Impact of Neuman model-guided stepped care on elderly gastric cancer patients’ postop recovery

Abstract

BACKGROUND

Owing to age-related physiological declines, elderly patients undergoing radical gastrectomy (RG) often experience physical and psychological challenges. Hence, appropriate nursing strategies need to be identified for optimizing patient outcomes.

AIM

To evaluate the effects of the Neuman Systems Model-guided stepped care intervention (NGSC) model on postoperative physical and psychological recovery in elderly patients with gastric cancer who underwent RG.

METHODS

In total, 80 elderly patients (≥ 65 years old) who underwent RG at the Shanxi Fenyang Hospital between January 2023 and June 2024 were included and randomly divided as follows: Control group (n = 40, those receiving conventional stepped care intervention); observation group (n = 40, those receiving NGSC). Postoperative recovery indices, anxiety/depression scores (Self-Rating Anxiety Scale/Self-Rating Depression Scale), quality of life (36-item short form health survey), and adverse event rates were compared between the groups.

RESULTS

Compared with the control group, the observation group presented significantly shorter recovery times for first bowel sounds, ambulation, flatus, oral intake, catheter removal, and hospitalization (all P < 0.05). Notably, in the observation group, Self-Rating Anxiety Scale/Self-Rating Depression Scale scores and the adverse event rate were significantly lower (all P < 0.05), whereas 36-item short form health survey scores were higher (P < 0.05), compared with those in the control group.

CONCLUSION

Overall, the findings of this study show that the proposed NGSC model accelerates postoperative recovery, alleviates psychological distress, improves quality of life, and reduces complications in elderly patients with gastric cancer who underwent RG, presenting potential for clinical application.

Key Words: Gastric cancer; Neuman Systems Model; Stepped care intervention; Elderly radical gastrectomy; Physical and psychological status; Postoperative recovery

Core Tip: This study innovatively applied the Neuman Systems Model to stepped care interventions during postoperative recovery for elderly gastric cancer patients. By systematically assessing patients’ stressors and hierarchically activating the physiological-psychological defense mechanisms, the Neuman Systems Model-guided approach could significantly accelerate functional recovery (32% reduction in bowel sound recovery time, 24% shorter hospitalization) and reduce anxiety/depression rates by 41%. Concurrently, it showed improvement in the quality of life scores (36-item short form health survey increased by 18.6 points), thereby establishing a theoretically driven practical paradigm for perioperative management in cases of geriatric oncology.

INTRODUCTION

Gastric cancer (GC) is the fifth most common cancer and the third leading cause of cancer-related mortality worldwide, and with an annual incidence of approximately 1 million new cases and 750000 deaths, it poses a significant global health burden[1]. Approximately 44% of global GC cases and 42% of deaths arise in East Asia, particularly China, Japan, and South Korea[2], highlighting the disproportionate impact in this region. GC presents a multifactorial etiology, with chronic “Helicobacter pylori” infection, as a major contributor, being associated with 70%-80% of cases and classified as a group 1 carcinogen by the International Agency for Research on Cancer[3]. Additional key risk factors of GC include advanced age, sex (male), high-salt and processed food diets, smoking, obesity, and genetic predispositions, such as hereditary diffuse, to GC[4]. Despite advances in endoscopic screening, most patients with GC are diagnosed at advanced stages, necessitating surgery-based multimodal therapies such as chemotherapy and radiation therapy[5]. Radical gastrectomy (RG) is the standard curative approach for treating early-to-mid-stage GC; however, persisting postoperative complications, including anastomotic leakage, malnutrition, and infections, considerably limit functional recovery and long-term quality of life[6]. Notably, elderly patients (≥ 65 years old) experience heightened risks owing to age-associated physiological frailty, comorbidities, and slower recovery, with 30-d complication rates reaching up to 38% and significant postoperative depression and anxiety rates (32% and 41%, respectively)[7-9].

Traditional nursing approaches often overlook the psychological, social, and environmental dimensions critical to holistic patient care, while prioritizing physiological monitoring. This necessitates the employment of holistic models, such as the Neuman Systems Model (NSM), to address aforementioned challenges through personalized, patient-centered care. The NSM is a comprehensive framework utilized for addressing this gap by emphasizing the dynamic interplay between individuals and their environments, with the ultimate aim to strengthen resilience against stressors and maintain systemic balance[10]. The NSM involves the following three levels of prevention: (1) Primary prevention, reducing stressors’ impact through education and support; (2) Secondary prevention, managing stressor-induced imbalances via therapeutic interventions; and (3) Tertiary prevention, mitigating residual effects and promoting recovery. Stepped care intervention (SCI), a tiered strategy based on the patient’s need that escalates support from basic to specialized care accordingly, complements NSM while ensuring efficient resource allocation and personalized care. Empirical evidence underscores the efficacy of SCI in reducing postoperative anxiety and depression and enhancing self-management capabilities of the patients, along with optimizing healthcare resource usage[12-14]. For instance, a trial including patients with colorectal cancer reported a 23% and 18% decrease in complications and recovery time with SCI, respectively[14]. NSM-guided SCI (NGSC) offers a powerful approach to patient care, exhibiting the combined strengths of holistic stressor management with structured, patient need-driven support. This synergistic approach can improve clinical outcomes and foster patient-centered care, addressing the full spectrum of patient needs, from prevention to recovery. Hence, further studies are required to explore the long-term benefits and cost-effectiveness of this integrated NGSC model across diverse patient populations.

Herein, NSM was innovatively integrated with SCI to develop an NGSC model. Through phased psychological support, nutritional management, functional exercise guidance, and family system reinforcement, the effects of the developed NGSC model were evaluated for postoperative outcomes, complications, and long-term quality of life in elderly patients with GC to provide a research basis for evidence-based geriatric oncology nursing.

MATERIALS AND METHODS

General information

This prospective study included 80 patients who underwent RG for GC at the Fenyang Hospital in Shanxi Province between January 2023 and June 2024. The study protocol was reviewed and approved by the hospital’s Ethics Committee, and all patients provided their written informed consent before their enrollment in the study.

The patients were assigned to the following groups: Control (n = 40): 19 males, 21 females, aged 63-81 (69.04 ± 1.26) years, body mass index 24.04 ± 1.09 kg/m², disease duration 0.68 ± 0.37 years, and 8 patients with lymph node metastasis. Observation group (n = 40): 23 male, 17 female, aged 64-83 (69.78 ± 1.34) years, body mass index 24.34 ± 1.06 kg/m², duration 0.70 ± 0.31 years, and 9 Lymph node metastases. There was no difference between the baseline data of the two groups (P > 0.05).

Inclusion and exclusion criteria

Inclusion criteria: (1) Pathologically confirmed GC; (2) Age ≥ 60 years; (3) History of RG with lymph node dissection; (4) Eastern Cooperative Oncology Group performance status 0-2; (5) No history of other malignancies; and (6) No severe cognitive or communication impairments.

Exclusion criteria: (1) Emergency surgery; (2) Distant metastasis; (3) Severe cardiovascular or respiratory comorbidities; and (4) Inability to participate in postoperative follow-up.

Methods-control group

Psychological nursing factors were implemented as follows. First, a professional psychological nursing team comprising gastrointestinal surgeons, psychologists, and specialized nurses with experience in clinical care for GC patients was established. All group members were required to have undergone a unified psychological knowledge training course before their enrollment, on the condition of having met predefined assessment standards.

During formulation: Before patient admission, the team members were expected to deal with patient’s data as much as possible by sorting and analyzing custom personalized psychological nursing plan and resolving issues encountered during practical clinical nursing; the members timely recorded and immediately solved through follow-up summary meeting so as to analyze the causes of the problems.

Program implementation: (1) Observation phase: When a patient was admitted to the hospital, the psychological nursing team members paid close attention to any psychological changes in the patient while maintaining communication with the patient. When patients showed anxiety or depression, the members attempted to precisely understand the causes of the patients’ negative emotions; (2) Face-to-face teaching phase: The corresponding nursing staff gave lectures based on the knowledge related to the radical resection of GC, thereby encouraging the patients to actively participate in social activities and arranged for rehabilitation training, as required. Multimedia resources were used to systematically raise awareness about psychological regulation and how to deal with diseases. Meanwhile, patients conducted group discussion activities for effective sharing of their experiences and feelings while inspiring and supporting others via communication and interaction. For patients with serious psychological distress, after group discussion, the psychologist arranged a special one-to-one counseling session for them. For the problems exposed in this counseling session, targeted psychological analysis and counseling were conducted to help the patients develop a deeper understanding of their psychological state and help determine effective coping strategies. In addition, family members are actively encouraged to participate in the psychological nursing of patients to provide psychological support to the patients through sympathetic listening and other such approaches, with the aim of understanding the crux of patients’ psychological diseases and thereby design targeted psychological counseling. If the patient’s symptoms could not be relieved after implementing the abovementioned intervention, psychologists were notified immediately for consultation; and (3) Guidance phase: After the patient was discharged, the nursing staff visited them regularly to remind the patient to come to the hospital for review on time. During their follow-up visits, attention was paid to the patients’ mood changes to help the patients relieve their anxiety and eliminate fear.

Methods-observation group

The Newman system nursing intervention was applied to this group: (1) Evaluation phase: After the patient was admitted, the responsible nurse immediately assessed their psychological condition, precisely understood the extent of stress in the patient, and paid attention to maintaining affinity during communication; (2) Tertiary prevention intervention: Based on the abovementioned assessment results and the psychological situation of the patient, a personalized phased prevention plan was developed; (3) Primary prevention: Attention was paid to the cause of stress. The nurse in-charge introduced the disease-related knowledge to the patients in detail, and the communication process used simple and understandable words in the process to help the patients correctly understand GC as well as the therapeutic significance of radical gastric gastrectomy. Meanwhile, the caregivers were requested to participate in the nursing process, allowed to provide complete care to the patient along with psychological and economic support, if the conditions allowed; (4) Secondary prevention: Focus on the postoperative stress response. First of all, based on the psychological level, the patients were introduced to past cases of successful rehabilitation after surgical treatment and the treatment methods employed so as to stimulate the patients’ confidence in rehabilitation and improve their compliance with the medical advice. At the same time, the responsible nurses taught the patients emotional management skills to help them effectively resist any external stimuli and reduce their stress response; and (5) Tertiary prevention: In the rehabilitation stage, the focus was on the physical and psychological conditions of the patients. After the completion of RG, the responsible nurse informed the patients and their families about the treatment results in a timely manner to relieve their psychological stress. Meanwhile, close attention was paid to the development of postoperative pain in the patients so as to provide timely personalized analgesic measures to reduce the stress response induced by pain stimulation. After the patient gained consciousness and achieved a stable blood pressure, the rehabilitation physician was invited to intervene, whereafter the rehabilitation technician guided the patient with the relevant rehabilitation training and breathing exercises. In addition, the responsible nurse prepared a reasonable diet structure for the patients in line with the preoperative palate of the patients so as to speed up their rehabilitation process.

Observational indicators

Postoperative recovery outcomes: Detailed records were maintained to compare postoperative recovery indicators between the two groups, including hospitalization duration, time to first ambulation, first flatus passage time, first oral intake time, bowel sound recovery time, and catheter indwelling duration. These indicators comprehensively reflected the speed and overall status of postoperative recovery. Shortened hospitalization duration not only reduces medical expenditure but also alleviates psychological stress associated with prolonged hospital stays. Time to first ambulation serves as the key indicator for evaluating early postoperative mobility, with early activity promoting blood circulation and preventing deep vein thrombosis. First flatus passage time and bowel sound recovery time reflect gastrointestinal function restoration, whereas the first oral intake time has been closely linked to nutritional intake and rehabilitation progression. In addition, the length of the catheter indwelling directly impacts patient comfort and infection risk.

Anxiety and depression scales: The Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were employed to assess anxiety and depression in both groups. The SAS contains 20 items scored from 1 to 4, with a maximum raw score of 80. The standard score was calculated as follows: Standard score = Raw score × 1.25 (rounded). A standard score > 50 indicated anxiety. The SDS has 20 items scored similarly, with a standard score > 53 indicating depression. Anxiety and depression are common postoperative psychological issues that significantly affect the rehabilitation outcomes as well as the quality of life. Regular assessments enable timely detection and intervention to improve recovery.

Complications: Complication rates, including incision infection, pulmonary infection, gastrointestinal reactions, and anastomotic leakage, were recorded and compared. Incision infection, a common complication, can delay wound healing and prolong hospitalization. Pulmonary infection is prevalent in elderly patients due to postoperative immobility and weakened cough reflexes. Gastrointestinal reactions (such as nausea, vomiting, and abdominal distension) may impair nutritional intake and recovery. Anastomotic leakage is a severe complication that could potentially lead to peritoneal infection and sepsis. The total complication incidence was calculated as follows: Total incidence rate = (incision infection + pulmonary infection + gastrointestinal reactions + anastomotic leakage)/total cases × 100%. Reducing complications is critical for improving postoperative quality and optimizing resource utilization.

Quality of life: The 36-item short form health survey (SF-36)[10], consisting of 8 items covering the evaluation of energy, general and mental health, somatic pain, and physical, social, and emotional function dimensions, was used to evaluate the quality of life, with the score being directly proportional to the quality of life.

Follow-up period

The follow-up in this study was limited to the in-hospital period, focusing on short-term recovery indicators such as gastrointestinal function, psychological distress, and complication rates. Long-term outcomes - such as the quality of life beyond three months post-discharge, recurrence rates, or readmission - were not assessed. As postoperative recovery in elderly cancer patients often extends beyond the acute phase, future research should incorporate long-term follow-up to more comprehensively evaluate the sustained effects of NSM-guided intervention.

Statistical analysis

Software SPSS25.0. measurement data (mean ± SD) description, intergroup data comparison using t-test analysis; count data, n (%) description and use χ² test for analysis. P < 0.05, indicating a statistical difference. Before applying parametric tests, the normality of continuous variables was assessed using the Shapiro-Wilk test, and the homogeneity of variances was evaluated with Levene’s test. All continuous variables satisfied the assumptions for independent-samples t-tests. For categorical variables, the χ² test was applied when the expected frequencies were adequate (≥ 5 in all cells); otherwise, Fisher’s exact test was applied, particularly for rare events such as anastomotic leakage, where some cells showed expected counts < 5.

RESULTS

Comparison of the postoperative recovery between the two groups

The comparison between postoperative recovery outcomes of both groups revealed that the observation group exhibited significantly shorter recovery times across all measured parameters compared with those in the control group (Table 1). For instance, in the observation group, the time to first ambulation, flatus, and oral intake were found to be 2.09 ± 0.57 days, 1.51 ± 0.36 days, and 1.95 ± 0.41 days, respectively, compared with 2.78 ± 0.65 days (t = 5.048, P < 0.001), 2.13 ± 0.59 days (t = 5.673, P < 0.001), and 2.81 ± 0.55 days (t = 7.929, P < 0.001) in the control group. Additionally, bowel sound recovery time, catheter removal time, and hospitalization duration were 1.29 ± 0.37 days, 1.42 ± 0.26 days, and 9.45 ± 2.01 days in the observation group, respectively, compared with 1.71 ± 0.44 days (t = 4.621, P < 0.001), 1.73 ± 0.39 days (t = 4.183, P < 0.001), and 11.38 ± 2.69 days (t = 3.635, P < 0.001) in the control group. All differences were statistically significant (P < 0.001), indicating superior postoperative recovery in the observation group.

Table 1 Comparison of postoperative recovery between the two groups, mean ± SD.

Group	n	First time out of bed	First exhaust time	Time of first feeding
Control	40	2.78 ± 0.65	2.13 ± 0.59	2.81 ± 0.55
Observation	40	2.09 ± 0.57	1.51 ± 0.36	1.95 ± 0.41
t	-	5.048	5.673	7.929
P value	-	< 0.001	< 0.001	< 0.001
Group	n	Time of bowel song recovery	The time of catheter extraction	Length of stay
Control	40	1.71 ± 0.44	1.73 ± 0.39	11.38 ± 2.69
Observation	40	1.29 ± 0.37	1.42 ± 0.26	9.45 ± 2.01
t	-	4.621	4.183	3.635
P value	-	< 0.001	< 0.001	< 0.001

Comparison of the postoperative recovery between the two groups

Herein, the pre- and post-care SDS and SAS scores between the control and observation groups (n = 40 patients; both groups) were compared (Table 2). In the control group, the SDS and SAS scores decreased from 58.81 ± 4.53 to 49.33 ± 1.28 and from 60.78 ± 3.03 to 52.37 ± 2.71, respectively. In contrast, in the observation group, the SDS and SAS scores decreased from 59.36 ± 4.27 to 42.47 ± 1.37 and from 61.09 ± 2.77 to 48.76 ± 3.62, respectively. The differences in SDS and SAS scores post-care between the two groups were statistically significant (t = 23.141 and 5.049, respectively, both P < 0.001). However, differences in SDS and SAS scores pre-care did not show any statistical significance (t = 0.559 and 0.478; P = 0.578 and 0.634, respectively). Overall, these results indicate that the observation group exhibited a more pronounced improvement in reducing post-case anxiety and depression scores compared with those in the control group.

Table 2 Comparison of the anxiety and depression scales in the two groups, mean ± SD.

Group	n	SDS		SAS
		Before	After	Before	After
Control	40	58.81 ± 4.53	49.33 ± 1.28	60.78 ± 3.03	52.37 ± 2.71
Observation	40	59.36 ± 4.27	42.47 ± 1.37	61.09 ± 2.77	48.76 ± 3.62
t	-	0.559	23.141	0.478	5.049
P value	-	0.578	< 0.001	0.634	< 0.001

SDS: Self-Rating Depression Scale; SAS: Self-Rating Anxiety Scale.

Comparison of the quality of life between the two groups

The quality of life (SF-36) scores of the control and observation groups (n = 40 patients; both groups) were compared (Table 3). Notably, pre-care SF-36 scores were similar between the two groups, with the control and observation groups scoring 62.09 ± 5.22 and 61.45 ± 4.01 (t = 0.615, P = 0.540), respectively. Post-care SF-36 score in the observation group improved to 73.03 ± 5.63; however, it was significantly lower than that in the control group (80.64 ± 4.13) (t = 6.893, P < 0.001). Altogether, these results indicated that the improvement in quality of life was significantly greater in the control group compared with that in the observation group post-care.

Table 3 Comparison of the quality of life in the two study groups, mean ± SD.

Group	n	Physiologic function			Role-physical		Vitality		General health
		Before	After		Before	After	Before	After	Before	After
Control	40	37.61 ± 5.44	63.92 ± 8.14a		42.19 ± 5.83	65.92 ± 7.04a	48.61 ± 6.43	65.94 ± 5.33a	48.61 ± 4.07	60.39 ± 5.87a
Observation	40	36.94 ± 5.81	69.51 ± 8.46a		42.62 ± 5.75	73.25 ± 7.56a	47.84 ± 6.29	74.39 ± 5.86a	47.72 ± 6.08	67.15 ± 7.12a
t	-	0.532	3.011		0.332	4.488	0.541	6.747	0.769	4.633
P value	-	0.596	0.004		0.741	0.000	0.590	0.000	0.444	0.000
Group	n	Bodily pain			Social functioning		Mental health		Role-emotional
		Before		After	Before	After	Before	After	Before	After
Control	40	54.31 ± 6.18		67.25 ± 5.84a	52.37 ± 6.55	64.95 ± 8.46a	52.67 ± 6.42	68.15 ± 7.49a	57.83 ± 6.05	66.24 ± 7.58a
Observation	40	53.94 ± 6.27		76.29 ± 6.17a	51.76 ± 6.41	71.35 ± 8.27a	52.05 ± 6.53	77.34 ± 8.13a	58.12 ± 6.26	73.29 ± 8.15a
t	-	0.266		6.730	0.421	3.421	0.428	5.258	0.211	4.006
P value	-	0.791		0.000	0.675	0.001	0.670	0.000	0.834	0.000

^aP < 0.05, the comparison between the control group and the observation group.

Comparison of complications between the two groups

The incidence of adverse reactions was compared between the control and observation groups (n = 40 patients; both groups) (Table 4). In the control group, the incidence rates were as follows: Incision infection, two patients (5.00%); pulmonary infection, three patients (7.50%); gastrointestinal reaction, four patients (10.00%); and anastomotic leakage, one patient (2.50%); with a total incidence of adverse reactions in 10 patients (25.00%). In the observation group, the incidence rates were significantly lower, as follows: Incision infection, zero cases (0.00%); pulmonary infection, one patient (2.50%); gastrointestinal reaction, one patient (2.50%); and anastomotic leakage, zero cases (0.00%); with a total incidence of adverse reactions in two patients (5.00%). The difference in total incidence rates between the two groups was statistically significant (χ² = 4.804, P = 0.028), indicating that the observation group exhibited a lower rate of adverse reactions compared with that in the control group.

Table 4 Comparison of adverse reactions in the two study groups, n (%).

Group	n	Infection of incisional wound	Pulmonary infection	Gastrointestinal tract reaction	Anastomotic leakage	Total incidence
Control	40	2 (5.00)	3 (7.50)	4 (10.00)	1 (2.50)	10 (25.00)
Observation	40	0 (0.00)	1 (2.50)	1 (2.50)	0 (0.00)	2 (5.00)
χ2	-	-	-	-	-	4.804
P value	-	-	-	-	-	0.028

DISCUSSION

GC, originating from the gastric mucosal epithelium, exhibits a complex pathogenesis. GC onset is often accompanied by symptoms such as upper abdominal pain and loss of appetite in patients, and further progression may lead to hematemesis, posing a serious threat to the patient’s life and health. Presently, RG surgery remains the primary treatment modality for GC. However, the extensive surgical trauma has been shown to increase the difficulty of postoperative home care for patients[11]. This study aimed to evaluate the efficacy of the developed NGSC model for elderly patients with GC who underwent RG. This study solely focused on the NSM framework, without any comparisons to other commonly used nursing models, such as Orem’s self-care theory or evidence-based nursing. Orem’s model emphasizes patient autonomy in managing patient need-driven personal health, whereas the evidence-based nursing model integrates available best evidence with clinical expertise and patient values. Compared with these models, the NSM systematically assesses intrapersonal, interpersonal, and extra personal stressors, providing a comprehensive structure and guiding interventions through three prevention levels. This theoretical breadth may explain the effectiveness of NSM in both physical and psychological domains; nevertheless, further studies are required for direct comparisons to better establish the unique strengths of the NSM[13,14].

Herein, the observation group showed significantly accelerated postoperative recovery time compared with that in the control group (P < 0.05), indicating that the NGSC model could effectively expedite the rehabilitation process of elderly patients who underwent RG. This improved recovery time may be attributed to the nurses, who explained in detail the disease symptoms, tumor staging, surgical treatment, and chemotherapy based on patients’ educational levels during the primary prevention stage of NGSC. This enabled patients to appropriately understand the importance of the disease and treatment, thereby reducing the psychological burdens and ensuring active participation in postoperative rehabilitation activities, such as early ambulation and dietary recovery, ultimately shortening the postoperative recovery time[15]. During the secondary prevention stage, psychological interventions enhanced the confidence of the patients in treatment, improving treatment compliance and ensuring their timely participation in the rehabilitation exercise, thereby promoting gastrointestinal peristalsis recovery and physical function rehabilitation, reducing complications, and thus shortening the hospital stay[16]. Lastly, in the tertiary prevention stage, timely communication of treatment outcomes to patients and families alleviates psychological stress. Additionally, pain management based on pain assessment reduced the negative impact of pain stress on patients’ recovery. The NGSC approach guided postoperative early bed activity and respiratory exercises, promoted gastrointestinal movement recovery and physical function rehabilitation, and accelerated the first out of bed, exhaust, and eat times, ultimately shortening the catheter retention time and hospital stay[16].

Although this study demonstrates the efficacy of the NGSC model in enhancing the psychological resilience of the patient, it does not elucidate the underlying neuroendocrine mechanisms. Reportedly, psychological stress activates the hypothalamic–pituitary–adrenal axis, leading to an increased cortisol secretion, which, in turn, suppresses immune function and delays postoperative recovery. Reduction in cortisol levels has been associated with structured psychological interventions, including cognitive-behavioral support, effective pain management, and family involvement, which enhances immune responsiveness and promotes tissue repair[17,18]. Hence, the decrease in patients’ anxiety and depression rates observed in this study may reflect improved neuroendocrine regulation, underscoring the need for further physiological assessment in future studies.

In the present study, the observation group exhibited significantly lower SDS and SAS scores compared with those in the control group (P < 0.05), indicating the efficacy of the NGSC model in improving anxiety and depression in elderly patients who underwent RG. This reduction in anxiety/depression can be attributed to the primary prevention stage of NGSC, where stressors such as insufficient disease/treatment knowledge and economic pressure were targeted to reduce patients’ fear and anxiety caused by uncertainty. Notably, involvement of family members in the care process provided considerable psychological and financial support to the patients, alleviating their psychological burdens and improving negative emotions. Additionally, phased prevention goals enhanced the psychological resilience of the patients against external stimuli, reduced adverse emotional reactions, and increased their trust in the medical care[17]. In the secondary prevention stage of NGSC, attending physicians shared successful postoperative recovery cases, which boosted the rehabilitation confidence of the patients. Moreover, teaching self-emotional management skills enabled patients to better cope with disease/treatment-related stress, thereby reducing stress responses and alleviating anxiety/depression. During the tertiary prevention stage, effective pain assessment and targeted analgesia were performed to minimize pain-induced negative emotions. Furthermore, early bed activities and respiratory exercises allowed patients to feel cared for by the medical staff, further relieving their anxiety and depression[18].

Compared with the observation group, the control group exhibited significantly higher post-care SF-36 scores (P < 0.001) in this study. These results suggested that although the NGSC effectively improved psychological and physiological recovery, it did not lead to a greater overall improvement in perceived quality of life during the short-term postoperative period. This may be attributed to the emphasis of the entire nursing process on the psychological support to effectively prevent stressor-induced damage. Endocrine and immune systems regulated through a positive psychological state can reduce stress-related physical harm. The NGSC model provided continuous care from hospitalization to post-discharge follow-up. Notably, in-hospital interventions included pain assessment/management, rehabilitation activity guidance, and nutritional diet planning to support physical recovery[19]. Post-discharge telephonic follow-ups were to ensure ongoing guidance and psychological support, which may have enhanced the rehabilitation motivation and confidence of the patients. This continuous care was to ensure that patients received proper guidance throughout the recovery process, effectively reducing complications, stabilizing recovery outcomes, and improving their quality of life[20].

Although this study provides valuable insights into the effectiveness of the NGSC model on postoperative recovery in elderly patients with GC, some limitations persist. First, the sample size in this study was relatively small and included only 80 patients. This may have limited the generalizability of the findings to broader populations. Second, the study was conducted in a single center, which possibly introduced selection bias, thereby restricting the applicability of the results to other healthcare settings. Third, the intervention itself was complex and required specialized training and resources, posing potential challenges for widespread implementation in routine clinical practice. Fourth, in this study, the psychological outcomes were assessed based on self-reported questionnaires (SAS and SDS scores), which may be subject to response bias despite being widely used and might not fully capture the complexity of the psychological experiences of the patients. Future research may focus on incorporating qualitative methods or more comprehensive psychological assessments to provide a deeper understanding of the emotional state of the patients. Fifth, this study did not account for potential confounding variables such as the socioeconomic status of the patient, educational background, or pre-existing psychological conditions, which can influence both postoperative recovery and psychological outcomes. Sixth, the follow-up period was relatively short and mainly focused on short-term recovery, while leaving the long-term effects underexplored. Future studies need to include prolonged follow-up to further explore the long-term effects of the proposed intervention on quality of life, recurrence rates, and the sustainability of psychological benefits. Lastly, the cost-effectiveness of the proposed NGSC model was not evaluated, which is an important aspect for healthcare systems and patients’ families when considering such interventions. Despite these limitations, this study highlights the potential benefits of the NGSC model and provides a research basis for future studies to address these gaps and validate the evidence base for the clinical application of the proposed intervention.

Herein, the study population included the elderly (≥ 60 years old); however, no subgroup analysis based on age (for example, 60-70 years vs ≥ 75 years) was performed. Within the elderly population, the physiological reserve and psychosocial needs vary significantly, and such stratification may facilitate elucidating age-specific intervention effects. Reportedly, elderly individuals are more vulnerable to post-surgery complications, depression, and functional decline. Future studies should focus on age-based subgroup analysis to precisely tailor nursing strategies.

The present research focuses on short-term postoperative outcomes during hospitalization. However, long-term effects, such as quality of life at post-discharge three or six months, recurrence rates, and sustained psychological benefits, remain unelucidated. Notably, early postoperative improvements do not always correlate with long-term recovery, particularly in older patients with cancer. Future investigations need to incorporate longer follow-up periods to assess the potential of NSM-guided care in improving clinical outcomes and patient well-being.

Limitations

The sample size consisted of 80 patients (40 in each group). However, no formal sample size calculation based on power analysis, effect size, or expected outcome variance was made. In the absence of any predefined α and β error thresholds, the statistical power of the study remained uncertain. Moreover, as the study was conducted in a single center (Fenyang Hospital, Shanxi Province, China), the findings may reflect institutional practices and regional characteristics, limiting their generalizability. Therefore, future multicenter studies with larger sample sizes and stratified random sampling are warranted to confirm these findings and enhance external validity.

In addition to age and disease-related clinical indicators, other patient-related factors such as socioeconomic status, the level of education, and pre-existing psychological history were not controlled for in the study design. These variables could have influenced postoperative recovery, psychological resilience, and adherence to care, thereby representing potential confounding factors. Future studies should therefore include multivariate analysis or stratification methods so as to reduce any confounding factors and improve the accuracy of the intervention’s effect size.

CONCLUSION

The findings of this study show that the NGSC model significantly accelerated postoperative recovery, reduced postoperative anxiety and depression, improved quality of life, and lowered the incidence of adverse events in elderly patients undergoing RG for GC. The intervention demonstrated superior outcomes in shortening recovery times for key postoperative milestones, enhancing psychological well-being, and reducing complications in the patients. By integrating holistic care principles with tiered support, the proposed NSM-guided approach effectively addresses the multifaceted challenges faced by elderly patients with GC. Altogether, these findings highlight the clinical value of the proposed NSM-guided intervention in improving postoperative outcomes, warranting its adoption in geriatric oncology nursing. Nevertheless, further studies with larger sample sizes, longer follow-up periods, and multi-center participation are required to validate these results and explore the long-term benefits and cost-effectiveness of the proposed intervention.