Quality of care combined with mindfulness-based stress reduction intervention in patients undergoing arterial interventional embolization for liver tumors

Abstract

BACKGROUND

Although transarterial chemoembolization (TACE) is an effective treatment for liver cancer, clinical practice has shown that many patients experience significant psychological distress following the procedure, which can hinder postoperative recovery and prognosis. Therefore, effective and evidence-based interventions are urgently needed to address this issue.

AIM

To evaluate the impact of nursing quality-sensitive indicators combined with mindfulness-based stress reduction (MBSR) interventions in patients undergoing TACE.

METHODS

A total of 84 patients who underwent TACE from June 2022 to March 2024 were enrolled in the study. They were randomly assigned to either the observation group (n = 42), which received nursing quality-sensitive indicator-based care combined with MBSR intervention, or the control group (n = 42), which received routine care combined with MBSR intervention. Psychological stress response levels [assessed using the Trait Meta-Mood Scale (TMMS)], coping strategies [measured with the Jalowiec Coping Scale (JCS)], quality of care [evaluated using the Perceived Nursing Service Quality (PNSQ) scale], and overall patient satisfaction were compared between the two groups.

RESULTS

After 4 weeks, the observation group demonstrated significantly higher TMMS scores, as well as increased optimism, support-seeking, bravery, PNSQ scores, and satisfaction (P < 0.05). In contrast, scores for self-dependence, conservatism, resignation, and avoidance in the JCS were significantly lower in the observation group than in the control group (P < 0.05).

CONCLUSION

The combination of nursing quality-sensitive indicators and MBSR intervention in TACE patients not only reduces psychological stress and encourages a more positive attitude toward illness but also enhances nursing quality and improves the overall patient experience.

Key Words: Sensitive indicators of nursing quality; Mindfulness stress intervention; Interventional embolization of liver tumor; Quality of nursing; Psychological stress

Core Tip: The intervention of nursing quality-sensitive indicators combined with mindfulness-based stress reduction can positively impact patients' psychological stress response and coping strategies. Additionally, it can enhance nursing practices and improve overall care quality, particularly for patients undergoing transarterial chemoembolization.

INTRODUCTION

Liver cancer is one of the most common malignant tumors in China, with a high incidence worldwide. It remains a significant global health challenge, and both the incidence and mortality rates in China are among the highest[1]. Transarterial chemoembolization (TACE) can improve therapeutic efficacy by providing a high concentration of chemotherapeutic drugs directly to tumor cells. However, clinical practice has shown that some patients experience negative emotions following TACE and may struggle with psychological stress[2], often due to side effects such as nausea and vomiting.

While routine nursing care provides some benefits, it lacks targeted and personalized interventions, making it difficult to fully address patients' diverse needs. As a result, the overall effectiveness of intervention remains suboptimal. Nursing quality-sensitive indicators serve as objective measures of nursing quality, enabling continuous improvement in nursing quality for patient care[3]. Meanwhile, mindfulness-based stress reduction (MBSR) interventions can help alleviate physical and psychological distress by enhancing internal focus and improving self-regulation[4]. However, there are limited clinical studies examining the combined effects of nursing quality-sensitive indicators and MBSR interventions. Therefore, this study aimed to further evaluate their impact through a comprehensive analysis.

MATERIALS AND METHODS

Study design

General information of patients: A total of 84 TACE patients who underwent interventional catheterization at Taixing People's Hospital from June 2022 to March 2024 were selected as study participants and randomly assigned to two groups. In the control group (n = 42), there were 25 male and 17 female patients, with an age range of 43-78 years and a mean age of 60.57 ± 5.82 years. The disease duration ranged from 1 to 5 years, with a mean disease duration of 3.06 ± 0.72 years. Tumor diameters ranged from 2.3 cm to 10.7 cm, with a mean diameter of 6.78 ± 1.45 cm. The number of tumors per patient ranged from 1 to 3, with a mean of 2.06 ± 0.31. Based on the Child-Pugh grading criteria for liver reserve function, 26 patients were classified as Grade A and 16 as Grade B. The clinical stage distribution was as follows: 11 patients in Stage I, 23 in Stage II, and 8 in Stage III. In the observation group (n = 42), there were 28 male and 14 female patients, with an age range of 45-76 years and a mean age of 60.74 ± 5.23 years. The disease duration ranged from 1 to 5 years, with a mean of 3.15 ± 0.71 years. Tumor diameters ranged from 3.2 cm to 10.9 cm, with a mean diameter of 7.10 ± 1.32 cm. The number of tumors per patient ranged from 1 to 3, with a mean of 2.14 ± 0.35. According to the Child-Pugh grading criteria, 24 patients were classified as Grade A and 18 as Grade B. The clinical stage distribution was as follows: 10 patients in Stage I, 25 in Stage II, and 7 in Stage III. There was no statistically significant difference between the two groups (P > 0.05).

The inclusion criteria: (1) Diagnosis of liver cancer confirmed through a comprehensive assessment of tumor markers and imaging examinations, meeting the diagnostic criteria for liver cancer[5]; (2) TACE treatment with no contraindications; (3) Clear awareness, with no cognitive impairment, auditory or visual deficits, or speech disorders; and (4) Voluntary participation with signed informed consent.

The exclusion criteria: (1) Presence of distant metastasis or recurrent liver cancer; (2) Liver diseases or malignant tumors; (3) Expected survival cycle of less than 6 months; and (4) Withdrawal from the study or participation in other studies.

This study was reviewed and approved by the Institutional Review Board of Taixing People's Hospital. All study participants and their legal guardians provided written informed consent before recruitment.

Methods

Mindful breathing: Patients were instructed to wear loose clothing and remove glasses, earrings, necklaces, and other accessories. They were guided to practice abdominal breathing by inhaling slowly through the nose and exhaling slowly through the mouth, repeating this process 2-3 times. Patients were encouraged to focus on their breath and allow their thoughts to flow naturally.

Mindful meditation: In a comfortable and quiet environment, patients were guided to observe the emergence and dissolution of negative emotions, helping them objectively recognize their feelings. This process aimed to support them in managing liver cancer with a positive mindset and calmly accepting the impact of radical resection of liver cancer. The MBSR program was structured as an 8-week course, with one session per week lasting 2.5-3.5 hours. Additionally, participants attended a one-day retreat during the sixth week of the program. Daily home practice was required, consisting of at least 45 minutes of formal mindfulness exercises and 5-15 minutes of informal practice, 6 days per week. The MBSR sessions were led by certified instructors with extensive experience in mindfulness-based interventions. Each instructor had a minimum of 10 years of MBSR teaching experience, ensuring a high level of expertise and strict adherence to standardized practices.

On this basis, the control group received routine care: Upon admission, patients were provided with a liver cancer health education manual for basic oral instruction. Postoperatively, comprehensive nursing care was administered, including close monitoring of vital signs, timely reporting of abnormalities, and appropriate interventions. Additionally, personalized meal plans and exercise rehabilitation programs were developed for each patient.

Based on this, the observation group received nursing care incorporating nursing quality-sensitive indicators:

Data collection: Database search: Literature was retrieved from CNKI, Wanfang, VIP, and PubMed databases: (1) Search terms: Keywords included “nursing quality”, “hepatocellular carcinoma”, “TACE”, and their related synonyms and specialized terms, combined using Boolean operators (AND, OR); (2) Search timeframe: The search was limited to studies published within the past 10 years to ensure the timeliness and relevance of the data; and (3) Screening process: Initial screening: Studies were first filtered based on titles and abstracts to exclude irrelevant literature. A full-text review was conducted on the remaining studies to assess their methodology, data sources, and study design, excluding low-quality studies. Relevant data on nursing quality-sensitive indicators, including emotional state, cognition, pain, and postoperative complications, were extracted from the eligible studies.

Emotional aspects: Strengthen communication with patients by understanding their true thoughts, causes of negative emotions, and emotional responses. Begin with appropriate verbal reassurance and supportive actions to provide comfort. Utilize music therapy and distraction techniques to help alleviate distress. Encourage patients to cultivate personal interests, such as practicing Tai Chi, gardening, or reading, to stabilize emotions. Finally, teach patients self-regulation techniques for managing their emotions effective.

Cognitive aspects: In addition to oral education, employ effective communication strategies and supplement explanations with visual aids such as images, animations, videos, and models. Conduct specialized health education lectures to clarify the benefits of TACE combined with nursing interventions. Additionally, use both positive and negative case studies to emphasize the importance and necessity of nursing intervention after TACE.

Pain management: Clearly identify the location, intensity, and duration of postoperative pain, reassuring patients that it is a normal occurrence. Provide explanations regarding the procedure, the causes of postoperative pain, and preventive measures. Encourage patients to use distraction techniques and relaxation therapies to alleviate discomfort.

Postoperative complications: Enhance postoperative monitoring and conduct thorough risk assessments for potential complications. Develop targeted intervention strategies based on assessment results. Create individualized nursing schedules tailored to each patient’s condition and recovery timeline.

Observational indicators

Psychological stress response level: Assessed using the Trait Meta-Mood Scale (TMMS)[6], which evaluates three dimensions across 22 items: Individual attention to emotional experience (7 items), differentiation of emotional experiences (9 items), and regulation of negative emotions (6 items). Each item is scored on a scale of 1 to 5, with higher scores indicating better emotional regulation and a more adaptive psychological stress response. Assessments were conducted pre-intervention and at 4 weeks post-intervention.

Response: Evaluated using the Jalowiec Coping Scale (JCS)[7], which measures eight coping strategies: Optimism, support-seeking, self-dependence, bravery, conservatism, resignation, emotional catharsis, and escape. The scale includes a total of 60 coping strategies, distributed as follows: 9, 5, 7, 10, 7, 7, 4, and 5 items, respectively. Each coping strategy is rated from 0 to 3, with higher scores indicating greater reliance on that strategy. Assessments were conducted pre-intervention and at 4 weeks post-intervention.

Nursing quality: Assessed using the Perceived Nursing Service Quality (PNSQ) scale[8], which consists of 29 items across four dimensions: Assurance (9 items), responsiveness (9 items), caring (8 items), and reliability (3 items). Each item is rated on a scale of 1 to 5, with higher scores indicating better perceived nursing quality. The assessment was conducted at 4 weeks post-intervention.

Satisfaction: Measured using the Newcastle Nursing Service Satisfaction Scale[9], which consists of 19 items. Patients rated their experiences on a scale of 1 to 5. Total scores were categorized as follows: 19-57: Dissatisfied; 57-76: Average satisfaction; and 76-95: Satisfied. Satisfaction was calculated as the sum of the satisfied and generally satisfied response rates. The evaluation was conducted at 4 weeks post-intervention.

Statistical analysis

All data collected in this study were analyzed using SPSS 27.0 software. Measurement data are expressed as following appropriate tests and adjustments, all data were confirmed to follow a normal distribution. Independent sample t-tests were used for between-group comparisons, while paired sample t-tests were applied for within-group comparisons. Categorical data are presented as percentage ratios (%), with χ² tests used for analysis. Ordinal data were analyzed using rank-sum tests (Z). A P value of less than 0.05 was considered statistically significant.

RESULTS

Comparison of the psychological stress response levels between the two groups

Before the intervention, the TMMS scores across all three dimensions were balanced between the groups, with no statistically significant differences (P > 0.05). However, after 4 weeks, the differences between the three dimensions became statistically significant (P < 0.05). Further details are provided in Table 1.

Table 1 Comparison of psychological stress response levels between the two groups (mean ± SD, points).

Group	n	Individual attention to emotional experience		Differentiation of emotional experiences		Regulation of negative emotions
		Before	After	Before	After	Before	After
Control	42	20.69 ± 5.25	25.24 ± 5.39a	27.42 ± 5.31	32.59 ± 5.64a	17.09 ± 5.27	20.23 ± 5.35a
Observation	42	20.47 ± 5.13	28.52 ± 5.46a	27.60 ± 5.47	36.07 ± 5.76a	17.23 ± 5.30	23.32 ± 5.45a
t		0.194	2.771	0.153	2.798	0.121	2.622
P value		0.846	0.007	0.879	0.006	0.904	0.010

^aP < 0.05, specific values against the same group before intervention.

Comparison of coping methods between the two groups

Before the intervention, the eight JCS scores were well balanced between the groups, with no statistically significant differences (P > 0.05). After 4 weeks, however, the differences became statistically significant (P < 0.05). Further details are presented in Tables 2 and 3.

Table 2 Comparison of coping methods between the two groups (mean ± SD, points).

Group	n	Optimistic		Support		Self-dependence		Square up
		Before	After	Before	After	Before	After	Before	After
Control	42	17.48 ± 2.25	20.94 ± 2.47a	7.25 ± 2.16	9.75 ± 2.24a	18.23 ± 2.52	13.17 ± 2.31a	20.42 ± 2.19	24.67 ± 2.28a
Observation	42	17.64 ± 2.39	22.42 ± 2.50a	7.34 ± 2.21	11.12 ± 2.43a	18.37 ± 2.48	11.82 ± 2.25a	20.52 ± 2.24	26.03 ± 2.52a
t		0.316	2.729	0.189	2.686	0.257	2.713	0.207	2.594
P value		0.753	0.008	0.851	0.009	0.798	0.008	0.837	0.011

^aP < 0.05, compared with the same group before the intervention.

Table 3 Comparison of coping methods between the two groups (mean ± SD, points).

Group	n	Guard		Trust to luck		Feeling relief		Escape
		Before	After	Before	After	Before	After	Before	After
Control	42	16.24 ± 2.46	12.35 ± 2.28a	8.74 ± 1.43	6.09 ± 1.18a	7.89 ± 2.07	9.48 ± 2.24a	22.28 ± 2.61	18.36 ± 2.45a
Observation	42	16.31 ± 2.52	11.06 ± 2.19a	8.68 ± 1.37	5.42 ± 1.03a	7.92 ± 2.17	10.86 ± 2.42a	22.32 ± 2.50	16.90 ± 2.28a
t		0.129	2.644	0.196	2.772	0.065	2.712	0.072	2.827
P value		0.898	0.010	0.845	0.007	0.948	0.008	0.943	0.006

^aP < 0.05, compared with the same group before the intervention.

Comparison of the quality of care between the two groups

After 4 weeks of intervention, a comparison of the four PNSQ dimensions between the groups showed statistically significant differences in the observation group (P < 0.05). Further details are provided in Table 4.

Table 4 Comparison of the quality of care between the two treatment groups (mean ± SD, score).

Group	n	Guarantee	Reactive mode	Caring	Reliability
Control	42	28.97 ± 5.45	27.06 ± 5.38	27.38 ± 5.19	9.09 ± 2.25
Observation	42	32.28 ± 5.36	30.32 ± 5.49	30.41 ± 5.26	10.41 ± 2.30
t		2.806	2.749	2.657	2.659
P value		0.006	0.007	0.009	0.009

Comparison of satisfaction between the groups

Satisfaction was significantly higher in the observation group, with 95.24% (40/42) of participants reporting higher satisfaction, a difference that was statistically significant (P < 0.05). Further details are presented in Table 5.

Table 5 Comparison of nursing satisfaction between the two groups, n (%).

Group	Unsatisfied	Commonly	Satisfied	Degree of satisfaction
Control	9 (21.43)	17 (40.48)	16 (38.10)	33 (78.57)
Observation	2 (4.76)	17 (40.48)	23 (54.76)	40 (95.24)
Z	2.025
P value	0.042

DISCUSSION

Liver cancer is not highly responsive to chemotherapy or radiotherapy, and commonly used treatments include surgical resection, liver transplantation, vascular intervention, and radiofrequency ablation. Early diagnosis and a comprehensive treatment approach, primarily surgical resection, are key to improving the long-term efficacy of hepatocellular carcinoma treatment. TACE not only increases the effective concentration of chemotherapy drugs in the tumor area while minimizing their impact on normal tissues but also blocks tumor blood flow through embolic agents, thereby inhibiting tumor growth. However, postoperative patients often face a significant burden, experiencing severe anxiety and depression, which can not only “discount” (compromise) the effectiveness of surgical treatment but also directly hinder the postoperative recovery process[10].

The results of this study showed that after 4 weeks, the TMMS score of the observation group was higher than that of the control group, and the improvement in the JCS score was significantly greater (P < 0.05). The underlying reasons are as follows: A diagnosis of liver cancer often triggers intense psychological stress responses, including fear, despair, and anxiety, a phenomenon commonly referred to as tumor “color change”. These reactions are further exacerbated by a lack of understanding of TACE, concerns about treatment efficacy, fear of postoperative recurrence, and changes in liver function. MBSR intervention is based on psychological theory, helps patients continuously perceive and observe their present experiences, enabling them to recognize their psychological state and adopt effective self-relaxation techniques to manage their emotions. In MBSR intervention, body scanning, mindful breathing, and mindful meditation were utilized to foster a positive patient-provider relationship, helping patients maintain emotional stability, face liver cancer with a proactive mindset, and approach TACE treatment with a more positive outlook. Ladenbauer and Singer[11] demonstrated that MBSR significantly improves psychological health in patients with breast cancer, reducing anxiety and depression levels while enhancing quality of life. Similar to our findings, this intervention model alleviates psychological stress by guiding patients to focus on their experiences. However, our study specifically examined patients with liver cancer undergoing TACE, thereby broadening the application of MBSR across different cancer types. When combined with a nursing quality-sensitive indicators, MBSR can enhance the quality of nursing care, promote a sense of well-being, alleviate psychological stress, and reduce emotional distress in patients.

When combined with MBSR interventions, effective patient cooperation can be achieved, further enhancing the intervention's effectiveness and significantly improving the quality of care. The results of this study showed that after 4 weeks, the observation group demonstrated significantly higher scores than the control group (P < 0.05). The reasons for this are as follows: By incorporating sensitive indicators of nursing quality from the patient's perspective in the formulation, implementation, and refinement of nursing intervention measures, all interventions can be accurately executed. This approach provides clear guidance and direction for clinical nursing practices, facilitating continuous improvements in nursing quality, establishing a systematic framework, and enhancing nursing efficiency. These findings align with those of Zhang et al[12], who reported that similar combined intervention models yielded favorable outcomes in other clinical settings. This approach not only improves patients' physiological and psychological well-being but also enhances overall nursing quality by optimizing care processes and increasing efficiency. Furthermore, as shown in Table 5, the satisfaction rate in the observation group reached 95.24%, indicating that the combined intervention model is more scientific, reliable, and practical, making it well-received by patients.

CONCLUSION

This study demonstrated that the combined application of nursing quality-sensitive indicators and MBSR interventions has demonstrated clear benefits. On one hand, this approach effectively addresses patients' psychological needs, accelerating the postoperative recovery process. On the other hand, continuously improving the quality of care ensures the effectiveness and safety of TACE, making this intervention model highly valuable for clinical practice. We propose integrating nursing quality-sensitive indicators with MBSR as a standardized intervention model in clinical settings. To enhance healthcare providers’ capabilities, structured protocols and specialized training programs should be developed, with flexible adjustments based on hospital size. Furthermore, multidisciplinary collaboration, supported by information technology, along with the establishment of long-term follow-up mechanisms, will help optimize intervention strategies and improve patient engagement. These measures are expected to significantly enhance both the quality of care and the overall experience of patients undergoing TACE.