Effectiveness of integrated nursing interventions in enhancing patient outcomes during postoperative intravesical instillation for non-muscle invasive bladder cancer: A comparative study

Abstract

This study aimed to investigate nursing strategies for patients with non-muscle invasive bladder cancer (NMIBC) undergoing postoperative intravesical instillation. We recruited 100 NMIBC patients from January 2017 to January 2022. Participants were randomly assigned to either the research group or the control group (n = 50 each) using random number tables. The control group received routine nursing interventions, while the research group received integrated nursing interventions. We compared and analyzed various parameters, including patient satisfaction, treatment compliance, General Self-Efficacy Scale (GSES) scores, core quality of life scale scores, bladder carcinoma specificity scale scores, disease coping scores, and the incidence of complications among patients undergoing instillation treatment. The research group exhibited significantly higher satisfaction scores and treatment compliance (P < .05). Additionally, GSES, Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) scores were significantly improved in the research group (P < .05). Scores on each dimension of the EORTC QLQ-C30 were higher (P < .05). The research group also had lower scores for post-nursing urinary system diseases, treatment problems, future worries, and intestinal symptoms in the QLQ-BLS24 score (P < .05). Furthermore, the research group experienced fewer postoperative complications (P < .05). Nursing interventions significantly enhance the outcomes of NMIBC patients undergoing intravesical instillation treatment. These interventions effectively improve treatment compliance, alleviate negative emotions, modify coping strategies, reduce the incidence of complications, and enhance overall nursing satisfaction.

1. Introduction

Bladder carcinoma stands out as the most prevalent tumor within the urinary system, carrying significant socioeconomic burdens and implications for mortality and morbidity. The World Health Organization ranks bladder cancer ninth among all malignant tumors, with a higher prevalence among men (sixth) than women (tenth).^[1–3] In China, the incidence of bladder cancer has been on the rise for a decade, albeit still lower than in Western developed countries.^[1–3]

Non-muscle invasive bladder cancer (NMIBC) represents the majority of bladder tumors, characterized by its early-stage nature and non-invasion of the detrusor muscle layer. Transurethral resection of bladder tumor (TURBT) serves as a diagnostic and potential therapeutic approach for NMIBC, although it carries certain limitations, including challenges in determining complete tumor resection after segmental resection and the risk of tumor re-implantation post-surgery. NMIBC exhibits suboptimal tumor control, with 1-year recurrence rates ranging from 15% to 61% and 5-year recurrence rates ranging from 31% to 78%.^[4–7]

Currently, the standard recommended treatment for NMIBC combines TURBT with intravesical instillation therapy. Postoperative intravesical chemotherapy is instrumental in reducing tumor recurrence rates and eliminating residual tumor cells during surgical intervention.^[8,9] However, intravesical instillation is a protracted process, often spanning several months to a year. Additionally, it entails frequent interventions in the early stages, involving repeated transurethral intubation of chemotherapy drugs and frequent cystoscopies. The side effects of chemotherapy drugs and the surgical stress involved can lead to the development of negative emotions.^[10] Notably, studies have reported that approximately 20% to 30% of cancer patients experience depression, sleep disturbances, low self-esteem, and personality changes, with around 23% of patients in later stages exhibiting symptoms such as loss of consciousness and hallucinations.^[11–13] Neglecting these negative emotions can lead to a cascade of physical and mental symptoms throughout the entire instillation treatment process, ultimately impacting treatment outcomes and quality of life.^[14] Furthermore, prior research has indicated that NMIBC patients with negative emotions exhibit low compliance with postoperative intravesical chemotherapy.^[15–18]

Relevant clinical studies have demonstrated the benefits of integrated nursing care in improving therapeutic outcomes. Collaboration among patients, their family members, medical staff, and the broader society is essential throughout the instillation treatment journey. While the integrated nursing model has shown promise in the care of NMIBC patients undergoing postoperative instillations, there remains a paucity of comprehensive studies in this domain. The promotion and application of this nursing model lack a robust theoretical foundation. In light of these considerations, further research in this area becomes imperative. In this prospective study, we recruited NMIBC patients undergoing intravesical instillations from January 2017 to January 2022. The subsequent sections present our findings.

2. Materials and methods

2.1. General information

This study received approval from the Ethics Committee of Xinhua Hospital, School of Medicine. From January 2017 to January 2022, the study enrolled NMIBC patients undergoing intravesical instillation. Inclusion criteria were as follows: Patients diagnosed with NMIBC through cystoscopy and pathological examination.^[19] Normal blood routine and biochemical indicators. Normal liver and kidney function. Healthy nutritional status. Patient consent for intravesical chemotherapy.

Exclusion criteria: Pregnant or breastfeeding patients; Patients with immune system diseases; Patients with other neoplastic diseases; Patients who cannot receive intravesical instillation therapy; and Patients with mental illness or communication difficulties.

To ensure the quality of nursing implementation, this study aimed to enroll a total of 100 NMIBC patients meeting the inclusion criteria. One hundred envelopes were prepared in advance, each containing group assignment information for either the control or experimental group, with 50 envelopes per group. These envelopes were sealed in a box. When eligible NMIBC patients were enrolled, one envelope was randomly drawn to assign the patient to either the control or experimental group, thus determining the subsequent nursing protocol.

The control group received routine nursing intervention, while the research group received comprehensive nursing intervention. All procedures conducted in this study adhered to the ethical standards of the Ethics Committee of our hospital and were in accordance with the 1964 Helsinki Declaration and its subsequent amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

In the control group, there were 30 men and 20 women with epithelial tumors, including 10 patients with carcinoma in situ and 90 patients with papillary carcinoma. In the research group, there were 29 men and 21 women with epithelial tumors, including 11 patients with carcinoma in situ and 89 patients with papillary carcinoma. There were no significant differences in basic information between the 2 groups (P > .05) (Table 1).

Table 1.

General information.

	Control group	Research group	P
Gender	30/20	29/21	>.05
Age	56.4 ± 3.6	56.7 ± 2.1	>.05
Pathological Pattern			>.05
Papillary Carcinoma	90	89
Carcinoma in Situ	10	11

The control group used the routine nursing method to nurse the patients receiving intravesical instillation therapy post-operation. Including: Intravesical Instillation Nursing: During the process of intravesical instillation, care should be taken to avoid damaging the urethral mucosa with the catheter. Local anesthesia with lidocaine can be used as needed to alleviate pain. Injecting 10 mL of air is recommended to prevent any medication residue in the ureter, thereby promoting better drug absorption. Observe the patient for symptoms such as increased urinary frequency, urgency, difficulty urinating, and fever. Post-Intravesical Instillation Treatment Nursing: Patients should rest appropriately in a supine position to ensure that the medication remains in the bladder for 2 hours. Guide patients to change their position every 15 minutes to ensure that the medication comes into full contact with the bladder mucosa, thus enhancing treatment efficacy. Instruct patients to maintain proper perineal hygiene, change underwear regularly, and avoid infection. Advise patients to drink an adequate amount of water, aiming for a daily urine output of 3000 mL for intravesical irrigation. During the treatment period, it is recommended that patients consume foods rich in vitamins, proteins, and high calories.

The research group used the integrated nursing mode to nurse the patients receiving postioerative intravesical instillation therapy. In addition to routine nursing care, ensure the accurate implementation of the recommendations for routine nursing care. Place particular emphasis on providing psychological counseling and nursing guidance during the treatment period and follow-up between instillations. Psychological intervention: Patients after TURBT were prone to anxiety, fear, and even reluctance to continue treatment. Nurses should actively communicate with patients, closely observe their psychological changes of patients, and actively intervene in their mental state of patients. Cognitive intervention: Health education is provided to patients according to the patients and the families’ awareness of the disease.

2.2. Observation index

All observational parameters were accurately documented by relevant healthcare professionals. During the data collection process, a blind assessment approach was employed, meaning that the professionals assessing post-injection outcomes were unaware of the specific group assignments. Observation index: The hospital’s self-made satisfaction questionnaire was adopted to assess the patients’ nursing satisfaction when the patients were discharged, including the care of the physical body, the receiving of information, the support of the individual, and respect for the individual; their treatment compliance was evaluated by nurses when the patient was discharged. The evaluation results could be divided into complete compliance (who could actively cooperate with the development of treatment work), and partial compliance (basically able to receive treatment in accordance). Treatment compliance rate = (complete compliance + partial compliance)/number of cases × 100%; The general self-efficacy scale (GSES)^[20] was adopted to assess the patients’ self-efficacy through 10 items. The full score was 40. The patients were evaluated by GSES at admission (before nursing) and after discharge (after nursing); Self-rating Anxiety Scale (SAS)^[21] was adopted to assess the anxiety of the patients: those with a total anxiety score of less than 50 were regarded as normal; those with a total anxiety score of 50 to 60 were regarded as mild, and those with a total anxiety score of 61 to 70 were regarded as moderate. Patients with a degree of anxiety above 70 were evaluated once at the time of admission (before nursing) and at the time of discharge (after nursing); Self-rating Depression Scale (SDS)^[22] was adopted to assess the depression of patients: those with a total anxiety score of less than 50 were regarded as normal; those with a total anxiety score of 50 to 60 were regarded as mild, and those with a total anxiety score of 61 to 70 were regarded as moderate. The degree of depression was above 70; the quality of life of cancer patients (EORTC QLQ-C30)^[23] and bladder tumor patients specificity scale (EORTC QLQ-BLS24)^[24] were evaluated. EORTCQLQ-C30 removed economic difficulties, retaining 5 functional areas (physical, role, cognitive, emotional, and social function). Patients were evaluated at admission (before nursing) and after discharge (after nursing). The EORTCQLQ-BLS24 scale included 4 items of urinary symptoms, treatment problems, future worries, and intestinal symptoms. The patients were evaluated at admission (before nursing) and after discharge (after nursing); Evaluation of coping style: medical coping questionnaire (MCMQ)^[25] was adopted to assess patients’ coping styles, which was divided into 3 dimensions: face, avoidance, and surrender, with full scores of 32, 28, and 20 respectively. A higher score means a better situation; The incidence of complications after instillations treatment (during hospitalization and within 1 month after discharge) was counted.

2.3. Statistical analysis

Statistical comparisons were performed using the statistical software package SPSS22.0 (IBM SPSS Inc., Chicago, USA). Percentages or numbers of cases [n (%)] were used to represent counting data, and the χ² test of the four-grid table was adopted to analyze the data. Normal distribution was derived by indicating the measurement data with ($\overline{x}$±s). For comparing between groups, an independent sample t test was adopted, and for comparing within groups, a paired sample t test was adopted. It was statistically remarkable that the difference existed (P < .05).

3. Results

3.1. Comparison of satisfaction scores

In the research group, patients demonstrated significantly higher levels of satisfaction in areas such as receiving information, support, respect, and the overall nursing process (P < .05). Table 2 presents a summary of the study’s findings.

Table 2.

The patient satisfaction scores ($\overline{x}$±s, n = 50).

Group	Body nursing	Accept information	Support	Respect	Nursing process
C Group	32.39 ± 4.28	18.33 ± 1.21	14.68 ± 2.37	10.81 ± 2.23	7.28 ± 1.53
R Group	41.42 ± 3.14	21.82 ± 2.01	16.32 ± 1.66	12.77 ± 1.39	10.81 ± 1.29
Cohen’s d	1.42	−3.537	−2.990	−3.45	−6.39
95% CI	−0.285 ± 0.845	−4.43 ± 0.664	−2.40 ± 0.536	−1.96 ± 0.568	−5.23 ± 0.938
t	12.029	10.458	4.008	5.274	12.472
P	<.05	<.05	<.05	<.05	<.05

3.2. Comparison of treatment compliance

The analysis of treatment compliance revealed that within the research group (Fig. 1), 33 patients exhibited complete compliance, 17 patients showed partial compliance, and there were no instances of noncompliance, resulting in a 100% compliance rate. In contrast, the control group had 16 patients with complete compliance, 26 with partial compliance, and 8 with noncompliance, resulting in an 84% compliance rate. When comparing the 2 groups, the research group exhibited a significantly higher rate of treatment compliance (P < .05). Table 2 provides a summary of the study’s findings.

Figure 1.

The treatment compliance.

3.3. Comparison of GSES, SAS, and SDS scores

Following nursing intervention, there was a significant increase in GSES scores and a decrease in both SAS and SDS scores. The magnitude of improvement in each of these scores was notably greater in the research group (P < .05). Table 3 provides a summary of the study’s findings.

Table 3.

GSES score, SAS score, and SDS score ($\overline{x}$±s, n = 50).

Group	GSES scoring (points)		SAS scoring (points)		SDS scoring (points)
	Before nursing	After nursing	Before nursing	After nursing	Before nursing	After nursing
C Group	28.32 ± 2.57	31.02 ± 2.27*	57.61 ± 7.23	49.32 ± 5.86*	59.76 ± 4.52	47.82 ± 4.26*
R Group	28.06 ± 2.42	35.47 ± 2.31†	57.34 ± 7.29	31.77 ± 3.26†	59.83 ± 5.63	34.66 ± 3.08†
Cohen’s d	0.104	−1.76	0.037	5.51	−0.01	4.76
95% CI	0.26 ± 0.545	−5.195 ± 1.275	−0.27 ± 0.205	17.55 ± 6.86	−0.07 ± 5.08	13.16 ± 5.43
t	0.521	9.716	0.186	18.506	0.069	17.702
P	>.05	<.05	>.05	<.05	>.05	<.05

The control group before and after nursing,

^*P < .05; the research group before and after nursing,

^†P < .05.

3.4. EORTC QLQ-C30 scores after nursing

There was no significant difference in the EORTC QLQ-C30 scores observed in patients who did not receive nursing care (P > .05). However, the scores for physical, role, cognitive, emotional, and social functions all showed improvement after nursing intervention. When comparing the 2 groups, it was evident that the EORTC QLQ-C30 scores of the research group were higher among those who received nursing intervention (P < .05). Table 4 provides a summary of the study’s findings.

Table 4.

EORTC QLQ-C30 scores before and after nursing ($\overline{x}$±s, n = 50).

Group	Physical function (points)		Role function (points)		Cognitive function (score)		Emotional function (points)		Social function (points)
	Before nursing	After nursing	Before nursing	After nursing	Before nursing	After nursing	Before nursing	After nursing	Before nursing	After nursing
C Group	60.26 ± 10.27	61.82 ± 9.25*	63.66 ± 9.32	68.17 ± 10.08*	64.31 ± 12.45	68.45 ± 14.23*	56.32 ± 9.42	63.44 ± 8.71*	38.66 ± 7.41	41.46 ± 7.08*
R Group	60.83 ± 10.36	66.82 ± 10.01†	62.83 ± 8.35	78.54 ± 9.34†	63.28 ± 14.88	77.42 ± 12.31†	56.38 ± 9.21	73.72 ± 9.08†	39.04 ± 8.12	48.21 ± 9.01†
Cohen’s d	−0.08	−0.50	0.07	−1.03	−0.07	0.63	0.05	0.58	0.23	0.78
95% CI	−0.57 ± 0.67	−5.00 ± 0.84	0.83 ± 1.24	−10.37 ± 2.03	−2.05 ± 2.29	−12.43 ± 3.43	−0.07 ± 1.23	−11.42 ± 1.24	−1.60 ± 1.62	−8.03 ± 1.73
t	0.276	2.594	0.469	5.336	0.375	3.371	0.032	5.777	0.244	4.165
P	>.05	<.05	>.05	<.05	>.05	<.05	>.05	<.05	>.05	<.05

The control group before and after nursing,

^*P < .05; the research group before and after nursing,

^†P < .05.

3.5. QLQ-BLS24 scores after nursing

Following nursing intervention, there was a decrease in scores related to urinary system disease, treatment problems, future worries, and intestinal symptoms. When compared to the control group, the research group exhibited significantly lower QLQ-BLS24 scores in all dimensions (P < .05). Table 5 provides a summary of the study’s findings.

Table 5.

QLQ-BLS24 scores before and after nursing ($\overline{x}$±s, n = 50).

Group	Urinary system symptoms		Problems arise from treatment		Worry about the future		Intestinal symptoms
	Before nursing	After nursing	Before nursing	After nursing	Before nursing	After nursing	Before nursing	After nursing
C Group	55.37 ± 15.82	53.07 ± 14.41*	64.36 ± 14.22	63.28 ± 10.21*	66.71 ± 12.62	64.03 ± 8.71*	11.31 ± 5.37	10.23 ± 6.37*
R Group	54.62 ± 16.33	46.72 ± 5.18†	64.83 ± 9.31	54.32 ± 9.92†	67.03 ± 10.88	57.82 ± 5.63†	11.42 ± 6.48	7.42 ± 3.08†
Cohen’s d	0.05	1.18	0.08	0.97	0.03	1.15	−0.02	0.43
95% CI	−4.24 ± 8.74	−14.68 ± 3.84	−5.23 ± 5.43	−1.32 ± 8.98	−1.47 ± 1.09	6.21 ± 1.41	−0.11 ± 0.91	2.81 ± 7.29
t	0.233	2.932	0.196	4.451	0.136	4.234	0.092	2.808
P	>.05	<.05	>.05	<.05	>.05	<.05	>.05	<.05

Control group before and after nursing,

^*P < 0.05, research group before and after nursing,

^†P < 0.05.

3.6. Coping styles of patients

Following nursing intervention, there was an increase in face scores and a decrease in avoidance and yield scores. The research group exhibited higher face scores and lower avoidance and yield scores compared to the control group (P < .05). Table 6 provides a summary of the study’s findings.

Table 6.

The coping styles.

Group	Face		Evade		Yield
	Before nursing	After nursing	Before nursing	After nursing	Before nursing	After nursing
C Group	19.38 ± 2.73	22.02 ± 3.46*	20.09 ± 1.83	16.32 ± 1.41*	14.22 ± 2.31	11.56 ± 2.02*
R Group	20.01 ± 2.97	27.63 ± 3.14†	20.13 ± 2.01	11.19 ± 1.34†	14.82 ± 2.63	8.81 ± 1.73†
Cohen’s d	−0.24	−1.60	−0.02	3.82	0.29	1.59
95% CI	−0.63 ± 3.35	−8.19 ± −5.35	−0.08 ± 0.09	5.13 ± 0.07	−0.60 ± 0.32	−2.75 ± 0.29
t	1.105	8.490	0.104	18.649	1.212	7.312
P	>.05	<.05	>.05	<.05	>.05	<.05

Control group before and after nursing,

^*P < .05, research group before and after nursing,

^†P < .05.

3.7. Incidence of complications in patients undergoing instillation treatment

Among patients who underwent instillation treatment, the incidence of complications in the research group was 8.00%, with 1 patient experiencing hematuria, 1 patient suffering from rectal injury, and 1 patient having a rupture wound. In contrast, the control group had a higher incidence of postoperative complications, at 38.00%, including 7 patients with hematuria, 3 patients with pelvic infections, 1 patient with rectal injury, and 3 cases of rupture wound. When comparing the 2 groups, it was evident that the research group had a significantly lower incidence of complications after chemotherapy (P < .05). The findings of this study are summarized in Figure 2.

Figure 2.

The incidence of complications after chemotherapy.

4. Discussion

Malignant tumors are a dreadful threat to human life and health. To reduce the recurrence and progression rates of NMIBC patients after TURBT, patients need to undergo continuous and standardized intravesical chemotherapy to extend their survival. However, long-term postoperative instillation chemotherapy can cause patients to experience nervousness, fear, increased psychological stress, anxiety, and resistance, which not only affects treatment compliance but also impairs treatment efficacy. Previous studies have shown that poor responses to intravesical instillation therapy can reduce the effective survival period of patients.^[26] Therefore, it is essential to implement reasonable and effective nursing interventions during the treatment process to protect the physical and mental health of patients.

It has been previously reported that patients with bladder cancer often experience poor mental health, characterized by symptoms such as somatization, anxiety, hostility, and depression.^[27] These negative emotions can significantly impact the effectiveness of treatment and may lead to further deterioration of the patient’s mental state, resulting in non-cooperation or resistance to treatment. Therefore, the provision of psychological counseling during perfusion therapy is of utmost importance. As early as 2002, Lu Liehong proposed that a caring attitude should be the primary focus in addressing psychological needs.^[28] Targeted psychological care has been shown to soothe and motivate patients, helping them shift from anxious to stable emotions and from a passive to an active attitude toward treatment.^[29] The previous research has indicated that comprehensive nursing contributes to enhancing compliance, optimizing psychological well-being, and improving lipid levels in patients with hyperlipidemic pancreatitis (HLP).^[30] However, there is currently no research that has explored the potential benefits of comprehensive nursing in the context of cancer chemotherapy. The present study demonstrates that, following nursing intervention, patients’ General Self-Efficacy Scale (GSES) scores increased, while their Self-Rating Anxiety Scale (SAS) scores and Self-Rating Depression Scale (SDS) scores decreased. This indicates that integrated nursing significantly enhances self-efficacy and reduces negative emotions in bladder tumor patients. Such nursing care not only aids in disease recovery but also fosters a stronger appreciation for nursing work and fosters a harmonious nurse-patient relationship.

Our research thoroughly examined various aspects of patients’ lives, including family, economic, psychological, physiological, and emotional conditions. Additionally, we provided patients with detailed information about the treatment’s purpose, specific procedures, potential discomfort, adverse drug reactions, complications, sequelae, and preventive measures. This comprehensive approach helps prepare patients psychologically for the treatment.

Interrupted intravesical instillation therapy often occurs due to a lack of knowledge about the procedure and fear of adverse drug reactions.^[31] A survey revealed that 29.37% of NMIBC patients with poor compliance cited adverse reactions as the reason for noncompliance.^[32] In our study, the research group achieved a 100% compliance rate, while the control group had an 84% compliance rate. The research group also experienced a noticeable reduction in postoperative complications, with a rate of 38.00%. The improved compliance can be attributed to the implementation of comprehensive care, which significantly reduced adverse reactions to instillation therapy, restoring patient confidence in their recovery and increasing treatment compliance.^[33] Therefore, it is crucial to emphasize standardized procedures and strengthen nursing practices to minimize adverse reactions during intravesical instillation therapy.

Furthermore, our results indicated that after nursing, patients in the research group showed increased scores in physical, role, cognitive, emotional, and social function. The EORTC QLQ-C30 dimension scores were higher in the research group. Additionally, after nursing, scores related to urinary system issues, treatment-related problems, future concerns, and intestinal symptoms decreased. In all dimensions, the research group had lower scores, which aligns with previous research findings. Medical staff should provide thorough explanations to patients regarding their condition, potential adverse reactions, and preventive measures to ensure patients understand the importance of treatment adherence and regular checkups. Patients should also be encouraged to adopt a healthy lifestyle and learn effective coping strategies.

Having a positive attitude towards the disease is undoubtedly more conducive to treatment. A favorable coping attitude not only promotes emotional relief for patients but also aids in problem-solving. Patients are more likely to adopt proactive and effective coping strategies rather than succumbing to negative approaches. Our research also indicates a similar pattern, where face scores increase, while avoidance and yield scores decrease. In the research group, avoidance and yield scores were higher. We recommend that integrated nursing care places importance on altering the coping strategies of NMIBC patients. Clinical physicians and nurses are advised to conduct effective health education, providing patients with relevant knowledge.

In conclusion, nursing interventions significantly enhance the well-being of NMIBC patients undergoing postoperative intravesical instillation treatment. These interventions effectively improve treatment compliance, alleviate negative emotions, facilitate a positive shift in coping strategies, reduce the occurrence of complications, and result in higher levels of nursing satisfaction. These findings underscore the importance of promoting such nursing interventions in clinical practice.

This study still has the following limitations. Firstly, through an update of our knowledge, we discovered more objective psychological assessment methods.^[34] However, considering that the assessments in this study were conducted before and after instillation, it was not possible to update the methods used in this study. Moreover, this study used classical scales and employed an assessor-blinded approach during the assessments, which still provides a certain level of authority and objectivity to the data. However, in future studies, more objective assessment methods will be considered. Secondly, this study focused on the outcomes of postoperative care, with patients entering the study at the initiation of postoperative intravesical instillation treatment. This limited our ability to comprehensively supplement environmental factors and procedure-related information. However, to minimize this bias, we employed a randomized patient enrollment method, which helped to balance confounding factors between the 2 groups to some extent.

Author contributions

Conceptualization: Wenwen Wang, Jun Gu.

Data curation: Wenwen Wang, Ying Chen, Jun Gu.

Formal analysis: Wenwen Wang, Ying Chen.

Investigation: Ying Chen.

Validation: Jun Gu.

Visualization: Jun Gu.

Writing – original draft: Wenwen Wang, Ying Chen, Jun Gu.

Writing – review & editing: Wenwen Wang, Jun Gu.