Nursing effect of narrative nursing intervention on postoperative patients with severe lung cancer

Abstract

BACKGROUND

Lung cancer is a common disease with high mortality, and psychological support is very important in the diagnosis and treatment of postoperative patients with cancer pain.

AIM

To explore the application effect of the narrative nursing method in postoperative lung cancer patients in the intensive care unit.

METHODS

A total of 120 patients diagnosed with lung cancer and experiencing cancer-related pain were randomly allocated into two groups: an observation group and a control group, each consisting of 60 cases. The control group was given routine analgesic and psychological care, while the research group applied the five-step narrative nursing method based on routine care, comparing the visual analogue scale scores, sleep status, anxiety and depression status, and quality of life of the two groups of patients before and after the intervention.

RESULTS

The pain scores, anxiety scores, and depression scores of the study group were lower than those of the control group after the intervention using the narrative nursing method, and the difference was statistically significant (P < 0.05).

CONCLUSION

Using narrative nursing methods to intervene in patients with lung cancer combined with cancerous pain can help patients to correctly recognize their disease, adjust their mentality, establish confidence, alleviate patients' subjective pain feelings, and improve their adverse emotions.

Key Words: Narrative care; Lung cancer; Care unit; Pain; Quality of life

Core Tip: Lung cancer is a high incidence and high mortality tumor disease. At present, routine postoperative care lacks psychological support for patients. Therefore, this paper aims to explore the application effect of narrative nursing method based on psychological support in postoperative intensive care unit patients. Through randomized controlled experiments, scale scores and statistical analysis, it was found that the pain score, anxiety score and depression score of patients under narrative nursing method were significantly reduced. The results show that narrative nursing method has great advantages in emotional support of patients with lung cancer complicated with cancer pain.

INTRODUCTION

Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer-related deaths globally, with approximately 2.1 million new lung cancer cases and 1.8 million deaths reported in 2018[1]. Cancer and pain are closely related clinical entities. Pain, as the fifth vital sign, is a common physiological response in postoperative lung cancer patients[2]. Patients with unrelieved pain experience somatic symptoms such as insomnia, anorexia, severe fatigue, cognitive decline, and overall decreased lung capacity[3]. The adverse emotions brought by the disease itself, coupled with persistent pain, and insecurity during intensive care unit (ICU) admission seriously affect the patient's quality of life and physical and mental health. Strengthening pain management for patients with comorbid cancer pain and relieving their pain symptoms is one of the main components of the clinical treatment of lung cancer. At the same time, in the process of diagnosis and treatment of patients with postoperative lung cancer combined with cancer pain, it is particularly important to provide psychological nursing intervention and psychological support to the patients.

Narrative nursing is a nursing practice in which caregivers listen to and assimilate the patient's story to help the patient to realize the reconstruction of the meaning of the story of life and illness and to discover the key points of nursing care from it, and then make nursing interventions for the patient[4-6]. Narrative care is considered to be a method for patients to talk about the illnesses and traumatic practices they have experienced[7]. By using narrative nursing, patients can fully express their feelings and needs, and healthcare personnel can better understand and deal with patients' demands, to fundamentally solve the problems raised by patients with different conditions and different literacy levels, and comprehensively improve the effect of psychological care and enhance the application value. In this study, patients with lung cancer combined with cancer pain admitted to the intensive care unit of our hospital were taken as research subjects, and conventional nursing care and narrative nursing care were applied respectively to explore the application effect of narrative nursing care in patients with lung cancer combined with cancer pain. The results are now reported as follows.

MATERIALS AND METHODS

Research participants

One hundred and twenty patients with lung cancer combined with cancer pain who were hospitalized from February 2021 to February 2022 were selected as study subjects by convenience sampling. The study subjects were numbered according to the order of admission, and computer Excel was applied to generate random numbers that correspond to the admission number, and then the random numbers were sorted according to their size, with the odd number of the sorting number as the intervention group and the even number as the control group. There were no lost visits in the two groups in this study, and the final sample size of 1120 cases was included, 60 cases in each group. The difference in general qualifications between the two groups was not statistically significant (P > 0.05) and was comparable, as shown in Table 1. This study was approved by the Ethics Committee of Wuhan Fourth Hospital.

Table 1 Comparison of general data between the two groups, n (%).

Variable	Control group (n = 60)	Observation group (n = 60)	Statistic, χ²	P value
Age, mean ± SD	69.80 ± 8.94	71.48 ± 7.82	t = -1.098	0.275
Gender			2.133	0.144
Female	26 (43.33)	34 (56.67)
Male	34 (56.67)	26 (43.33)
Place of residence			0.033	0.855
Urban	28 (46.67)	29 (48.33)
Rural	32 (53.33)	31 (51.67)
Educational level			3.006	0.222
Elementary school and below	16 (26.67)	25 (41.67)
Middle school	23 (38.33)	18 (30.00)
College and above	21 (35.00)	17 (28.33)
Marital status			0.533	0.465
Married	28 (46.67)	32 (53.33)
Divorced/widowed/unmarried	32 (53.33)	28 (46.67)
Monthly income			5.504	0.138
< 1000	27 (45.00)	16 (26.67)
1000-2999	16 (26.67)	16 (26.67)
3000-4999	8 (13.33)	13 (21.67)
≥ 5000	9 (15.00)	15 (25.00)
Payment Methods			0.134	0.714
Medical insurance	33 (55.00)	31 (51.67)
Self-financed	27 (45.00)	29 (48.33)
TNM			1.826	0.609
I	18 (30.00)	12 (20.00)
II	16 (26.67)	16 (26.67)
III	10 (16.67)	12 (20.00)
IV	16 (26.67)	20 (33.33)
The surgical procedure			0.912	0.634
Pulmonary wedge resection	22 (36.67)	19 (31.67)
Segmentectomy	19 (31.67)	17 (28.33)
Pulmonary lobectomy	19 (31.67)	24 (40.00)

Inclusion and exclusion criteria

Inclusion criteria: (1) Age 18 years and above; (2) clear consciousness, able to clearly express their own will and subjective feelings; (3) patients diagnosed with lung cancer by pathological examination and clinical diagnosis, and admitted to ICU after radical lung cancer surgery; Exclusion criteria: (1) Patients or family members with poor compliance, do not cooperate with the diagnosis and treatment; (2) combined with serious heart, brain, liver, kidney, and other important organs; (3) recurrent, metastatic lung cancer patients or other serious illnesses that may affect the study. Patients with recurrent or metastatic lung cancer or other serious diseases that may affect the study.

Methods

Patients in the control group were given routine nursing interventions, and the nurse in charge verbally instructed patients on daily routine, diet, medication and rehabilitation exercise methods, etc., while closely monitoring the patients' conditions, paying attention to the patients' moods, often giving psychological comfort to patients with large emotional fluctuations, and patiently answering the questions of the patients and their families. In the intervention group, narrative nursing was implemented based on conventional nursing care, guided by the five core techniques of externalization, deconstruction, rewriting, external witnesses, and therapeutic documents.

Establishment of a research group

A five-member research team was formed, including a psychotherapist engaged in psychological counseling for patients with malignant tumors, a head nurse of the ward, two specialist nurses of the custody unit, and a specialist nurse of the oncology unit, and the members had received eight weeks of systematic narrative nursing training. The head nurse of the ward was responsible for coordinating the work of the intensive care unit and quality supervision, the psychotherapist was responsible for guiding the process of narrative nursing intervention, and the oncology specialist nurses and the specialist nurses of the care unit were involved in the whole process of narrative nursing intervention.

Narrative care training

(1) Theoretical knowledge of Narrative Nursing: Using the textbook "Narrative Nursing" as a guide, learn the theoretical knowledge, implementation skills, and clinical practice of narrative nursing through the online course "Narrative Therapy" and "Narrative Therapy Application Cases" through video; (2) Narrative care skills practice: Practice in groups of two. The narrator mentally thinks of a recent troubling event and describes his/her problem to the narrative care practitioner, who then asks questions according to the learned narrative care delivery skills, practices how to trigger the narrator's desire to talk, as well as how to tap into the underlying meanings through the narrator's words, and guides the narrator to change his/her perception of the problem to one of positive action, and then switches roles to ensure that all members of the intervention team can master the methodology of narrative care delivery. members delivering the intervention master the methods of narrative care delivery; and (3) Evaluation: At the end of the training, the Medical Narrative Competence Questionnaire for Healthcare Professionals[8] was applied to evaluate the three aspects of concern listening, understanding response, and reflective reproduction, and the score of the questionnaire > 163 means that the level of narrative medical competence is high before the implementation of narrative nursing intervention can be started.

Development of intervention plans

(1) Phase 1: After the patients enter the custody unit for physical recovery, complete the collection of their general information, pain, sleep status, anxiety and depression status, and quality of life status scores, and analyze the scores of the questionnaire's dimensions to understand the patients' conditions; (2) Phase 2: Narrative nursing intervention is implemented for patients receiving postoperative care for lung cancer in the monitoring room, mainly taking the form of bedside interviews to apply the narrative nursing intervention to patients; (3) Phase 3: Patients' pain status was collected again after patients completed all narrative nursing interventions. Intervention place and time: intensive care unit, in the second phase of the implementation of two weeks of narrative interviews, a total of seven narrative care. 1-2 times per week, each narrative interview lasted 30-45 min; and (4) Phase 4: Patients' sleep status, anxiety, and depression status, and quality of life data were collected again after 1 month of follow-up.

Implementation of intervention programs

Focus on the patient and build a trusting relationship with them: Patients admitted to ICU first familiarize themselves with each other and establish a trusting relationship with the patients, and learn the general information about the patients' family basic situation, cultural background, economic status, religious beliefs, hobbies and interests, and social support. Purpose: To bring patients closer so that they can relax physically and mentally, and to find out the patients' psychological distress through communication.

Externalization problems

Guiding patients to narrate is the first step in the implementation of narrative care. Patients vent their negative emotions and psychological distress by talking. Nurses listen to patients in the process of listening to the timely response, respect the privacy of patients, and do not evaluate the views expressed by the patient, but also can be appropriate to share their own stories, strengthen the relationship of trust, promote the patient's storytelling, so that the patient to fully vent their emotions, and then to find the entry point of the problem of disturbing the patient. Purpose: To concretize the problem, increase the patient's sense of control over the problem, and focus on solving the problem.

Deconstruction problems

The process of exploring a patient's problem or behavior about the cultural context in which it is embedded is deconstruction. Identifying the relationship between the patient's self-identity and the socio-cultural context in which he or she lives, and then breaking that relationship to reconstruct the patient's self-identity about the illness, thereby changing the patient's perception of the illness. Purpose: To unearth the deeper socio-cultural-related factors behind the patient's perception and thoughts that give rise to such perceptions and thoughts through the patient's answers, to explain to the patient the root causes of the problem from the perspective of the cultural context in which he or she is living, and to separate the patient from the problem so that he or she can see the problem from the perspective of the objectivist.

Rewriting Guide the patient to review similar life events in the past as a branch story, through the deconstruction of the branch story, tap the patient's unnoticed good qualities and affirm and appreciate them, and transfer these good qualities to the present problem, thus enhancing the determination to solve the problem. Purpose: To guide patients to make positive evaluations of themselves by asking questions, to recognize and appreciate these evaluations, and to continue to guide them; "What would one do in the face of the present problem?" Accommodate the patient's positive evaluations of themselves into the existing problem and guide the patient to make a decision for themselves, develop an implementation plan, and complete the process of rewriting.

External witnesses

Family members, friends, healthcare workers, and other people who care for and about the patient were chosen to witness the patient's changes according to the wishes of the study participants. Purpose: Allowing more people to see the patient's progress can make the progress more real, thus encouraging the patient to continue to develop in a good direction.

Effectiveness evaluation

The two groups of patients were evaluated separately before and after treatment by a professionally trained nurse who was not involved in the treatment and who was unaware of the grouping of the patients being evaluated.

Patients' pain status

Before the intervention and 1 mo after the intervention, the visual analogue scale (VAS) was used to assess the pain level of the two groups of patients, with a total score of 0 to 10, with 0 indicating no pain and 10 indicating intolerable severe pain, with higher scores indicating more severe pain[9].

Patients' psychological status: Before the intervention and 1 mo after the intervention, the patient's psychological status was assessed by using the self-rating depression scale and self-rating anxiety scale, each with 20 items and a total score of up to 100 points, with higher scores indicating that the patients' negative emotions were more serious[10,11].

Patient sleep status

Before the intervention and 1 month after the intervention, the Pittsburgh Sleep Quality Index (PSQI) was used to assess patients' sleep. The scale consists of 19 self-assessment items and 5 other-assessment items. In this study, only the first 18 self-assessment items were scored, which consisted of 7 components, each of which was scored from 0 to 3 out of a possible 21 points, with higher scores indicating poorer sleep quality[12].

Patients' quality of life

Before the intervention and 1 mo after the intervention, the World Health Organization quality of life assessment instrument brief version (WHOQOL-BREF) was used to evaluate the quality of life of the patients, which contains 4 dimensions and 24 entries, namely, physiological (7 entries), psychological (6 entries), social relationship (3 entries) and environment (8 entries), each entry is scored from 1-5, and the higher the score, the better the quality of life of the patients. The higher the score, the better the quality of life of the patient[13].

Statistical analysis

In this study, SPSS20.0 was used for statistical processing. Research includes counting data and measurement data. Counting data were analyzed using the chi-square test and the measurement data were analyzed using the t-test. P > 0.05 was used as a cut-off value for statistical significance.

RESULTS

Comparison of pain status between the two groups

Before the intervention, the difference between the pain VAS scores of the two groups was not statistically significant. After the intervention, the pain score of the observation group was smaller than that of the control group, and the difference was statistically significant (P < 0. 05; Table 2).

Table 2 Comparison of pain status between the two groups.

	VAS
	Pre-intervention	Post-intervention
Observation group	3.87 ± 1.27	2.05 ± 1.13
Control group	4.15 ± 1.41	2.83 ± 1.39
t	1.156	3.368
P value	0.250	0.001

VAS: Visual analogue scale.

Comparison of psychological status between the two groups

Before the intervention, the difference between the anxiety and depression scores of the two groups was not statistically significant. After the intervention, the anxiety and depression scores of the observation group were smaller than those of the control group, and the difference was statistically significant (P < 0.05; Table 3).

Table 3 Comparison of psychological status between the two groups.

	SAS		SDS
	Pre-intervention	Post-intervention	Pre-intervention	Post-intervention
Observation group	54.10 ± 3.97	33.34 ± 4.12	56.53 ± 3.83	47.74 ± 3.85
Control group	54.00 ± 3.64	42.07 ± 3.46	56.93 ± 3.55	49.32 ± 3.42
t	-0.144	12.537	0.593	2.383
P value	0.886	< 0.001	0.554	0.019

VAS: Visual analogue scale; SDS: Self-rating depression scale.

Comparison of sleep conditions between the two groups

After the intervention, the sleep quality of the two groups improved significantly compared with that before the intervention, and the total PSQI scores of the observation group were smaller than those of the control group after the intervention, and the difference was statistically significant (P < 0.05; Table 4).

Table 4 Comparison of sleep status between the two groups.

	PSQI
	Pre-intervention	Post-intervention
Observation group	15.42 ± 5.94	10.46 ± 3.74
Control group	16.73 ± 6.17	15.92 ± 6.54
t	1.191	5.587
P value	0.236	< 0.001

PSQI: Pittsburgh Sleep Quality Index.

Comparison of quality of life between the two groups

After the intervention, the physical, psychological, social relationship, and environmental scores of the two groups improved, and the observation group was higher than the control group (P < 0.05; Table 5).

Table 5 Comparison of quality of life between the two groups.

	Physiology		Psychology		Social relation		Surroundings
	Pre-intervention	Post-intervention	Pre-intervention	Post-intervention	Pre-intervention	Post-intervention	Pre-intervention	Post-intervention
Observation group	16.60 ± 5.68	25.80 ± 5.67	10.37 ± 5.05	22.26 ± 6.13	6.47 ± 3.23	12.75 ± 6.01	18.02 ± 6.45	30.90 ± 5.99
Control group	15.08 ± 5.65	22.75 ± 5.65	9.68 ± 4.75	13.39 ± 6.02	5.85 ± 3.32	7.92 ± 3.51	19.23 ± 6.18	24.80 ± 6.01
t	-1.466	-2.957	-0.764	-7.994	-1.032	-5.411	1.055	-5.572
P value	0.145	0.004	0.446	< 0.001	0.304	< 0.001	0.293	< 0.001

DISCUSSION

The early stage of lung cancer patients' clinical manifestations are not obvious, mainly chest pain, with the progress of the disease can appear cough, hemoptysis, blood in sputum, fever, chest tightness, chest pain, dysphagia, hoarseness, etc., and some patients can also be manifested as malignant quality, etc., and the serious condition will also occur in distant metastasis, the most common of which is the metastasis of lymph nodes, which seriously affects the patients' physical functions[14,15]. Clinical selection of treatment is mainly based on the patient's physical condition, and at present, there are mainly surgery, radiotherapy, targeted therapy, etc., of which surgery is the primary treatment method and the only way to cure lung cancer[16,17]. However, postoperative ICU patients with lung cancer are in critical condition and their lives may be in danger at any time. In addition, the postoperative pain of lung cancer patients is intense, and they are in a relatively closed environment and lack care and attention from their relatives, which leads to the patients being very prone to adverse emotions such as nervousness, anxiety, and even depression, which affects the clinical efficacy and prognosis of the patients. In addition, the sound of various instruments, alarms, and rescue sounds in the ICU makes patients more prone to psychological stress, and the application of their own special treatments and complex equipment for examination makes them suffer, while the changes in the conditions of other patients, intermittent physical groans, and even the death of the nightmare news can make the patients fearful and aggravate their adverse psychological state. To alleviate the physical and mental suffering of these patients, in addition to conventional treatment and care measures, it is necessary to build a bridge of communication between doctors and patients. According to Alo[18], narrative is a nursing intervention method that uses narrative to help patients let go and discard past life episodes and construct new, positive and meaningful new life concepts. Narrative nursing allows healthcare professionals to see the afflictions and emotions behind the patient through the disease, enter the patient's mind, and cathartically release the pain and bewilderment that the patient has experienced after the illness, so that their repressed emotions can be vented.

Through the narrative care for postoperative lung cancer patients in the intensive care unit, the VAS scores of patients in the observation group were significantly lower than those of the control group (P < 0.001), which was the same as the results of the related study by Liu et al[19], indicating that narrative care can effectively reduce the pain level of postoperative lung cancer patients in the intensive care unit. The reason for this is that personalized narrative care can distract patients' attention through storytelling and recalling positive events in daily life, thus reducing pain sensation; furthermore, the relief of psychological pressure can also effectively improve patients' sleep quality, which in turn can lead to a small decrease in the level of inflammatory markers in the organism. Therefore, narrative nursing helps patients find positive meanings in stories and life by patiently listening to their stories and encouraging and comforting them, to provide psychological nursing care and fundamentally relieve their anxiety and pain caused by lung cancer. This kind of nursing method is very humanized, and it can help patients build up confidence and courage to give birth, eliminate their fear, and enhance their tolerance to pain.

Through the narrative care for postoperative lung cancer patients in the intensive care unit, the VAS scores of patients in the observation group were significantly lower than those of the control group (P < 0.001), The reason for this is that personalized narrative care can distract patients' attention by telling stories and recalling positive events in daily life, thus reducing the pain sensation; furthermore, the alleviation of psychological pressure can also effectively improve the sleep quality of patients, which in turn leads to a small decrease in the level of inflammatory markers in the organism. Therefore, narrative nursing helps patients find positive meanings in stories and life by patiently listening to their stories and encouraging and comforting them, to provide psychological nursing care and fundamentally relieve their anxiety and pain caused by lung cancer. This kind of nursing method is very humanized, and it can help patients build up confidence and courage to give birth, eliminate their fear, and enhance their tolerance to pain.

Lung cancer patients' physical defects caused by lung resection, disease, pain caused by radiotherapy, and economic burden have caused great pressure on their psychology. Negative emotions can significantly affect the prognosis of patients, and narrative nursing is a humanized nursing model based on the concept of "physiological-psychological-social", which can encourage patients to vent their emotions by understanding their inner feelings, giving them emotional support, guiding them to expand their inner world step by step during the nursing process, encourage and help them to establish normal values and confidence in treatment, face the disease with a positive mindset, and develop a positive attitude towards the disease, as well as a positive attitude towards the disease. In the nursing process, we can gradually guide the patients to expand their inner world, encourage and help them to establish normal values and confidence in treatment, face the disease with a positive attitude, and improve their anxiety and depression. The results of this study show that narrative nursing can effectively relieve postoperative anxiety and depression in lung cancer patients, compared with the conventional nursing group This is similar to Lu et al[20] and Feng et al[21] who found that narrative care can improve negative emotions such as psychological distress, anxiety, and depression in cancer patients to some extent. Nursing staff then capture important information according to the patient's narrative, help patients externalize psychological problems, carry out psychological guidance, and correct misperceptions, which can further regulate the negative emotions of patients such as depression, anxiety, restlessness, and reduce the impact of emotions on sleep, thus improving the quality of sleep of patients. This study showed that the narrative care group could significantly improve patients' sleep (10.46 ± 3.74 vs 15.92 ± 6.54, P < 0.001).

This study found that there were statistical differences in the four dimensions of quality of life in the intervention group, and the WHOQOL-BREF scores of the observation group were higher than those of the control group (P < 0.001), which shows that the quality of patient's lives can be improved through narrative nursing. Narrative nursing attaches importance to the regulation of patients' physiological, psychological, social, and spiritual aspects, in the process of narrative, patients can take the initiative to vent their emotions, feel the care from others, and gain more warmth; and nursing staff can gradually integrate into the patient's story by listening and responding to the patient's story, understand the patient's life experience, and cause empathy between the two, which can further promote the patient-nurse relationship, and make the patient full of self-confidence in the treatment and life. The patient's storytelling process is not only a good way to understand the patient's life experience, but also a good way to promote the nurse-patient relationship and make the patient feel confident in treatment and life. The patients not only reveal their physical level of pain in the process of narrative but also reflect the psychological level of the problem, such as low self-acceptance, mood anxiety, and depression; but through the narrative to the caregivers, the patients can open up their hearts, produce an open-minded emotional experience, to further correct their psychological condition and improve the quality of life.

Limitations: This study was conducted in only one hospital using the convenience sampling method, which may have an under-representative sample size, and it is recommended that the sample size can be expanded to conduct a multi-center study in the future.

CONCLUSION

In conclusion, for patients with lung cancer combined with cancerous pain, intervention through systematic narrative nursing method can help patients recognize and understand their disease, adjust their mindset, establish confidence in overcoming the disease, accept and cooperate with the treatment in a positive attitude, alleviate the pain feeling in patients' subjective consciousness, alleviate their adverse emotions, reduce anxiety, and improve the quality of sleep and quality of life.

ARTICLE HIGHLIGHTS

Research background

Lung cancer, a notoriously prevalent and often fatal illness, poses a significant threat to human health. With high mortality rates, this grueling disease leaves patients and their families reeling from its impact. Postoperative patients with cancer pain, specifically, require extensive psychological support during their treatment and recovery process.

Research motivation

The mental well-being of these patients is crucial, as the excruciating pain associated with cancer not only impacts their physical health but also their emotional state.

Research objectives

The objective of this study is to investigate the impact of implementing the narrative nursing approach on the outcomes of postoperative lung cancer patients admitted to the intensive care unit.

Research methods

Before the intervention, the control group was administered routine analgesia and psychological care, while the observation group implemented the five-step narrative care method in addition to routine care. The variables assessed included visual analogue scale scores, sleep patterns, anxiety and depression levels, and quality of life.

Research results

The observation group had lower pain, anxiety and depression scores after the narrative care intervention than the control group.

Research conclusions

The systematic narrative care approach is an effective intervention.

Research perspectives

For patients with lung cancer and cancer pain, through the system narrative nursing method intervention can help patients know and understand their disease, adjust mentality, establish the confidence to overcome the disease, actively accept and cooperate with treatment, relieve pain in patients with subjective consciousness, reduce bad mood, reduce anxiety, improve the quality of sleep and quality of life.