering continued emotional support after hours, or struggling to contain their own exhaustion, the nurses’ accounts reflect the deep personal cost of their commitment. P4 described the cumulative impact: “It’s exhausting and emotionally demanding, and the meetings can be very long … it can be draining, and then I have to move on to the next woman, so it’s intense”.
A recurring pattern in the interviews was the participants’ descriptions of blurring boundaries between work and personal life. Many nurses spoke of what they described as taking emotional and practical aspects of their role beyond clinic hours, answering calls late at night, and continuing support long after official sessions ended. P1, P3, P7, and P8, described learning over time to establish clearer boundaries: as P3 explained: “At first, I used to take a lot of work home with me, and I also allowed patients to call me … Nowadays, I’m more distant.”
While participants described their commitment as reflecting deep care and dedication, they also reported that it created tensions around personal limits, self-care, and personal well-being. Participants noted that for some, the lack of boundaries they experienced led to burnout or emotional exhaustion, while others described learning, over time, to set clearer limits to protect their own well-being.
A sense of meaning – satisfaction versus frustration. Participants described the profound sense of meaning they derive from their role. Despite the challenges, feelings of fulfillment, purpose, and even strength emerged from their interviews.
Participants consistently emphasized that patient feedback and gratitude were central sources of meaning and motivation. P11 draws upon “the feedback” from the women: “I feel like I’ve done something good, something right. It gives me the ability and strength for the next time.” For P4, P7 and P5 fulfillment is derived when the women “thank me”. However, not all experiences were uniformly positive: “Feelings of satisfaction when I succeed, and frustration when I don’t.” (P1)
This final theme captures the fundamental tension running through participants’ accounts: deep professional meaning coexisting with significant emotional cost. The fulfillment nurses described appeared tightly linked to patient gratitude and perceived success, creating a reward structure dependent on external validation rather than institutional recognition or support. This pattern - where meaning-making relies heavily on individual patient interactions in the absence of formal role definition or organizational acknowledgment - may contribute to both the resilience and vulnerability evident in participants’ experiences.

Summary
The findings reveal four interconnected themes that characterize Israeli BCNs’ experiences in breast cancer surgery preparation: lack of formal protocols, dual role perception, deep personal engagement, and the tension between emotional toll and profound meaning.
These themes are deeply interrelated. The absence of formal protocols enabled personalized, patient-responsive care but also placed substantial responsibility on individual nurses to define their roles and make discretionary decisions about information delivery. Deep personal engagement enriches therapeutic connections while intensifying emotional vulnerability. Throughout, participants derived profound meaning from their work derived from the challenges they faced, relying on patient feedback as their primary source of professional validation in the absence of institutional recognition. Together, these themes reveal both the complexity and importance of their contribution to breast cancer care, while highlighting the need for greater institutional support and role clarity.

Discussion
This phenomenological study explored the lived experiences of BCNs in preparing women for breast surgery, revealing four interconnected themes that illuminate both the challenges and meaningful aspects of their professional role. The findings demonstrate a complex landscape in which nurses work without standardized protocols, navigate dual responsibilities of providing information and emotional support, engage deeply and personally with patients, and face emotional strain while finding profound professional meaning in their work.

Lack of protocol: the informal nature of preoperative preparation by BCNs
The central theme of this study is the absence of formal training protocols and standardized preparation procedures among Israeli BCNs. Participants consistently described learning their roles through trial and error, peer consultation, and direct patient interaction, often creating their own educational materials and independently defining their professional responsibilities. This observation aligns with international reports on the lack of global standardization in BCN roles [4, 5].
However, our findings reveal a distinct pattern of adaptive role construction in which nurses actively shaped their professional identities in response to perceived patient needs rather than institutional formal protocols. This bottom-up development, while demonstrating remarkable professional initiative and responsiveness, also raises critical questions about equity of care, consistency across settings, and the burden placed on individual practitioners to develop expertise without systematic support. The tension between the flexibility that enables personalized care and the risks of unstandardized practice represents a central challenge for the profession.
Our findings mirror those of Dopelt et al. [6], who identified the lack of clearly defined roles for oncology clinical nurses in Israel, attributing this to tensions between professional associations that hinder productive cooperation.
Drawing on Hardy and Conway’s (1988) adaptation of role theory to healthcare, the nurses in our study experienced role ambiguity—unclear expectations about their duties—while simultaneously engaging in role innovation by actively shaping their professional identities to meet observed needs. Their descriptions of “inventing and reinventing” their roles illustrate their function as “role pioneers,” crafting professional identities in response to patient demands rather than established protocols. Furthermore, the absence of formal protocols has enabled nurses to develop highly personalized, patient-centered approaches, resonating with Benner’s [51] concept of “practical wisdom”, where experienced nurses cultivate intuitive knowledge that resists standardization.
However, participants’ accounts suggest that this informal approach raises concerns about the burden placed on individual nurses to develop expertise without institutional support, as well as questions about consistency of care and potential for treatment biases. Moreover, the strong personal identification between predominantly female nurses and their female breast cancer patients may heighten the risk of unconscious biases influencing care delivery. Research shows that healthcare decisions can be affected by factors such as patient age and provider-patient identification [52], underscoring the need for systematic frameworks to ensure equitable care across diverse patient populations.

Dual role perception: balancing information and emotion
The second theme revealed how Israeli BCNs conceptualize their dual role as encompassing both information provision and emotional support, requiring constant adaptation to individual patients. Participants demonstrated sophisticated clinical judgment by tailoring the information they provided based on each patient’s emotional state, reflecting advanced skills developed through experience and emotional attunement. This individualization extended beyond adapting communication style to include making discretionary decisions about what medical information to withhold or modify based on subjective assessments of patients’ emotional capacity, a practice undertaken without standardized decision-making frameworks or formal training in psychological assessment. This raises important questions about the boundary between personalized care and potentially paternalistic gatekeeping of information that patients may have a right to receive. Consistent with our participants’ approaches, existing evidence suggests effective patient education requires individualized communication rather than standardized delivery [53, 54].
Additionally, participants identified avoiding patient overwhelm emerged as a central guiding principle, describing how they frequently made real-time decisions to withhold or modify information based on their assessment of each patient’s emotional capacity. This approach is supported by research showing significant individual variation among cancer patients in their preferences for the amount and timing of information received [55].
Balint’s [56] three-level model of the therapeutic relationship provides a useful framework for understanding this multifaceted role, distinguishing between the physiological level (information provision), the psychological level (emotional support), and the dynamic level (complex relational processes involving empathy, identification, and mutual emotional influence). This framework highlights the emotional labor and reflective engagement required of nurses, and helps explain why informal, personalized approaches naturally arise in the absence of rigid protocols.
Furthermore, participants’ descriptions of the dual nature of the BCN role aligns with the concept of the “therapeutic use of self,” where nurses consciously employ their personal qualities, communication skills, and emotional presence as integral tools for care [57]. Our participants exemplified this by using self-disclosure, reassurance, and emotional presence with the intention of creating a supportive, healing environments for their patients.

Deep personal engagement: the integration of professional and personal
The third theme illuminated how Israeli BCNs draw extensively on personal experiences and maintain strong emotional identification with their patients. This finding reveals the profound human dimension of BC nursing, where professional competence is enhanced by personal experience and emotional resonance. This deep integration of personal and professional raises critical questions about boundaries, sustainability, and the potential for vicarious traumatization. While participants’ reliance on personal experience was perceived as enriching empathetic connection, it also intensified emotional vulnerability, particularly in the absence of formal support structures to help nurses process these identifications and maintain psychological well-being. The pattern suggests a profession that depends heavily on practitioners’ personal emotional resources without providing systematic mechanisms to replenish them.
Many participants described using their own experiences of illness, caregiving, or crisis as sources of empathy and insight in their practice. Participants’ accounts aligns with research on the concept of wounded healers in healthcare, suggesting that personal experience of suffering can deepen practitioners’ capacity to provide meaningful support [58]. However, our findings also highlight potential risks of this approach, including increased emotional labor and challenges in maintaining professional boundaries.
The high level of identification with patients—particularly as women confronting threats to femininity and body image after breast surgery—reflects the gendered nature of breast cancer care. This finding is consistent with prior research suggesting that same-gender healthcare providers may offer unique advantages in intimate care settings [30, 31]. However, it also highlights participants’ reports of heightened emotional vulnerability they experienced as female nurses caring for patients with conditions that resonated personally.
Participants’ descriptions of their approach reflects the concept of “connected knowing” [59], which involves understanding others through empathy and personal connection rather than detached observation. By drawing on their own feelings and experiences, the nurses employed an empathetic approach intended to develop strong therapeutic relationships and emotionally attuned support.
Notably, the use of self-disclosure as a therapeutic intervention emerged as a complex strategy with both benefits and risks. While participants perceived that sharing personal experiences reduced patient anxiety and enhanced connection, this practice also blurred professional boundaries and potentially increased nurses’ emotional vulnerability. This finding points to the value of education and support around appropriate use of self-disclosure in oncology nursing.

Role impact: navigating emotional toll and meaning
The fourth theme captured the profound impact of BCN work on practitioners themselves, revealing both the costs and rewards of deep engagement in cancer care. This finding reflects the inherent tension in oncology nursing between the emotional demands of the work and the meaning derived from making a difference in patients’ lives. Critically, our findings reveal that the meaning participants derived from their work was tightly coupled with patient gratitude and perceived success rather than institutional recognition or systemic support. This dependence on external validation creates a precarious foundation for professional fulfillment, leaving nurses vulnerable when patient outcomes are poor or gratitude is not forthcoming. The emotional economy of BCN work, as participants described it, appears structured around individual patient interactions rather than sustainable organizational support, a pattern that may contribute to both the deep satisfaction and significant burnout risk evident in their accounts.
The emotional toll described by participants manifests in several ways: reactivation of personal trauma, difficulty maintaining boundaries between work and personal life, and the cumulative effect of repeated exposure to patient distress. Participants’ descriptions of emotional toll align with extensive research on burnout and compassion fatigue in oncology nursing [35, 36]. The emotional demands identified in this study place BCNs at significant risk for compassion fatigue [60], particularly given the absence of formal support structures.
The blurring of work–life boundaries was particularly pronounced in our sample, with nurses frequently extending support beyond formal working hours and struggling to “switch off” emotionally after challenging encounters. Participants described a reduced capacity to listen attentively both at work and at home, illustrating the far-reaching effects of their professional emotional investment. Over time, participants described how this sustained strain may diminish their ability to empathize fully, potentially affecting both nurse well-being and the quality of patient care.
Despite these challenges, participants consistently described their work as meaningful and fulfilling, finding deep satisfaction in their ability to support women through a vulnerable and frightening journey. Participants’ accounts of finding meaning despite challenges resonate with research on meaning-making in nursing, which suggests that the ability to make a meaningful difference in patients’ lives can buffer against job stress and promote resilience [61].
These findings can be understood through several theoretical frameworks.
Role theory [62] explains how nurses navigate the ambiguity and complexity of their professional responsibilities in the absence of clear organizational guidelines. The concept of emotional labor (Hochschild, 1983) illuminates the sophisticated emotional work required of BCNs as they consciously manage their own emotional responses while providing psychological support to patients. Participants described continuously monitoring and regulating their emotions - suppressing distress when patients were suffering, maintaining optimism in the face of poor prognoses, and managing their own grief while supporting others. This sustained emotional performance, particularly without adequate organizational support, may contribute to emotional exhaustion.
The emotional demands identified in this study place BCNs at significant risk for compassion fatigue [60], defined as the profound emotional and physical exhaustion that develops from continuous exposure to others’ suffering. The reactivation of personal trauma, difficulty maintaining boundaries, and cumulative toll of repeated empathetic engagement are hallmark features of compassion fatigue, particularly given the absence of formal support structures in participants’ work environments.
While some participants described experiences reminiscent of moral distress [63], psychological suffering that occurs when one knows the ethically appropriate action but feels constrained from taking it - our findings suggest this was less pronounced than in other healthcare contexts. This may be because nurses’ ability to create autonomous roles aligned with their professional values reduced conflicts between personal ethics and institutional demands. However, the tension between wanting to provide comprehensive emotional support and facing time or resource constraints did create frustration for some participants.
Balint’s [56] three-level model of the therapeutic relationship encompassing physiological, psychological, and dynamic dimensions, provides a comprehensive framework for understanding the multi-level complexity of nurse-patient interactions. By simultaneously operating across all three levels (providing medical information, offering emotional support, and engaging in deep relational processes), BCNs experience a complexity of emotional engagement that is both enriching and exhausting, explaining why they experience such intense emotional responses.
The concept of caring as the essence of nursing [64] is evident throughout participants’ accounts of their deep engagement with patients and commitment to providing holistic support.

Implications and recommendations
The absence of standardized preoperative preparation protocols identified by participants represents both a challenge and an opportunity. Based on our findings, healthcare institutions may benefit from developing, formal training programs for Israeli BCNs that should incorporate evidence-based clinical knowledge about BC care and emotional support skills, emphasize tailoring communication to individual patient needs, and acknowledge the valuable role of personal experience while providing frameworks for appropriate self-disclosure and maintaining professional boundaries. Research demonstrates that structured interventions led by specialist cancer nurses can effectively improve patient outcomes and nurse competence [24, 26]. Educational programs that combine technical knowledge with communication skills training may address the gaps identified by participants while building on the strengths of their experiential learning.
Our findings suggest that healthcare may benefit from recognizing the emotional demands reported by BCNs and providing adequate support structures, including regular supervision, peer support groups, and clear policies on after-hours patient contact to protect work-life boundaries. Systematic reviews consistently identify organizational support as a key factor in reducing burnout and compassion fatigue among oncology nurses [35, 36, 38]. Interventions such as regular clinical supervision, peer support programs, and clear boundaries around after-hours contact have been associated with improved nurse well-being and job satisfaction [37]. Training should also include bias awareness components to ensure equitable care delivery across diverse patient populations. Particularly given evidence that healthcare decisions can be influenced by provider-patient identification and demographic factors [52].
It is important to note that our sample comprised exclusively Jewish Israeli nurses, limiting our ability to draw conclusions about the broader Israeli healthcare context, which is characterized by significant cultural and ethnic diversity [28]. The participants’ strong identification with patients and the personal approaches they described may reflect characteristics specific to this demographic group. The informal and flexible ways participants described developing their roles may reflect adaptation to systemic gaps in professional development. While participants reported that this supports personalized care, it also underscores the potential value of formalized training programs that are sensitive to the diverse cultural contexts in which BCNs practice.

Limitations and future research
Several limitations should be acknowledged, emerging from our methodology. The use of non-probability snowball sampling limits the representativeness of the sample and may have introduced selection bias, as participants who volunteered may differ systematically from those who did not.
A critical limitation is the homogeneity of our sample. All participants were Jewish Israeli women, and the sample lacked representation from diverse ethnic groups. This homogeneity sharply limits our ability to address the stated aim of exploring experiences within Israel’s diverse cultural context. The findings therefore reflect the experiences of a specific demographic group and cannot be generalized to the broader population of Israeli BCNs or to nurses working in Israel’s culturally diverse healthcare settings. Future research should prioritize recruiting participants from varied cultural, ethnic, and demographic backgrounds to more comprehensively capture the range of BCN experiences in Israel. Additionally, the sample was drawn from a single country with specific healthcare system characteristics, which limits the transferability of findings to other national contexts.
It is important to note that the study focused exclusively on nurses’ perspectives and did not include patient experiences or outcomes, limiting our ability to assess the impact of nurses’ practices on patient satisfaction or clinical results. Phenomenological approach, while providing rich insights into lived experience, limits generalizability to other populations or contexts. The sample was drawn from a single country with specific cultural and healthcare system characteristics, and reliance on self-reported experiences, which may be subject to social desirability bias or retrospective recall limitations.
Future research should develop and test standardized training protocols for BCNs, examine the effectiveness of different approaches to patient preparation, and investigate the role of self-disclosure in therapeutic relationships. Longitudinal studies tracking BCN career trajectories and well-being would provide insights into factors that promote resilience and prevent burnout. Mixed-methods studies incorporating patient perspectives would provide a more comprehensive understanding of the preparation process. Research should also examine organizational factors that support effective BCN practice and develop evidence-based support interventions to address compassion fatigue risks.

Conclusions
This study provides valuable insights into the lived experiences of Israeli BCNs in preparing women for breast surgery, revealing a complex landscape of challenges and rewards. The findings suggest the potential value of systematic approaches to BCN training and support while recognizing the valuable innovations participants described developing in the absence of formal protocols.
The deep personal engagement demonstrated in their accounts reflects both the caring tradition of nursing and the particular demands of cancer care. While participants described how this engagement enabled the provision of meaningful support to patients, it places significant emotional demands on practitioners that should be acknowledged and addressed through comprehensive organizational support systems.
These findings contribute to the growing body of knowledge about specialty nursing roles and may have implications for nursing education, clinical practice, and healthcare policy. Based on these findings and supported by existing literature, the development of comprehensive support systems, standardized training protocols, and bias-aware practice guidelines is recommended and may contribute to supporting both patient care quality and nurse well-being and job satisfaction in this critical area of healthcare.