Application of information-motivation-behavioral skill model evidence-based nursing combined with cognitive behavioral intervention in children after brain tumor surgery

Abstract

BACKGROUND

Brain tumor resection under general anesthesia is the core treatment for intracranial tumors in children, but postoperative pain, anxiety, and poor compliance with rehabilitation care have become key factors affecting the prognosis of children. Because children’s cognitive development is immature, they have a stronger fear response to surgical trauma, which may cause long-term psychological trauma. As a mature behavioral change theoretical framework, the information-motivation-behavior (IMB) skills model is still blank in neurosurgery research. Based on this model, this study integrates evidence-based nursing and cognitive behavioral intervention to explore its impact on children after brain tumor resection under general anesthesia.

AIM

To study the application of evidence-based nursing and cognitive behavioral intervention based on the IMB model in the children.

METHODS

Ninety children undergoing brain tumor resection under general anesthesia at the hospital between January 2024 and January 2025 were randomly divided into a control group and an observation group, 45 cases in each group. The control group received routine perioperative care. The observation group, on the other hand, received an integrated program based on the IMB model, supported by evidence-based nursing. SPSS22.0 software was used for data analysis, and P < 0.05 was regarded as a statistically significant difference.

RESULTS

Following attrition, 40 controls and 42 intervention subjects finished follow-up. Eight weeks later, the intervention cohort showed markedly superior Functional Independence Measure for Children and Gesell Developmental Scales results (P < 0.05) and outperformed controls on all PedsQL™ dimensions: Physical, emotional, social, and role functioning (P < 0.05). Parents’ overall disease knowledge mastery rate was 97.62% in the observation group, higher than 80.00% in the control group (P < 0.05). Parent satisfaction was 97.62% in the observation group, higher than 77.50% in the control group (P < 0.05).

CONCLUSION

The IMB model-based integrated care effectively promotes neurological recovery, improves quality of life, and enhances parental knowledge and satisfaction in children after brain tumor surgery.

Key Words: Information-motivation-behavioral skill model; Evidence-based nursing; Cognitive behavioral intervention; Brain tumor resection under general anesthesia; Children

Core Tip: This study pioneered a comprehensive intervention based on the information-motivation-behavior model, integrating evidence-based nursing with cognitive behavioral therapy for the resection of brain tumors in children. It uniquely addresses the triple problems of information, motivation and behavioral skills through tailor-made development strategies (such as three-dimensional animation education, gamified rewards, etc.), demonstrating outstanding results in neural recovery and family empowerment. The innovation of this model lies in connecting psychological and physical rehabilitation, providing a replicable framework for pediatric neurosurgical care.

INTRODUCTION

Central nervous system tumors are the most common solid tumors in pediatrics, accounting for approximately 25% of all childhood malignant tumors, second only to leukemia[1]. In 2019, there were approximately 47600 new cases worldwide, and 23500 deaths that year[2]. Surgical resection is the first-line treatment[3]. However, due to the combined effects of tumor invasion and surgical trauma after surgery, children often face multiple problems such as neurological dysfunction, persistent pain, anxiety, depression, and sleep disorders[4]. Studies have shown that brain tumor patients are very likely to develop moderate to severe anxiety after surgery, and the incidence of pain is as high as 60%. If not intervened in time, it may not only delay functional recovery and reduce quality of life, but also significantly increase the burden of family care[5-7]. Therefore, it is of great significance for children with brain tumors to build an efficient, systematic, and physical and mental characteristics of perioperative care model[8]. Traditional perioperative care is disease-centered, focusing on vital sign monitoring and doctor’s order execution. It lacks pain and emotion management strategies tailored to the cognitive development level of children, and interventions are fragmented and have poor compliance. Although evidence-based care can fill the evidence gap, its effectiveness is often limited in pediatric settings due to the single form of education and insufficient parental participation[9]. Cognitive behavioral therapy (CBT) relieves pain and anxiety through cognitive reconstruction and behavioral activation, and has been gradually introduced into the pediatric field. However, single CBT is difficult to systematically integrate the three core elements of information, motivation, and behavioral skills[10]. The information-motivation-behavioral (IMB) skills model emphasizes the synergistic effect of information acquisition, motivation reinforcement, and behavioral skills training. Its effectiveness has been verified in college students’ health behavior and adult chronic disease management[11,12]. However, its application effect in perioperative care of children is still unclear. Based on this, this study uses the IMB model as a theoretical framework, integrates evidence-based nursing evidence with CBT technology, and constructs a comprehensive intervention program covering the entire process of “preoperative-postoperative-home”. The purpose is to explore the impact of this model on the neurological function, quality of life, and parental care ability of children after brain tumor resection under general anesthesia, and to provide empirical evidence for optimizing perioperative care in pediatric neurosurgery.

MATERIALS AND METHODS

Research object

The study included 90 pediatric patients who underwent general anesthesia for brain tumor resection from January 2024 to January 2025. The block randomization method was adopted, and SPSS22.0 software was used to generate a random allocation sequence, and the patients were finally divided into a control group and an observation group, with 45 cases in each group. Allocation protocols were maintained by an independent study coordinator, and allocation concealment was implemented through sequentially numbered, sealed, light-tight envelopes. Children and parents have no idea which group they will be assigned to before enrolling. Eight patients were lost to follow-up after surgery, with a loss-to-follow-up rate of 8.89%. A total of 42 patients were included in the observation group and 40 patients in the control group. Due to the particularity of the intervention, this study could not blind the children, parents, and the nursing team that implemented the intervention. However, in order to ensure the objectivity of the outcome assessment, the research assistant responsible for collecting the primary and secondary outcomes was completely blind to the grouping situation and did not participate in any nursing intervention. Data entry and statistical analysis were completed by another researcher who was unaware of the group codes. Baseline characteristics showed no significant intergroup differences in general information between the two groups of children and their main caregiver parents (P > 0.05), ensuring group comparability (Tables 1 and 2). This study has been rigorously reviewed and formally approved by our hospital’s ethics committee.

Table 1 General data comparison between both patient groups, n (%)/mean ± SD.

Project	Control group (n = 40)	Observation group (n = 42)	t/ χ2	P value
Age (years)	7.83 ± 1.95	7.93 ± 2.09	0.232	0.817
Gender			0.069	0.793
Male	24 (60.00)	24 (57.14)
Female	16 (40.00)	18 (42.86)
ASA classification			0.205	0.650
Level I	18 (45.00)	21 (50.00)
Level II	22 (55.00)	21 (50.00)
Pathological category			0.002	0.965
Benign	24 (60.00)	25 (59.52)
Malignant	16 (40.00)	17 (40.48)
Pathological type			0.747	0.945
Astrocytoma	16 (40.00)	17 (40.48)
Ependymal retention	10 (25.00)	12 (28.57)
Embryonal tumors	9 (22.50)	7 (16.67)
Craniopharyngioma	4 (10.00)	4 (9.52)
Other	1 (2.50)	2 (4.76)

ASA: American Society of Anesthesiologists.

Table 2 General data comparison of both patient groups’ primary caregivers, n (%)/mean ± SD.

Project	Control group (n = 40)	Observation group (n = 42)	t/ χ2	P value
Age (years)	37.50 ± 5.80	37.93 ± 6.03	0.328	0.744
Mainly caring for parents			0.574	0.449
Mother	34 (85.00)	38 (90.48)
Other	6 (15.00)	4 (9.52)
Educational level			0.496	0.481
High school and above	33 (82.50)	32 (76.19)
Junior high school and below	7 (17.50)	10 (23.81)
Monthly household income (yuan)			0.005	0.946
> 4000	26 (65.00)	27 (64.29)
≤ 4000	14 (35.00)	15 (35.71)

Exclusion and inclusion criteria

Inclusion criteria: (1) 5 years old to 12 years old; (2) Diagnosed with brain tumor, with clear pathological diagnosis, and undergoing brain tumor resection under general anesthesia; (3) No mental retardation or cognitive impairment before surgery; and (4) The patient and his/her guardian voluntarily signed the informed consent form.

Exclusion criteria: (1) Patients with unstable vital signs and major complications after surgery; (2) Patients with diseases of important organ systems; (3) Patients with severe mental illness; and (4) Patients lost to follow-up.

Methods

Control group: Traditional nursing intervention measures were implemented. Specific measures included: Routine preoperative visits to verify the patient’s identity and explain the surgical and anesthesia procedures; maintaining a clean and quiet ward, strictly controlling temperature and humidity (22 °C to 24 °C, 50% to 60%), and light intensity to create a favorable postoperative recovery environment for the patient; closely monitoring pupil changes, consciousness, respiratory rate, pulse, body temperature, and electrocardiogram within 24 hours after surgery, recording every 2 hours, and promptly addressing any abnormalities; observing the patient’s progress during daily life, noting changes in body language, and reporting any abnormalities to the attending physician promptly; providing necessary safety and health education to the patient and their parents, verbally informing parents of postoperative fasting time, positioning requirements, and activity restrictions, and implementing fall prevention measures such as bedrail protection and anti-slip mats; and administering intravenous fentanyl (0.5 μg/kg) as directed for pain management, and administering metoclopramide (0.1 mg/kg) as needed for vomiting.

Observation group: Based on the control group’s standard nursing care to introduce the IMB model, evidence-based nursing, and cognitive behavioral intervention strategies for integrated intervention. The integrated nursing program uses the IMB model as the theoretical framework, systematically integrating evidence-based nursing and cognitive behavioral intervention techniques to form an intervention system throughout the entire perioperative process: (1) Establish an integrated nursing intervention team: The team members include 1 attending physician: Participate in the formulation and decision-making of the final personalized intervention plan; 1 head nurse: Coordinate information delivery and monitor fidelity of nursing interventions; 1 nutritionist: Participate in formulating and providing personalized nutritional support; 1 psychological counselor: Participate in formulating and providing personalized nutritional support; 7 specialist nurses: Execute intervention plans and implement nursing measures. All team members have received relevant training based on the IMB model and passed the assessment; (2) Preoperative: The core goal of this stage is information transmission and motivation stimulation. Multimodal evidence-based education tools and cognitive behavioral intervention techniques are used for intervention, and at least one primary caregiver is required to accompany the learning process throughout. Based on the latest systematic review evidence, the research team uses three-dimensional animation to visually demonstrate the surgical process and medical equipment functions for children aged 5 years old to 6 years old, effectively reducing the children’s fear and anxiety levels of unknown medical environments. At the same time, it is equipped with a personalized pain management audio guide, recorded by a child announcer and embedded with the children’s favorite background music. Information transmission adopts the principle of small amounts and multiple times, each time not exceeding 15 minutes. Children aged 7 years old to 12 years old are provided with painting therapy to defeat monsters, guiding the children to visualize medical fears and perform cognitive reconstruction. At the same time, a brochure with pictures and texts is provided to guide reading so that they can understand the knowledge related to the surgery. A brave reward plan is simultaneously implemented to establish motivation for treatment cooperation through positive behavioral reinforcement; (3) 0 hour to 72 hours after surgery: This stage is the key recovery period after surgery, and the focus is on cultivating the child’s pain self-management ability and parent care skills. Use physical teaching aids with a dial pointer as a pain thermometer to improve the self-assessment compliance of young children. Focus on the application of cognitive behavioral technology for children aged 5 years old to 6 years old, “blowing out birthday candles”-style deep breathing training and tablet games with dynamic difficulty adjustment are designed to effectively divert attention from pain. Parent training uses standardized video demonstrations, covering core skills such as postoperative posture management and vomiting treatment, and is equipped with situational comfort speech templates. Establish a real-time feedback system for bravery medals for children aged 7 years old to 12 years old, transforming abstract behavioral goals into concrete grade rewards (silver/gold/diamond medals) and a list of role models for other children. Continuously strengthen positive behaviors through a closed-loop design of daily goal setting-achievement-reward. Medical staff evaluate the intervention effect every 8 hours and adjust the plan in a timely manner; (4) Before discharge: This stage focuses on the consolidation of behavioral skills and the transfer of family scenarios. Learning outcomes are tested through scenario simulation assessments, and a “family emergency drill” program is designed to simulate common postoperative conditions such as headache attacks. Train children and parents to respond according to standardized procedures and inform parents in advance that intervention may cause minor discomforts such as temporary mood swings in children, so as to prevent parents from being overly anxious due to emergencies. Before discharge, gradually downplay external rewards and transition from tangible rewards to social rewards such as praise and internal incentives such as a sense of achievement to reduce over-dependence or inappropriate behavior in children. Cognitive behavioral homework includes an emotional weather diary and a behavioral record sheet, which not only cultivates children’s emotional awareness but also helps parents master behavioral analysis techniques. The research team provides WeChat support after discharge, pushes rehabilitation tips every day, and has a full-time nurse to answer questions. At the same time, a paper version of the postoperative rehabilitation manual is distributed, which transforms key nursing points into a level-breaking game to ensure the long-term maintenance of the intervention effect; and (5) After discharge: Establish a personalized follow-up mechanism. Use an intelligent rehabilitation management platform, which includes four core functional modules: An intelligent reminder system that can realize personalized medication reminders, follow-up appointments, and rehabilitation training task push; online medical consultation services provided by the rehabilitation team with 12 hours real-time response; a multimedia learning center that updates rehabilitation micro-courses weekly; and a peer support community that promotes experience sharing among families of children with the disease. Video follow-up assessments are conducted on the third and seventh days after discharge, focusing on monitoring wound healing, pain control, and psychological adaptation. In addition, ask the children whether they ask for excessively or resist intervention games and use the “0-point to 3-point Anxiety Self-Assessment Scale” (0 = no anxiety, 3 = severe anxiety) to quickly assess the parents’ emotions so that psychological counselors can intervene in a timely manner. Thereafter, regular follow-up visits are conducted every two weeks to comprehensively track rehabilitation progress.

Observation indicators

Neurological function: Neurological function was assessed using the Functional Independence Measure for Children (WeeFIM)[13] and Gesell Developmental Scales[14] at baseline and 8 weeks post-intervention. Higher scores on these standardized measures indicated greater functional independence and better neurological recovery outcomes in the pediatric patients.

Quality of life score: The quality of life of children was measured at baseline and 8 weeks after intervention using the validated Chinese version of PedsQL™ 4.0[15]. This 23-item tool assesses four key areas: Physical, emotional, social and role functions. The higher the comprehensive score, the better the quality of life.

Brain tumor postoperative rehabilitation knowledge questionnaire: A self-developed questionnaire on postoperative rehabilitation knowledge for brain tumors was used to assess parents’ knowledge of the five dimensions of postoperative care, complication identification, emergency management, rehabilitation training methods, and medication precautions. A score of < 60 indicated a lack of knowledge, 60 to 80 indicated basic knowledge, and 80 to 100 indicated knowledge.

Satisfaction survey: At the time of discharge, a three-level rating scale was used to survey the satisfaction of children and their parents, including “very satisfied”, “moderately satisfied”, and “dissatisfied”.

Statistical analysis

Statistical analyses were performed with SPSS22.0 (IBM Corp, NY, United States). Continuous variables are presented as mean ± SD, analyzed using paired t-tests (within-group) and independent t-tests (between-group). Categorical data are shown as n (%) and compared by χ² tests, with statistical significance set at P < 0.05.

RESULTS

Comparison of neurological function

Both groups’ WeeFIM and Gesell scores rose following the intervention, with the observation group’s scores being noticeably higher than the control group’s (P < 0.05) (Table 3 and Figure 1).

Figure 1 Recovery of brain function in comparison to both child groups. ^aP < 0.0001, compared with before intervention control group. WeeFIM: Functional Independence Measure for Children.

Table 3 Recovery of brain function in comparison to both child groups, mean ± SD.

Group	n	WeeFIM rating		Gesell score
		Before intervention	After intervention	Before intervention	After intervention
Control group	40	38.48 ± 5.48	54.08 ± 6.27a	52.30 ± 5.49	63.23 ± 5.03a
Observation group	42	37.48 ± 5.16	62.31 ± 7.57a	52.05 ± 5.83	70.24 ± 7.49a
t		0.850	5.351	0.202	4.999
P value		0.398	< 0.001	0.841	< 0.001

^aP < 0.05, compared with before intervention.

WeeFIM: Functional Independence Measure for Children.

Comparison of quality of life score

Following the intervention, both groups’ PedsQL™ score indicators rose, with the observation group’s indicators being noticeably higher than the control group’s (P < 0.05) (Table 4 and Figure 2).

Figure 2 Quality of life comparison between both child groups. ^aP < 0.05, ^bP < 0.01, ^cP < 0.001, ^dP < 0.0001, compared with before intervention control group.

Table 4 Quality of life comparison between both child groups, mean ± SD.

Group	n	Physiological functions		Emotional function		Social features		Role function
		Before intervention	After intervention	Before intervention	After intervention	Before intervention	After intervention	Before intervention	After intervention
Control group	40	68.40 ± 9.60	82.68 ± 8.24b	65.23 ± 9.42	71.38 ± 6.26b	61.15 ± 9.09	81.15 ± 9.14b	61.95 ± 9.39	77.95 ± 10.08b
Observation group	42	68.69 ± 10.18	88.45 ± 6.25b	65.67 ± 10.36	81.17 ± 9.19b	61.41 ± 9.46	85.86 ± 7.86b	62.12 ± 9.42	83.69 ± 8.43b
t		0.133	3.588	0.202	5.661	0.124	2.504	0.081	2.802
P value		0.895	0.001	0.841	< 0.001	0.901	0.014	0.935	0.006

^bP < 0.05, compared with before intervention.

Comparison of brain tumor postoperative rehabilitation knowledge questionnaire

The observation group’s parents knew a lot more about the disease than the control group did (P < 0.05) (Table 5).

Table 5 Knowledge of diseases compared between both parent groups, n (%).

Group	n	Master	Basic mastery	Not mastered	Overall situation
Control group	40	16 (40.00)	16 (40.00)	8 (20.00)	32 (80.00)
Observation group	42	34 (80.95)	7 (16.67)	1 (2.38)	41 (97.62)
χ2					6.509
P value					0.011c

^cP < 0.05, compared with before intervention.

Comparison of satisfaction survey

The parent satisfaction in the observation group was significantly higher than that in the control group (P < 0.05) (Table 6).

Table 6 Parent satisfaction in both groups is compared, n (%).

Group	n	Very satisfied	Generally satisfied	Dissatisfied	Satisfaction rate
Control group	40	14 (35.00)	17 (42.50)	9 (22.50)	31 (77.50)
Observation group	42	18 (42.86)	23 (54.76)	1 (2.38)	41 (97.62)
χ2					7.745
P value					0.005d

^dP < 0.05, compared with before intervention.

DISCUSSION

Given their young age and cognitive impairments, as well as the shock of surgery and a new setting, children undergoing brain tumor resection under general anesthesia are more likely to have adverse postoperative reactions, including pain, anxiety, and behavioral withdrawal. This can delay neurological recovery and reduce their quality of life[16-18]. While routine perioperative care can provide vital sign monitoring and basic analgesia, it lacks systematic intervention targeting children’s psychological and behavioral characteristics, making it difficult to significantly improve postoperative recovery quality and parent satisfaction[19]. Therefore, constructing a nursing model that is consistent with the developmental characteristics of children is of great significance for optimizing the postoperative rehabilitation pathway. The IMB model served as the theoretical foundation for this study, which combined cognitive behavioral intervention with evidence-based nursing evidence. The findings demonstrated that this combined strategy has strong clinical promotion value and can successfully increase children’s quality of life and parents’ level of disease understanding while also reducing surgical pain and promoting neurological recovery.

The results of this study showed that the WeeFIM score and Gesell score of children in the observation group before and after intervention were significantly better than those in the control group (P < 0.05), showing that postoperative psychological and behavioral problems in children with brain tumors are closely related to neurological functional recovery, which is consistent with the research conclusions of the former[20,21]. At the same time, this result shows that this intervention program, through the IMB model system, integrates information transmission (three-dimensional animation), motivational stimulation (warrior medal reward system), and behavioral training (scenario simulation assessment), effectively reducing the interference of medical fear on neurorecovery. And the emotional weather diary and attention diversion techniques in cognitive behavioral intervention synergistically promoted neuroplasticity by improving emotional regulation and activating prefrontal cortex function[22,23]. In terms of pain management, the observation group significantly reduced pain-related stress behaviors, and parent satisfaction reached 97.62%, considerably greater than the control group’s 77.50% (P < 0.05). Pain education based on the IMB model improves young children’s self-assessment ability through physical teaching aids. Furthermore, “blowing out birthday candles” deep breathing exercises effectively reduces pain sensitivity by activating the parasympathetic nervous system[24-26]. Among the results of this study, the observation group’s rate of parents’ disease information mastery was 97.62%, which was noticeably greater than the control group’s (P < 0.05), suggesting that evidence-based tools such as the WeChat support platform and the postoperative rehabilitation manual effectively strengthened family care capabilities by converting professional knowledge into actionable behavioral guidelines. In addition, in terms of quality of life, the results of this study showed that the PedsQL™ scores of children in the observation group were significantly higher than those in the control group (P < 0.05). Integrated intervention was particularly significant in improving the emotional function and role function of quality of life (P < 0.01). This indicates that this hospital-family continuous intervention model may create more favorable conditions for children’s postoperative recovery by improving the family support environment[27]. These findings also explain that psychosocial adaptation may improve before physiological function recovers, which serves as a foundation for developing phased rehabilitation goals[28].

In summary, a comprehensive approach integrating evidence-based nursing care with cognitive behavioral intervention based on the IMB model effectively promotes neurological recovery and improves quality of life in children undergoing brain tumor resection under general anesthesia, while significantly enhancing parental caregiving competence and satisfaction. This model, through its innovative design driven by theory, multidisciplinary collaboration, and family empowerment, offers new insights into perioperative care in pediatric neurosurgery. Future work will further validate its long-term efficacy in a larger, multicenter setting and explore its applicability to postoperative rehabilitation for other tumors.

CONCLUSION

In summary, the results of this study show that using a full-process program based on the IMB model that integrates evidence-based nursing and cognitive behavioral intervention for children after brain tumor resection under general anesthesia can bring better nursing effects, significantly improve the quality of life of children and their parents, and improve the children’s neurological function recovery and pain sensitivity. Compared with previous single IMB interventions, these findings were innovatively designed by integrating evidence-based care with cognitive behavioral intervention. Future studies should expand the sample size and extend the follow-up period to verify the long-term effects of this intervention and explore its applicability in other relevant postoperative children.