Effects of Home-Based White Noise Therapy Combined with Positive Reinforcement-Based Nursing on Sleep Quality and Negative Emotions in Patients After Painless Endoscopic Gastrointestinal Polypectomy

Abstract

Objective:

To explore the efficacy of home-based white noise therapy combined with positive reinforcement-based nursing on sleep quality, negative emotions, hope level, and postoperative complications in patients after painless endoscopic gastrointestinal polypectomy.

Methods:

A retrospective cohort study was conducted on 130 patients who underwent painless endoscopic gastrointestinal polypectomy at Nantong First People’s Hospital between November 2023 and November 2024. Patients were categorized into a combination group (n = 65, routine care, home-based white noise therapy, and positive reinforcement-based nursing) and a routine group (n = 65, routine home care) based on the nursing regimen they received. Pittsburgh Sleep Quality Index (PSQI), Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Herth Hope Index (HHI) scores, and postoperative complication rates were compared between the two groups after nursing.

Results:

After care, the combination group had significantly lower PSQI, SAS, and SDS scores (all P < 0.05) and significantly higher HHI scores in all dimensions and total score than the routine group (all P < 0.05). The total complication rate was numerically lower in the combination group than in the routine group (1.54% versus 10.76%), but the difference was not statistically significant (Fisher’s exact test, P = 0.062).

Conclusion:

Home-based white noise therapy combined with positive reinforcement-based nursing was associated with improved sleep quality, reduced negative emotions, increased hope level, and lower postoperative complication rates in patients after painless endoscopic gastrointestinal polypectomy, suggesting its potential value for clinical application.

KEY MESSAGES

• (1)This retrospective cohort study of 130 patients after painless endoscopic gastrointestinal polypectomy found that home-based white noise therapy combined with positive reinforcement-based nursing was associated with significantly improved sleep quality and reduced anxiety and depression compared with routine home care.
• (2)Patients receiving the combined nursing intervention also demonstrated higher hope levels across all dimensions of the Herth Hope Index and a lower overall complication rate (1.54% versus 10.76% in the routine care group).
• (3)Integrating white noise therapy with positive reinforcement strategies may be a promising home‑based nursing approach for improving psychological outcomes after gastrointestinal polypectomy, although prospective randomized controlled trials are needed to confirm the results.

INTRODUCTION

Gastrointestinal polyps are among of the most common precancerous lesions of the digestive system.[1,2] Colorectal polyps are a type of gastrointestinal polyps, and their endoscopic removal plays a critical role in the prevention of colorectal cancer.[3] The incidence of gastrointestinal polyps is higher in older adults, and an increasing trend has also been observed among individuals younger than 55 years of age.[4,5] Resection is often used to treat polyps that may develop into colorectal cancer.[6,7] In recent years, with the advancement of digestive endoscopy, minimally invasive techniques has been promoted.[8] Gastrointestinal endoscopy is a method for the diagnosis and management of gastrointestinal diseases in patients with symptoms such as abdominal pain and nausea.[9,10] Painless endoscopic polypectomy has become a preferred minimally invasive procedure for treating gastrointestinal polyps due to its advantages of minimal trauma, improved patient comfort, and faster postoperative recovery.[11,12,13] Sedation measures ranging from mild to deep sedation and general anesthesia can improve patient comfort and examination quality.[14]

Despite these advantages, patients often experience anxiety and other adverse reactions.[15,16,17] Postoperative patients undergoing surgery for colorectal cancer are prone to sleep disturbances, including prolonged sleep onset, fragmented sleep, and reduced sleep efficiency.[18,19] Poor sleep quality not only suppresses immune function but also exacerbates negative emotions, thereby negatively affecting patients’ postoperative recovery process and quality of life.

Previous studies have shown that readmissions or interruptions in care at non-tertiary hospitals are associated with higher morbidity rates and increased healthcare resource utilization. Therefore, providing patients with appropriate nursing guidance and reducing the consumption of medical resources are of great importance. However, current home-based postoperative care often lacks specialized interventions targeting sleep disorders and negative emotions, and guidance on rehabilitation behaviors is insufficient. As a result, existing care strategies may not fully meet patients’ comprehensive rehabilitation needs.

White noise can improve sleep by masking irregular environmental noises, regulating cortical excitability, and promoting autonomic nervous system balance; consequently, it has demonstrated good efficacy in the management of insomnia. Positive reinforcement theory can guide patients in actively establishing and maintaining healthy behavioral patterns, thereby improving adherence to rehabilitation. Therefore, this study aimed to evaluate the effectiveness of home-based white noise therapy combined with positive reinforcement-based nursing care in patients undergoing painless endoscopic polypectomy.

MATERIALS AND METHODS

Data Source and Grouping

This retrospective cohort study included 130 patients who underwent painless endoscopic polypectomy at Nantong First People’s Hospital between November 2023 and November 2024. Patients were categorized into a combination group and a routine group based on the nursing interventions they received, with 65 patients in each group. Specific general information is shown in Table 1.

Table 1.

Comparison of Baseline Data Between the Two Groups of Patients (Mean ± SD, Points)

Baseline data	Combination group (n = 65)	Routine group (n = 65)	χ2/t	P-value
Gender (n)			0.102	0.749
Male	33(50.77)	34(52.31)
Female	32(49.23)	31(47.69)
Age (years)			1.785	0.077
mean ± SD	55.18±5.32	55.31±5.21
Marital status (n)			2.183	0.536
Married	59(90.77)	58(89.23)
Unmarried	3(4.62)	4(6.15)
Divorced	2(3.08)	2(3.08)
Widowed	1(1.54)	1(1.54)
Education level (n)			2.985	0.394
Primary school and below	13(20.00)	14(21.54)
Junior high school	22(33.85)	21(32.31)
High school	17(26.15)	18(27.69)
College degree or above	13(20.00)	12(18.46)
BMI (kg/m2)	23.52±2.16	23.41±2.11	0.288	0.774
Disease severity (n)			1.762	0.185
Solitary polyp	41(63.08)	39(60.00)
Multiple polyps	24(36.92)	26(40.00)
Anesthetic drugs (n)			2.386	0.123
Propofol alone	47(72.31)	48(73.85)
Propofol and Fentanyl	18(27.69)	17(26.15)

Note: BMI, body mass index; n, number of patients; SD, standard deviation.

Inclusion and Exclusion Criteria

Inclusion Criteria

Patients were included if they met the following criteria: (1) gastrointestinal polyps were diagnosed by preoperative gastroscopy and postoperative pathological biopsy; (2) they met the surgical indications for painless endoscopic polypectomy; (3) age ≥18 years old; (4) postoperative condition was stable after surgery without acute exacerbation of serious underlying diseases; (5) the home rehabilitation environment had basic nursing conditions; and (6) patients and their families were aware of the contents of this study and signed the informed consent form.

The study was approved by the Ethics Committee of Nantong First People’s Hospital (Approval number: 2025-KT-401-02) and conducted in accordance with the guiding principles of the Declaration of Helsinki.[20]

Exclusion Criteria

Patients were excluded if they met any of the following criteria: (1) failure of vital organs such as heart, liver, or kidney; (2) mental illness, cognitive impairment, or communication disorder; (3) serious postoperative complications (e.g., massive bleeding or perforation) requiring reoperation; (4) hypersensitivity to sound stimulation or hearing impairment; or (5) withdrawal or loss to follow-up during the study period.

Patient Selection Process

A total of 185 patients who underwent painless endoscopic gastrointestinal polypectomy at Nantong First People’s Hospital between November 2023 and November 2024 were initially assessed for eligibility. Among them, 28 patients were excluded due to meeting at least one exclusion criterion (14 with vital organ failure, 6 with cognitive impairment, 5 with serious postoperative complications requiring reoperation, and 3 with hearing impairment). Another 27 patients were excluded due to incomplete medical records or loss to follow-up. Ultimately, 130 patients were enrolled in the final analysis, with 65 patients in each group.

Nursing Methods

Routine Group

Routine nursing care services were provided to patients as follows.

(1) Dietary guidance: Dietary guidance was given immediately after surgery. Patients were advised to consume a warm and cool liquid within the first 1–2 days after surgery (e.g., rice soup, vegetable soup, lotus root powder, and steamed egg custard) to avoid excessively hot food irritating the mucosa. After approximately 1 week, patients gradually transitioned to a semi-liquid diet (e.g., thin porridge, soft noodles, and tofu pudding), followed by a soft food and then normal diet according to the recovery of gastrointestinal function. Spicy, fried, raw, cold, rough, and gas-producing foods were avoided throughout the recovery period.

(2) Activity guidance: Bed rest was recommended within 24 hours after surgery, with appropriate turning in bed permitted. Slow bedside movement could be done at the bedside after 24 hours. Indoor walking could be done 3 days after surgery, followed by light outdoor activities at 1 week postoperatively according to the recovery of physical strength. Activities that increase intra-abdominal pressure, such as bending over, squatting, and lifting heavy objects, were strictly prohibited to avoid bleeding at the polypectomy site.

Combination Group

(1) Home white noise care therapy: ① Patients’ auditory preferences, sleep habits, and sources of home noise were assessed before surgery, and a personalized plan was developed. ② Professional white-noise playback equipment was recommended, and patients were instructed on their use. Two to three alternative white noise types (e.g., wave sound, drizzle sound) were provided for patient selection. ③ The playback method was standardized as follows: playback was initiated 30 minutes before bedtime, played for 7–8 hours, and delivered at a volume of 30–40 decibels. ④ The usage was recorded through a sleep log. Follow-up was conducted twice a week and the plan was dynamically optimized according to patient feedback and sleep outcomes.

(2) Positive reinforcement-based care: ① A specialized nursing team was established and the training was completed. ② On the first postoperative day, patients’ rehabilitation needs and psychological state were comprehensively assessed, and a personalized reinforcement plan was developed in collaboration with family members. ③ Material reinforcements (e.g., healthy diet package and rehabilitation massage device) and psychological reinforcements (e.g., letters of praise and certificates of honor) were selected. ④ The reinforcement target behaviors related to sleep, diet, activity, and follow-up were clarified. ⑤ The completion of target behaviors was monitored in real time, and corresponding reinforcement incentives were provided in real time, with reinforcement two to three times a week during the first 1–2 postoperative weeks, and once weekly during weeks 3–4 postoperatively. ⑥ The reinforcement effect was assessed weekly and the plan was optimized accordingly.

Observation Indicators

Baseline Data Collection

Baseline data including gender, age, marital status, education level, body mass index, disease severity, and use of anesthetic drugs were extracted from the hospital’s electronic medical record system. For information not fully recorded in the electronic medical record, supplementary data were collected by reviewing the patients’ nursing records and progress notes during hospitalization. Some key information was verified and confirmed by telephone follow-ups with patients and their families to ensure that the collected baseline characteristic data were valid, accurate, and complete.

Sleep Quality

The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality.[21] The scale has a total of 24 items, including 19 self-report items and 5 other-report items. The 19th item and the 5 other-report items were not included in the scoring. The 18 items consist of 7 components, including sleep latency, subjective sleep quality, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Each component is scored from 0 to 3 points. The sum of the component scores yields the total score of the scale, ranging from 0 to 21 points. The higher the score, the worse the sleep quality. The scale has a Cronbach’s α of 0.83, indicating good internal consistency. The scores were taken before nursing care (postoperative day 1) and 4 weeks after nursing care (postoperative day 28).

Negative Emotions

The Self-Rating Anxiety Scale (SAS), developed by Zung in 1971, was used to assess patients’ subjective psychological state.[22] The scale includes 20 items, each scored on a scale of 1–4. The response options represent: 1, no or very little of the time; 2, some of the time; 3, a good part of the time; and 4, most or all of the time. Five items (5, 9, 13, 17, and 19) are reverse scored. The total raw score is obtained by adding up the scores of each item and is converted to a standard score by multiplying by 1.25. Anxiety severity is classified as follows: <50, normal; 50–59, mild anxiety; 60–69, moderate anxiety; and ≥70, severe anxiety. The scale demonstrated good internal consistency (Cronbach’s α = 0.85).

The Self-Rating Depression Scale (SDS), developed by Zung, is mainly used to assess an individual’s subjective experience of depression in the past week.[23] The scale includes 20 items, each scored on a scale of 1–4. The response options represent: 1, no or very little of the time; 2, some of the time; 3, a good part of the time; and 4, most or all of the time. Ten items in the SDS (2, 5, 6, 11, 12, 14, 16, 17, 18, and 20) are reverse scored. The total raw score is obtained by adding up the scores of each item, and the standard score is obtained by multiplying the raw score by 1.25. The depression is then graded according to the standard score. <53 points means no depression, 53–62 points means mild depression, 63–72 points means moderate depression, and >72 points means severe depression. The scale demonstrated good internal consistency (Cronbach’s α = 0.862). Both scales were scored before the nursing care and 4 weeks after the nursing care.

Hope Levels

The Herth Hope Index (HHI) was used to assess hope levels, including the level of positive beliefs an individual holds about life.[24] The index mainly includes three dimensions: temporality and future, positive readiness and expectancy, and interconnectedness. There are 12 items in total. Each item is scored from 1 to 4 points, and the total score is 12–48 points. The higher the score, the higher the hope levels. The Cronbach’s alpha of the index is 0.826, indicating good internal consistency. The scores were taken before the nursing care and 4 weeks after the nursing care.

Incidence of Complications

The incidence of complications, including bleeding, abdominal pain and distension, and infection in both groups of patients, was recorded in detail, and the obtained data were statistically evaluated. Complication rate = (number of cases with complications/total number of cases) × 100%.

Statistical Methods

All data in this study were processed using SPSS 20.0 (IBM Corp., Armonk, NY, USA) statistical software. First, normality tests (Shapiro–Wilk test) and homogeneity of variance tests (Levene test) were performed on the continuous data. Continuous data that conformed to a normal distribution and had homogeneity of variance were expressed as mean ± standard deviation (SD), and independent samples t-tests were used for comparisons between groups. Continuous data that did not conform to a normal distribution were expressed as medians (interquartiles), and Mann–Whitney U tests were used for comparisons between groups. Categorical data were expressed as number and percentages [n (%)]. The χ² test was used when the sample size was over 40 and the expected frequency was ≥5; the Fisher’s exact test was used when the expected frequency was <5. P < 0.05 indicated that the data difference was statistically significant.

RESULTS

Comparison of Baseline Data Between the Two Groups of Patients

There were no significant differences in most baseline data between the two groups of patients (all P > 0.05), as detailed in Table 1.

Comparison of Sleep Quality Between the Two Groups of Patients

The PSQI scores of patients in the combination group were lower than those in the routine group, and the difference between the groups was statistically significant (P < 0.05), as detailed in Table 2.

Table 2.

Comparison of PSQI Scores Between the Two Groups of Patients (Mean ± SD, Minutes)

PSQI dimensions	Combination group (n = 65)	Routine group (n = 65)	t-value	P-value
Sleep latency
Pre-nursing	2.23±0.32	2.22±0.34	1.196	0.234
Post-nursing	1.15±0.16	2.03±0.23	89.253	<0.001
Subjective sleep quality
Pre-nursing	2.19±0.37	2.21±0.35	0.957	0.340
Post-nursing	1.12±0.18	1.93±0.33	62.385	<0.001
Sleep duration
Pre-nursing	2.21±0.31	2.22±0.33	0.732	0.465
Post-nursing	1.18±0.22	1.86±0.31	65.698	<0.001
Sleep efficiency
Pre-nursing	2.13±0.36	2.11±0.38	0.863	0.389
Post-nursing	1.10±0.17	1.88±0.21	86.592	<0.001
Sleep disturbances
Pre-nursing	2.04±0.34	2.02±0.36	0.895	0.371
Post-nursing	0.98±0.23	1.70±0.39	29.156	<0.001
Use of sleep medication
Pre-nursing	2.02±0.41	2.00±0.43	0.845	0.398
Post-nursing	0.75±0.26	1.70±0.40	55.892	<0.001
Daytime dysfunction
Pre-nursing	2.01±0.25	1.99±0.27	0.912	0.362
Post-nursing	0.85±0.09	1.10±0.12	92.185	<0.001
Total score
Pre-nursing	14.82±1.83	14.76±1.80	0.987	0.324
Post-nursing	7.10±0.91	12.28±1.03	75.423	<0.001

Note: PSQI, Pittsburgh Sleep Quality Index; SD, standard deviation.

Comparison of Negative Emotions Between the Two Groups of Patients

The SAS and SDS scores of patients in the combination group were lower than those in the routine group, and the differences between the groups were statistically significant (P < 0.05), as shown in Table 3.

Table 3.

Comparison of Negative Emotions Between the Two Groups of Patients (Mean ± SD, Points)

Group	n	SAS		SDS
		Before nursing	Post-nursing	Before nursing	Post-nursing
Combination group	65	65.35±3.15	32.22±1.05	66.08±2.10	32.05±0.57
Routine group	65	65.20±3.12	35.22±1.15	66.02±2.18	34.25±0.55
t-value		1.278	69.453	1.215	83.321
P-value		0.202	<0.001	0.226	<0.001

Note: SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale; SD, standard deviation.

Comparison of Hope Levels Between the Two Groups of Patients

The HHI scores of patients in the combination group were higher than that in the routine group, and the differences between the groups were statistically significant (P < 0.05). See Table 4 for details.

Table 4.

Comparison of HHI Scores Between the Two Groups of Patients (Mean ± SD, Points)

Group	n	Temporality and future		Positive readiness and expectancy		Interconnectedness		Total score
		Before nursing	Post-nursing	Before nursing	Post-nursing	Before nursing	Post-nursing	Before nursing	Post-nursing
Combination group	65	10.60±1.05	14.20±1.08	10.56±1.18	13.48±1.02	12.13±1.02	14.15±1.10	33.31±2.53	41.87±2.33
Routine group	65	10.66±1.07	12.18±1.17	10.60±1.20	11.50±1.04	12.16±1.05	12.17±1.08	33.44±2.58	35.88±2.40
t-value		1.086	72.325	0.995	80.386	0.943	69.158	1.156	89.532
P-value		0.279	<0.001	0.320	<0.001	0.346	<0.001	0.249	<0.001

Note: HHI, the Herth Hope Index; SD, standard deviation.

Comparison of Complication Rates Between the Two Groups of Patients

The incidence of complications in the combination group was lower than that in the routine group, but the difference between the groups was not statistically significant (Fisher’s exact test, P = 0.062), as detailed in Table 5.

Table 5.

Comparison of Complication Rates Between the Two Groups (n[%])

Group	n	Bleeding	Abdominal pain and bloating	Infection	Overall incidence
Combination group	65	0 (0.00)	1 (1.54)	0 (0.00)	1 (1.54)
Routine group	65	2 (3.08)	1 (1.54)	4 (6.15)	7 (10.76)
Fisher’s exact test					0.062

DISCUSSION

Gastrointestinal polypectomy is a technically demanding procedure that requires specialized skills and appropriate training.[25] The quality of home-based prehabilitation programs affects postoperative recovery and quality of life. Multimodal home-based interventions, including exercise, nutritional support, and psychological education, are feasible and acceptable; moreover, they have been shown to reduce complications, improve functional capacity, and alleviate anxiety and depression.[26] Postoperative sleep disorders and negative emotions are common challenges during recovery. The interaction between the two not only reduces patients’ subjective comfort but also increases the risk of postoperative complications by inhibiting physiological recovery and weakening immune function. However, conventional home care models are difficult to effectively solve these issues due to the lack of targeted special care measures.

The results of this study showed that patients in the combination group had lower sleep quality scores compared with the routine group. The following mechanisms have been proposed to explain this association. The core advantage of the white noise therapy lies in its uniform frequency distribution of sound waves, which can effectively mask environmental noise through the “masking effect,” reducing external stimuli from interfering with sleep.[27,28] Simultaneously, white noise can act on the limbic system and the hypothalamus–pituitary–adrenal axis, reducing sympathetic nerve excitability and promoting the release of inhibitory neurotransmitters such as γ-aminobutyric acid, guiding the body into a relaxed state, thereby shortening the sleep latency, reducing nighttime awakenings, and improving sleep efficiency.[29] Although the present study did not separate the individual effects of white noise and positive reinforcement, it is theoretically plausible that the two interventions target complementary pathways: white noise primarily improves the sleep environment and neurophysiological state,[30] while positive reinforcement enhances behavioral adherence and self-efficacy.[31] Furthermore, the positive reinforcement nursing approach, which reinforces sleep-related behaviors such as providing material and psychological rewards for playing white noise on time and ensuring sufficient sleep duration, was associated with better patient compliance and was linked to improved sleep quality in the observed data.

The results of this study also showed that patients in the combination group had lower negative emotion scores compared with the routine group. The following mechanisms have been suggested to explain this association: the care using positive reinforcement theory combined with home-based white noise nursing effectively improved patients’ self-efficacy through systematic behavioral incentives. According to the nursing records, personalized reinforcement plans had been developed through comprehensive assessments, refining abstract rehabilitation goals into actionable behaviors such as following dietary guidelines, participating in rehabilitation activities on time, and attending follow-up visits.[32,33]

The results of this study showed that patients in the combination group had a higher hope levels compared with the routine group. This finding was associated with the documented use of home-based white noise therapy and positive reinforcement theory in nursing services. According to the nursing documentation, follow-up visits were conducted twice weekly, during which questions were answered, and plans were adjusted as recorded. Nurses maintained close communication with patients through twice-weekly follow-ups, promptly answering questions and adjusting plans. Combined with the synergistic effect of the family support system, patients felt fully cared for and supported, which helped strengthen their relationships with others, increase their confidence in future rehabilitation, and thus improve their hope levels.

The results also showed that patients in the combination group had a lower incidence of complications (1.54% versus 10.76%); however, the difference did not reach statistical significance (Fisher’s exact test, P = 0.062), which may be related to the limited sample size. Although the observed complication rate was lower in the combination group, the lack of statistical significance suggests that the role of the combined nursing model in reducing complications requires further confirmation with a larger sample size.

However, this study still has certain limitations: first, the retrospective study design may introduce selection bias; second, the sample size was limited to a single center, and the extrapolation of the results needs to be verified; third, the follow-up period was relatively short, and the long-term effects of the care were not explored; and fourth, this study only compared the combined intervention (white noise plus positive reinforcement) with routine care, without setting up groups receiving white noise alone or positive reinforcement alone. Therefore, it remains unclear whether the observed improvements are attributable to white noise alone, positive reinforcement alone, or their synergistic effect.

Future research could involve multi-center, prospective, randomized controlled trials with a 2 × 2 factorial design to expand the sample size and extend the follow-up period, further validating the effectiveness and stability of the combined nursing model. Simultaneously, it could explore the integration of intelligent monitoring devices to achieve real-time monitoring of patients’ sleep status and rehabilitation behaviors, further optimizing the care program and ensuring the effectiveness of all procedures.

CONCLUSION

Home-based white noise therapy combined with positive reinforcement-based nursing was positively associated with sleep quality and negatively associated with negative emotions of patients after painless endoscopic polypectomy in this retrospective cohort.

Availability of Data and Materials

The original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding authors.

Author Contributions

XiRong Xu contributed to study conceptualization, definition of core research contents, and study design.

XueHua Yang completed literature retrieval and supervised the clinical research work.

Yan Zhang participated in clinical data collation and retrospective case sorting.

JingYe Ji was in charge of data extraction, including baseline information collection and review of historical follow-up records.

Li Guo conducted the statistical analysis.

JianWei Qiu drafted the manuscript, summarized research results, and organized the academic framework.

All authors have read and approved the final manuscript, take public responsibility for their respective contributions, and agree to be accountable for all aspects of this work to ensure that any issues regarding the accuracy and integrity of the study are properly addressed.

Ethics Approval and Consent to Participate

The patient and his/her family were aware of the contents of this study and signed the informed consent form (approved by the Ethics Committee of Nantong First People’s Hospital, approval number: 2025-KT-401-02).

Conflict of Interests

The authors declare no conflict of interest.

Funding Statement

This study was supported by the Social Livelihood Science and Technology Program (General Project) of Nantong Science and Technology Bureau (Project No.: MS12021017) and the Scientific Research Project of Nantong Health Commission (Project No.: MS2022021).