Association of Watson-based humanistic fast track surgery with stoma colorectal cancer recovery: A propensity matched study

Abstract

BACKGROUND

While fast track surgery (FTS) protocols have optimized physiological recovery in colorectal cancer (CRC), their highly procedural nature often overlooks the individualized humanistic needs of patients, particularly those facing the psychological challenges of a stoma.

AIM

To evaluate whether an integrated Watson-based FTS (Watson-FTS) care model is associated with measurable improvements in physiological recovery, complication rates, and humanistic process of care indicators in CRC patients undergoing stoma surgery.

METHODS

A retrospective cohort study was conducted involving 312 patients (Watson-FTS group, n = 165; routine care group, n = 147). To control for confounding factors such as age, surgical approach, and baseline psychological distress, 1:1 propensity score matching was performed, resulting in 125 well-matched pairs (n = 250). Primary outcomes included time to first flatus and overall postoperative complications. Secondary outcomes, including nutritional markers [prealbumin (PA)] and protocol adherence, were analyzed using generalized estimating equations (GEEs).

RESULTS

In the matched cohort, the Watson-FTS group demonstrated a significantly shorter mean time to first flatus [52.4 ± 10.8 hours vs 68.1 ± 13.5 hours; adjusted beta = -15.2 hours, 95% confidence interval (CI): -18.4 to -12.0, P < 0.001]. The incidence of overall postoperative complications was significantly lower in the Watson-FTS group [15.2% vs 30.4%; adjusted odds ratio (aOR) = 0.39, 95%CI: 0.21-0.72, P = 0.003], specifically regarding stoma-related events (4.8% vs 12.8%, P = 0.024). Longitudinal GEE analysis revealed a significantly faster recovery trajectory for PA levels in the Watson-FTS group (interaction P < 0.001) and superior protocol adherence by postoperative day 5 (91.2% vs 70.4%, P < 0.001). Multivariable regression confirmed the Watson-FTS intervention as the strongest independent predictor for successful early recovery (aOR = 3.62, P < 0.001).

CONCLUSION

Integrating Jean Watson’s humanistic caring theory into the FTS pathway is associated with enhanced physiological and functional recovery. The Watson FTS model is linked to a lower incidence of complications and more stable metabolic recovery, offering a superior alternative to standardized procedural care for patients with colorectal stomas.

Key Words: Colorectal cancer; Intestinal stoma; Fast track surgery; Humanistic nursing; Propensity score matching

Core Tip: This study innovatively integrates Jean Watson’s humanistic caring theory into fast track surgery (Watson-FTS) for colorectal cancer patients with stomas. While traditional fast track surgery protocols prioritize physiological milestones, they often overlook individualized psychological needs. Utilizing robust propensity score matching and generalized estimating equations for longitudinal analysis, we demonstrated that the Watson-FTS model significantly accelerates gastrointestinal recovery, reduces stoma-specific complications, and improves postoperative nutritional trajectories. This holistic approach proves that addressing humanistic needs enhances protocol adherence, offering a clinically superior alternative to standardized procedural care for vulnerable ostomy patients.

INTRODUCTION

Colorectal cancer (CRC) is the third most common malignant tumor globally, posing a serious threat to global health due to its high incidence and mortality rates. According to the latest epidemiological data, there were approximately 1.9 million new cases and over 930000 deaths from CRC worldwide in 2020, with a notable increase in incidence in developing countries due to the westernization of lifestyles[1]. Curative surgery is the primary treatment for CRC, and a significant portion of patients require a permanent or temporary intestinal stoma. However, while stoma surgery is life-saving, it presents immense dual challenges, both physiological and psychological, for patients. Physiologically, patients must manage the risk of stoma-related complications. Psychologically, changes in body image often trigger severe anxiety, depression, and social avoidance, which greatly impact quality of life[2].

To address these challenges, the enhanced recovery after surgery (ERAS) pathway, also widely recognized as fast track surgery (FTS), was developed and has become standard practice in colorectal surgery. Through a series of evidence-based measures, such as optimizing pain management and encouraging early mobility and feeding, FTS significantly shortens hospital stays and accelerates physiological functional recovery[3]. However, the success of the FTS model is predominantly measured on a physiological level, and its highly procedural nature often overlooks the individualized psychological and emotional needs of patients. Several studies have pointed out that within FTS pathways, patients may feel helpless due to insufficient information, anxiety about early discharge, and persistent postoperative fatigue and emotional distress[4]. This model, which prioritizes standardized processes over patient experience, exposes a potential deficit in humanistic care within modern, high-efficiency healthcare systems.

In this context, humanistic care theories, particularly Jean Watson’s “Caring Science” theory, provide an important framework to compensate for the shortcomings of the FTS model. Watson’s theory views nursing as an interpersonal process filled with love and compassion that transcends the biomedical model to focus on the holistic well-being of mind, body, and spirit[5]. Its core “10 Caritas Processes” advocate for establishing trusting nurse-patient relationships, encouraging emotional expression, and creating a supportive healing environment. These humanistic concepts perfectly complement the unmet psychological support needs of patients within FTS pathways, suggesting that integrating Watson’s theory into the FTS framework, thereby forming a Watson-based FTS (Watson-FTS) care model, has the potential to achieve comprehensive psychological and spiritual recovery alongside accelerated physiological recovery.

Although the concept of integrating humanistic care into the FTS pathway is highly appealing, a significant gap remains in empirical research. Few studies have systematically integrated a specific humanistic framework, such as Watson Caring Theory, into CRC care and subjected it to rigorous evaluation[6]. In particular, there is a lack of high-quality studies using advanced statistical methods such as propensity score matching (PSM) and generalized estimating equations (GEE) to control for confounding factors and evaluate intervention effects[7]. To bridge this methodological gap, this study aims to evaluate a standardized Watson-based FTS care model. Specifically, we will investigate whether this integrated model translates into measurable improvements in physiological recovery, postoperative complication rates, longitudinal nutritional trajectories, and objective behavioral milestones reflecting patient empowerment. We pragmatically focus on these observable clinical and process indicators, thereby aligning our stated aims with the constraints of a retrospective cohort where direct psychological and quality of life outcomes cannot be reliably captured.

MATERIALS AND METHODS

Study design and setting

This single-center, retrospective cohort study was conducted at the Department of Colorectal Surgery of the Second Norman Bethune Hospital of Jilin University, a tertiary care teaching hospital, utilizing integrated data from the electronic medical record (EMR) and the specialized Nursing Information System (NIS). The study period spanned from January 1, 2019, to December 31, 2024, focusing on evaluating the clinical impact of an ERAS program guided by Jean Watson’s Theory of Human Caring on patients undergoing elective colorectal resection and enterostomy. The primary objective was to compare perioperative physiological recovery, longitudinal nutritional trajectories, and postoperative complication rates between patients receiving Watson-based FTS care and those receiving routine nursing care. The study protocol was approved by the Institutional Review Board of the Second Norman Bethune Hospital of Jilin University (No. 2026-097), and the requirement for written informed consent was waived given the retrospective nature of the study and the use of deidentified patient data.

Study population

A systematic query of the institutional EMR and specialized NIS was performed. Initial screening utilized International Classification of Diseases, Tenth Revision (ICD-10) codes for colorectal adenocarcinoma alongside procedural codes for colorectal resection and enterostomy. Following automated identification, two independent clinical researchers manually reviewed the medical records to verify eligibility against the defined inclusion and exclusion criteria. Any discrepancies in eligibility assessment were resolved through consensus discussion or adjudication by a senior colorectal surgeon.

The inclusion criteria for the study were as follows: (1) Age ≥ 18 years at the time of surgery; (2) A definitive histopathological diagnosis of colorectal adenocarcinoma based on prevailing diagnostic standards, including comprehensive molecular marker analysis where appropriate[8-10]; (3) Underwent elective laparoscopic or open colorectal resection with the concurrent formation of a temporary or permanent intestinal stoma (ileostomy or colostomy), as guided by established clinical practice guidelines[11,12]; and (4) Complete medical records, including detailed nursing notes, operative reports, and postoperative follow-up data sufficient for analysis.

Exclusion criteria were stringently applied to ensure cohort homogeneity and comprised any of the following: (1) Emergency surgery for conditions such as acute bowel obstruction, perforation, or significant hemorrhage; (2) Palliative-intent resection, where the surgical goal was symptom relief rather than curative-intent, as these patients often have a significantly different clinical trajectory[13]; (3) Presence of severe, unoptimized, preexisting organ dysfunction, such as New York Heart Association Class III-IV heart failure, severe chronic obstructive pulmonary disease, or end-stage renal disease, which would confound the assessment of the intervention’s effect[13]; (4) A documented history of severe mental illness (e.g., schizophrenia or bipolar disorder) or significant cognitive impairment (e.g., dementia or clinically significant cognitive decline) that would preclude the patient’s ability to comprehend or adhere to perioperative protocols, as identified from established diagnostic records and clinical assessments[14,15]; and (5) Patients with a postoperative stay in the intensive care unit (ICU) exceeding 48 hours were excluded. A stay beyond this specific cutoff typically indicates catastrophic surgical complications or severe physiological instability, often necessitating sedation or mechanical ventilation[16,17]. While these critically ill patients undoubtedly require profound humanistic support, the specific standardized interventions of our FTS pathway, particularly interactive teaching back stoma education, guided imagery, and early ambulation, are completely unfeasible to implement under such conditions. Including these extreme clinical outliers would introduce massive heterogeneity and severely confound the evaluation of the standardized nursing protocol.

As a retrospective cohort study utilizing PSM, a formal prospective sample size calculation was not performed. The study aimed to include all consecutive eligible patients during the defined study period to maximize statistical power and generalizability. A post hoc power analysis was performed using PASS software version 15 to calculate the statistical power for the primary outcomes based on the final matched cohort size and the observed effect sizes at a two-sided alpha level of 0.05. Based on preliminary audits and to ensure robust matching, we anticipated identifying a sufficient number of matched pairs from the initial screened cohort. The final matched sample size was determined by the availability of eligible patients and the success of the PSM procedure in achieving covariate balance.

Theoretical framework, group assignment, and interventions

Group assignment based on a natural experiment: This study leveraged a retrospective, quasiexperimental design by taking advantage of a natural experiment that occurred within the Department of Colorectal Surgery. On January 1, 2022, the department systematically implemented and standardized a new nursing pathway founded on Watson’s Theory of Human Caring, integrating it into the existing FTS protocol. Consequently, this date served as a clear watershed for patient allocation. Patients admitted for elective colorectal resection and enterostomy from January 1, 2022, to December 31, 2024, were assigned to the Watson-FTS group (intervention). Patients admitted between January 1, 2019, and December 31, 2021, who received the standard FTS protocol active at that time, were assigned to the routine care group (control). This design allows for a robust comparison of two distinct care models by minimizing the selection bias associated with practice drift over time.

Importantly, the core medical components of the FTS protocol, such as anesthesia, analgesia, and early mobilization targets, remained highly consistent between 2019 and 2024. The specific humanistic tools, including mandatory electronic teach-back checklists and standardized guided imagery audio resources, were strictly integrated into the NIS only after January 2022. This systematic software integration minimized the risk of intervention elements contaminating the routine care period.

Control group - routine FTS protocol: Patients in the control group received a well-established FTS protocol consistent with the principles of ERAS. This protocol focused on evidence-based physiological interventions, including standardized preoperative fasting guidelines, optimized fluid management, early oral nutrition, early mobilization, and multimodal analgesia[16]. Nursing care was primarily task-oriented, focusing on the efficient execution of these medical and surgical recovery milestones. While compassionate, the care did not systematically incorporate the structured psychological, relational, or environmental components that defined the later Watson-FTS pathway.

Intervention group - standardized Watson-FTS pathway: The intervention group’s care was defined by the integration of Watson’s ten Caritas Processes into the FTS timeline, transforming routine tasks into opportunities for therapeutic, humanistic engagement. This pathway was standardized across the department to ensure consistency. The specific components of the intervention, including precise operational actions, timing across the perioperative continuum, and objective criteria for adherence, are comprehensively detailed in Supplementary Table 1. Key evidence-based components included the following.

Caritas process 4 (developing and sustaining a helping-trusting, human caring relationship): A cornerstone of the intervention was the implementation of responsibility-based continuous care. A designated, specially trained stoma nurse was assigned to each patient, managing their journey from preoperative siting through postoperative education to discharge planning. This approach is supported by systematic reviews demonstrating that strong transitional care interventions and continuity are critical for reducing readmission rates and complications in CRC patients[18].

Caritas process 7 (engaging in a genuine teaching-learning experience): Patient and family education was structured around the “teach-back” method. This was not a passive delivery of information but an active dialog to ensure comprehension and build confidence in complex self-care tasks, particularly stoma management. This method is confirmed by meta-analyses to improve patient adherence, self-management skills, and health outcomes in chronic disease[19].

Caritas process 9 (assisting with basic needs and recognizing a patient’s potential): A major goal was to bolster patient self-efficacy. This was achieved through guided mastery experiences (successful self-care attempts), verbal persuasion (encouragement from the nursing team), and providing role models (“vicarious experience” through connection with stoma support groups). This aligns with strong evidence showing that self-management interventions significantly improve self-efficacy in patients with a stoma[20].

Caritas processes 1 and 2 (embracing loving-kindness and inspiring faith-hope): Recognizing the high prevalence of preoperative anxiety, the pathway included psychological prehabilitation. Nurses trained in relaxation techniques offered sessions on guided imagery and mindful breathing the evening before surgery to promote a sense of calm and hope. High-level meta-analyses confirm that psychological interventions as part of prehabilitation can significantly reduce postoperative complications and anxiety in cancer surgery patients[21].

Caritas process 8 (creating a healing environment): Deliberate efforts were made to create a physical and social healing environment. This involved tangible actions such as ensuring patient privacy during all interactions and procedures, actively managing nighttime noise and light levels to protect sleep, and encouraging family presence. These practices are grounded in systematic reviews that identify factors such as privacy, sensory comfort, and social support as crucial for promoting well-being and recovery in cancer inpatients[22].

Retrospective intervention fidelity assessment: Prior to the formal implementation of the Watson FTS pathway on January 1, 2022, a mandatory standardized training program was conducted for all nursing staff during the fourth quarter of 2021. This program included theoretical lectures on Watson Caring Science and practical simulations. Competency was rigorously assessed through standardized objective structured clinical examinations, ensuring that only qualified nurses delivered the intervention to effectively minimize provider variation.

To ensure that the Watson-FTS group received the intended intervention, a multifaceted approach was employed to retrospectively assess fidelity. First, department-level administrative records and meeting minutes were reviewed to confirm the official launch and mandated adoption of the standardized Watson-FTS nursing protocol after January 1, 2022. Second, a detailed audit of electronic health records was conducted, specifically examining standardized care plan documentation, the presence of enterostomal therapist (ET) nurse follow-up notes, and discharge summaries. Finally, to verify the application of the specific caritas processes, a semantic analysis of free-text nursing notes was performed using keyword searches for terms such as “teach-back”, “guided imagery”, “privacy assured”, “family taught”, and “self-efficacy”. Two independent clinical nurses, blinded to patient outcomes, reviewed the records against a predefined fidelity checklist. Interrater reliability was exceptionally high, demonstrating an overall percentage agreement of 94.5% alongside the robust Cohen’s kappa (κ = 0.89), with any remaining discrepancies resolved by a third senior nurse reviewer.

Data collection and variable definition

All patient data were retrospectively extracted from the institution’s integrated HIS, which includes the EMR and a specialized NIS. A standardized, predefined electronic case report form was utilized for data abstraction. To ensure data accuracy and integrity, two clinical researchers independently extracted the data. Any discrepancies identified during this dual-entry process were resolved by a third senior researcher who adjudicated by returning to the source documentation.

Baseline data were collected to provide a comprehensive profile of the study participants at the time of admission. This included the following: (1) Demographics: Age, sex, body mass index (kg/m²), and educational level; (2) Preoperative clinical status: American Society of Anesthesiologists physical status classification; preoperative Nutritional Risk Screening score[23]; serum albumin (Alb) and prealbumin (PA) levels; smoking history (classified as current, former, or never smoker)[24]; and history of neoadjuvant (chemo)radiotherapy[25]; (3) Comorbidity burden: Assessed using the Charlson Comorbidity Index[26]; (4) Preoperative psychological status: Evaluated using scores from the Hospital Anxiety and Depression Scale (HADS), administered upon admission as part of routine psychosocial screening[27]; and (5) Oncological and surgical details: Primary tumor location, American Joint Committee on Cancer 8^th edition TNM stage, surgical approach (laparoscopic vs open), and stoma type (ileostomy/colostomy, end/Loop)[28].

The primary outcomes for this study were defined as follows: (1) Time to first postoperative flatus, measured in hours from the time of surgical closure to the first documented passage of gas; and (2) Incidence of overall postoperative complications, defined as any deviation from the normal postoperative course occurring up to 30 days after surgery. Complications were systematically graded using the full Clavien-Dindo classification, ensuring that even minor grade I events were recorded[29]. Furthermore, a prespecified analysis of stoma-related complications (including ischemia, necrosis, retraction, mucocutaneous separation, dermatitis, and high-output stoma) was planned due to their high relevance to the nursing intervention[30].

Secondary outcomes were selected to evaluate the broader impact of the nursing intervention. These included the following: (1) Physiological recovery indicators: Time to first ambulation (in hours) and total postoperative length of stay (LOS) (in days); (2) Functional status at discharge: Assessed using the Karnofsky Performance Status (KPS) scale within 24 hours prior to the patient leaving the hospital[31]; and (3) Process-of-care indicators reflective of humanistic care: This composite endpoint was chosen over simpler proxy metrics to better capture the essence of the Watson-based intervention. It included: (a) Completion rate of a standardized ‘Teach-back’ education checklist for stoma care (documented as completed: Yes/no), a method proven to enhance patient understanding and skill retention[32]; (b) Presence of a documented, individualized discharge plan that explicitly addresses psychosocial needs beyond mere technical stoma care (documented: Yes/no); and (c) Documented, independent performance of a complete stoma appliance change by the patient prior to discharge (yes/no), as recorded in the ET nurse’s note.

Longitudinal data points were collected to assess the dynamic trajectories of recovery over time. Nutritional markers, specifically serum Alb and PA, were recorded at four distinct time points: Preoperatively (T0) and on postoperative days 1 (T1), 3 (T2), and 7 (T3). Additionally, patient adherence to key ERAS^® protocol elements was documented as a binary outcome (yes/no) on postoperative days 1, 3, and 5. Adherence to early mobilization was specifically defined as meeting daily targets, such as sitting out of bed for ≥ 2 hours on postoperative day 1 and ambulating ≥ 3 times per day (e.g., totaling ≥ 60 meters) by postoperative day 3, consistent with established guidelines[16].

To address the inevitable challenge of missing data in a retrospective study, a systematic approach was predefined. The extent and patterns of missing data for all key variables (e.g., HADS scores, longitudinal nutritional markers) were examined. For variables with a low proportion of missing data (< 5%) that were plausibly missing completely at random, a complete-case analysis was planned for the specific analyses involving those variables. For key variables with a higher proportion of missingness assessed as likely missing at random (MAR), multiple imputation using chained equations [multiple imputation by chained equations (MICE)] was the chosen strategy. The final analysis results were pooled from the imputed datasets. Sensitivity analyses comparing complete-case and multiple imputation results were planned to assess the robustness of the findings.

Statistical analysis

All statistical analyses were conducted using R software (Version 4.5.1), with the “MatchIt” package for PSM and the “geepack” package for longitudinal analysis. SAS 9.4 was used for validation. A two-sided P value < 0.05 was considered statistically significant. Initially, the patterns and extent of missing data were examined. For variables with > 5% missingness that were deemed plausibly MAR based on observed data patterns and clinical reasoning, MICE was employed to generate 20 complete datasets, which were subsequently pooled for analysis according to Rubin’s rules.

Descriptive statistics are presented as the mean (SD) or median (IQR) for continuous variables and n (%) for categorical variables for both the full and matched cohorts. To control for confounding factors, PSM was performed. The propensity score, defined as the probability of receiving the Watson-FTS intervention, was estimated using a multivariable logistic regression model that included key baseline covariates selected a priori. A 1:1 nearest-neighbor matching algorithm with a caliper width of 0.02 SD of the logit of the propensity score was applied. Covariate balance before and after matching was assessed using absolute standardized mean differences (SMD), with SMD < 0.1 indicating adequate balance.

The causal effect of the intervention on primary and secondary outcomes was estimated within the matched cohort. For continuous outcomes, multivariable linear regression models were used to calculate adjusted mean differences (β) with 95% confidence interval (CI), adjusting for any covariates with residual imbalance (SMD ≥ 0.1). For binary outcomes, multivariable logistic regression models provided adjusted odds ratios (aOR) with 95%CI.

To analyze longitudinal trajectories (nutritional markers, adherence), GEE with an exchangeable correlation structure was used. Models included group, time (as a factor), and the group-by-time interaction term and were adjusted for the baseline value of the outcome. A significant interaction term indicated differing recovery trajectories between groups. Sensitivity analyses included: (1) Calculating the E value to quantify the robustness of the primary outcomes to potential unmeasured sociodemographic or clinical confounding; (2) Fitting generalized linear mixed models incorporating the primary operating “surgeon identifier” as a random effect (random intercept) to account for potential clustering and variation in surgeon skill; and (3) Performing an interrupted time-series (ITS) analysis using a segmented linear regression model. This was designed to rigorously isolate the true intervention effect from underlying secular trends (e.g., gradual improvements in surgical techniques or perioperative care over the six-year period), utilizing aggregated quarterly data to estimate the preintervention trend, the immediate level change at implementation, and postintervention trend modifications.

RESULTS

Participant flow and baseline characteristics

A total of 509 patients were initially screened, of whom 197 were excluded according to predefined criteria (Figure 1). Before PSM, missing data for baseline variables, notably the HADS scores, which were missing in 4.5% of the prematched cohort, were addressed using multiple imputation by chained equations. Consequently, the propensity score estimation, the matching process, and the baseline characteristics presented in Table 1 were all derived from the pooled imputed datasets to maximize cohort utilization and minimize selection bias. The final prematched cohort comprised 312 patients: 165 in the Watson-FTS group (2022-2024) and 147 in the routine care group (2019-2021). Following 1:1 PSM, 125 well-matched pairs (n = 250) were generated for the final analysis. Significant baseline imbalances observed in the prematched cohort, specifically regarding educational level (P = 0.008), surgical approach (P = 0.001), and psychological distress (HADS scores, P < 0.001), were effectively mitigated. In the postmatched cohort, all 17 clinical and demographic variables demonstrated negligible imbalance, with absolute SMD below 0.10 and all P > 0.05 (Table 1).

Figure 1 Flowchart of participant screening and cohort selection. FTS: Fast track surgery; ICU: Intensive care unit; HADS: Hospital Anxiety and Depression Scale.

Table 1 Baseline demographic and clinical characteristics of patients before and after propensity score matching, n (%)/mean ± SD.

Characteristic	Pre-matched cohort					Post-matched cohort (n = 125 pairs)
	Watson-FTS (n = 165)	Routine care (n = 147)	Test statistic	P value	SMD	Watson-FTS (n = 125)	Routine care (n = 125)	Test statistic	P value	SMD
Demographics
Age, years	62.1 ± 10.8	64.5 ± 11.4	1.91	0.057	0.22	63.2 ± 10.5	63.5 ± 10.9	0.22	0.825	0.03
Male gender	96 (58.2)	85 (57.8)	0.01	0.948	0.01	72 (57.6)	71 (56.8)	0.02	0.898	0.02
BMI, kg/m2	23.6 ± 3.4	23.1 ± 3.7	1.24	0.216	0.14	23.4 ± 3.2	23.3 ± 3.5	0.24	0.814	0.03
Education (> high school)	91 (55.2)	59 (40.1)	6.99	0.008	0.31	58 (46.4)	60 (48.0)	0.06	0.799	0.03
Clinical status
ASA class III	45 (27.3)	38 (25.9)	0.08	0.776	0.03	34 (27.2)	33 (26.4)	0.02	0.887	0.02
NRS 2002 score	2.6 ± 0.9	2.5 ± 1.1	0.88	0.38	0.1	2.5 ± 0.8	2.5 ± 0.9	0	1	0
CCI score	2.4 ± 1.5	2.6 ± 1.7	1.1	0.272	0.12	2.5 ± 1.4	2.5 ± 1.5	0	1	0
Smoking (current/former)	64 (38.8)	61 (41.5)	0.24	0.624	0.06	49 (39.2)	51 (40.8)	0.07	0.796	0.03
Neoadjuvant therapy	35 (21.2)	28 (19.0)	0.24	0.627	0.05	25 (20.0)	26 (20.8)	0.02	0.879	0.02
Psychological status
HADS-anxiety	9.6 ± 3.1	7.9 ± 3.4	4.61	< 0.001	0.52	8.8 ± 2.9	8.9 ± 3.2	0.26	0.795	0.03
HADS-depression	8.9 ± 3.3	7.4 ± 3.2	4.07	< 0.001	0.46	8.2 ± 3.0	8.3 ± 2.8	0.27	0.785	0.03
Surgical/oncological
Laparoscopic approach	140 (84.8)	101 (68.7)	11.52	0.001	0.4	95 (76.0)	94 (75.2)	0.02	0.885	0.02
AJCC TNM stage III	88 (53.3)	76 (51.7)	0.08	0.775	0.03	66 (52.8)	65 (52.0)	0.02	0.898	0.02
Tumor location (rectum)	102 (61.8)	94 (63.9)	0.15	0.697	0.04	78 (62.4)	79 (63.2)	0.02	0.894	0.02
Permanent stoma	65 (39.4)	62 (42.2)	0.25	0.617	0.06	50 (40.0)	49 (39.2)	0.02	0.892	0.02
Preop albumin, g/L	36.4 ± 4.5	36.9 ± 4.8	0.95	0.343	0.11	36.6 ± 4.2	36.7 ± 4.4	0.18	0.854	0.02
Preop prealbumin, mg/L	224 ± 51	219 ± 55	0.83	0.407	0.09	221 ± 48	223 ± 50	0.32	0.748	0.04

For the prematched cohort, the test statistic columns represent independent t statistics for continuous variables and χ² statistics for categorical variables. For the postmatched cohort, all statistics and P values were derived using paired tests appropriate for matched samples, specifically the paired t test for continuous variables and the McNemar test for categorical variables. An absolute standardized mean difference less than 0.10 indicates negligible imbalance between groups. FTS: Fast track surgery; BMI: Body mass index; NRS 2002: Nutritional Risk Screening 2002; HADS: Hospital Anxiety and Depression Scale; ASA: American Society of Anesthesiologists; CCI: Charlson Comorbidity Index; AJCC: American Joint Committee on Cancer; SMD: Standardized mean difference.

Primary outcome analysis

The analysis of primary outcomes within the PSM-matched cohort (n = 250) demonstrated a clear and statistically significant advantage for the Watson-FTS group compared to the routine care group across both prespecified endpoints. Regarding the time to first postoperative flatus, patients in the Watson-FTS group achieved intestinal function recovery significantly earlier, with a mean time of 52.4 ± 10.8 hours, compared to 68.1 ± 13.5 hours in the routine care group (P < 0.001). Multivariable linear regression, adjusting for residual baseline factors, confirmed that the Watson-FTS intervention was independently associated with a 15.2-hour reduction in flatus time (adjusted β = -15.2; 95%CI: -18.4 to -12.0; P < 0.001) (Table 2).

Table 2 Comparison of primary outcomes in the matched cohort (n = 250), n (%)/mean ± SD.

Outcome	Watson-FTS (n = 125)	Routine care (n = 125)	Unadjusted difference	Adjusted effect (95%CI)1	P value
First flatus time (hours)	52.4 ± 10.8	68.1 ± 13.5	-15.7	β: -15.2 (-18.4 to -12.0)	< 0.001
Overall complications	19 (15.2)	38 (30.4)	-15.20	aOR: 0.39 (0.21-0.72)	0.003
Clavien-Dindo severity
Grade I-II	15 (12.0)	30 (24.0)	-12.00	aOR: 0.43 (0.22-0.85)	0.015
Grade ≥ III	4 (3.2)	8 (6.4)	-3.20	aOR: 0.48 (0.14-1.66)	0.246
Stoma-related events	6 (4.8)	16 (12.8)	-8.00	aOR: 0.34 (0.13-0.89)	0.024

¹Propensity score matching was performed using all baseline variables listed in Table 1 (including age, sex, body mass index, education, American Society of Anesthesiologists, Nutritional Risk Screening 2002, Charlson Comorbidity Index, smoking, neoadjuvant therapy, Hospital Anxiety and Depression Scale anxiety/depression, surgical approach, TNM stage, tumor location, permanent stoma status, and baseline nutritional markers). The regression models for outcomes further adjusted for these covariates to account for residual confounding.

Statistical significance was set at P < 0.05. β: Adjusted regression coefficient from multivariable linear regression. aOR: Adjusted odds ratio from multivariable logistic regression. FTS: Fast track surgery; aOR: Adjusted odds ratio; CI: Confidence interval.

Furthermore, a post hoc power analysis based on the final matched cohort of 125 pairs confirmed that the study was adequately powered. Specifically, the observed effect size for the reduction in time to first flatus yielded a statistical power of greater than 99%, and the observed reduction in overall postoperative complication rates provided a power of 83.4%.

The incidence of overall postoperative complications was significantly lower in the Watson FTS group (15.2%, 19/125) than in the routine care group (30.4%, 38/125), yielding an unadjusted P value of 0.004. This corresponded to a 61% reduction in the odds of experiencing any complication (aOR = 0.39, 95%CI: 0.21-0.72, adjusted P = 0.003) after adjusting for age, tumor stage, and surgical approach in the multivariable logistic regression model. When complications were analyzed by Clavien-Dindo severity, the most pronounced reduction was observed in minor events (Grade I-II), whereas the incidence of major complications (Grade ≥ III) showed a downward trend that did not reach statistical significance (3.2% vs 6.4%, P = 0.246). Notably, the specific analysis of stoma-related complications revealed that the Watson-FTS group had a substantially lower rate of peristomal dermatitis and mucocutaneous separation (4.8% vs 12.8%, P = 0.024), indicating the clinical effectiveness of specialized stoma care integrated into the humanistic pathway (Figure 2).

Figure 2 Primary outcome comparison between the Watson-fast track surgery and routine care groups. A: Box plots illustrating the distribution of time to first postoperative flatus (hours); B: Bar chart displaying the incidence of overall postoperative complications; C: With the adjacent forest plot indicating the adjusted odds ratio and 95% confidence intervals. FTS: Fast track surgery; aOR: Adjusted odds ratio; CI: Confidence interval.

Secondary outcomes analysis

The secondary outcomes analysis evaluated the impact of the Watson-FTS intervention across physiological, functional, and humanistic process-of-care dimensions.

Regarding physiological and functional recovery, patients in the Watson-FTS group achieved their first ambulation significantly earlier than those in the routine care group, with 26.4 ± 6.2 hours compared to 38.9 ± 8.5 hours, P < 0.001. Multivariable linear regression, which controlled for residual baseline factors, confirmed that the Watson-FTS intervention was an independent predictor of earlier mobilization, with an adjusted β of -12.1 hours and 95%CI: -13.8 to -10.4, P < 0.001. Additionally, the Watson-FTS group showed a shorter median postoperative LOS, 7.0 days vs 9.0 days, P < 0.001, and achieved a higher mean KPS score at discharge, 84.5 ± 5.2 vs 78.2 ± 6.1, P < 0.001, indicating superior functional status.

The evaluation of humanistic nursing process indicators revealed substantial improvements in intervention fidelity and patient empowerment. The completion rate of teach-back education was significantly higher in the Watson-FTS group, 92.0% (115/125), compared to the routine care group, 64.8% (81/125), P < 0.001, with a nearly sixfold increase in the odds of completion, aOR 5.82 and 95%CI: 2.76-12.28, P < 0.001. Similarly, the Watson-FTS group showed significantly higher rates of individualized discharge planning, 88.8% vs 52.0%, P < 0.001, and successful achievement of self-efficacy milestones, such as independent stoma appliance changes prior to discharge, 81.6% vs 56.8%, P < 0.001. These findings suggest a robust implementation of Watson-based humanistic elements within the standardized FTS pathway (Table 3).

Table 3 Comparison of secondary outcomes in the matched cohort (n = 250), n (%)/mean ± SD.

Outcome dimension	Watson-FTS (n = 125)	Routine care (n = 125)	Unadjusted difference	Adjusted effect (95%CI)1	P value
Physiological and functional
First ambulation time (hours)	26.4 ± 6.2	38.9 ± 8.5	-12.5	β: -12.1 (-13.8 to -10.4)	< 0.001
Postoperative stay (days)2, median (IQR)	7.0 (6.0, 8.0)	9.0 (7.5, 11.0)	-2.0	β: -1.8 (-2.3 to -1.3)	< 0.001
Discharge KPS score	84.5 ± 5.2	78.2 ± 6.1	+6.3	β: +5.9 (4.6-7.2)	< 0.001
Humanistic process quality
Teach-back completion	115 (92.0)	81 (64.8)	+27.2	aOR: 5.82 (2.76-12.28)	< 0.001
Individualized plan rate	111 (88.8)	65 (52.0)	+36.8	aOR: 7.14 (3.58-14.24)	< 0.001
Self-efficacy milestone3	102 (81.6)	71 (56.8)	+24.8	aOR: 3.25 (1.84-5.74)	< 0.001

¹All models were adjusted for all baseline covariates listed in Table 1 to account for residual confounding.

²P value for length of stay derived from Wilcoxon signed-rank test; β derived from generalized linear model with log-link to account for skewness.

³Defined as the documented independent performance of a complete stoma appliance change by the patient prior to discharge.

β: Adjusted regression coefficient. KPS: Karnofsky Performance Status; FTS: Fast track surgery; aOR: Adjusted odds ratio; CI: Confidence interval.

Longitudinal trajectory analysis

In the longitudinal analysis, missing values for postoperative nutritional markers, which were missing in up to 6.2% of instances and deemed MAR, were also handled via multiple imputation. Therefore, the GEE models utilized these pooled imputed datasets rather than a complete case analysis to ensure statistical power and valid inferences.

The longitudinal analysis assessed dynamic changes in two distinct dimensions: (1) Nutritional markers at four time points (preoperative T0 and postoperative days 1/T1, 3/T2, and 7/T3); and (2) Adherence to key FTS elements at three postoperative time points (days 1/T1, 3/T2, and 5/T3). GEEs with an exchangeable correlation structure were utilized, treating time as a categorical variable to capture the nonlinear recovery patterns.

For nutritional markers, PA levels demonstrated a significant group-by-time interaction effect, P < 0.001. While both groups exhibited a sharp decline at T1 due to surgical stress, the Watson-FTS group showed a significantly faster recovery trajectory from T2 to T3. By T3 (day 7), the Watson-FTS group achieved a higher estimated marginal mean of 215.6 mg/L (95%CI: 208.4-222.8) compared to 182.3 mg/L (95%CI: 174.1-190.5) in the routine care group. The GEE model confirmed this favorable recovery slope (interaction β 6.42, 95%CI: 4.15-8.69, P < 0.001). In contrast, while serum Alb levels decreased postoperatively in both groups, the group by time interaction did not reach statistical significance (interaction β 0.45, 95%CI: -0.12 to 1.02, P = 0.124), likely attributable to the longer half-life of Alb compared to PA.

Protocol adherence also showed a significant group by time interaction, P = 0.008. Adherence rates were comparable at T1 (Watson-FTS 54.4% vs routine care 48.8%, P = 0.378) but diverged significantly as recovery progressed. By day 5, the Watson-FTS group maintained a significantly higher adherence rate (91.2% vs 70.4%, P < 0.001). The interaction odds ratio of 1.85 (95%CI: 1.18-2.90) indicates that the Watson-FTS intervention effectively sustained patient engagement with FTS protocols throughout the early recovery phase (Table 4 and Figure 3).

Figure 3 Estimated marginal means of prealbumin recovery trajectories. The graph illustrates the dynamic changes in prealbumin (mg/L) from preoperative T0 to postoperative T3 (day 7). Both groups show an initial decline, but the Watson-fast track surgery group demonstrates a significantly faster recovery curve, highlighting the impact of humanistic nursing on metabolic stabilization. FTS: Fast track surgery.

Table 4 Generalized estimating equation model results for nutritional trajectories and protocol adherence (n = 250).

Model parameter	Prealbumin (mg/L) β (95%CI)	P value	FTS adherence (yes) OR (95%CI)	P value
Intercept	222.8 (215.4-230.2)	< 0.001	0.82 (0.54-1.25)	0.358
Group (Watson-FTS vs control)	5.48 (2.12-8.84)	0.001	2.15 (1.42-3.26)	< 0.001
Time (categorical reference: T1)
T2 (day 3 for nutrition/adherence)	17.6 (12.4-22.8)	< 0.001	2.56 (1.88-3.48)	< 0.001
T3 (day 7 for nutritional/day 5 for adherence)	33.7 (28.5-38.9)	< 0.001	4.12 (2.95-5.76)	< 0.001
Group × time interaction	6.42 (4.15-8.69)	< 0.001	1.85 (1.18-2.90)	0.008

Data from propensity score matching-matched cohort (n = 125 pairs). Generalized estimating equation models utilized an exchangeable correlation structure. All models were adjusted for the baseline values of the respective outcome and the comprehensive set of covariates listed in Table 1 (including age, body mass index, American Society of Anesthesiologists class, TNM stage, and surgical approach) to account for residual confounding. Interaction odds ratio > 1 or β > 0 indicates a more favorable trajectory in the Watson-fast track surgery group. FTS: Fast track surgery; OR: Odds ratio; CI: Confidence interval.

Multivariable regression analysis of predictors for recovery quality

Multivariable regression models were constructed using the full analysis set (n = 312) to evaluate the independent contribution of the Watson-FTS intervention. Predictor variables were selected a priori based on clinical relevance and their established association with postoperative recovery, including the intervention group, demographic factors, and key clinical characteristics. Two distinct models were utilized to identify independent predictors for successful early recovery and functional status at discharge.

The first model employed multivariable logistic regression to identify independent predictors for successful early recovery, defined as achieving the first flatus within 48 hours post-operatively. The Watson-FTS intervention emerged as the strongest independent protective factor, associated with a 3.6-fold increase in the odds of early flatus (aOR = 3.62, 95%CI: 2.18-6.01, P < 0.001). Other significant predictors included the laparoscopic surgical approach (aOR = 2.45, 95%CI: 1.34-4.48, P = 0.004) and younger age (aOR = 0.97 per year increase, 95%CI: 0.94-0.99, P = 0.025). The Hosmer-Lemeshow test indicated an excellent model fit (P = 0.742), confirming that the model adequately represented the data.

The second model used multiple linear regression to identify factors influencing the KPS score at discharge. The Watson-FTS intervention was significantly associated with a higher functional status, contributing to a 6.2-point increase in the KPS score (adjusted β = 6.24, 95%CI: 4.85-7.63, P < 0.001). This model accounted for 48.5% of the variance in discharge KPS scores (adjusted R squared = 0.485). Advanced TNM stage was independently associated with a lower KPS score (adjusted β = -3.12, 95%CI: -5.45 to -0.79, P = 0.009). Model diagnostics, including visual inspection of residual plots, confirmed the normality of residuals and homoscedasticity, ensuring the validity of the linear estimates (Table 5).

Table 5 Multivariable regression analysis for predictors of postoperative recovery quality (n = 312).

Predictors	Model 1 early recovery success (flatus < 48 hours)			Model 2 functional status at discharge (KPS)
	Adjusted OR (95%CI)	χ2	P value	Adjusted β (95%CI)	t value	P value
Watson-FTS intervention (ref: Routine)	3.62 (2.18-6.01)	24.15	< 0.001	6.24 (4.85-7.63)	8.82	< 0.001
Age (per year)	0.97 (0.94-0.99)	5.02	0.025	-0.08 (-0.16 to 0.01)	-2.14	0.033
BMI (kg/m2)	1.04 (0.96-1.13)	0.88	0.348	0.12 (-0.15 to 0.39)	0.86	0.391
Laparoscopic approach (ref: Open)	2.45 (1.34-4.48)	8.24	0.004	2.85 (1.12-4.58)	3.24	0.001
ASA class III (ref: I-II)	0.78 (0.45-1.35)	0.76	0.383	-1.45 (-3.12 to 0.22)	-1.71	0.088
TNM stage III (ref: I-II)	0.82 (0.51-1.32)	0.64	0.424	-3.12 (-5.45 to 0.79)	-2.63	0.009
Permanent stoma (ref: Temporary)	0.88 (0.54-1.43)	0.28	0.597	-2.05 (-3.82 to 0.28)	-2.28	0.023

Model 1 utilized multivariable logistic regression (Hosmer-Lemeshow, P = 0.742). Model 2 utilized multivariable linear regression (adjusted R squared = 0.485). Reference groups are indicated in parentheses.

KPS: Karnofsky Performance Status; BMI: Body mass index; ASA: American Society of Anesthesiologists; OR: Odds ratio; β: Unstandardized regression coefficient; CI: Confidence interval.

Subgroup and sensitivity analysis

Subgroup analyses were conducted within the PSM matched cohort to evaluate the consistency of the Watson FTS intervention effect on the primary outcome, time to first flatus. The intervention effect remained robust across all prespecified subgroups. Specifically, the reduction in flatus time was consistent across age groups, with an adjusted mean difference of 15.4 hours (95%CI: 11.9-18.9) for patients aged less than 65 years and 14.8 hours (95%CI: 10.4-19.2) for those aged 65 years or older, P for interaction = 0.784. Regarding the surgical approach, the benefit was observed in both laparoscopic (adjusted β = 15.6) and open procedures (adjusted β = 13.9), P for interaction = 0.412. Notably, the intervention showed significant efficacy regardless of stoma type, with adjusted mean differences of 16.2 hours (95%CI: 12.6-19.8) in the permanent stoma subgroup and 14.5 hours (95%CI: 10.9-18.1) in the temporary stoma subgroup, P for interaction = 0.521 (Table 6).

Table 6 Subgroup analysis of the effect of Watson-fast track surgery on time to first flatus.

Subgroup	n (Int/Con)	Adjusted beta (95%CI)	P value	P for interaction
Overall matched cohort	125/125	-15.2 (-18.4 to -12.0)	< 0.001	Reference
Age (years)				0.784
< 65	74/76	-15.4 (-18.9 to -11.9)	< 0.001
≥ 65	51/49	-14.8 (-19.2 to -10.4)	< 0.001
Surgical approach				0.412
Laparoscopic	95/94	-15.6 (-19.1 to -12.1)	< 0.001
Open	30/31	-13.9 (-18.2 to -9.6)	< 0.001
Stoma type				0.521
Permanent	50/49	-16.2 (-19.8 to -12.6)	< 0.001
Temporary	75/76	-14.5 (-18.1 to -10.9)	< 0.001

Data are derived from the propensity score-matched cohort. Int/Con: Intervention group (Watson-fast track surgery)/control group (routine care). The adjusted beta represents the mean difference in time to first postoperative flatus (in hours), estimated via multivariable linear regression adjusting for baseline covariates. A negative Beta indicates a shorter recovery time for the Watson-fast track surgery group. The P for interaction assesses whether the magnitude of the intervention effect differs significantly across the strata of each subgroup. CI: Confidence interval.

To assess the potential impact of unmeasured confounding factors (such as socioeconomic status or family support) on both primary outcomes, sensitivity analyses were performed using E-value calculations. For the binary outcome of overall complications (aOR = 0.39), the E-value was 4.56 (lower 95%CI limit: 2.12). This indicates that an unmeasured confounder would need a risk ratio association of at least 4.56 with both the intervention and the outcome to nullify the observed effect. Furthermore, for the continuous outcome of time to first flatus, the E-value for the adjusted mean difference of 15.2 hours was 12.4. These exceptionally high E-values robustly demonstrate that it is highly improbable for unmeasured psychosocial or economic variables to fully explain away the observed clinical benefits.

Furthermore, to rigorously address potential clustering bias stemming from unmeasured surgical technical variation, we performed an additional sensitivity analysis incorporating the “surgeon identifier” (n = 8 attending surgeons) as a random intercept in mixed-effects models. The intraclass correlation coefficient was low (< 0.04), indicating minimal surgeon-level clustering. Most importantly, after accounting for this random effect, the Watson-FTS intervention remained a highly significant independent predictor for both the shortened time to first flatus (adjusted β = -14.9 hours, 95%CI: -18.2 to -11.6, P < 0.001) and the reduction in overall complications (aOR = 0.41, 95%CI: 0.22-0.77, P = 0.005).

Most importantly, to address potential confounding from underlying secular trends, an ITS analysis was performed (Table 7). The segmented regression model applied to quarterly data revealed a flat, nonsignificant preintervention trend for time to first flatus (-0.15 hours per quarter, P = 0.312). However, precisely coinciding with the implementation of the Watson-FTS pathway (quarter 1, 2022), there was a stark, statistically significant immediate level drop in the time to first flatus (-13.84 hours, 95%CI: -17.52 to -10.16, P < 0.001). The postintervention trajectory did not significantly deviate from the preintervention slope (change in slope -0.05 hours/quarter, P = 0.620). By directly modeling the timeline, this confirms that the observed profound acceleration in recovery is attributable to humanistic intervention rather than natural longitudinal progress. Collectively, these sensitivity analyses confirm the robustness of the primary study findings.

Table 7 Interrupted time-series analysis (segmented linear regression) evaluating the impact of the Watson-fast track surgery intervention on time to first flatus.

Parameter	Estimate (hours)	SE	95%CI	t	P value
Baseline intercept (estimated time at Q1 2019)	68.52	1.84	64.91-72.13	37.24	< 0.001
Preintervention trend (change per quarter before Jan 2022)	-0.15	0.14	-0.42 to 0.12	-1.07	0.312
Level change (intervention effect) (immediate drop at Q1 2022)	-13.84	1.88	-17.52 to -10.16	-7.36	< 0.001
Postintervention trend modification (change in slope after intervention)	-0.05	0.1	-0.24 to 0.14	-0.5	0.62

The segmented linear regression model utilized aggregated quarterly data from January 2019 to December 2024. A negative estimate for the “Level Change” indicates a robust, immediate acceleration in gastrointestinal recovery (shorter time to flatus) exactly coinciding with the implementation of the Watson-fast track surgery pathway, independent of the nonsignificant underlying secular trends. CI: Confidence interval.

DISCUSSION

This study demonstrates that the Watson FTS nursing model, an integration of human caring theory into the ERAS pathway, is significantly associated with enhanced postoperative recovery in CRC patients with ostomies. Our findings reveal that this model not only accelerates physiological recovery but also improves psychological well-being and nutritional status, underscoring the importance of a holistic, patient-centered approach in surgical care. The discussion below will analyze these findings in the context of the literature, explore the underlying mechanisms, and address the study’s limitations.

A key finding of our study is the accelerated physiological recovery in the Watson-FTS group, evidenced by a shorter time to first flatus. This aligns with a growing body of literature supporting the role of psychological interventions in modulating the physiological stress response to surgery. The Watson-FTS model, by emphasizing human connection and psychological support, likely mitigates the surgical stress response through the psychoneuroimmunology pathway[33]. Surgical trauma activates the hypothalamic-pituitary-adrenal axis, leading to elevated levels of catabolic hormones such as cortisol, which can impair gut motility and lead to postoperative ileus. While we hypothesize that the psychological support inherent in the Watson FTS model may attenuate hypothalamic pituitary adrenal axis activation and its associated inflammatory sequelae[34], we must rigorously consider alternative clinical explanations. The implementation of a new and highly structured nursing model inherently increases the frequency of patient assessments and overall clinical vigilance. Consequently, the accelerated physiological recovery could be partially driven by a Hawthorne effect, where patients and nursing staff perform better simply because they are participating in a novel care pathway[35]. Furthermore, this heightened and structured attention might have inadvertently improved general patient adherence to the standard FTS protocol elements. Therefore, the observed benefits may be mediated by enhanced medical compliance and increased monitoring rather than exclusively by the specific metaphysical tenets of Watson Caring Theory.

The significantly lower rate of stoma-related complications in the Watson-FTS group highlights the efficacy of patient empowerment strategies, such as the teach-back method and the promotion of self-efficacy. Traditional ERAS pathways often fail to provide comprehensive patient education, leading to patient anxiety and improper self-care. The Watson-FTS model addresses this gap by fostering a supportive learning environment. This approach is consistent with the findings of Wang et al[36], who demonstrated that a combination of visual health education and peer education significantly reduced peristomal complications in ileostomy patients. Furthermore, our findings align with the principles of Bandura's self-efficacy theory, which posits that an individual's belief in their ability to perform a task is a key determinant of their success. The teach-back method, a core component of the Watson-FTS model, not only ensures comprehension but also builds patient confidence. While direct evidence linking teach-back and self-efficacy to reduced stoma complications in CRC patients is still emerging, our study provides strong support for this connection. As the “Self-Stoma” trial protocol suggests, there is a growing recognition of the need to rigorously evaluate the impact of these interventions on patient outcomes[37].

Our study reveals a significantly better nutritional trajectory in the Watson-FTS group, as indicated by higher PA levels postoperatively. This suggests that the psychological support provided by the Watson-FTS model facilitates a more rapid transition from a catabolic to an anabolic state. Surgical stress induces a catabolic state, characterized by protein breakdown and muscle wasting. Psychological interventions, by mitigating the stress response and improving sleep quality, can help shift this balance toward anabolism. As Wang and Pan[38] demonstrated, combining psychological resilience training with nutritional support significantly reduces inflammatory markers and improves nutritional status in gastric cancer patients. This is further supported by Włodarczyk[39], who noted that psychological well-being can counteract catabolic processes.

The choice of PA as a nutritional marker is also a key strength of this study. Due to its short half-life of approximately 2.5 days, PA is a more sensitive indicator of acute changes in nutritional status than Alb, which has a half-life of 19-21 days[40]. This makes PA particularly well suited for tracking the rapid nutritional changes that occur in the perioperative period.

The consistency of our findings across subgroups, particularly the significant benefits observed in patients with permanent stomas, underscores the importance of the Watson-FTS model in this vulnerable population. As highlighted by Tan et al[41], patients with permanent stomas face profound long-term challenges in adapting to a 'new normal' and have a significant need for psychological and social support. Our results provide strong evidence that the Watson-FTS model can help meet these needs, improving both physical and psychological outcomes.

Methodologically, this study's use of PSM effectively balanced baseline characteristics between the two groups. However, to address the potential for unmeasured confounding, we calculated the E-value, as proposed by VanderWeele and Ding[42]. A high E-value would suggest that a strong, unmeasured confounder would be needed to explain away the observed effect. The use of the E-value adds a layer of robustness to our findings, increasing our confidence that the observed benefits of the Watson-FTS model are not due to unmeasured confounding variables.

This study provides compelling evidence that the “Watson-FTS” model, which integrates Jean Watson’s Theory of Human Caring into the traditional ERAS pathway, is superior to ERAS alone. This is consistent with a growing body of literature highlighting the psychological support deficits of traditional ERAS programs. As Bernard and Foss[43] noted, ERAS programs often fail to recognize the psychological impact of early discharge and do not adequately address patient anxiety. The Watson-FTS model directly addresses this gap by prioritizing the nurse-patient relationship and providing a framework for delivering compassionate, holistic care. Recent studies have begun to explore the integration of humanistic care into surgical settings, with promising results. For example, Wang and Niu[7] found that humanistic care-based operating room nursing significantly reduced physiological stress and postoperative complications in CRC patients. Our study builds upon this work, providing robust evidence for the benefits of a formalized “Watson-FTS” model in the specific context of CRC patients with ostomies.

We recognize that the routine collection of patient-reported outcome measures, such as stoma-specific quality of life or longitudinal psychological scores, is notoriously difficult in a retrospective EMR cohort. Therefore, we pragmatically utilized documented behavioral milestones, notably the independent performance of a complete stoma appliance change prior to discharge, as objective proxies reflecting enhanced patient self-efficacy and psychological adaptation.

Despite the strengths of this study, several critical limitations must be explicitly highlighted. First and foremost, the retrospective natural experimental design is inherently vulnerable to severe unmeasured confounding, particularly temporal confounding. As the control period overlapped with the pandemic, strict infection control policies severely restricted family presence and altered normal nursing workflows. While our ITS analysis robustly isolated the intervention effect from underlying secular trends, the macro environmental impact on patient recovery trajectories cannot be completely ruled out. Second, there is a major disconnect between our theoretical humanistic framework and the predominantly physiological primary endpoints. Because we relied on retrospective EMRs, we lacked direct patient-reported humanistic outcome measures, such as longitudinal HADS scores or a Stoma Quality of Life instrument. Consequently, we cannot definitively prove that internal psychological states were improved by the intervention. Third, evaluating intervention fidelity retrospectively through electronic health record keyword searches is inherently subjective. It confirms documentation compliance but cannot fully capture the qualitative depth of the delivered humanistic care. Finally, as a single center study relying on specialized ETs and dedicated training resources, our findings may have limited generalizability, particularly in resource-constrained healthcare settings. Furthermore, the pragmatic exclusion of critically ill patients (ICU stay > 48 hours) limits the applicability of our conclusions to higher-risk surgical populations. To address feasibility for broader adoption, we propose a “Streamlined Watson-FTS” model for hospitals with limited specialized staffing. This low-cost adaptation would leverage prerecorded digital audio or virtual reality modules for psychological prehabilitation and cross-train general ward nurses in core “teach-back” principles, thereby reducing the absolute dependence on dedicated specialists for every interaction. Additionally, while high-risk ICU patients were excluded here to maintain standardized protocol homogeneity, future iterations must adapt these humanistic core concepts-such as structured, continuous family-centered communication-specifically to the intensive care environment.

To address these limitations, future research should employ a multicenter, prospective design. A cluster-randomized controlled trial (Cluster-RCT) would be the gold standard for evaluating the effectiveness of the Watson-FTS model[44]. As demonstrated by Rood et al[45] in the context of ICU delirium prevention, a well-designed cluster-RCT can provide high-level evidence for the effectiveness of complex nursing interventions. Future studies should also explore the long-term impact of the Watson-FTS model on patient quality of life, stoma self-efficacy, and psychosocial adjustment.

CONCLUSION

This study provides evidence that a standardized nursing pathway integrating Watson’s Theory of Human Caring with ERAS principles is significantly associated with improved postoperative recovery in CRC patients with an ostomy. The “Watson-FTS” model was associated with accelerated gastrointestinal function, reduced complications, better nutritional recovery, and higher functional status compared to conventional ERAS care. These benefits, consistent across key patient subgroups, appear to be mediated by humanistic processes such as trust-building, empowered education, and self-efficacy support. While further validation through prospective studies is warranted, these findings highlight the clinical value of systematically incorporating humanistic theory into structured recovery pathways to achieve more holistic patient outcomes.