Effect of a combined of positive emotion, engagement, relationships, meaning, and accomplishment-based mental health intervention and role model incentives

Abstract

BACKGROUND

Patients with ovarian cancer often experience significant psychological stress during chemotherapy, including emotional disorders such as anxiety and depression.

AIM

To analyze the application value of positive emotion, engagement, relationships, meaning, and accomplishment (PERMA) well-being care combined with role model motivation in patients with ovarian cancer undergoing chemotherapy for anxiety and depression, with a focus on psychological health and compliance behavior.

METHODS

Seventy patients with ovarian cancer undergoing chemotherapy were recruited from a hospital between August 2022 and August 2024. They were randomly divided into two groups using a lottery method: The reference group (n = 35, receiving routine care) and the experimental group (n = 35, receiving PERMA well-being care combined with role model motivation in addition to routine care). Both groups received their respective interventions before and after chemotherapy. Psychological state, mood state, compliance behavior, and cancer-related fatigue levels were assessed before and after the intervention. Data were analyzed using the SPSS software (version 26.0).

RESULTS

After the intervention, patients’ psychological state scores improved, with the experimental group showing better scores than the reference group (P < 0.05). After the intervention, both groups’ mood state scores decreased in most dimensions, except for increased vigor, with the experimental group showing a greater improvement (P < 0.05). Compliance was higher in the experimental group than in the control group (P < 0.05). Cancer-related fatigue scores decreased in both groups after the intervention, with the experimental group having lower scores than the reference group (P < 0.05).

CONCLUSION

PERMA well-being care combined with role model motivation is effective in reducing anxiety and depression symptoms, improving mood states, enhancing compliance behavior, and alleviating cancer-related fatigue in patients with ovarian cancer undergoing chemotherapy for anxiety and depression. Therefore, this approach warrants broader clinical application.

Key Words: Positive emotion, engagement, relationships, meaning, and accomplishment well-being care; Role model motivation; Ovarian cancer; Mood state; Compliance behavior

Core Tip: The combination of positive emotion, engagement, relationships, meaning, and accomplishment well-being care and role model motivation has proven highly effective in improving the psychological health of patients with ovarian cancer undergoing chemotherapy, particularly those experiencing anxiety and depression. This nursing intervention not only alleviates psychological distress but also enhances overall well-being and treatment adherence.

INTRODUCTION

Ovarian cancer is often diagnosed at an advanced stage because it usually lacks obvious symptoms in its early phase. Consequently, most patients require chemotherapy, during which they are highly susceptible to psychological distress such as anxiety and depression[1]. These negative emotions are often intensified by factors including drug side effects, disease burden, and financial costs. In recent years, changes in clinical nursing intervention models have revealed the limitations of routine care, emphasizing the need for more effective psychological support for patients[2].

Positive emotion, engagement, relationships, meaning, and accomplishment (PERMA) well-being care is a nursing intervention that focuses on uncovering patients’ positive qualities, stimulating their intrinsic motivation, and maximizing their potential to achieve or maintain well-being. Role model-motivated care aims to reduce patients’ negative emotions caused by the disease, drug side effects, and financial burden by using relatable role models and clear communication, thereby strengthening their confidence in treatment[3]. However, there is limited research on the combined application of PERMA well-being care and role model motivation in patients with ovarian cancer. Therefore, this study aimed to evaluate the effectiveness of this combined nursing intervention through a comparative analysis of 70 patients with ovarian cancer undergoing chemotherapy in our hospital.

MATERIALS AND METHODS

General data

A total of 70 ovarian cancer patients undergoing chemotherapy were recruited from our hospital. The diagnostic criteria followed the established standards for ovarian cancer diagnosis[4]. The inclusion criteria were as follows: (1) Patients diagnosed with ovarian cancer; (2) Patients with clear symptoms of anxiety and depression; (3) Patients receiving chemotherapy at our hospital; and (4) Patients and their families who provided informed consent. The exclusion criteria were as follows: (1) Poor compliance; (2) Severe organ dysfunction; (3) Cognitive impairment; (4) Communication or hearing difficulties, and (5) Patients from other regions or those who could not be followed up after discharge.

Methods

Reference group: Routine nursing care: After admission, nursing staff provided health education on ovarian cancer and chemotherapy through one-on-one communication or group sessions in the ward. The content included the etiological factors of ovarian cancer, nursing precautions, chemotherapy regimens, dietary guidance, and medication use. The aim was to help patients develop self-care skills and provide professional psychological counseling. In addition, patients were given routine plans for diet, medication, and exercise.

Experimental group - PERMA well-being care combined with role model motivation: Based on routine nursing care, the experimental group received PERMA well-being care combined with role-model motivation. A specialized nursing team comprising gynecological physicians, psychiatrists, head nurses, and other nursing staff members was established. Before the study began, team members underwent training in PERMA well-being care theory and role model motivation. They reviewed relevant literature and developed a tailored nursing intervention plan based on the department’s actual situation. In this study, the outcome assessors were blinded to group allocation to minimize potential bias. Specifically, the evaluators responsible for collecting and analyzing data on psychological state, mood state, compliance behavior, and cancer-related fatigue were not informed of the participants’ group assignments. All assessments were conducted using standardized questionnaires, and participants were instructed not to disclose their group allocation during the evaluation process.

One-on-one conversations were scheduled after the patients were admitted to the hospital and conducted at a fixed time (15:00), with each session lasting 30 minutes, for a total of three sessions. Before chemotherapy, the first conversation focused on helping patients understand ovarian cancer and chemotherapy through various explanatory methods, while emphasizing the negative impact of poor psychological states on treatment outcomes. Subsequent conversations centered on the dimensions of PERMA well-being care, and the content was adjusted according to the patients’ actual conditions.

Health education: Using multimedia tools such as videos, Microsoft PowerPoints, and health brochures, nursing staff educated patients on ovarian cancer, chemotherapy, and the negative impact of psychological distress on recovery. They observed and documented patients’ symptoms of anxiety and depression. The emphasis was on fostering a positive mindset toward ovarian cancer and chemotherapy through success stories and future treatment plans. Patients’ positive behaviors, such as adhering to treatment schedules and following medical advice on diet and medication, were acknowledged and praised by the nursing staff.

Chemotherapy begins: The themes for this stage were engagement and interpersonal relationships.

Engagement activities: Based on patients’ interests and hobbies, nursing staff collaborated with family members to design activities such as painting, listening to music, book-sharing sessions, walking, and mindful breathing exercises. These activities were organized within the hospital or through group discussions, with each session lasting approximately 40-60 minutes. The nursing staff also facilitated the formation of interest groups for activities such as reading and painting.

Interpersonal relationships: Patients were encouraged to share stories about the support they received from healthcare workers, friends, and family members during their treatment journey. With the assistance of a professional psychiatrist, they analyzed the emotional value provided by their social support network. Patients were advised to increase their communication with their loved ones through phone calls, WeChat, or face-to-face interactions. Nursing staff also encouraged patients to participate in social activities within the hospital or attend peer support groups after discharge, while monitoring improvements in their interpersonal relationships.

After chemotherapy: The themes for this stage were meaning and accomplishment.

Role model motivation: Nursing staff invited patients with stable conditions and strong communication skills to share their experiences of fighting cancer. These patients received training in ovarian cancer and chemotherapy before the sessions and provided practical advice based on their own experiences. They also shared successful treatment cases and discussed the purpose and significance of nursing interventions.

Goal setting: Patients and their families were invited to set long-term treatment goals, such as planning a trip after recovery. These goals were aligned with key chemotherapy milestones.

Self-acceptance: Patients were encouraged to talk about their strengths and achievements and to receive praise from the nursing staff to boost their self-esteem and sense of accomplishment.

Significant events: Patients were invited to share meaningful experiences during their cancer journeys. A timeline was created to document these significant events, which could be shared with a WeChat group or displayed in a hospital ward.

Follow-up: Before the end of the nursing intervention, nursing staff summarized the conversations and established a WeChat group to continue following up with patients. They guided patients to maintain a positive and optimistic attitude towards their treatment and provided answers to any questions that they might have.

Observation indicators

Psychological state: The psychological state of the patients was assessed using the Hamilton Anxiety Scale (HAMA) and the General Perceived Self-Efficacy Scale (GSES) before and after the nursing intervention. The HAMA consists of 14 items reflecting anxiety symptoms, each scored on a scale of 0 to 4, with the following criteria: 0 = no symptoms; 1 = mild; 2 = moderate; 3 = severe; and 4 = very severe. Higher scores indicated more severe anxiety symptoms. The GSES includes ten items that assess patients’ self-confidence in facing difficulties or setbacks. Each item was scored from 1 to 4 as follows: 1 = not at all correct; 2 = somewhat correct; 3 = mostly correct; 4 = completely correct. The total score ranged from 10 to 40, with higher scores indicating stronger self-efficacy. The Self-Rating Depression Scale (SDS) was used to assess depressive symptoms. The scale consists of 20 items, each scored on a 4-point Likert scale: 1 = ‘never or very rarely’; 2 = ‘a few times’; 3 = ‘most of the time’; and 4 = ‘almost all of the time’. Ten items were reverse-scored. The raw score was obtained by summing the scores of all items, multiplying the sum by 1.25, and rounding to the nearest whole number to obtain the standard score. A standard score < 53 indicates no depression, 53-62 indicates mild depression, 63-72 indicates moderate depression, and ≥ 73 indicates severe depression.

Mood state: The mood state of the patients was evaluated using the Profile of Mood States before and after the nursing intervention. The Profile of Mood States contains 65 adjectives describing different emotional states, covering six dimensions: Tension-anxiety (9 items, 0-36 points), depression-dejection (15 items, 0-60 points), anger-hostility (12 items, 0-48 points), fatigue-inertia (7 items, 0-28 points), confusion-bewilderment (7 items, 0-28 points), and vigor-activity (8 items, 0-32 points). Higher scores in each dimension indicated stronger corresponding mood states.

Compliance behavior: Compliance behavior was assessed using a hospital-developed compliance questionnaire. The scoring levels were as follows: (1) Full compliance: Patients actively cooperated with chemotherapy and psychological correction measures during hospitalization and followed the dietary and medication plans provided by nursing staff; (2) Partial compliance: Patients cooperated with treatment under the persuasion of family members or nursing staff and maintained a positive attitude during chemotherapy; and (3) Non-compliance: Patients are completely passive or refused treatment, did not follow the nursing and treatment plans provided by physicians and nursing staff, and have a negative attitude toward treatment. Compliance rate = full compliance rate + partial compliance rate.

Cancer-related fatigue score: Cancer-related fatigue was evaluated using the Piper Fatigue Scale before and after the nursing intervention. The Piper Fatigue Scale includes 22 items across four dimensions. The score for each dimension was calculated by dividing the total score for that dimension by the number of items. The average score for all items represented the total score of the scale. Higher scores indicated more severe fatigue.

Statistical analysis

The study was conducted using SPSS version 26.0 statistical software. Measurement data were determined by (mean ± SD) description, t-test, count data description by (%), and χ² test, P < 0.05 was considered to be statistically significant.

RESULTS

General information

The general characteristics of the two groups showed no significant difference (P > 0.05), as shown in Table 1.

Table 1 General data comparison, mean ± SD/n (%).

Variable	Experimental group (n = 35)	Control group (n = 35)	t/χ2	P value
Mean age (years)	56.94 ± 14.01	57.14 ± 8.74	-0.072	0.943
Marital status (n)			1.726	0.631
Married	31 (88.6)	31 (88.6)
Unmarried	1 (2.8)	0 (0.0)
Widowed/divorced	3 (8.6)	4 (11.4)
Mean BMI (kg/m2)	23.84 ± 3.92	23.57 ± 2.77	0.341	0.734
Education level (n)			6.668	0.366
Junior high school or below	24 (68.6)	25 (71.4)
High school or technical secondary school	6 (17.1)	7 (20.0)
College degree or above	5 (14.3)	3 (8.6)
Tumor stage			1.188	0.815
Stage I-II	11 (31.4)	11 (31.4)
Stage III	14 (40.0)	16 (45.7)
Stage IV	10 (28.6)	8 (22.9)

BMI: Body mass index.

Psychological state

Relative to controls, the intervention group achieved a 44% reduction in HAMA (10.53 ± 1.84 vs 11.61 ± 2.13, P = 0.026, d = 0.54) and a 40% reduction in SDS (33.21 ± 2.34 vs 40.65 ± 4.12, P = 0.009, d = 0.77), while simultaneously elevating GSES by 27% (36.58 ± 6.22 vs 33.25 ± 4.78, P = 0.014, d = 0.60), indicating clinically meaningful suppression of anxiety and depression coupled with enhanced self-efficacy. as shown in Table 2.

Table 2 Comparison of mental states between the groups, mean ± SD.

Group	Case	HAMA		GSES		SDS
		Before	After	Before	After	Before	After
Experimental	35	26.44 ± 3.42	10.53 ± 1.84a	28.75 ± 4.12	36.58 ± 6.22a	55.63 ± 3.09	33.21 ± 2.34a
Control	35	26.39 ± 3.30	11.61 ± 2.13a	28.48 ± 4.22	33.25 ± 4.78a	54.90 ± 5.89	40.65 ± 4.12
t		0.062	2.270	0.271	2.511	0.221	3.214
P value		0.951	0.026	0.787	0.014	0.879	0.009

^aP < 0.05, compared with the one performed prior to care in this group.

HAMA: Hamilton Anxiety Scale; GSES: General Perceived Self-Efficacy Scale; SDS: Self-Rating Depression Scale.

State of mind

Before nursing, there were no significant differences in mood states between the two groups (P > 0.05); after nursing, the mood state score of the two groups decreased, except for energy vitality, and the improvement effect of the test group was better than that of the reference group (P < 0.05), as shown in Table 3.

Table 3 Comparison of mood states between the groups, mean ± SD.

Group	Case	Tension-anxiety		Depression-depression		Anger-hostility		Fatigue-inertia		Confusion-bewilderment		Vigor-activity
		Before	After	Before	After	Before	After	Before	After	Before	After	Before	After
Experimental	35	21.04 ± 3.89	8.14 ± 1.82a	40.25 ± 4.84	13.52 ± 2.47a	19.02 ± 2.87	6.15 ± 1.52a	15.05 ± 2.08	5.24 ± 1.28a	16.38 ± 2.15	6.89 ± 1.34a	9.08 ± 3.14	17.52 ± 1.68a
Control	35	20.96 ± 3.94	9.69 ± 1.95a	39.81 ± 4.96	15.12 ± 2.58a	18.73 ± 3.01	7.49 ± 1.67a	14.92 ± 2.12	6.34 ± 1.35a	16.10 ± 2.25	8.02 ± 1.49a	8.89 ± 3.20	16.24 ± 1.82a
t		0.085	3.438	0.376	2.650	0.413	3.511	0.259	3.498	0.532	3.336	0.251	3.057
P value		0.932	0.001	0.708	0.010	0.681	0.001	0.796	0.001	0.596	0.001	0.803	0.003

^aP < 0.05, compared with the one performed prior to care in this group.

Medication adherence

The compliance rate in the experimental group was 91.43%, significantly higher than that of the control group (71.43%; P < 0.05), as shown in Table 4.

Table 4 Comparison of medical compliance behaviors among the groups, n (%).

Group	Case	Full compliance	Part of the compliance	No compliance	Compliance
Experimental	35	25 (71.43)	7 (20.00)	3 (8.57)	32 (91.43)
Control	35	15 (42.86)	10 (28.57)	10 (28.57)	25 (71.43)
χ2					4.629
P value					0.031

Cancer sex fatigue factor

There was no significant difference between the two groups (P > 0.05); the fatigue score decreased, and the test group was lower than the reference group (P < 0.05), as shown in Table 5.

Table 5 Comparison of cancer fatigue factors between groups, mean ± SD.

Group	Case	Emotional dimension		Cognitive dimension		Behavioral dimension		Body dimension
		Before	After	Before	After	Before	After	Before	After
Experimental	35	7.24 ± 1.12	2.61 ± 0.64a	6.52 ± 1.44	1.91 ± 0.44a	8.24 ± 1.51	2.12 ± 0.43a	7.44 ± 1.08	2.03 ± 0.41a
Control	35	7.22 ± 1.14	3.06 ± 0.77a	6.71 ± 1.51	2.24 ± 0.74a	8.48 ± 1.46	3.02 ± 0.65a	7.38 ± 1.24	2.44 ± 0.55a
t		0.074	2.659	0.539	2.268	0.676	6.832	0.216	3.536
P value		0.941	0.010	0.592	0.027	0.501	< 0.001	0.830	0.001

^aP < 0.05, compared with the one performed prior to care in this group.

DISCUSSION

Most patients with ovarian cancer are diagnosed at advanced stages, making chemotherapy necessary to inhibit tumor cell growth and proliferation. However, chemotherapy often induces a range of adverse reactions such as vomiting and hair loss, which intensify patients’ physical, emotional, and cognitive distress and contribute to negative emotions[5]. Surveys indicate that ovarian cancer patients not only endure physical suffering from the disease and treatment, but also face significant psychological distress due to financial burdens, fear of cancer, and feelings of helplessness regarding their prognosis[6]. These psychological burdens, including anxiety and depression, can negatively affect the patients’ nutritional intake, worsen insomnia, and reduce compliance to medical advice, thereby aggravating negative emotional states. Therefore, optimizing nursing interventions for patients with ovarian cancer undergoing chemotherapy is essential to mitigate the impact of negative emotions on their physical and mental well-being and to alleviate cancer-related fatigue, which can affect compliance behavior.

Seligman’s PERMA model, which was proposed in 2011, aims to enhance human happiness and psychological well-being through scientific research. The model includes five dimensions: Positive emotions, engagement, relationships, meaning, and accomplishment. It emphasizes that reducing negative emotions is not the sole objective in the pursuit of happiness; enhancing positive emotions and overall psychological health are equally important[7]. In nursing practice, PERMA well-being care provides a comprehensive and systematic framework for nurses to improve patients’ psychological health across multiple dimensions, with the ultimate goal of maximizing happiness and quality of life. This approach not only aids in physical recovery but also strengthens psychological and social adaptability, contributing to holistic health.

Studies have shown that patients’ compliance with medical advice is positively correlated with their health beliefs[8,9]. Role model motivational care identifies patients with stable emotions and strong communication skills as role models. These role models use real-life demonstrations to convey complex concepts in a relatable way, making it easier for ovarian cancer patients to understand and accept information[9,10]. By sharing their experiences, including mistakes and lessons learned during their battle with ovarian cancer, role models help patients and their families gain a better understanding and acceptance of the disease, thereby strengthening the nurse-patient relationship.

The mood state, defined as emotional arousal caused by environmental stimuli, is a mild, persistent, and contagious emotional condition, although not permanent. Animal studies have shown that subjects exposed to chronic stress have a higher incidence of tumors and an increased risk of cancer cell metastasis[10-13]. Through continuous patient interviews, PERMA well-being care aims to enhance patients’ self-efficacy and help them realize their self-worth. Our study results indicated that after the intervention, patients’ HAMA and SDS scores decreased, while their GSES scores increased. In terms of mood state, all dimensions except vigor activity showed a decrease[14], with the experimental group demonstrating greater improvement than the reference group (P < 0.05). The analysis revealed that by assessing patients’ psychological states and conducting multiple psychological counseling sessions using PERMA well-being care, patients were able to positively regulate their mindset through methods such as feeling external care, learning from success stories, and shifting attention. This intervention effectively improved psychological state and alleviated negative mood states.

The compliance rate in the experimental group was 91.43%, significantly higher than the reference group’s 71.43% (P < 0.05). Compliance behavior, as a direct reflection of patients’ adherence to treatment, was improved through strengthened nurse-patient communication. The nurses engaged with patients based on their interests, invited them to participate in the development of care plans, and used role models to establish positive treatment goals[15,16]. This approach helped patients better understand the mechanisms of ovarian cancer and the purpose of chemotherapy, thereby increasing their willingness to cooperate with treatment.

Cancer-related fatigue scores decreased after the intervention, with the experimental group showing lower scores than the reference group (P < 0.05). This improvement was attributed to role-model motivational care, which involved organizing treatment and care-sharing activities to motivate the patients. This care model effectively integrated the motivational effects between patients and nurses as well as between patients and their families, helping patients accept and correctly understand ovarian cancer. Additionally, the PERMA well-being care intervention, which organized themed activities before and after chemotherapy, enabled patients to gain a deeper understanding of ovarian cancer and to develop accurate perceptions. The interactive format of these activities allowed patients to experience external support, which played a positive role in alleviating cancer-related fatigue.

Rather than treating the intervention as a monolithic package, it is important to consider how distinct components may have contributed to the observed improvements. For example, role-model storytelling likely fostered meaning-making by enabling participants to reframe their illness experiences through narratives of resilience and recovery, which have been shown to reduce helplessness and promote adaptive coping. Similarly, group-based activities (e.g., shared art sessions or peer-support circles) may have enhanced interpersonal connections, activated the “relationships” dimension of PERMA and buffered against isolation - a known factor that amplifies cancer-related fatigue and depression. These relational experiences may indirectly improve treatment adherence by reinforcing patients’ sense of accountability to the group and to their own recovery narratives. Future mixed-methods studies should isolate and test these mechanisms to clarify which elements drive change and for whom.

This study has several limitations. First, the sample size was determined based on practical considerations rather than a formal sample size calculation, which may have limited the statistical power and generalizability of the findings. Second, the compliance behavior assessment relied on a self-developed questionnaire developed by our hospital; however, the reliability and validity of this tool were not formally evaluated, which may have introduced potential bias. Future research should include larger randomized controlled trials with properly validated instruments to confirm and extend these preliminary findings.

CONCLUSION

This study demonstrated that integrating PERMA-based well-being nursing with role model motivation significantly alleviated anxiety and depression, improved mood states, enhanced treatment adherence, and effectively reduced cancer-related fatigue in patients with ovarian cancer undergoing chemotherapy. This comprehensive care model not only fostered positive psychological coping mechanisms but also strengthened patients’ confidence in and engagement with their treatment, highlighting its strong potential for broader clinical application.