Effects of a Discharge Preparation Program Based on the Cox Interaction Model of Client Health Behavior in Patients Undergoing Laryngeal Cancer Surgery

Abstract

Background

Readiness for hospital discharge is critical for rehabilitation outcomes, yet traditional discharge education often fails to meet individualized needs after laryngeal cancer surgery. The Cox Interaction Model of Client Health Behavior (IMCHB) provides a patient-centered framework emphasizing interaction and empowerment, but its application in this population is rarely reported. IMCHB-based discharge preparation intervention in patients undergoing laryngeal cancer surgery was evaluated.

Material/Methods

This quasi-experimental, non-randomized controlled study used convenience sampling to recruit patients undergoing laryngeal cancer surgery at a tertiary hospital. Sixty-five patients (33 intervention, 32 control) were assigned by admission order. The control group received routine nursing care; the intervention group received an IMCHB-based discharge preparation intervention plus routine care. Groups were compared for readiness for hospital discharge, self-management ability, and anxiety/depression before the intervention, at discharge, and 1 month after discharge. Effect sizes and 95% CIs were calculated for key between-group comparisons.

Results

At discharge, the intervention group had higher readiness-for-discharge scores (99.97 ± 6.31 vs 88.09 ± 6.14; MD = 11.88, 95% CI: 8.65–14.71; Cohen’s d = 1.91), higher self-management ability (174.73 ± 9.35 vs 152.13 ± 12.78; MD = 22.60, 95% CI: 17.05–28.15; Cohen’s d = 2.02), and lower anxiety scores (41.48 ± 2.89 vs 43.19 ± 3.70; MD = −1.71, 95% CI: −3.36 to −0.06; Cohen’s d = 0.51). One month after discharge, self-management remained higher (189.00 [186.00, 191.50] vs 144.00 [133.00, 154.50]; Mann-Whitney r = 0.86), and depression scores were lower (40.73 ± 3.18 vs 46.75 ± 3.09; MD = −6.02, 95% CI: −7.57 to −4.47; Cohen’s d = 1.92).

Conclusions

IMCHB-based discharge preparation was associated with higher readiness for discharge and self-management ability and lower anxiety/depression scores after laryngeal cancer surgery. These findings should be interpreted cautiously, and randomized controlled trials are needed to confirm its effectiveness and clinical utility.

Introduction

Laryngeal cancer is a common malignant tumor of the head and neck, accounting for approximately 20% of all head and neck malignancies, with a relatively high mortality rate among head and neck cancers [1,2]. For early-stage tumors with favorable anatomical accessibility, minimally invasive surgical resection is one of the main treatment options for laryngeal cancer [3]. Common postoperative problems reported in laryngectomy and partial-laryngectomy populations include tracheostomy-site infection, pharyngocutaneous fistula, pulmonary infection, and speech and swallowing dysfunction [4,5]. These complications not only seriously affect patients’ physical health but also create substantial challenges for psychosocial adaptation. In addition, postoperative recurrence remains an important concern in laryngeal squamous cell carcinoma and advanced laryngeal cancer [6,7]. These findings underscore the importance of long-term post-treatment monitoring and management.

Readiness for hospital discharge is an important composite indicator for evaluating whether a patient is adequately prepared to leave the hospital and is a key factor affecting rehabilitation outcomes [8]. Studies have shown that comprehensive discharge preparation can reduce postoperative complications, mortality, and unplanned readmissions, while also lowering healthcare costs and improving resource utilization [9]. Traditional discharge education often relies on one-way information delivery and pays insufficient attention to the dynamic interaction among patient motivation, practical skills, and support from the nursing system. As a result, it may fail to meet patients’ individualized and ongoing rehabilitation needs. Moreover, with continued healthcare reform and the implementation of enhanced recovery after surgery, perioperative pathways for patients undergoing laryngectomy are becoming more standardized and time-sensitive, and the postoperative length of stay for patients with laryngeal cancer has decreased substantially [10]. Shorter or more protocolized hospitalization can reduce the time available for sustained and effective nurse-patient communication, which can lead to inadequate discharge preparation and poor self-management, ultimately contributing to adverse health outcomes.

Against this background, the Cox Interaction Model of Client Health Behavior (IMCHB) [11] provides an appropriate theoretical framework for developing patient-centered discharge preparation programs that emphasize interaction and empowerment. The IMCHB includes 3 major components: patient singularity, nurse-client interaction, and health outcomes. It highlights the identification of determinants of health-related behaviors from the patient’s perspective and promotes active participation in behavioral decision-making through individualized nurse-patient interaction. In this model, health outcomes arise from the ongoing dynamic interaction between patients’ personal characteristics, such as knowledge, skills, motivation, and self-efficacy, and nursing interventions, such as education, support, and resources. Previous studies have suggested that this model is particularly suitable for patients with chronic disease or those recovering after surgery who require long-term behavioral adjustment and complex self-management [12,13]. Although favorable results have been reported in chronic conditions such as coronary heart disease and rheumatoid arthritis, its application in discharge preparation for patients after laryngeal cancer surgery has rarely been reported. Therefore, this study developed an IMCHB-based discharge preparation program for patients after laryngeal cancer surgery and evaluated the outcomes associated with its implementation and follow-up.

Material and Methods

Study Population

This quasi-experimental, non-randomized controlled study enrolled patients who underwent surgery for laryngeal cancer in the Department of Otolaryngology-Head and Neck Surgery of a tertiary hospital in Zhengzhou, China, between January and December 2025. A total of 65 patients were included and allocated to the control group (n = 32) or the intervention group (n = 33) according to admission order. Randomization was not used, because the intervention required structured ward-based education, peer-support activities, and coordination among physicians and nurses; random allocation within the same clinical setting was considered difficult to implement without disrupting routine care. Therefore, this design may introduce selection bias, and baseline variables were compared to assess initial group comparability. The inclusion criteria were as follows: (1) age 18 years or older; (2) clinically and pathologically confirmed laryngeal cancer scheduled for an initial elective partial or total laryngectomy; (3) no impairment in limb function, vision, cognition, communication, or consciousness; and (4) a stable condition with an expected survival of at least 6 months. Eligibility for the criterion of no impairment in limb function, vision, cognition, communication, or consciousness was determined by the responsible physician and nurse through medical record review and bedside clinical assessment during admission; no standardized neuropsychological or visual-function scale was used. The exclusion criteria were as follows: (1) tumor metastasis or concurrent malignant tumors; (2) severe comorbid injury to major organs such as the heart, brain, or kidneys; and (3) participation in other ongoing studies. Withdrawal criteria were as follows: (1) death or discontinuation of treatment during the study; and (2) voluntary withdrawal. Sample size was estimated using a 2-sample comparison of means for the primary outcome of readiness for hospital discharge. The formula is

$$n_1=n_2=2{\left[\frac{\left({\mu }_a+{\mu }_{\beta }\right)\sigma }{\delta }\right]}^2,$$

where α = 0.05, β = 0.10, μ_α = 1.960, and μ_β = 1.282; 27 patients were required in each group based on preliminary data. After allowing for a 15% dropout rate, the required total sample size was 64. Ultimately, 65 patients were enrolled, including 33 in the intervention group and 32 in the control group. This study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (approval No. 2024-KY-2178-002). All participants provided written informed consent.

Intervention Group

Establishment of the IMCHB Intervention Team

The IMCHB intervention team consisted of 7 members drawn from the expert panel and the research team. The expert panel included 2 members: 1 associate chief physician in otolaryngology, who was responsible for patient assessment, treatment planning, and disease-related education; and 1 associate chief nurse, who was responsible for protocol revision, implementation guidance, and team training. The research team included 5 members: the head nurse served as the team leader and coordinated implementation and quality control; the principal investigator developed the initial protocol, revised it according to expert consultation and pilot-testing results, and finalized the intervention plan; 1 master’s-level nursing graduate student was responsible for data collection, organization, statistical analysis, and interpretation; and 2 senior nurses delivered the intervention.

Development of the IMCHB-Based Discharge Preparation Program

This patient-centered model based on the IMCHB emphasizes each patient’s uniqueness and the influence of nurse-patient interaction on health outcomes. In patients after laryngeal cancer surgery, patient singularity can be assessed through background variables, such as sociodemographic characteristics, environment, and social group factors, and dynamic variables, such as intrinsic motivation, cognitive appraisal, and emotional responses. By identifying determinants that influence health behaviors, nursing interactions can then be delivered across 4 domains: health information, professional skills, emotional support, and decision-making support. In this way, the model can mobilize patients’ initiative in disease management, enhance self-management ability, and ultimately improve health outcomes.

The present discharge preparation program was developed under the guidance of the IMCHB framework. We systematically reviewed domestic and international intervention protocols related to perioperative discharge preparation and health management for patients with cancer. The intervention content was organized into modules based on the 4 domains: health information, professional skills, emotional support, and decision-making support. A preliminary discharge preparation program was then developed according to the characteristics of patients with laryngeal cancer and the features of the disease. After the initial draft was completed, 2 rounds of expert consultation were conducted with 12 specialists. The program was revised based on expert feedback and then pilot-tested in 8 eligible patients. Further adjustments were made according to the implementation experience and patient feedback, as follows: (1) the health education manual was revised into an illustrated booklet with less text and more visual material; (2) a QR code linking to postoperative exercise videos was added to the booklet; and (3) an interactive quiz component with small rewards was added to the PowerPoint lecture materials. After these modifications, the final IMCHB-based discharge preparation program was established (Table 1).

Table 1.

Content of the Interaction Model of Client Health Behavior–based discharge preparation program.

Intervention period	Intervention objective	Personnel	Details
Preoperative period (from admission to the day before surgery)	Improve disease awareness and enhance motivation for action	Associate chief physician Senior nurse Graduate nursing student	Health information: (1) Self-directed learning: perioperative health education booklets were distributed to patients and their families, together with QR codes linked to instructional videos. (2) Case-based sessions: classic cases were presented using PowerPoint and short videos to explain the etiology, clinical manifestations, treatment methods, possible postoperative complications, emergency management, and common rehabilitation exercises related to laryngeal cancer. Interactive quizzes with small rewards were used to promote engagement. (3) Roundtable discussions: discussions focused on the importance of postoperative rehabilitation and the consequences of inadequate recovery. Patients were encouraged to describe or write down anticipated difficulties, and tailored guidance was provided on site. Emotional support: (1) Individual support session: patients were encouraged to express concerns and anxiety in a supportive one-to-one session, with counseling provided by psychologists. (2) Coping-skills training: patients were taught strategies for coping with psychological stress, such as deep breathing and meditation, through live demonstration and video-assisted learning. Decision-making support: family members were invited to participate in care planning, encouraged to become actively involved in patient care, and guided to provide emotional support, supervision, and motivation
Postoperative period (from the day of surgery to the day before discharge)	Improve care skills and strengthen self-management	Associate chief physician Senior nurse	Health information: (1) Nutrition education: patients received guidance on feeding posture, including a head-of-bed elevation, to reduce swallowing risks. Family members were advised to avoid fried and hard foods and instead provide high-protein, high-fiber, soft foods. Food charts were distributed, and personalized dietary guidance was provided. For patients receiving enteral nutrition, detailed instruction on administration and precautions was delivered through demonstration and video teaching. Professional skills: (1) Swallowing rehabilitation: one-to-one guidance was provided on sensory stimulation and neuromuscular techniques, together with training in appropriate feeding posture. Patients were encouraged to share their experience with peers. (2) Tracheostomy care: nurses demonstrated tracheostomy management, replacement of pads and ties, management of partial or complete tube dislodgement, and airway humidification. Then, the patient and their family practiced the relevant procedures and corrected the errors with the help of the nurse. Decision-making support: (1) Motivational guidance: patients and family members collaborated with healthcare providers to formulate treatment and rehabilitation plans. Short-term and long-term goals were established according to individual circumstances. Small rewards were used to encourage adherence, and barriers to low completion were discussed. (2) Peer-support sessions: patients regularly shared difficulties encountered during rehabilitation, while professionals provided guidance to strengthen social support and decision-making ability
Day of discharge and post-discharge period	Maintain a positive mindset and cope with illness constructively	Senior nurse	Health information: patients’ understanding of rehabilitation knowledge was assessed on the day of discharge. Patients and family members were asked questions about home rehabilitation, and any knowledge gaps were addressed immediately. Professional skills: speech rehabilitation training was delivered step by step through and video demonstration, with gradually increasing difficulty. Family members were encouraged to learn the techniques and assist the patient. Emotional support: peer education was provided by inviting patients with better rehabilitation outcomes to share their experiences and self-management strategies, thereby enhancing confidence

Implementation of the IMCHB-Based Discharge Preparation Program

To assess patient singularity, before the intervention began, the research team developed a patient singularity questionnaire and interview outline based on a literature review to comprehensively evaluate patient status. The questionnaire covered disease understanding, readiness for discharge, knowledge needs, psychological status, and willingness to participate in shared decision-making after laryngeal cancer surgery. Face-to-face, one-on-one interviews were conducted by graduate nursing students and psychological counselors. Through open-ended questioning and reflective listening, the interviews explored patients’ perceptions of and needs for discharge preparation, clarified their motivation to participate in the program, identified perceived barriers, and assessed their psychological status.

During the nurse-patient interaction, patients and their family members were invited to participate in the development of care plans. The intervention covered the entire perioperative period and was delivered by associate chief physicians, head nurses, and graduate nursing students. It included 4 dimensions: health information, professional skills, emotional support, and decision-making support. Detailed intervention content is shown in Table 1. At 1 month after discharge, patients were reminded by telephone to return for follow-up, and the outcome data were collected on site.

Control Group

The control group received routine perioperative nursing care for laryngeal cancer from nurses who were not members of the research team. Routine care included the following: (1) admission guidance, including admission assessment and verbal orientation; (2) perioperative guidance, including explanation of disease-related knowledge, preoperative and postoperative assessment, verbal health education for patients and their families, and demonstration of speech rehabilitation training; and (3) discharge instructions, including verbal guidance regarding home care after discharge and follow-up scheduling.

Outcome Measures

Readiness for Hospital Discharge

The Readiness for Hospital Discharge Scale (RHDS), originally developed by Weiss et al and translated into Chinese by Lin et al [14], was used for assessment. The scale contains 12 items across 3 dimensions: personal status (3 items), adaptive capacity (5 items), and anticipated support (4 items). Each item is scored from 0 to 10. The total score ranges from 0 to 120, with higher scores indicating greater readiness for discharge. In the present study, the RHDS showed a content validity index of 0.88 and a Cronbach’s α of 0.89, indicating good validity and reliability.

Self-Management Capacity

The Cancer Patient Self-Management Ability Scale developed by Cheng and Sun [15] was used for assessment. This 44-item scale includes 6 dimensions: daily life management (11 items), psychological management (9 items), symptom management (7 items), information management (3 items), communication with healthcare providers (4 items), and self-efficacy (10 items). Each item is scored from 1 to 5, with higher scores indicating better self-management ability. In this study, the scale showed a Cronbach’s α of 0.959, indicating high reliability.

Anxiety and Depression

The Self-Rating Anxiety Scale and Self-Rating Depression Scale developed by Zung [16] were used to evaluate anxiety and depression, respectively. Previous studies have shown that the Chinese versions of both scales have good reliability and validity [17]. Each scale contains 20 items scored on a 4-point Likert scale ranging from 1 (“never”) to 4 (“often”). Higher scores indicate more severe anxiety or depression.

Data Collection

Before the study began, all personnel received standardized training and passed the assessment. Before data collection, the researcher explained the purpose and significance of the study and the requirements for questionnaire completion. All participants signed informed consent before the survey. Data were collected at 3 time points (Table 2). Because of the behavioral nature of the intervention, participants and outcome data collectors could not be fully blinded to group assignment. To reduce information bias, standardized questionnaire instructions were used for both groups. All completed questionnaires were checked on site, and any missing or unclear responses were clarified immediately. All 65 enrolled participants completed the discharge and 1-month follow-up assessments and were included in the final analysis; therefore, no imputation of missing data was required.

Table 2.

Time points for data collection.

Outcome measure	Before intervention	At discharge	1 month after discharge
Baseline characteristics	√	/	/
Readiness-for-discharge scale	/	√	/
Self-management ability scale	√	√	√
Self-rating anxiety and depression scales	√	√	√

Statistical Methods

Data were analyzed using IBM SPSS Statistic 24.0. Categorical variables are described as frequency and percentage, whereas continuous variables were expressed as mean ± standard deviation or median (P25, P75), as appropriate. Between-group comparisons were performed using the independent-samples t test, Mann-Whitney U test, chi-square test, or Fisher exact test, as appropriate. Within-group comparisons across time points were performed using 1-way ANOVA or the Kruskal-Wallis H test, as appropriate. Generalized estimating equation models including group, time, and group × time interaction terms were used to compare self-management ability and anxiety and depression outcomes between groups after the intervention. Degrees of freedom were reported for Wald χ² statistics. Baseline comparisons were considered descriptive because group allocation was non-randomized. Because this exploratory study involved several prespecified and clinically related outcomes, no formal Bonferroni correction was applied; instead, exact P values, effect sizes, and 95% CIs were provided where possible, and results were interpreted cautiously in light of the potential risk of type I error. For normally distributed between-group outcomes, mean differences with 95% CIs and Cohen’s d were calculated. For non-normally distributed between-group outcomes, the Mann-Whitney effect size r was calculated as |Z| / √N. A 2-sided P value of < 0.05 was considered statistically significant.

Results

Comparison of Baseline Characteristics

Baseline comparisons of general characteristics between the 2 groups (Table 3) showed no statistically significant differences in any variable (P > 0.05), indicating acceptable baseline comparability between groups. Figure 1 summarizes participant allocation, follow-up, and analysis. All 65 enrolled patients completed the discharge and 1-month assessments and were included in the final analysis.

Table 3.

Baseline characteristics of the participants.

Characteristic		Control group (n = 32,%)	Intervention group (n = 33,%)	Statistic	P value
Sex	Male	27 (84.4)	29 (87.9)	Fisher’s exact	0.733
	Female	5 (15.6)	4 (12.1)
Age (years)	18–49	6 (18.8)	5 (15.2)	Z = −0.262	0.793
	50–59	10 (31.3)	14 (42.4)
	60–69	12 (37.5)	10 (30.3)
	≥ 70	4 (12.5)	4 (12.1)
Marital status	Married	25 (78.1)	27 (81.8)	χ2 = 0.138	0.710
	Unmarried	7 (21.9)	6 (18.2)
Education	Elementary or below	13 (40.6)	13 (39.4)	χ2 = 1.271	0.736
	Middle school	9 (28.1)	6 (18.2)
	High school or vocational school	6 (18.8)	8 (24.2)
	College degree or above	4 (12.5)	6 (18.2)
Employment status	Employed	12 (37.5)	10 (30.3)	χ2 = 0.376	0.540
	Unemployed	20 (62.5)	23 (69.7)
Per capita monthly income (yuan)	< 1000	7 (21.9)	4 (12.1)	Z = −0.575	0.565
	1000–1999	14 (43.8)	18 (54.5)
	2000–2999	10 (31.3)	8 (24.2)
	≥ 3000	1 (3.1)	3 (9.1)
Place of residence	Rural	20 (62.5)	24 (72.7)	χ2 = 0.777	0.378
	Urban	12 (37.5)	9 (27.3)
Medical payment type	Self-funded	4 (12.5)	3 (9.1)	χ2 = 0.406	0.816
	Employee medical insurance	9 (28.1)	8 (24.2)
	Resident medical insurance	19 (59.4)	22 (66.7)
Living arrangement	Solitary living	5 (15.6)	3 (9.1)	Fisher’s exact	0.475
	Non-solitary living	27 (84.4)	30 (90.9)
Comorbidity	Yes	22 (68.8)	19 (57.6)	χ2 = 0.871	0.351
	No	10 (31.3)	14 (42.4)
Clinical stage	Stage I	3 (9.4)	5 (15.2)	Z = −1.180	0.238
	Stage II	12 (37.5)	16 (48.5)
	Stage III	13 (40.6)	8 (24.2)
	Stage IV	4 (12.5)	4 (12.1)

Notes: χ² values are shown for chi-square tests; Z values are shown for rank-sum tests; Fisher’s exact test was used where indicated.

Figure 1.

Participant recruitment, allocation, follow-up, and analysis flow. Abbreviations: RHDS, Readiness for Hospital Discharge Scale; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale; IMCHB, Cox Interaction Model of Client Health Behavior.

Comparison of Readiness-For-Discharge Scores After the Intervention

After the intervention, the intervention group had a higher total readiness-for-discharge score (99.97 ± 6.31) than the control group (88.09 ± 6.14). The between-group mean difference was 11.88 points (95% CI: 8.65 to 14.71; Cohen’s d = 1.91), corresponding to approximately 9.9% of the 0- to 120-point RHDS range. Significant between-group differences were also observed in all 3 dimensions—personal status, adaptive capacity, and anticipated support (all P < 0.05). Detailed results are shown in Table 4.

Table 4.

Comparison of readiness-for-discharge scores between groups.

Group	n	Total score	Personal status	Adaptive capacity	Anticipated support
Intervention group	33	99.97 ± 6.31	24.97 ± 2.52	42.55 ± 3.86	32.45 ± 3.60
Control group	32	88.09 ± 6.14	20.34 ± 2.79	39.56 ± 4.07	28.19 ± 3.11
t		7.683	7.022	3.033	5.112
P		< 0.001	< 0.001	0.004	< 0.001

Comparison of Self-Management Ability at Different Time Points

Before the intervention, self-management scores did not differ significantly between the 2 groups (P > 0.05). Over time, self-management ability increased in both groups after the intervention; however, the intervention group had higher scores than the control group at discharge (174.73 ± 9.35 vs 152.13 ± 12.78; MD = 22.60, 95% CI: 17.05 to 28.15; Cohen’s d = 2.02). At the 1-month follow-up, the self-management score in the intervention group remained higher than that in the control group (189.00 [186.00, 191.50] vs 144.00 [133.00, 154.50]; Mann-Whitney r = 0.86). Detailed results are presented in Table 5.

Table 5.

Comparison of self-management ability between groups.

Group	n	Before intervention	At discharge	1 month after discharge	Statistic	P value
Intervention group	33	145.15 ± 11.33	174.73 ± 9.35	189.00 (186.00, 191.50)	76.758	< 0.001
Control group	32	145.22 ± 11.49	152.13 ± 12.78	144.00 (133.00, 154.50)	7.074	0.029
Statistical value		t = −0.024	t = 8.156	Z = −6.933
P		0.981	< 0.001	< 0.001

Notes: Values in the Statistic column are Kruskal-Wallis H values (df = 2); values in the Statistical value row are t or Z statistics as indicated. Between-group comparison using the generalized estimating equation: Wald χ² time(2) = 145.398, Wald χ² group(1) = 262.451, and Wald χ² interaction(2) = 139.784 (all P < 0.001).

Comparison of Anxiety and Depression Scores at Different Time Points

Before the intervention, there were no statistically significant differences between the 2 groups in anxiety or depression scores (P > 0.05). At discharge and 1 month after discharge, both groups showed reductions in anxiety and depression scores (P < 0.05). The intervention group had lower anxiety and depression scores than the control group at both post-intervention time points. At discharge, the anxiety score difference was moderate in magnitude (41.48 ± 2.89 vs 43.19 ± 3.70; MD = −1.71, 95% CI: −3.36 to −0.06; Cohen’s d = 0.51), whereas the depression score difference was smaller (45.85 ± 3.86 vs 47.34 ± 3.69; MD = −1.49, 95% CI: −2.94 to −0.04; Cohen’s d = 0.51, calculated from the reported t statistic). At 1 month after discharge, anxiety scores were lower in the intervention group (42.00 [40.00, 43.50] vs 47.00 [38.00, 58.00]; Mann-Whitney r = 0.25), and depression scores were substantially lower (40.73 ± 3.18 vs 46.75 ± 3.09; MD = −6.02, 95% CI: −7.57 to −4.47; Cohen’s d = 1.92). Detailed results are shown in Tables 6 and 7.

Table 6.

Comparison of anxiety scores between groups.

Group	n	Before intervention	At discharge	1 month after discharge	Statistic	P value
Intervention group	33	50.00 ± 3.76	41.48 ± 2.89	42.00 (40.00, 43.50)	52.702	< 0.001
Control group	32	51.88 ± 4.33	43.19 ± 3.70	47.00 (38.00, 58.00)	25.482	< 0.001
Statistical value		t = −1.866	t = −2.072	Z = −2.018
P		0.067	0.042	0.044

Notes: Values in the Statistic column are Kruskal-Wallis H values (df = 2); values in the statistical value row are t or Z statistics as indicated. Between-group comparison using the generalized estimating equation: Wald χ² time(2) = 176.956, P < 0.001; Wald χ² group(1) = 17.509, P < 0.001; and Wald χ² interaction(2) = 6.237, P = 0.044.

Table 7.

Comparison of depression scores between groups.

Group	n	Before intervention	At discharge	1 month after discharge	Statistic	P value
Intervention group	33	50.00 (44.50, 52.50)	45.85 ± 3.86	40.73 ± 3.18	43.556	< 0.001
Control group	32	52.00 (48.50, 54.00)	47.34 ± 3.69	46.75 ± 3.09	20.391	< 0.001
Statistical value		Z = −1.936	t = −2.048	t = −7.747
P		0.057	0.045	< 0.001

Notes: Values in the Statistic column are Kruskal-Wallis H values (df = 2); values in the statistical value row are t or Z statistics as indicated. Between-group comparison using the generalized estimating equation: Wald χ² time(2) = 89.383, P < 0.001; Wald χ² group(1) = 42.549, P < 0.001; and Wald χ² interaction(2) = 13.498, P = 0.001.

Discussion

IMCHB-Based Discharge Preparation Program Was Associated With Higher Readiness for Discharge

A key feature of the IMCHB-based discharge preparation program for patients after laryngeal cancer surgery is its comprehensive and multidimensional assessment. This approach extends beyond routine physiological monitoring and systematically evaluates readiness for discharge from several perspectives, including physical function, psychological status, cognitive preparedness, and available social support. The transition from hospital to home is a critical stage and is also the period during which patients and their families have the greatest demand for health information [18]. Tailored interventions delivered during this period may shorten hospital stay and promote recovery [19]. In the present study, the intervention group achieved higher total readiness-for-discharge scores and higher scores in all dimensions than the control group (P < 0.05), which is consistent with the findings of Bai and Shang [20]. These results suggest that an IMCHB-based discharge preparation program may be associated with better discharge readiness in patients after laryngeal cancer surgery. Guided by the IMCHB, healthcare providers can tailor perioperative interactions according to each patient’s individual characteristics, rather than relying on uniform health education. In this study, the research team used a self-designed questionnaire and conducted in-depth face-to-face interviews to assess demographic characteristics, social background, previous disease knowledge, discharge needs, and the safety of the home environment. This process helped identify potential barriers to health behaviors in advance and facilitated the development of individualized discharge plans. In addition, unlike traditional 1-way education, this intervention emphasized interactive learning. The program incorporated case-based instruction, roundtable discussion, peer education, short videos, and interactive quizzes, which strengthened nurse-patient communication and encouraged patients to shift from passive recipients of information to active participants in rehabilitation. The use of staged rehabilitation goals may also have improved adherence, thereby further contributing to discharge readiness.

IMCHB-Based Discharge Preparation Program Was Associated With Higher Self-Management Ability

An important goal of an IMCHB-based discharge preparation program is to improve patients’ self-care skills and self-management ability after laryngeal cancer surgery. Strong self-management capacity can enhance patients’ ability to cope with illness and promote better health outcomes [21]. The IMCHB emphasizes timely and effective communication between healthcare professionals and patients. Through continuous interactive education, it may promote positive changes in disease cognition and health beliefs among postoperative patients. One major manifestation of this process is that patients gradually develop a more objective and comprehensive understanding of long-term postoperative rehabilitation. In contrast, traditional 1-way information delivery may leave patients insufficiently informed, leading to unnecessary fear and misunderstanding. Effective communication can enhance motivation, encourage active engagement in disease management, promote health-related behaviors, and ultimately improve self-management ability [22]. In the present study, the intervention group had higher self-management scores than the control group both at discharge and at 1 month after discharge (P < 0.05), which is consistent with previous studies [23,24]. In addition, significant time effects and group effects were observed (P < 0.001), indicating that self-management ability changed over time in both groups, while the intervention group consistently performed better. The wider interquartile range in the control group at 1 month suggested heterogeneity in post-discharge self-management, possibly reflecting differences in family support, understanding of verbal instructions, and opportunities to practice home care skills. The structured program may have reduced this variability by providing repeated education, demonstration, feedback, and peer support. In this study, patients received illustrated educational booklets on admission, participated in peer-support activities, and heard experience sharing from patients with better rehabilitation outcomes. Through repeated communication and feedback, this interactive approach provided systematic education on postoperative swallowing, voice production, and long-term complication management. It also helped patients establish realistic expectations regarding recovery, correct misconceptions, stimulate initiative, and strengthen disease management ability. In addition, one-to-one rehabilitation guidance further improved patients’ awareness of their role in recovery and enhanced their self-management capacity. Overall, higher self-management may help patients better cope with long-term postoperative problems and reduce the impact of treatment-related adverse effects, thereby laying a foundation for better quality of life.

IMCHB-Based Discharge Preparation Program Was Associated With Lower Anxiety and Depression Scores

Patients undergoing laryngectomy for laryngeal cancer often experience a substantial symptom burden and psychological distress because of laryngeal resection and the associated functional loss. Anxiety and depression are therefore important problems that can seriously affect quality of life [25]. In the present study, anxiety and depression scores were lower in the intervention group than in the control group both at discharge and at 1 month after discharge (P < 0.05). Significant group effects and time effects were also observed, indicating that negative emotions decreased over time in both groups, with greater reductions in the intervention group. These findings suggest that the IMCHB-based discharge preparation program may be associated with lower anxiety and depressive symptoms, which is consistent with the findings reported by Yuan [26]. Comprehensive health education and structured guidance on self-management and care may help patients view their illness more positively and reduce anxiety. Such support may also improve readiness for discharge and facilitate adaptation to family and social life after discharge [27]. In this study, the intervention emphasized patient singularity and used interactive approaches such as quizzes and individual listening sessions to elicit positive emotions, increase participation in family and social interaction, and reduce feelings of isolation. Previous studies have shown that collaborative coping and structured psychological intervention can reduce fear related to illness and improve coping ability [28,29]. By involving family members in decision-making, supervision, and encouragement, the present program may have helped patients respond more actively to disease-related stress and generate more positive emotions. In addition, one-to-one interviews, psychological adjustment, family support, and experience sharing from peers may have strengthened patients’ confidence in postoperative recovery, thereby contributing to lower anxiety and depression scores.

Clinical Significance and Practical Interpretation

Although several statistically significant differences were observed, clinical significance should be interpreted cautiously because minimal clinically important differences for the RHDS, the Cancer Patient Self-Management Ability Scale, the Self-Rating Anxiety Scale, and the Self-Rating Depression Scale have not been firmly established for patients after laryngeal cancer surgery. Therefore, in the present study, we interpreted practical importance using the scale range, between-group mean differences, 95% CIs, and standardized effect sizes. The 11.88-point difference in RHDS total score represented approximately 9.9% of the 0- to 120-point range and had a large standardized effect size (Cohen’s d = 1.91), suggesting a potentially meaningful difference in discharge preparedness. The 22.60-point self-management difference at discharge (Cohen’s d = 2.02) and the large rank-based effect at 1 month (r = 0.86) also suggest practical relevance. In contrast, the difference in anxiety at discharge and at 1 month was modest, whereas the 1-month difference in depression was larger. These findings indicate that the program may be most clinically relevant for discharge readiness and self-management, while psychological outcomes require confirmation in larger trials with validated minimal clinically important difference thresholds.

Limitations and Implications for Practice

This study has several limitations. First, the non-randomized allocation by admission order may have introduced selection bias and unmeasured confounding. Second, participants and outcome assessors could not be fully blinded, which may have increased detection bias. Third, because the intervention group received more structured contact, education, and attention than the control group, a Hawthorne effect cannot be excluded. Fourth, both groups were recruited from the same department; therefore, contamination between groups cannot be completely ruled out, although routine care was delivered by nurses who were not members of the intervention team. Fifth, this was a single-center study with a relatively small sample size and only 1 month of follow-up, limiting generalizability and conclusions about long-term outcomes. Sixth, no formal multiple-comparison correction was applied; therefore, some secondary findings should be considered exploratory. From a practical perspective, the program is feasible because it relies on structured education, illustrated booklets, QR-code videos, family participation, and scheduled follow-up; however, implementation requires staff time, multidisciplinary coordination, and peer-support organization. Future multicenter randomized trials should evaluate long-term outcomes, workload, cost-effectiveness, and implementation fidelity.

Conclusions

In this quasi-experimental study, the IMCHB-based discharge preparation program was associated with higher readiness for discharge, higher self-management ability, and lower anxiety and depression scores in patients undergoing laryngeal cancer surgery. These findings support the potential value and feasibility of structured, interaction-based discharge preparation in routine perioperative nursing. However, because of the non-randomized, single-center design, lack of blinding, possible contamination and Hawthorne effects, small sample size, and short follow-up period, randomized multicenter studies with workload and cost-effectiveness evaluations are needed to further assess the long-term effectiveness and clinical utility of this model.