Effects of Noise Reduction Protocol-Based Integrated Nursing Care on Perceived Comfort Level and Physiological and Psychological Stress Responses in Patients with Gastrointestinal Tumors

Abstract

Objective:

The effects of noise reduction protocol–based integrated nursing care on perceived comfort level and stress responses were analyzed in patients with gastrointestinal tumors.

Methods:

A retrospective analysis was conducted on clinical data from 110 surgical patients with gastrointestinal tumors treated at our institution between January 2023 and January 2024. The patients were assigned according to postoperative nursing care received: 56 patients received conventional care (conventional care group), and 54 patients received noise reduction protocol-based integrated nursing care (integrated noise reduction group). Both groups were monitored until discharge. Outcome measures included postoperative recovery parameters, comfort level [Kolcaba General Comfort Questionnaire (GCQ)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], psychological stress [Hospital Anxiety and Depression Scale–Depression (HADS-D) and −Anxiety (HADS-A) subscales], quality of life [Generic Quality of Life Inventory-74 (GQOLI-74)], and environmental noise levels.

Results:

No significant differences were found between the groups in time to first ambulation, length of hospital stay, or Visual Analog Scale pain scores on postoperative day 7 (P > 0.05). The integrated noise reduction group showed significantly greater improvements in GCQ and all domains of the GQOLI-74 than the conventional care group (P < 0.05). Significantly greater reductions in preoperative PSQI, HADS-D, and HADS-A scores; equivalent continuous sound levels; and maximum sound levels were observed in the integrated noise reduction group (P < 0.05).

Conclusion:

Noise reduction protocol–based integrated nursing care effectively reduces environmental noise exposure in patients with gastrointestinal tumors and is associated with decreased psychological stress, improved sleep quality, and enhanced perceived comfort and quality of life.

KEY MESSAGES

• (1)Implementing a noise reduction protocol–based integrated nursing care in patients with gastrointestinal malignancies remarkably reduces ambient noise levels in hospital wards.
• (2)Implementing a noise reduction protocol–based integrated nursing care markedly reduces psychological stress reactions in patients with gastrointestinal cancers via neuroendocrine modulation.
• (3)Implementing noise reduction protocol–based integrated nursing care in patients with digestive tract malignancies improves sleep quality, comfort, and quality of life.

Introduction

Gastric and esophageal carcinomas are prevalent gastrointestinal malignancies with progressively increasing incidence rates.[1] Surgical intervention remains the primary treatment modality for these tumors; however, postoperative sleep disturbances are frequently reported and are a common complication after invasive surgical procedures. These disturbances adversely affect recovery by disrupting neuroendocrine–immunological pathways,[2] leading to impaired immune, endocrine, and neurological functions; compromised intrinsic tissue repair; and prolonged convalescence. Additionally, they exacerbate physiological and psychological stress responses that negatively influence patient outcomes.[3] Beyond disease- and treatment-related factors, environmental influences play a critical role in postoperative sleep disruption in this patient population.[4] Elevated noise levels in hospital wards are identified as a predominant contributor to sleep disorders among hospitalized patients.[5] Accordingly, the implementation of evidence-based, integrated noise reduction protocols is essential to optimize the hospital environment, enhance patient comfort, and reduce noise-induced complications during hospitalization. This study aims to evaluate the clinical efficacy of noise reduction protocol–based integrated nursing care in patients with gastrointestinal tumors.

MATERIALS AND METHODS

Study Design

Clinical data from 110 surgical patients with gastrointestinal tumors treated between January 2023 and January 2024 from The First Hospital of Putian City were retrospectively analyzed. The patients were categorized according to the postoperative nursing care received: 56 patients undergoing conventional care were assigned to the conventional care group, and 54 patients receiving noise reduction protocol–based integrated nursing care were assigned to the integrated noise reduction group. The study protocol complied with the Declaration of Helsinki,[6] obtained informed consent and ensured confidentiality. This study was approved by the Ethics Committee of The First Hospital of Putian City (Approval No: 2024-137).

Inclusion and Exclusion Criteria

Inclusion criteria: (1) Histopathologically confirmed gastric or esophageal carcinoma; (2) early-stage disease, defined as tumor confined to primary site and regional lymph nodes without distant metastasis; (3) adequate systemic tolerance for surgery with uneventful completion; (4) complete medical documentation; (5) neurologically intact for protocol compliance; (6) preoperative Pittsburgh Sleep Quality Index (PSQI) score of ≤7[7]; (7) Mini-Mental State Examination score of ≥24 for valid assessment.[8]

Exclusion criteria: (1) Severe functional disorders of important organs such as the heart, liver, and kidneys (New York Heart Association cardiac function grades Ⅲ–Ⅳ, Child–Pugh liver function grade C and laboratory-confirmed renal insufficiency); (2) pregnancy or lactation; (3) postoperative coagulopathy (platelets of <50 × 10⁹/L or international normalized ratio of >1.5)[9]; (4) hearing loss (binaural pure-tone average of >40 dB HL).[10]

Nursing Methods

Both groups underwent identical surgical procedures, and nursing protocols were initiated immediately after the operation. The conventional care group received standard postoperative care comprising continuous monitoring of vital signs; enhanced incision and drainage tube management with encouragement of respiratory exercises; multimodal analgesia incorporating pharmacological and physical interventions supplemented by psychological support as needed; phase-appropriate nutritional support, including initial fasting, gradual dietary progression, and long-term supplementation; prevention of complications, such as surgical site infections, deep vein thrombosis, and anastomotic leakage; maintenance of optimal ward environmental conditions through cleanliness and comfort protocols; and structured postoperative health education.

The integrated noise reduction group received the same baseline care supplemented by a noise reduction protocol–based integrated nursing intervention, which included (1) acoustic awareness initiatives using strategically placed visual cues (e.g., “Quiet Zone” signage at entrances and elevators, bedside reminders, such as “Rest in Progress–Please Lower Voices”), alongside infographic-based noise reduction guidance; (2) mitigation of medical equipment noise through scheduled maintenance of heating, ventilation, and air conditioning systems, televisions, infusion pumps, call systems and monitors to minimize operational noise, adoption of low-volume or visual alert modes on alarms, installation of sound-absorbing curtains and acoustic panels around high-noise devices, and use of silent-castor mobile equipment with regular lubrication; (3) staff behavioral modification through standardized noise-reduction training emphasizing conversational voice modulation during rounds and handovers, noise-minimizing ambulation techniques, controlled handling of equipment and doors and clustering of nonurgent tasks during daytime hours, and reinforced staffing during peak noise periods; (4) architectural acoustic optimization involving spatial reorganization to reduce sound propagation, installation of sound-dampening ceiling tiles and wall panels, bedside acoustic partitions, and sealing of doors and windows with compressible gaskets; (5) personal hearing protection through nightly provision (21:00) of reusable earplugs (noise reduction rating: 25–40 dB according to manufacturer specifications) and standardized insertion training covering hand hygiene, cylindrical compression, insertion to two-thirds canal depth, and retention until full expansion; and (6) institutional noise governance including real-time ward noise monitoring, appointment of noise-control officers, compliance auditing, and implementation of incentive and disciplinary measures. All interventions were maintained until patient discharge.

Quality Control Measures

To ensure consistent implementation of noise reduction protocols within the experimental group and maintain measure homogeneity across all participants, the following quality control measures were implemented: (1) Personnel training and standardization: Healthcare personnel in the experimental group underwent centralized, standardized training to ensure uniform proficiency in all noise reduction procedures (including device silent mode configuration, proper earplug insertion techniques, and behavioral guidelines). (2) Noise monitoring system deployment: Continuous acoustic surveillance was conducted using installed noise monitoring systems, and automated data logging was performed in all wards serving and used as objective, quantifiable metrics for protocol adherence. (3) Protocol compliance audits: A structured noise reduction protocol implementation checklist was developed, which required daily verification of critical parameters (e.g., sound-absorbing curtain closure status, equipment silent mode activation, and signage integrity) by head nurses or designated supervisors with signature documentation. (4) Hearing protection management: A dedicated noise-reducing earplug issuance and recovery registry was established for the meticulous tracking of daily distribution, collection, and sterilization processes. (5) Regular auditing and feedback: A supervisory committee comprising core research members conducted monthly reviews of nursing documentation and analyzed noise metric data. Protocol deviations or anomalous noise level elevations triggered immediate corrective action through structured feedback mechanisms.

Observation Indicators

General Information

Gender, age, tumor type, educational level, and comorbidities (diabetes, hypertension, and hyperlipidaemia) were obtained.

Noise Indicators

Ambient noise levels were continuously monitored over a 24-hour period with a CRY2851 sound level meter (Hangzhou Zhaohua Electronics Co., Ltd.), which was positioned horizontally 10 cm from each patient’s external auditory meatus. Measurements were conducted in A-weighted mode, and the sampling interval was 1 second. The microphone was maintained unobstructed and installed away from reflective surfaces throughout data collection. Equivalent continuous sound level (Leq, 24-hour average) and maximum sound level (Lmax) were recorded.

Postoperative Recovery Parameters

The time of first postoperative ambulation [defined as effective ambulation when the patient can stand briefly or walk slowly (>5 minutes) with assistance, starting from the transfer to the general ward after surgery and ending when the patient leaves the bed and performs effective ambulation], postoperative hospital stay (starting from the day of surgery and ending on the day of discharge), and pain in 7 days postoperation [assessed using the Visual Analog Scale (VAS) for pain intensity in 7 days postoperation, with a Cronbach’s É coefficient of 0.880; scores ranged from 0 to 10, with lower scores indicating lower pain levels] were recorded.[11]

Comfort Level

Comfort was evaluated using the Kolcaba General Comfort Questionnaire (GCQ) before nursing (within 4 to 6 hours following full recovery of cognitive and perceptual functions postoperatively) and at discharge (within 2 hours before discharge).[12] The GCQ has a Cronbach’s É coefficient of 0.899 and covers four aspects with a total of 28 items: physical, psychological, environmental, and sociocultural. Each item is scored on a 1 to 4 scale, with a total score range of 28 to 112, and a lower score indicating poorer comfort.

Sleep Quality

Sleep quality was evaluated using PSQI before nursing (within 2 hours after surgery) and at discharge (within 2 hours before discharge). The PSQI has a Cronbach’s É coefficient of 0.895 and consists of seven items scored on a 0 to 3 scale. The total score ranges from 0 to 21, and a low score indicates improved sleep quality.

Psychological Stress

Psychological stress was assessed using the Hospital Anxiety and Depression Scale (HADS) before an intervention and at discharge. The evaluation incorporated two subscales: the Depression Subscale (HADS-D; Cronbach’s α = 0.855) and Anxiety Subscale (HADS-A; Cronbach’s α = 0.849).[13] Each subscale comprises seven items scored on a 0- to 3-point Likert scale, yielding total scores ranging from 0 to 21. High scores indicate increased severity of anxiety and depression symptoms.

Quality of Life

Quality of life was assessed using the Generic Quality of Life Inventory-74 (GQOLI-74), which is routinely employed in local clinical practice before an intervention and at discharge. This instrument demonstrates high internal consistency (Cronbach’s α = 0.898) and encompasses four domains: physical functioning, social functioning, psychological well-being, and material well-being. Raw scores for each domain were converted to standardized scores ranging from 0 to 100, with higher scores indicating improved quality of life.[14]

Statistical Methods

Data analysis was performed using SPSS statistical software (IBM, USA, version 23.0). The normality of all continuous variables was assessed using the Kolmogorov–Smirnov test. Normally distributed continuous data were presented as mean ± standard deviation and compared between groups with the independent samples t-test after the verification of homogeneity of variance with Levene’s test (homogeneity assumed if Sig. > 0.05). Within-group comparisons were conducted using the paired samples t-test. Categorical data were expressed as frequencies and percentages (n, %) and compared between groups with the chi-square (χ ²) test. A two-tailed P-value of <0.05 was considered statistically significant.

Results

General Information

No significant differences in baseline demographic and clinical characteristics were observed between the conventional care and integrated noise reduction groups (P > 0.05 for all comparisons; Table 1)

Table 1.

Comparative Analysis of General Information.

Project		Conventional Care Group (n = 56)	Integrated Noise Reduction Group (n=54)	χ2/t	P
Age (years)		40.84 ± 10.26	39.52 ± 9.99	0.683	0.496
Gender [n (%)]	Male	36 (64.29)	34 (62.96)	0.021	0.885
	Female	20 (35.71)	20 (37.04)
BMI (kg/m2)		22.43 ± 1.65	22.40 ± 1.43	0.102	0.919
Tumor size (cm)		4.10 ± 0.50	4.25 ± 0.48	1.604	0.112
Education [n (%)]	>High school	46 (82.14)	43 (79.63)	0.112	0.737
	≤High school	10 (17.86)	11 (20.37)
Comorbidities (diabetes/hypertension/hyperlipidemia) [n (%)]	Merger	6 (10.71)	5 (9.26)	0.065	0.799
	Unmerged	50 (89.29)	49 (90.74)
Tumor type [n (%)]	Gastric carcinoma	30 (53.57)	30 (55.56)	0.044	0.834
	esophagus cancer	26 (46.43)	24 (44.44)

BMI = body mass index.

Noise Indicators

No statistically significant differences in premeasure noise metrics were found between the two groups (P > 0.05). At discharge, the integrated noise reduction group demonstrated significantly lower Leq (50.62 ± 7.34 dB) and Lmax (70.37 ± 8.74 dB) than the conventional care group (Leq: 68.54 ± 9.32 dB; Lmax: 98.49 ± 9.71 dB; t = 8.058 and 7.440, respectively; P < 0.05 for both comparisons; Table 2).

Table 2.

Comparative Analysis of Noise Indicators.

Group	N	Equivalent Continuous Sound Level		Maximum Sound Level
		At Baseline	At Discharge	At Baseline	At Discharge
Conventional care group	56	70.55 ± 10.82	68.54 ± 9.32	100.55 ± 11.24	98.49 ± 9.71
Integrated noise reduction group	54	70.56 ± 10.76	50.62 ± 7.34*	100.45 ± 11.25	70.37 ± 8.74*
t		0.005	8.058	0.047	7.440
P		0.996	<0.001	0.963	<0.001

^*Compared with the baseline of this group, P < 0.05.

Postoperative Recovery Parameters

No statistically significant intergroup differences in postoperative recovery parameters, including time to first ambulation, length of hospitalization, or postoperative day 7 VAS scores, were observed (P > 0.05; Table 3).

Table 3.

Comparative Analysis of Postoperative Recovery Parameters.

Group	N	Time to First Ambulation (h)	Length of Hospitalization (days)	VAS Score at Postoperative Day 7
Conventional care group	56	30.01 ± 10.59	17.88 ± 4.55	5.02 ± 0.43
Integrated noise reduction group	54	30.99 ± 10.60	17.72 ± 4.57	5.00 ± 0.30
t		0.485	0.184	0.282
P		0.629	0.854	0.779

VAS = visual analog scale

Comfort Level and Sleep Quality

No statistically significant intergroup differences in GCQ and PSQI scores were observed at baseline (P > 0.05). At discharge, the integrated noise reduction group demonstrated significantly greater improvement in GCQ scores (85.65 ± 8.65) than the conventional care group (75.32 ± 8.52) and a significantly more pronounced reduction in PSQI scores (8.07 ± 1.06 vs. 10.10 ± 2.24; P < 0.05 for both; Table 4).

Table 4.

Comparison of General Comfort Questionnaire and Pittsburgh Sleep Quality Index Scores between Groups (Points).

Group	N	GCQ Score		PSQI Score
		At Baseline	At Discharge	At Baseline	At Discharge
Conventional care group	56	62.32 ± 5.28	75.32 ± 8.52*	12.73 ± 2.36	10.10 ± 2.24*
Integrated noise reduction group	54	61.02 ± 5.32	85.65 ± 8.65*	11.95 ± 2.39	8.07 ± 1.06*
t		1.286	8.498	1.722	8.800
P		0.201	<0.001	0.088	<0.001

GCQ = Kolcaba General Comfort Questionnaire, PSQI = Pittsburgh Sleep Quality Index; ^*Compared with the baseline of this group, P < 0.05.

Psychological Stress

No statistically significant differences in premeasurement HADS-D and HADS-A scores were observed between the two groups (P > 0.05). At discharge, the integrated noise reduction group demonstrated significantly lower scores in HADS-D (5.02 ± 1.37) and HADS-A (5.10 ± 1.28) compared to the conventional care group (7.35 ± 1.50 and 7.38 ± 1.43, respectively) (t = 8.498 and 8.800, respectively; P < 0.05 for both comparisons; Table 5).

Table 5.

Comparative Analysis of Hospital Anxiety and Depression Scale-Depression and Hospital Anxiety and Depression Scale-Anxiety Scores.

Group	N	HADS-D		HADS-A
		At Baseline	At Discharge	At Baseline	At Discharge
Conventional care group	56	11.51 ± 2.09	7.35 ± 1.50*	11.56 ± 2.12	7.38 ± 1.43*
Integrated noise reduction group	54	11.48 ± 2.08	5.02 ± 1.37*	11.59 ± 2.15	5.10 ± 1.28*
t		0.075	8.498	0.074	8.800
P		0.940	<0.001	0.941	<0.001

^*Compared with the baseline of this group, P < 0.05; HADS-A = Hospital Anxiety and Depression Scale-Anxiety, HADS-D = Hospital Anxiety and Depression Scale-Depression.

Quality of Life

No statistically significant differences in premeasurement GQOLI-74 domain scores between the two groups (P > 0.05). At discharge, the integrated noise reduction group demonstrated significantly higher scores across all GQOLI-74 domains (72.62 ± 6.30; 75.35 ± 6.71; 76.62 ± 6.20; 75.60 ± 7.12, respectively) than the conventional care group (65.54 ± 6.35; 64.49 ± 6.75; 65.45 ± 5.57; 65.27 ± 6.15, respectively; t = 5.869, 8.460, 9.947, 8.152; P < 0.05 for all comparisons; Table 6)

Table 6.

Comparative Analysis of Generic Quality of Life Inventory-74 Domain Scores.

Group	N	Physical Functioning		Social Functioning		Psychological Function		Material Well-being
		At Baseline	At Discharge	At Baseline	At Discharge	At Baseline	At D	At Baseline	At Discharge
Conventional care group	56	55.56 ± 5.82	65.54 ± 6.35*	56.57 ± 5.29	64.49 ± 6.75*	53.46 ± 5.62	65.45 ± 5.57*	54.47 ± 5.35	65.27 ± 6.15*
Integrated noise reduction group	54	55.96 ± 5.85	72.62 ± 6.30*	57.40 ± 5.32	75.35 ± 6.71*	53.42 ± 5.80	76.62 ± 6.20*	54.90 ± 5.32	75.60 ± 7.12*
t		0.359	5.869	0.820	8.460	0.037	9.947	0.423	8.152
P		0.720	<0.001	0.414	<0.001	0.971	<0.001	0.673	<0.001

^*Compared with the baseline of this group, P < 0.05.

DISCUSSION

Excessive noise levels represent a pervasive environmental challenge within healthcare settings, adversely affecting postoperative patients by disrupting circadian regulation of sleep, dietary intake, and mobility. Additionally, noise exposure contributes to immunosuppression, endocrine dysregulation, and heightened psychological stress responses, which collectively impair tissue repair mechanisms, increase complication risks, reduce perceived comfort, and compromise quality of life, thereby impeding overall prognosis.[15,16] Consequently, the implementation of multimodal noise abatement protocols is an essential element of evidence-based postoperative care for patients with gastrointestinal malignancies.

Empirical evidence substantiates the detrimental impact of noise pollution on postoperative recovery. Gabor et al.[17] objectively quantified intensive care unit acoustic environments alongside patient-reported outcomes, identifying excessive noise as the primary cause of sleep disturbances in 20.9% of patients. Similarly, Ugras and Oztekin[18] reported that 57.6% of surgical patients implicated environmental noise as a major disruptor of sleep architecture. Consistent with these findings, the present study demonstrated that the integrated noise reduction group exhibited significantly lower Leq and Lmax values and PSQI, HADS-D, and HADS-A scores at discharge. These results indicate that noise reduction protocol–based integrated nursing care effectively attenuates ambient noise in hospital wards, mitigates psychological stress responses and improves sleep quality in patients with gastrointestinal tumors.

The efficacy of this intervention likely derives from the synergistic application of multiple measures, including acoustic awareness initiatives, medical equipment noise control, healthcare staff behavioral modification, optimized ward layout, personal hearing protection, and institutional noise governance.[19,20] These strategies reduce noise generation at the source through standardized equipment operation and moderated vocal communication while impeding sound transmission via physical barriers and sound-absorbing materials. The concurrent use of personal protective equipment, such as earplugs, provides individual noise attenuation, collectively minimizing acoustic exposure through multiple pathways. This noise reduction facilitates the downregulation of sympathetic nervous system hyperactivity and stress hormone secretion, promoting psychological stabilization and normalization of sleep architecture.[21,22]

Furthermore, both groups exhibited significant improvements in the Kolcaba GCQ scores and GQOLI-74 domain scores at discharge relative to baseline, and the integrated noise reduction group achieved substantially greater gains. This finding corroborates the conclusion that noise reduction protocol–based integrated nursing care enhances perceived comfort and quality of life in gastrointestinal oncology patients. The underlying mechanisms include conventional nursing measures promoting physiological restoration and psychological stress mitigation, which are complemented by noise abatement strategies that reduce environmental noise exposure.[23,24] These synergistic effects optimize sleep architecture, fostering a physiological state characterized by reduced metabolic rates and activation of intrinsic reparative processes, which are critical for replenishing physical and cognitive reserves.[25,26]Conversely, no significant intergroup differences were observed in time to first ambulation, length of hospitalization, or postoperative day 7 VAS pain scores, suggesting that noise reduction protocols do not accelerate functional recovery kinetics. This outcome may reflect the comprehensive physiological support provided by standard perioperative care, including vigilant monitoring, multimodal analgesia, nutritional optimization, and complication prophylaxis, which adequately addresses core determinants of physical recovery.[27] Noise abatement strategies optimize the healing environment and improve psychoneurological status, but their effects appear restricted to environmental modulation and do not directly influence tissue repair chronobiology or nociceptive processing.[28,29] Consequently, intrinsic surgical recovery timelines, as measured by mobilization capacity and hospitalization duration, remain unaffected.

This study has several methodological limitations. First, its exclusive focus on patients with gastric and esophageal carcinomas, combined with a relatively small sample size and limited study duration, may limit statistical power and the generalizability of findings to a broad gastrointestinal oncology population. Future research should incorporate larger, more diverse cohorts across tumor subtypes and extend follow-up periods. Second, the retrospective design and nonrandomized group allocation based on clinical nursing protocols introduce potential selection bias, unmeasured confounding, and incomplete data capture, despite comparable baseline characteristics. Prospective studies employing propensity score matching or randomized controlled designs are warranted to strengthen causal inference. Third, the absence of an a priori sample size calculation inherent to the retrospective approach poses a risk of type II error. Accordingly, well-powered, prospective, multicenter randomized controlled trials are necessary to validate these findings conclusively.

Conclusion

The implementation of noise reduction protocol–based integrated nursing care demonstrates potential efficacy in attenuating ambient noise levels, mitigating psychological stress responses, improving sleep quality, and enhancing perceived comfort and quality of life in patients with gastrointestinal tumors.

Availability of data and materials

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Author contributions

XiaoRong Huang: Led the research design and execution, managed data collection and analysis, and authored the initial draft of the manuscript.

BiQin Wu: Contributed to the research design, supported data analysis, and made initial revisions to the manuscript.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of The First Hospital of Putian City (Approval No: 2024-137). All subjects who participated in this study have provided informed consents.

Conflicts of interest

The authors declare no conflicts of interest.

Funding Statement

This study is funded by Putian Science and Technology Program (2024sy006).