Process-based nursing using explanation-simulation-practice-communication-support model for pain management after liver cancer intervention

Abstract

BACKGROUND

Liver cancer is highly prevalent and fatal; transcatheter arterial chemoembolization is its main interventional therapy. Post-transcatheter arterial chemoembolization pain is common and affects recovery, demanding optimized nursing strategies.

AIM

To explore the application of process-based nursing using the Explain-Simulate-Practice-Communication-Support (ESPCS) model for pain management after interventional therapy for liver cancer.

METHODS

A total of 500 patients who underwent interventional therapy for liver cancer and were admitted to Ganzhou Fifth People’s Hospital between January 2022 and January 2025 were selected and divided into a control group (n = 250, treated with routine nursing intervention) and an observation group (n = 250, treated with process-based nursing intervention using the ESPCS model) using a random number table method. Both groups received the intervention until discharge. The Visual Analog Scale scores at 2 hours, 6 hours, 12 hours, and 24 hours after surgery, the scores of the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-General before and after intervention, and the incidence of complications were compared between the two groups.

RESULTS

At 2 hours, 6 hours, 12 hours, and 24 hours postoperatively, the Visual Analog Scale scores in the observation group were significantly lower than those in the control group (2 hours: 4.18 ± 0.85 vs 4.36 ± 1.03, P = 0.034; 6 hours: 3.31 ± 0.67 vs 3.69 ± 0.82, P < 0.001; 12 hours: 2.89 ± 0.58 vs 3.13 ± 0.65, P < 0.001; 24 hours: 1.82 ± 0.69 vs 2.51 ± 0.82, P < 0.001). After intervention, HADS-Anxiety and HADS-Depression scores were significantly lower in the observation group than in the control group (HADS-Anxiety: 7.15 ± 1.57 vs 8.43 ± 1.82; HADS-Depression: 6.72 ± 1.49 vs 7.26 ± 1.76; both P < 0.001). Functional Assessment of Cancer Therapy-General domain scores in the observation group were significantly higher than those in the control group, including physical well-being (26.25 ± 3.01 vs 24.40 ± 2.77), social/family well-being (18.33 ± 2.65 vs 16.06 ± 2.12), emotional well-being (28.35 ± 3.43 vs 25.70 ± 3.12), and functional well-being (18.45 ± 3.03 vs 16.84 ± 2.86) (all P < 0.001). The incidence of complications was significantly lower in the observation group than in the control group (3.20% vs 7.20%, P = 0.044).

CONCLUSION

Process-based nursing interventions based on the ESPCS model can effectively alleviate the degree of pain in patients after interventional therapy for liver cancer, improve their psychological state and quality of life, and reduce the incidence of complications.

Key Words: Liver cancer; Interventional therapy; Explain-Simulate-Practice-Communication-Support model; Process-based nursing; Pain management

Core Tip: Process-based nursing based on the Explain-Simulate-Practice-Communication-Support model significantly reduced postoperative pain scores, alleviated anxiety and depression, improved quality of life, and lowered complication rates in patients undergoing transcatheter arterial chemoembolization for liver cancer. This model provides an evidence-based and structured nursing framework for postoperative pain management.

INTRODUCTION

Control group: Routine nursing intervention was implemented, including: (1) Continuous monitoring of vital signs every 30 minutes within the first 2 hours after transcatheter arterial chemoembolization (TACE) and every 4 hours thereafter[1]; (2) Routine postoperative health education (approximately 15-20 minutes per session, once daily), covering basic disease knowledge and postoperative precautions[2]; (3) Standard pain assessment using the Visual Analog Scale (VAS) at 2 hours, 6 hours, 12 hours, and 24 hours postoperatively, with analgesics administered according to physicians’ orders when VAS ≥ 4[3]; (4) Dietary guidance according to medical advice; (5) Guidance on gradual mobilization beginning 6 hours postoperatively; and (6) Basic psychological support through bedside communication (10-15 minutes per day). The routine nursing intervention was continued until discharge[4,5].

The Explain-Simulate-Practice-Communication-Support (ESPCS) model is developed using the five-step teaching method proposed by Benner[6], an American scholar, in 2011, namely “Engage, Simulate, Practice, Confirm, and Support”. It can combine theoretical knowledge of diseases with nursing practice, strengthen doctor-patient communication through a multi-angle and process-based approach, consolidate and enhance patients’ correct cognition of diseases, and improve their self-management ability to achieve the purpose of intervening in patients’ physical and psychological conditions. It has been widely used recently in clinical nursing management and has achieved satisfactory results[7,8]. However, its application in patients after interventional therapy for liver cancer has not yet been reported, and an effective reference basis is lacking. Therefore, we explored the application of process-based nursing using the ESPCS model for pain management after interventional therapy for liver cancer.

MATERIALS AND METHODS

General information

A total of 500 patients who underwent interventional therapy for liver cancer and were admitted to Ganzhou Fifth People's Hospital between January 2022 and January 2025 were selected and divided into two groups using a random number table method: The control group (n = 250, treated with routine nursing intervention) and the observation group (n = 250, treated with process-based nursing intervention using the ESPCS model). No statistically significant differences were observed in the general information between the two groups (P > 0.05), indicating comparability (Table 1). This study was approved by the Medical Ethics Committee of the Ganzhou Fifth People’s Hospital.

Table 1 Baseline characteristics of patients in the two groups, n (%).

General information	Control group (n = 250)	Observation group (n = 250)	χ2/t	P value
Gender			0.298	0.585
Male	145 (58.00)	151 (60.40)
Female	105 (42.00)	99 (39.60)
Lesion location			0.457	0.496
Left lobe	72 (28.80)	75 (30.00)
Right lobe	125 (50.00)	128 (51.20)
Bilobar	53 (21.20)	47 (18.80)
Number of lesions			0.090	0.765
Solitary	182 (72.80)	179 (71.60)
Multiple	68 (27.20)	71 (28.40)
Maximum lesion diameter			0.130	0.719
≥ 5 cm	138 (55.20)	142 (56.80)
< 5 cm	112 (44.80)	108 (43.20)
Child-Pugh classification			0.093	0.760
Grade A	64 (25.60)	67 (26.80)
Grade B	186 (74.40)	183 (73.20)
Age (year), mean ± SD	58.62 ± 6.37	58.33 ± 6.40	0.508	0.612
BMI (kg/m2), mean ± SD	22.56 ± 1.44	22.51 ± 1.48	0.383	0.702
Number of interventional treatments, mean ± SD	3.10 ± 0.86	3.06 ± 0.82	0.532	0.595

BMI: Body mass index.

Inclusion and exclusion criteria

Inclusion criteria: (1) All patients met the clinical diagnostic criteria for liver cancer[9]; (2) All patients underwent TACE with a smooth surgical process; (3) Patients had good cognitive, verbal expression, reading and writing abilities; and (4) Informed consent was obtained from all patients, who were able to cooperate throughout the entire research process.

Exclusion criteria: (1) Patients with malignant tumors in other parts of the body; (2) Patients with an expected survival period of less than 3 months; (3) Patients with contraindications to TACE; (4) Patients with severe organic lesions of vital organs such as the heart and lungs; and (5) Patients with mental disorders who were unable to cooperate with the study.

Intervention methods

Control group: Routine nursing intervention was implemented, which included routine vital sign monitoring after interventional therapy, explanation of disease-related knowledge to patients, and provision of psychological counseling. The patients’ diets were adjusted after the interventional therapy in accordance with the doctors’ advice. Patients were encouraged to get out of bed as early as possible and guided to perform the rehabilitation exercises.

Observation group: A process-based nursing intervention based on the ESPCS model was adopted, based on the routine nursing intervention applied in the control group, and the specific measures were as follows: (1) Explaining session: A relaxed and harmonious atmosphere was created. Nurses used the comprehensive assessment results of the patients’ disease data and physical conditions to conduct systematic health education through group lectures (including display boards, animations, and videos) and one-on-one interviews. The content covers the purpose of interventional therapy for liver cancer and the significance of postoperative pain management, daily healthcare, and precautions. After health education, the patients’ mastery of disease knowledge was evaluated using knowledge quizzes and verbal retelling. Positive feedback and encouragement were given to patients who answered fluently and mastered the knowledge proficiently, such as “your answer is excellent” and “we believe that with our joint efforts, a good rehabilitation effect will be achieved”, to enhance patients’ confidence in treatment. For patients who retold the content vaguely or had questions, nurses patiently answered their doubts, communicated closely with them to identify the causes of poor mastery, and provided reeducation on relevant knowledge; (2) Simulated session: Before performing functional training, patients were guided by nurses to watch videos to learn the methods and precautions for early rehabilitation functional training. In addition, patients and/or their family members were initially taught to recognize the pain rating scale and conduct self-assessment of pain. Subsequently, nurses demonstrated the content in the videos on-site, with each action demonstrated thrice, and the patients were encouraged to imitate. Nurses provided guidance throughout the process and answered the patients’ questions promptly during imitation, ensuring that all patients fully mastered the correct training methods and pain self-assessment skills; (3) Practice session: The operative limb was immobilized for 6 hours after interventional therapy, and the head of the bed was elevated by 15 degrees. The patients performed knee flexion exercises with the unaffected limb and ankle pump exercises with the operative limb under the guidance of nurses. According to the patients’ physical tolerance, they were assisted to perform rehabilitation training, including bed-chair transfer, out-of-bed sitting, standing, and walking, for 30 minutes per session and two sessions per day. Patients self-assessed their pain intensity at 2 hours, 4 hours, 6 hours, 12 hours, and 24 hours after surgery and actively reported the assessment results. Medical staff implemented pain management strategies combining non-pharmacological analgesic methods (chatting, listening to music, reading, guided imagery meditation, and mindfulness thinking) and pharmacological analgesia (in accordance with the doctors’ advice) based on the patients’ pain levels; (4) Communication session: Inductive communication was adopted to guide patients in expressing their subjective feelings to completely understand their psychological characteristics and emotional expression styles. Based on respecting patients’ feelings and emotions, nurses put themselves in patients’ shoes to achieve appropriate empathy and used micro-expressions such as eye contact and smiling to help patients relax and establish a trusting relationship. Subsequently, the Hospital Anxiety and Depression Scale (HADS)[10] was used to evaluate patients’ psychological status. Psychological interventions, including deep breathing training, music therapy, and mindfulness-based cognitive therapy, were conducted for patients with symptoms of anxiety and depression. The patients were guided to utilize their internal positive strengths to manage the disease and effectively improve their psychological state; and (5) Support session: “anti-cancer stars”, i.e., patients with liver cancer and good rehabilitation effects, were invited to share their own anti-cancer experiences to further enhance patients’ confidence in rehabilitation. When communicating with patients and their family members, nurses emphasized that the prognosis of patients’ rehabilitation was not only related to the medications they took but also associated with better material life, family companionship, support, and encouragement. The aim was to help patients establish a support system with their families and relatives, encourage family members to actively participate in disease management, and provide emotional and practical help. Patients were guided to actively participate in cancer patient support and mutual-aid groups, and use the medical consortium’s doctor-nurse integration platform and the “internet plus” platform for information sharing and emotional release to obtain support from other patients.

The above interventions were implemented until all patients were discharged from the hospital.

Outcome measures

Pain score: The VAS[11] was used to assess pain intensity at 2 hours, 6 hours, 12 hours, and 24 hours after surgery. The scores range from 0 to 10, with higher scores indicating more severe pain.

Psychological status: The HADS[10] was applied to evaluate psychological status before and after intervention. The scale consists of two subscales: The HADS-Anxiety (HADS-A) and HADS-Depression (HADS-D), each with a score range of 0 to 21. Higher scores indicated more severe anxiety and depression. Cronbach’s α coefficients of the HADS-A and HADS-D subscales were 0.820 and 0.807, respectively.

Quality of life: The Functional Assessment of Cancer Therapy-General[12] was adopted to measure the quality of life before and after the intervention. The scale comprises four domains, including physical well-being, with 27 items. Each item is scored from 0 to 4, with higher total scores indicating better quality of life. Cronbach’s α coefficients for the physical well-being, social/family well-being, emotional well-being, and functional well-being domains of the scale were 0.884, 0.821, 0.867, and 0.835, respectively.

Incidence of complications: The occurrence of postoperative complications such as puncture site hematoma, infection, and dysuria/urinary retention was recorded for both groups.

Statistical analysis

All statistical data were analyzed using the SPSS 26.0 statistical software. Count data are expressed as n (%) and compared using the χ² test. Measurement data conforming to a normal distribution are presented as mean ± SD and compared between groups using the independent samples t-test. Statistical significance was set at P < 0.05.

RESULTS

Comparison of postoperative pain scores between the two groups

The VAS score at 24 hours postoperatively was markedly lower in the observation group (1.82 ± 0.69) compared with the control group (2.51 ± 0.82), with a statistically significant difference (t = 10.180, P < 0.001), indicating a clinically meaningful reduction in pain intensity as shown in Table 2.

Table 2 Comparison of postoperative pain scores between the two groups, mean ± SD.

Group	Case	2 hours postoperatively	6 hours postoperatively	12 hours postoperatively	24 hours postoperatively
Control	250	4.36 ± 1.03	3.69 ± 0.82	3.13 ± 0.65	2.51 ± 0.82
Observation	250	4.18 ± 0.85	3.31 ± 0.67	2.89 ± 0.58	1.82 ± 0.69
t	-	2.131	5.674	4.356	10.180
P value	-	0.034	< 0.001	< 0.001	< 0.001

Comparison of psychological status scores between the two groups

Before intervention, there were no significant differences in HADS-A or HADS-D scores between the two groups (P > 0.05). After intervention, the HADS-A score was significantly lower in the observation group (7.15 ± 1.57) than in the control group (8.43 ± 1.82) (t = 8.420, P < 0.001), indicating more effective alleviation of anxiety symptoms. Similarly, the HADS-D score after intervention was lower in the observation group (6.72 ± 1.49) compared with the control group (7.26 ± 1.76), with a statistically significant difference (t = 3.703, P < 0.001), suggesting improved control of depressive symptoms. These findings demonstrate that ESPCS-based nursing contributed to better psychological outcomes (Table 3).

Table 3 Comparison of psychological status scores between the two groups, mean ± SD.

Group	Case	HADS-A		HADS-D
		Before	After	Before	After
Control	250	14.95 ± 2.51	8.43 ± 1.82a	14.01 ± 2.40	7.26 ± 1.76a
Observation	250	15.09 ± 2.55	7.15 ± 1.57a	13.98 ± 2.32	6.72 ± 1.49a
t	-	0.619	8.420	0.142	3.703
P value	-	0.536	< 0.001	0.887	< 0.001

^aP < 0.05 vs the pre-intervention level in the same group.

HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression.

Comparison of quality of life scores between the two groups

After intervention, the physical well-being score was significantly higher in the observation group (26.25 ± 3.01) than in the control group (24.40 ± 2.77) (t = 7.151, P < 0.001), reflecting improved physical status. The social/family well-being score was also higher in the observation group (18.33 ± 2.65 vs 16.06 ± 2.12; t = 10.576, P < 0.001), indicating enhanced social support perception. In terms of emotional well-being, the observation group scored 28.35 ± 3.43 compared with 25.70 ± 3.12 in the control group (t = 9.037, P < 0.001), demonstrating improved emotional adjustment. The functional well-being score was likewise significantly higher in the observation group (18.45 ± 3.03 vs 16.84 ± 2.86; t = 6.110, P < 0.001), indicating better recovery of daily functioning. Collectively, these results indicate that ESPCS-based nursing significantly enhanced multidimensional quality of life (Table 4).

Table 4 Comparison of quality of life scores between the two groups, mean ± SD.

Group	Case	Physiological status		Social/family status		Emotional state		Function status
		Before	After	Before	After	Before	After	Before	After
Control	250	14.05 ± 2.18	24.40 ± 2.77a	10.53 ± 1.82	16.06 ± 2.12a	13.61 ± 2.72	25.70 ± 3.12a	12.61 ± 2.45	16.84 ± 2.86a
Observation	250	14.03 ± 2.15	26.25 ± 3.01a	10.49 ± 1.90	18.33 ± 2.65a	13.65 ± 2.77	28.35 ± 3.43a	12.74 ± 2.53	18.45 ± 3.03a
t	-	0.103	7.151	0.240	10.576	0.163	9.037	0.584	6.110
P value	-	0.918	< 0.001	0.810	< 0.001	0.871	< 0.001	0.560	< 0.001

^aP < 0.05 vs the pre-intervention level in the same group.

Comparison of the incidence of complications between the two groups

The total incidence of complications was significantly lower in the observation group (3.20%, 8/250) than in the control group (7.20%, 18/250), with a statistically significant difference (χ² = 4.057, P = 0.044), suggesting improved safety and postoperative recovery. Specifically, puncture site hematoma occurred in 2.00% of patients in the observation group compared with 3.60% in the control group; infection occurred in 0.80% vs 2.00%; dysuria/urinary retention occurred in 0.40% vs 0.80%; and no cases of venous thrombosis were observed in the observation group. These findings indicate that process-based nursing based on the ESPCS model effectively reduced postoperative complications (Table 5).

Table 5 Comparison of complication incidence rates between the two groups, n (%).

Group	Number of cases	Puncture site hematoma	Infection	Dysuria/urinary retention	Venous thrombosis	Total
Control group	250	9 (3.60)	5 (2.00)	2 (0.80)	2 (0.80)	18 (7.20)
Observation group	250	5 (2.00)	2 (0.80)	1 (0.40)	0 (0.00)	8 (3.20)
χ2	-	-	-	-	-	4.057
P value	-	-	-	-	-	0.044

DISCUSSION

TACE is currently the primary treatment modality for liver cancer, and its efficacy and safety have been widely validated in clinical practice[13-15]. However, with the advancement of clinical practice, several studies have found that TACE for liver cancer requires regular and repeated administration, which tends to induce several toxic side effects and seriously compromise patients’ quality of life[16,17]. Traditional clinical nursing focuses primarily on disease management and lacks multidimensional professional guidance in psychology, rehabilitation medicine, and other fields. Relatively, single content failed to yield optimal nursing outcomes. In contrast, process-based nursing, based on the ESPCS model, which is derived from medical simulation education, consists of five components: Explain, simulate, practice, communication, and support. It unleashes the advantages of combining theory with practice, emphasizes communication between medical staff and patients, and provides guidance and support in patient disease management. This model has been proven to play an important guiding role in improving patients’ self-care abilities and accelerating the rehabilitation process[18].

Process-based nursing intervention based on the ESPCS model effectively alleviates postoperative pain in patients undergoing interventional therapy for liver cancer

Previous studies have demonstrated that structured nursing interventions significantly improve postoperative recovery in patients undergoing TACE. Yu et al[18] reported that the ESPCS model improved self-management ability and postoperative tolerance in patients with colon cancer. Similarly, integrative psychological interventions recommended by the American Society of Clinical Oncology have been shown to reduce anxiety and depressive symptoms in cancer patients[19,20]. Consistent with these findings, the present study further confirms that the ESPCS-based nursing model can simultaneously improve pain control, psychological well-being, and quality of life in liver cancer patients receiving interventional therapy. Compared with conventional routine nursing, the structured and interactive nature of the ESPCS model may better address multidimensional patient needs.

Process-based nursing intervention based on the ESPCS model improves the psychological status and quality of life of patients after interventional therapy for liver cancer

Previous studies have demonstrated that psychological symptoms are prevalent among cancer patients, with anxiety and depression being the most common[20]. In particular, patients undergoing interventional therapy for liver cancer are more prone to negative psychological symptoms due to traumatic stress responses, fear of cancer recurrence, and other contributing factors[21,22]. Therefore, greater attention should be paid to patients’ psychological symptoms when strengthening disease management for these patients. Several international guidelines recommend mindfulness-based stress reduction, music therapy, and cognitive behavioral therapy as effective approaches for managing anxiety and depression in patients with cancer[23,24]. After the intervention, the HADS-A and HADS-D scores of the observation group were lower than those of the control group, and the Functional Assessment of Cancer Therapy-General scores were higher than those of the control group. This analysis suggests that the ESPCS-based nursing process fully embodies a patient-centered, holistic nursing concept. Patients can gain a comprehensive understanding of liver cancer-related management through different educational methods. Moreover, repeated communication and counseling, combined with psychological interventions, such as deep breathing training, music therapy, and mindfulness-based cognitive therapy, not only greatly boost patients’ confidence in rehabilitation but also provide effective channels for releasing negative emotions, thereby reducing the level of psychological stress response. Comprehensive interventions, including inspiration from “anti-cancer stars”, family emotional support, and peer support groups, positively affect patients’ rehabilitation, helping them return to normal life and society earlier, which is more conducive to improving their psychological status and quality of life.

Process-based nursing intervention using the ESPCS model reduces the incidence of postoperative complications in patients undergoing interventional therapy for liver cancer

The literature reports that bed rest and immobilization after liver cancer interventional therapy increase the risk of complications, such as pressure injuries and urinary retention. Furthermore, because patients with cancer are often in a hypercoagulable state, the incidence of venous thrombosis increases with a prolonged duration of postoperative immobilization[25]. The results of this study demonstrated that the incidence of complications was lower in the observation group than in the control group (3.20% vs 7.20%). Multifaceted nursing interventions, including explain, communication, and support sessions under the ESPCS-based process nursing model, can alleviate patients’ psychological and physiological stress responses, enabling them to maintain a positive mental state and reduce the immunosuppressive effect of tumors. Enhanced pain assessment and management can reduce postoperative stress responses, significantly improve physiological comfort, and facilitate better cooperation between different treatments and nursing measures. Rehabilitation exercises not only enhance immune function and cardiopulmonary capacity but also promote limb blood circulation. The combined implementation of the above nursing measures maximally meets the patients’ multilevel nursing needs and lays a solid foundation for postoperative rehabilitation, thereby reducing the incidence of complications.

Limitations

However, several limitations should be acknowledged. First, this was a single-center study, which may limit the generalizability of the findings. Second, although randomization was performed, blinding was not implemented due to the nature of the nursing intervention, which may introduce potential performance bias. Third, the follow-up period was limited to hospitalization, and long-term outcomes such as chronic pain, recurrence-related anxiety, and sustained quality-of-life improvements were not evaluated. In addition, potential confounding factors such as socioeconomic status and family support level were not quantitatively analyzed. Future multicenter randomized controlled trials with long-term follow-up are needed to further validate these findings and explore the sustainability of the ESPCS nursing model.

CONCLUSION

In conclusion, process-based nursing interventions based on the ESPCS model can effectively alleviate postoperative pain, improve the psychological status and quality of life, and reduce the incidence of complications in patients undergoing interventional therapy for liver cancer, all of which have significant clinical application value. However, this study had certain limitations. For instance, the study population was recruited from only one hospital, which may have led to a selection bias. In addition, the research period was relatively short, and no follow-up survey was conducted to evaluate the long-term effects of the intervention. Therefore, large-sample multicenter studies are warranted in the future to further verify and validate the findings of this study.