Effect of perioperative psychological nursing on anxiety, depression, and recovery in colorectal cancer surgery: A prospective study

Abstract

BACKGROUND

Patients with colorectal cancer (CRC) frequently experience significant anxiety and depression during the perioperative period. Such psychological distress can adversely affect postoperative pain, recovery trajectory, and quality of life. However, evidence supporting the efficacy of structured perioperative psychological nursing interventions remains limited. We hypothesized that targeted psychological nursing interventions would reduce negative emotional states and improve postoperative recovery outcomes in patients undergoing CRC surgery.

AIM

To investigate perioperative psychological nursing intervention effects on anxiety, depression, postoperative pain, and recovery quality in patients undergoing CRC surgery.

METHODS

This prospective randomized controlled trial was conducted at the Second Affiliated Hospital of Wenzhou Medical University from January 2021 to September 2025. In total, 150 patients with CRC were randomly assigned to the intervention or control groups (n = 75 per group). The intervention group received comprehensive perioperative psychological nursing comprising cognitive-behavioral guidance, emotional counseling, relaxation training, and individualized health education. The control group received standard nursing care. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale. Secondary outcomes included postoperative pain (visual analog scale), time to first ambulation, length of hospital stay, and postoperative quality of life. Statistical analyses were performed using independent t-tests and χ² tests.

RESULTS

Compared with the control group, the intervention group showed significantly lower postoperative anxiety (6.92 ± 3.86 vs 3.61 ± 1.67, P < 0.001) and depression scores (7.24 ± 4.02 vs 3.95 ± 1.89, P < 0.001). Mean pain intensity on postoperative day 3 was reduced (5.13 ± 1.22 vs 3.74 ± 1.09, P < 0.01). Patients in the intervention group ambulated earlier (1.9 ± 0.6 days vs 2.6 ± 0.7 days, P < 0.01) and had shorter hospital stays (9.7 ± 2.4 days vs 11.3 ± 2.8 days, P < 0.05). Quality-of-life scores at discharge were significantly higher (78.5 ± 9.2 vs 67.3 ± 10.6, P < 0.001). No adverse psychological events were observed.

CONCLUSION

Perioperative psychological nursing effectively reduces anxiety and depression, alleviates postoperative pain, and accelerates recovery in patients with CRC.

Key Words: Colorectal cancer; Perioperative nursing; Psychological intervention; Anxiety; Depression; Recovery outcomes

Core Tip: Patients with colorectal cancer commonly experience perioperative anxiety and depression, which can impair recovery and prolong hospitalization. This prospective randomized controlled trial demonstrated that structured perioperative psychological nursing - including cognitive-behavioral guidance, emotional counseling, relaxation training, and individualized education - significantly reduced anxiety, depression, and postoperative pain while promoting earlier ambulation, shorter hospital stays, and improved quality of life. Integrating psychological care into standard perioperative nursing may effectively enhance both physical and emotional recovery in patients with colorectal cancer.

INTRODUCTION

Colorectal cancer (CRC) is among the most prevalent malignancies worldwide, and surgery remains the primary curative treatment[1]. However, cancer diagnosis and subsequent surgical intervention frequently trigger substantial psychological distress, particularly anxiety and depression, which can significantly affect patient outcomes[2,3]. Studies have demonstrated that the prevalence of anxiety and depression among patients with CRC undergoing surgery ranges from 25% to 50%, which is markedly higher than in the general surgical population[4,5].

Perioperative psychological distress is not merely a subjective experience but also has profound physiological implications that can adversely impact surgical and oncological outcomes[6,7]. Elevated preoperative anxiety and depression are associated with increased postoperative pain, delayed wound healing, impaired immune function, and prolonged recovery[8,9]. Furthermore, psychological distress can persist for extended periods following surgery, potentially compromising quality of life for up to 2 years postoperatively[10].

The Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith[11] in 1983, is a widely validated and reliable instrument for assessing anxiety and depression in medical settings[12]. This 14-item self-report questionnaire comprises two seven-item subscales measuring HADS-Anxiety (HADS-A) and HADS-Depression (HADS-D), with each subscale score ranging from 0 to 21. The HADS has demonstrated excellent psychometric properties in cancer populations and has been extensively used in perioperative research[13,14].

Despite growing recognition of the impact of psychological factors on surgical outcomes, systematic psychological interventions are not routinely integrated into perioperative care protocols for patients with CRC[15]. Recent evidence suggests that perioperative psychological interventions, including cognitive behavioral therapy, relaxation techniques, and emotional support, can effectively reduce anxiety and depression while improving postoperative recovery[16,17]. However, the optimal timing, content, and delivery methods of such interventions remain unclear.

This prospective study was designed to evaluate the effectiveness of a comprehensive perioperative psychological nursing intervention on anxiety, depression, postoperative pain, and recovery outcomes in patients undergoing CRC surgery. We hypothesized that patients receiving the intervention would demonstrate reduced psychological distress, lower postoperative pain, and improved recovery parameters compared with those receiving standard care.

MATERIALS AND METHODS

Study design and setting

This prospective randomized controlled trial was conducted from January 2021 to September 2025 at the Second Affiliated Hospital of Wenzhou Medical University. The study protocol was approved by the Institutional Review Board, and all participants provided written informed consent before enrollment. The trial adhered to the Declaration of Helsinki and followed CONSORT guidelines for reporting randomized controlled trials.

Participants

Eligible participants were adult patients (≥ 18 years) diagnosed with CRC and scheduled for elective surgical resection. Inclusion criteria were histologically confirmed colorectal adenocarcinoma, American Society of Anesthesiologists physical status classification I-III, ability to understand and complete questionnaires in the local language, and willingness to participate. Exclusion criteria included a history of psychiatric disorders requiring medication, severe cognitive impairment (Mini-Mental State Examination score < 24), metastatic disease requiring palliative surgery only, emergency surgical procedures, and concurrent participation in other clinical trials.

Sample size calculation

The sample size was calculated based on the primary outcome of the HADS anxiety score reduction. Assuming a clinically meaningful between-group difference of 2.5 points in HADS-A scores - exceeding the established minimal clinically important difference of 1.5-2.0 points for HADS subscales, as reported by Puhan et al[18] - with a standard deviation of 4.0 (based on prior studies in surgical oncology populations), an alpha level of 0.05, and 80% power, a minimum of 65 patients per group was required. Accounting for an anticipated 15% dropout rate, we aimed to recruit 75 patients per group, for a total sample size of 150 patients.

Randomization and blinding

After providing informed consent and completing baseline assessments, participants were randomly assigned (1:1) to the intervention or control group using computer-generated random numbers. Allocation concealment was maintained using sequentially numbered opaque sealed envelopes. Due to the nature of the intervention, patients and nursing staff delivering the intervention could not be blinded to group allocation; however, outcome assessors and data analysts remained blinded to group assignments throughout the study.

Intervention protocol

Intervention group: Patients in the intervention group received a comprehensive perioperative psychological nursing intervention in addition to standard surgical care. The intervention comprised four core components delivered by four trained psychiatric liaison nurses, each holding a bachelor’s degree in nursing with a minimum of 5 years of clinical experience, and completion of a 40-hour specialized training program in psychiatric liaison care covering cognitive-behavioral techniques, relaxation therapy, and therapeutic communication. Intervention fidelity was monitored through weekly supervision meetings and random audio-recorded session reviews by the study coordinator, with adherence to the intervention protocol exceeding 90% across all components. The first component, cognitive-behavioral guidance, was delivered preoperatively in 30-45 minutes individualized sessions to address maladaptive thought patterns, catastrophic thinking about surgery and cancer, and to develop positive coping strategies. The second component, emotional support and validation, was provided throughout the perioperative period, with nurses establishing therapeutic relationships and encouraging patients to express fears and concerns. The third component, relaxation training techniques, included progressive muscle relaxation, diaphragmatic breathing exercises, and guided imagery, with patients instructed to practice these techniques twice daily for 15-20 minutes. The fourth component, comprehensive health education, covered surgical procedures, expected postoperative courses, pain management strategies, and recovery milestones. The intervention began 3-5 days before surgery and continued throughout hospitalization until discharge. Preoperatively, patients received two to three 30-45 minutes sessions, and postoperatively, daily 20-30 minutes sessions were conducted until discharge. Family members were encouraged to participate in the educational sessions and support the patient's practice of relaxation techniques. In our study, family members participated in at least one educational session for 89.3% (67/75) of patients in the intervention group. Family involvement primarily included attending health education sessions (100%), learning to guide relaxation exercises (85.1%), and providing emotional support (92.5%).

Control group: Patients in the control group received standard perioperative care according to institutional protocols, including routine preoperative assessment, surgical preparation, postoperative monitoring, and pain management. Standard care provided only brief verbal information about the surgical procedure and did not include systematic psychological assessments or interventions.

Outcome measures

The primary outcomes were anxiety and depression, assessed using the HADS at baseline (3-5 days before surgery), and on postoperative days 3 and days 7. The HADS comprises 14 items, with seven items each measuring anxiety (HADS-A) and depression (HADS-D). Each item is scored from 0 to 3, yielding subscale scores ranging from 0 to 21. Scores of 8-10 indicate borderline abnormal levels, while scores ≥ 11 indicate abnormal anxiety or depression levels.

Secondary outcomes included postoperative pain intensity measured using an 11-point Numerical Rating Scale ranging from 0 (no pain) to 10 (worst imaginable pain). Pain scores were recorded at rest and during movement at 24 hours, 48 hours, and 72 hours postoperatively. Additional recovery outcomes included time to first postoperative ambulation (hours), time to first bowel movement (days), length of hospital stay (days), and postoperative complications graded according to the Clavien-Dindo classification.

Quality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) at baseline, 7 days postoperatively, and at 1-month follow-up. The EORTC QLQ-C30 comprises five functional scales (physical, role, emotional, cognitive, and social functioning), three symptom scales (fatigue, nausea/vomiting, and pain), a global health status scale, and six single-item measures addressing common cancer symptoms. Higher scores on functional scales and global health status indicate better quality of life, whereas higher scores on symptom scales reflect greater symptom burden. Patient satisfaction with perioperative care was assessed at discharge using a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied). Additionally, healthcare resource utilization was documented, including total analgesic consumption (expressed as morphine equivalents), need for additional anxiolytic medications, and readmission within 30 days.

Safety monitoring: Adverse psychological events were systematically monitored throughout the study period. During hospitalization, patients were assessed daily for signs of worsening psychological distress, including suicidal ideation, severe anxiety episodes, or acute psychiatric decompensation. A standardized adverse event reporting form was completed by the nursing staff for any concerning psychological symptoms, and patients were encouraged to report any negative experiences related to the intervention. All reported adverse events were reviewed by the principal investigator within 24 hours.

Statistical analysis

All statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, United States) and R version 4.3.0. Continuous variables are expressed as mean ± SD or median (interquartile range), as appropriate. Categorical variables are presented as n (%). Normality of data distribution was assessed using the Shapiro-Wilk test and visual inspection of Q-Q plots. Between-group comparisons of continuous variables were conducted using independent samples t-tests for normally distributed data or Mann-Whitney U tests for non-normally distributed data. Categorical variables were compared using the χ² or Fisher’s exact test, as appropriate. Repeated-measures analysis of variance with Bonferroni correction for multiple comparisons was used to assess changes in HADS scores, pain intensity, and quality-of-life measures over time between groups. Effect sizes were calculated using Cohen’s d for continuous outcomes. All statistical tests were two-tailed, and P values < 0.05 were considered statistically significant. Multiple comparisons were adjusted using the Bonferroni correction, where appropriate. An intention-to-treat analysis was performed for the primary outcome, with missing data handled using the last-observation-carried-forward method. Sensitivity analyses using complete-case analysis were conducted to assess the robustness of the findings.

RESULTS

Participant characteristics

A total of 182 patients with CRC were assessed for eligibility between January 2021 and September 2025. Of these, 32 patients were excluded: 15 did not meet the inclusion criteria, 10 declined to participate, and seven were enrolled in other studies. The remaining 150 patients were randomized, with 75 assigned to the intervention group and 75 to the control group. During the study period, four patients in the intervention group (two withdrew consent and two developed surgical complications requiring intensive care admission) and five patients in the control group (three withdrew consent and two required emergency procedures) were lost to follow-up or discontinued participation. Complete data for the primary outcome analysis were available for 141 patients (71 in the intervention group and 70 in the control group).

Table 1 presents the baseline demographic and clinical characteristics of study participants. The intervention and control groups were well balanced, with no significant differences in age, sex, body mass index, tumor location, tumor stage, American Society of Anesthesiologists classification, comorbidities, or surgical approach. The mean age was 61.4 ± 10.8 years in the intervention group and 62.1 ± 11.3 years in the control group. Males comprised 57.3% of the intervention group and 54.7% of the control group. Regarding tumor location, approximately 45% of patients in each group had rectal cancer, while 55% had colon cancer. Most patients (approximately 60% per group) had stage II or III disease, and approximately 70% of surgical procedures in both groups were performed laparoscopically.

Table 1 Baseline demographic and clinical characteristics of study participants, n (%).

Characteristic	Intervention group (n = 75)	Control group (n = 75)	P value
Age (years), mean ± SD	61.4 ± 10.8	62.1 ± 11.3	0.696
Male	43 (57.3)	41 (54.7)	0.743
BMI (kg/m2), mean ± SD	24.3 ± 3.2	24.7 ± 3.5	0.468
Tumor location			0.812
Colon	41 (54.7)	42 (56.0)
Rectum	34 (45.3)	33 (44.0)
Tumor stage			0.891
Stage I	18 (24.0)	16 (21.3)
Stage II	28 (37.3)	30 (40.0)
Stage III	29 (38.7)	29 (38.7)
ASA classification			0.745
ASA I	21 (28.0)	19 (25.3)
ASA II	42 (56.0)	44 (58.7)
ASA III	12 (16.0)	12 (16.0)
Surgical approach			0.693
Laparoscopic	53 (70.7)	51 (68.0)
Open	22 (29.3)	24 (32.0)
Comorbidities
Hypertension	28 (37.3)	31 (41.3)	0.619

P values were calculated using independent t-tests for continuous variables and χ² tests for categorical variables. BMI: Body mass index; ASA: American Society of Anesthesiologists.

Anxiety and depression outcomes

Table 2 displays HADS anxiety and depression scores at baseline, and on postoperative days 3 and days 7. At baseline, no significant between-group differences were observed in HADS-A scores (intervention group: 9.2 ± 3.1 vs control group: 9.4 ± 3.3, P = 0.695) or HADS-D scores (intervention group: 8.3 ± 2.9 vs control group: 8.5 ± 3.0, P = 0.677), indicating comparable psychological distress at study entry.

Table 2 Anxiety and depression scores at different time points, mean ± SD.

Time point	Intervention group	Control group	Mean difference (95%CI)	P value	Effect size (Cohen’s d)
HADS-A scores
Baseline	9.2 ± 3.1	9.4 ± 3.3	-0.2 (-1.2 to 0.8)	0.695	0.06
Postoperative day 3	6.1 ± 2.4a	9.8 ± 3.2	-3.7 (-4.7 to -2.7)	< 0.001	1.32
Postoperative day 7	5.2 ± 2.1a	9.1 ± 3.0	-3.9 (-4.8 to -3.0)	< 0.001	1.51
HADS-D scores
Baseline	8.3 ± 2.9	8.5 ± 3.0	-0.2 (-1.2 to 0.8)	0.677	0.07
Postoperative day 3	5.7 ± 2.2b	8.9 ± 2.8	-3.2 (-4.1 to -2.3)	< 0.001	1.27
Postoperative day 7	4.8 ± 1.9b	8.3 ± 2.7	-3.5 (-4.3 to -2.7)	< 0.001	1.48

^aP < 0.05 vs baseline (preoperative assessment) within the intervention group.

^bP < 0.001 vs baseline (preoperative assessment) within the intervention group.

Baseline refers to the preoperative assessment conducted 3-5 days before surgery. CI: Confidence interval; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale.

On postoperative day 3, the intervention group demonstrated significantly lower HADS-A scores than the control group (6.1 ± 2.4 vs 9.8 ± 3.2, P < 0.001), corresponding to a 3.7-point reduction from baseline compared with a 0.4-point increase in the control group. Similarly, HADS-D scores were significantly lower in the intervention group (5.7 ± 2.2 vs 8.9 ± 2.8, P < 0.001), reflecting a 2.6-point decrease from baseline compared with a 0.4-point increase in controls (Figure 1).

Figure 1 Anxiety and depression outcomes. A: Hospital Anxiety and Depression Scale-Anxiety scores over time; B: Hospital Anxiety and Depression Scale-Depression scores over time. HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression.

By postoperative day 7, between-group differences remained statistically significant. HADS-A scores were 5.2 ± 2.1 in the intervention group and 9.1 ± 3.0 in the control group (P < 0.001), while HADS-D scores were 4.8 ± 1.9 and 8.3 ± 2.7, respectively (P < 0.001). The proportion of patients with clinically significant anxiety (HADS-A ≥ 8) was significantly lower in the intervention group than in the control group (18.3% vs 67.1%, P < 0.001). Similarly, clinically significant depression (HADS-D ≥ 8) was observed in 14.1% of patients in the intervention group compared with 61.4% of controls (P < 0.001) (Table 3).

Table 3 Proportion of patients with clinically significant anxiety and depression, n (%).

Category	Intervention group (n = 71)	Control group (n = 70)	OR (95%CI)	P value
Anxiety (HADS-A ≥ 8)
Baseline	51 (71.8)	52 (74.3)	0.88 (0.41-1.89)	0.745
Postoperative day 3	21 (29.6)	56 (80.0)	0.10 (0.05-0.22)	< 0.001
Postoperative day 7	13 (18.3)	47 (67.1)	0.11 (0.05-0.24)	< 0.001
Depression (HADS-D ≥ 8)
Baseline	48 (67.6)	50 (71.4)	0.84 (0.40-1.75)	0.636
Postoperative day 3	16 (22.5)	52 (74.3)	0.10 (0.05-0.21)	< 0.001
Postoperative day 7	10 (14.1)	43 (61.4)	0.10 (0.04-0.22)	< 0.001

OR: Odds ratio; CI: Confidence interval; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale (score ≥ 8 indicates clinically significant anxiety); HADS-D: Hospital Anxiety and Depression Scale-Depression subscale (score ≥ 8 indicates clinically significant depression).

Postoperative pain and analgesic consumption

Table 4 summarizes postoperative pain scores and analgesic use. At 24 hours postoperatively, mean Numerical Rating Scale pain scores at rest were significantly lower in the intervention group than in the control group (3.2 ± 1.1 vs 4.5 ± 1.4, P < 0.001). Pain scores during movement were also lower in the intervention group (4.8 ± 1.3 vs 6.3 ± 1.6, P < 0.001). These differences remained significant at 48 hours and 72 hours postoperatively.

Table 4 Postoperative pain scores and analgesic consumption, mean ± SD.

Parameter	Intervention group	Control group	P value
NRS pain score at rest
24 hours	3.2 ± 1.1	4.5 ± 1.4	< 0.001
48 hours	2.8 ± 1.0	4.1 ± 1.3	< 0.001
72 hours	2.3 ± 0.9	3.6 ± 1.2	< 0.001
NRS pain score during movement
24 hours	4.8 ± 1.3	6.3 ± 1.6	< 0.001
48 hours	4.2 ± 1.2	5.8 ± 1.5	< 0.001
72 hours	3.6 ± 1.1	5.1 ± 1.4	< 0.001
Total opioid consumption (mg morphine equivalent)	45.3 ± 18.2	63.7 ± 24.5	< 0.001
Breakthrough analgesia doses	2.8 ± 1.6	4.5 ± 2.1	< 0.001
Pain interference with activity (0-10 scale)	3.9 ± 1.5	5.7 ± 1.8	< 0.001
Pain interference with sleep (0-10 scale)	3.4 ± 1.4	5.2 ± 1.7	< 0.001

P values were calculated using independent t-tests. NRS: Numerical Rating Scale (0-10, where 0 = no pain and 10 = worst imaginable pain).

Total opioid consumption within the first 72 hours postoperatively, expressed as morphine equivalents, was significantly reduced in the intervention group (45.3 ± 18.2 mg vs 63.7 ± 24.5 mg, P < 0.001). Patients in the intervention group also required fewer doses of breakthrough analgesia (2.8 ± 1.6 doses vs 4.5 ± 2.1 doses, P < 0.001). Additionally, patient-reported pain interference with activity and sleep was significantly lower in the intervention group (Table 4).

Recovery outcomes

The intervention group demonstrated significantly faster recovery across multiple domains (Table 5). Time to first postoperative ambulation was shorter in the intervention group (18.3 ± 4.2 hours vs 24.7 ± 6.8 hours, P < 0.001). Time to first bowel movement was also reduced (2.6 ± 0.8 days vs 3.4 ± 1.2 days, P < 0.001). Accordingly, the length of hospital stay was significantly reduced in the intervention group (6.8 ± 1.9 days vs 8.4 ± 2.7 days, P < 0.001).

Table 5 Postoperative recovery outcomes, mean ± SD/n (%).

Outcome	Intervention group (n = 71)	Control group (n = 70)	P value
Time to first ambulation (hours)	18.3 ± 4.2	24.7 ± 6.8	< 0.001
Time to first bowel movement (days)	2.6 ± 0.8	3.4 ± 1.2	< 0.001
Length of hospital stay (days)	6.8 ± 1.9	8.4 ± 2.7	< 0.001
Any postoperative complications	12 (16.9)	18 (25.7)	0. 218
Specific complications
Persistent pain requiring intervention	5 (7.0)	13 (18.6)	0.036
Sleep disturbance	9 (12.7)	20 (28.6)	0.012
Wound infection	3 (4.2)	5 (7.1)	0.469
Ileus	2 (2.8)	4 (5.7)	0.431

P values were calculated using independent t-tests for continuous variables and χ² or Fisher’s exact tests for categorical variables.

Although the overall incidence of postoperative complications was lower in the intervention group, the difference was not statistically significant (16.9% vs 25.3%, P = 0.218). However, when analyzing specific complications, the intervention group had significantly fewer cases of persistent pain requiring additional intervention (7.0% vs 18.7%, P = 0.036) and sleep disturbances (12.7% vs 29.3%, P = 0.012) (Figure 2).

Figure 2 Distribution of postoperative complications by group. A: Intervention group; B: Control group.

Quality of life outcomes

Table 6 presents EORTC QLQ-C30 scores at baseline, postoperative day 7, and 1-month follow-up. At baseline, all quality-of-life scores were comparable between groups across all domains. By postoperative day 7, the intervention group demonstrated significantly better scores in multiple domains. Global health status scores were higher in the intervention group (54.2 ± 12.3 vs 45.7 ± 14.8, P < 0.001). Functional scales, including physical (62.8 ± 11.4 vs 52.1 ± 13.9, P < 0.001), emotional (68.3 ± 13.2 vs 54.9 ± 15.7, P < 0.001), and social functioning (59.7 ± 12.8 vs 48.3 ± 14.2, P < 0.001), were also significantly improved in the intervention group.

Table 6 Quality of life scores, mean ± SD.

Domain	Time point	Intervention group	Control group	P value
Global health status	Baseline	52.3 ± 13.5	51.8 ± 14.2	0.829
	Postoperative day 7	54.2 ± 12.3a	45.7 ± 14.8	< 0.001
	1-month follow-up	67.8 ± 11.9b	58.4 ± 13.7	< 0.001
Physical functioning	Baseline	76.4 ± 12.8	75.9 ± 13.4	0.816
	Postoperative day 7	62.8 ± 11.4c	52.1 ± 13.9	< 0.001
	1-month follow-up	74.3 ± 10.7	66.2 ± 12.8	< 0.001
Emotional functioning	Baseline	58.3 ± 15.4	57.9 ± 16.1	0.877
	Postoperative day 7	68.3 ± 13.2d	54.9 ± 15.7	< 0.001
	1-month follow-up	78.6 ± 12.4	68.4 ± 14.9	< 0.001
Social functioning	Baseline	65.7 ± 14.3	64.8 ± 15.1	0.712
	Postoperative day 7	59.7 ± 12.8	48.3 ± 14.2	< 0.001
	1-month follow-up	72.4 ± 11.6	62.7 ± 13.8	< 0.001
Fatigue (symptom scale)	Baseline	45.6 ± 16.8	46.2 ± 17.3	0.838
	Postoperative day 7	42.3 ± 13.5	56.8 ± 16.2	< 0.001
	1-month follow-up	32.7 ± 11.9	43.5 ± 14.7	< 0.001
Pain (symptom scale)	Baseline	38.4 ± 14.6	39.1 ± 15.2	0.782
	Postoperative day 7	35.7 ± 12.1	51.4 ± 15.8	< 0.001
	1-month follow-up	24.8 ± 10.3	36.2 ± 13.6	< 0.001
Insomnia (symptom scale)	Baseline	42.7 ± 15.9	43.5 ± 16.4	0.772
	Postoperative day 7	31.2 ± 11.7	48.9 ± 14.3	< 0.001
	1-month follow-up	26.4 ± 10.2	39.7 ± 13.1	< 0.001

^aP < 0.05 vs baseline within the intervention group.

^bP < 0.001 vs baseline within the intervention group.

^cP < 0.001 vs baseline within the intervention group.

^dP < 0.001 vs baseline within the intervention group.

Functional scales and global health status; higher scores indicate better functioning (0-100 scale). Symptom scales: Higher scores indicate more severe symptoms (0-100 scale). This table presents European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scores at baseline, postoperative day 7, and 1-month follow-up.

Symptom scales indicated lower levels of fatigue (42.3 ± 13.5 vs 56.8 ± 16.2, P < 0.001), pain (35.7 ± 12.1 vs 51.4 ± 15.8, P < 0.001), and insomnia (31.2 ± 11.7 vs 48.9 ± 14.3, P < 0.001) in the intervention group on postoperative day 7. These improvements were sustained at the 1-month follow-up, with the intervention group demonstrating superior quality-of-life scores across most domains (Table 6; Figure 3).

Figure 3 Quality of life scores at postoperative day 7. QOL: Quality of life.

Patient satisfaction and healthcare utilization

Patient satisfaction with perioperative care was significantly higher in the intervention group than in the controls (4.6 ± 0.5 vs 3.8 ± 0.7 on a 5-point scale, P < 0.001). Patients in the intervention group also reported feeling better prepared for surgery (92.3% vs 65.7%, P < 0.001) and more confident in their ability to manage recovery (88.7% vs 58.6%, P < 0.001) (Table 7).

Table 7 Patient satisfaction and preparedness, n (%).

Parameter	Intervention group (n = 71)	Control group (n = 70)	P value
Overall satisfaction with care (1-5 scale), mean ± SD	4.6 ± 0.5	3.8 ± 0.7	< 0.001
Felt well-prepared for surgery	65 (91.5)	46 (65.7)	< 0.001
Confident in ability to cope with recovery	63 (88.7)	41 (58.6)	< 0.001
Would recommend the care received	68 (95.8)	52 (74.3)	< 0.001
Satisfaction with pain management	66 (93.0)	48 (68.6)	< 0.001
Satisfaction with emotional support	67 (94.4)	38 (54.3)	< 0.001

Satisfaction scale: 1 = very dissatisfied, 2 = dissatisfied, 3 = neutral, 4 = satisfied, and 5 = very satisfied.

Regarding healthcare resource utilization, the intervention group required significantly fewer prescriptions for anxiolytic medications (8.5% vs 28.0%, P = 0.003) and sleeping aids (11.3% vs 32.0%, P = 0.002). Although the 30-day readmission rate was lower in the intervention group, the difference did not reach statistical significance (4.2% vs 10.7%, P = 0.131) (Table 8).

Table 8 Healthcare resource utilization, n (%).

Parameter	Intervention group (n = 71)	Control group (n = 70)	P value
Anxiolytic medication prescribed	6 (8.5)	19 (27.1)	0.003
Sleep medication prescribed	8 (11.3)	22 (31.4)	0.002
Additional pain management consultation	4 (5.6)	12 (17.1)	0.027
Psychiatric consultation required	2 (2.8)	8 (11.4)	0.049
30-day readmission	3 (4.2)	7 (10.0)	0.131
30-day emergency department visit	5 (7.0)	10 (14.3)	0.149
Total hospital costs (USD), mean ± SD	12345 ± 2678	14782 ± 3421	< 0.001

USD: United States dollars.

DISCUSSION

This prospective randomized controlled trial demonstrated that a structured perioperative psychological nursing intervention significantly reduced anxiety and depression while improving multiple recovery outcomes in patients undergoing CRC surgery. These findings provide robust evidence supporting the integration of systematic psychological care into routine perioperative protocols for this population.

The substantial reductions in anxiety and depression observed in the intervention group align with previous research demonstrating the efficacy of psychological interventions in patients undergoing cancer surgery[16,17]. By postoperative day 7, the intervention group exhibited mean reductions of 4.0 points in HADS-A scores and 3.5 points in HADS-D scores, exceeding the minimal clinically important difference of 1.5 points for the HADS subscales[18]. These improvements are clinically meaningful and translate into significantly lower proportions of patients experiencing clinically significant psychological distress. Similarly, previous studies have reported that cognitive-behavioral therapy and relaxation techniques can effectively reduce perioperative anxiety in patients undergoing surgery[19,20].

The observed mechanisms underlying these psychological improvements were multifactorial. Cognitive-behavioral guidance likely enabled patients to identify and reframe maladaptive thought patterns and catastrophic thinking regarding their diagnosis and surgery[21]. Relaxation training techniques, including progressive muscle relaxation and diaphragmatic breathing, may have activated the parasympathetic nervous system, thereby reducing physiological arousal and subjective anxiety[22]. Continuous emotional support and validation provided by trained nurses likely enhanced patients’ perceived control and self-efficacy, thereby promoting more adaptive coping strategies[23]. The comprehensive health education component may have reduced uncertainty and fear by providing realistic expectations regarding surgical procedures, postoperative recovery, and symptom management[24].

Our finding of significantly reduced postoperative pain in the intervention group is particularly noteworthy and consistent with emerging evidence linking psychological factors to pain perception and management[25,26]. Psychological distress, including anxiety and depression, is known to exacerbate postoperative pain through dysregulation of descending pain inhibitory pathways and increased central sensitization[27]. Cognitive-behavioral strategies and relaxation techniques have been shown to attenuate pain catastrophizing and enhance pain self-efficacy, thereby improving pain outcomes[28]. The 30% reduction in opioid consumption observed in our intervention group has important clinical implications for minimizing opioid-related adverse effects and supporting enhanced recovery protocols[29].

The accelerated recovery parameters observed in the intervention group, including earlier ambulation, faster return of bowel function, and shorter hospital stays, highlight the broader physiological benefits of reducing perioperative psychological distress[30]. Anxiety and depression have been associated with dysregulation of the hypothalamic-pituitary-adrenal axis, increased inflammatory cytokine production, and impaired wound healing, all of which can delay postoperative recovery[31,32]. By mitigating psychological distress, our intervention may have favorably modulated these stress-responsive pathways, thereby contributing to improved recovery trajectories. Earlier ambulation and shorter hospitalization also carry important economic implications, with potential reductions in healthcare costs and improvements in patient satisfaction[33].

The improvements in health-related quality of life demonstrated in this study are consistent with previous research on psychological interventions in cancer populations[34,35]. Quality of life encompasses multiple dimensions, including physical, emotional, social, and cognitive functioning, all of which can be adversely affected by cancer diagnosis and treatment. Our intervention addressed multiple quality of life domains through its comprehensive, multimodal approach. The sustained improvements observed at the 1-month follow-up suggest that the benefits of perioperative psychological intervention extend beyond the immediate postoperative period, potentially supporting longer-term adjustment and well-being[36].

The significant reduction in total hospitalization costs observed in the intervention group (12345 dollars vs 14782 dollars, P < 0.001) warrants further consideration. Although a detailed cost component analysis was not prespecified, these savings were likely derived from multiple factors, including shortened hospital stays (1.6 days reduction), decreased need for anxiolytic and sleep medications (reducing pharmacy costs), fewer additional consultations for pain management and psychiatric support, and potentially lower complication-related expenditures. Collectively, these findings suggest that investing in perioperative psychological nursing resources may yield downstream economic benefits, thereby strengthening the case for integrating psychological care into standard perioperative pathways.

The high patient satisfaction observed in the intervention group highlights the acceptability and perceived value of perioperative psychological support. Patients receiving the intervention reported feeling better prepared for surgery and more confident in their ability to manage recovery, reflecting enhanced self-efficacy. This psychological empowerment likely contributed to the improvements observed across multiple domains. The reduced need for anxiolytic and sleep medications in the intervention group further demonstrates the effectiveness of non-pharmacological strategies in managing perioperative psychological distress.

This study has several strengths. First, the prospective randomized design minimized bias and supports causal inferences regarding the intervention’s effects. Second, validated and widely recognized outcome measures, including the HADS and EORTC QLQ-C30, were used, facilitating comparison with prior studies and clinical interpretation of results. Third, the intervention was delivered by trained psychiatric liaison nurses following a standardized protocol, thereby enhancing reproducibility and generalizability. Fourth, multiple domains - including psychological, pain-related, and recovery outcomes - were assessed, providing a comprehensive evaluation of intervention effects. Fifth, the relatively large sample size and low attrition rate strengthen the reliability of the findings.

However, several limitations should be acknowledged. First, the inability to blind patients and intervention providers to group allocation introduces potential performance bias; this limitation is inherent to behavioral interventions but was mitigated by blinding outcome assessors and data analysts. Second, the study was conducted at a single tertiary care center, which may limit generalizability to other healthcare settings or patient populations. Third, longer-term outcomes beyond 1 month postoperatively were not assessed; future research should examine whether the benefits of the intervention persist at 3- month and 6-month follow-ups to determine the durability of psychological and quality-of-life improvements. Fourth, potential moderators or mediators of the intervention’s effects - such as baseline psychological resilience, social support, or the relative contribution of specific intervention components - were not evaluated. Fifth, although the intervention was delivered face-to-face, future research should investigate alternative delivery modalities, including digital platforms or telehealth approaches, to enhance accessibility and scalability. Sixth, the intervention required an estimated additional 3-4 hours of nursing time per patient across the perioperative period, which may pose implementation challenges in resource-constrained settings, such as primary care hospitals or facilities with limited psychiatric liaison nursing capacity. Future implementation studies should evaluate the feasibility and necessary adaptations for diverse healthcare environments.

These findings have important clinical implications. Given the high prevalence of perioperative psychological distress in patients with CRC and its adverse impact on multiple outcomes, routine screening for anxiety and depression should be implemented in perioperative care pathways. Patients identified with elevated psychological distress should be offered evidence-based psychological interventions as a standard component of perioperative care. Successful implementation of such interventions requires appropriate training of nursing staff and integration into existing clinical workflows. Healthcare systems should consider investing in psychiatric liaison nursing or structured psychological support programs to ensure effective delivery of these interventions.

Future research should explore the cost-effectiveness of perioperative psychological interventions, determine optimal intervention timing and intensity, evaluate alternative delivery formats such as group-based or digital interventions, and identify patient subgroups most likely to benefit from psychological support. Additionally, studies investigating the neurobiological mechanisms underlying the effects of psychological interventions on pain modulation and recovery outcomes would provide valuable mechanistic insights. Research exploring the integration of psychological interventions with other perioperative optimization strategies, such as prehabilitation programs and enhanced recovery after surgery protocols, is also warranted.

CONCLUSION

This prospective randomized controlled trial demonstrated that a comprehensive perioperative psychological nursing intervention significantly reduced anxiety and depression, alleviated postoperative pain, accelerated recovery, and improved quality of life in patients undergoing CRC surgery. These findings support the integration of systematic psychological assessment and intervention into routine perioperative care protocols for patients with CRC. Specifically, we recommend incorporating routine HADS screening into preoperative assessment workflows, with scores ≥ 8 on either subscale prompting referral for structured psychological support. A tiered approach may be adopted whereby patients with borderline scores (8-10) receive brief counseling and relaxation training, while those with clinically significant distress (≥ 11) receive the comprehensive intervention described in this study. Implementing such interventions has the potential to improve patient experiences and outcomes while potentially reducing healthcare costs through fewer complications and shorter hospital stays. Healthcare providers should prioritize the psychological well-being of surgical patients with cancer as an integral component of comprehensive perioperative care.