Impact of narrative therapy and standard ostomy care on postoperative recovery and complications in permanent colostomy

Abstract

BACKGROUND

Permanent colostomy poses substantial physical and psychological challenges that impede postoperative recovery.

AIM

To evaluate whether adding narrative therapy (NT) to standard ostomy care (SOC) improves postoperative outcomes in patients undergoing permanent colostomy.

METHODS

This retrospective cohort study included patients who underwent elective permanent colostomy from June 2022 to June 2025. Patients were divided into an NT combined with SOC (NTSOC) group and an SOC group on the basis of receipt of postoperative NT. Outcomes assessed included gastrointestinal recovery, early mobilization, hospital stay, self-care ability at 3 months, stoma complications within 3 months, psychosocial adaptation at 3 months, and stigma perception immediately postoperatively and at 3 months.

RESULTS

The baseline information of each group was comparable. The NTSOC group showed significantly faster gastrointestinal recovery (first oral rehydration: 48.24 hours vs 56.43 hours, P < 0.001) and earlier resumption of normal activities (3.31 days vs 3.75 days). The length of hospital stay was significantly shorter in the NTSOC group than in the SOC group (11.46 days vs 12.37 days, P = 0.016). By 3 months, the NTSOC group exhibited lower persisting concern than the SOC group (12.27 vs 13.75, P = 0.002). A significant difference was found in terms of accepting life (11.59 vs 10.36, P = 0.002); more optimistic attitude (17.44 vs 16.02, P = 0.001); and reduction in the stigmatized perception of social isolation, internalized shame, and perceived social exclusion. However, economic insecurity did not vary significantly (P = 0.091).

CONCLUSION

NTSOC is associated with accelerated recovery, fewer complications, enhanced self-care, better psychosocial adaptation, and reduced stigma in patients undergoing permanent colostomy.

Key Words: Narrative therapy; Permanent colostomy; Postoperative recovery; Ostomy complications; Psychosocial adaptation; Stigma

Core Tip: Permanent colostomy poses substantial physical and psychological challenges that impede postoperative recovery. This retrospective study of 148 patients indicates that narrative therapy combined with standard ostomy care is associated with accelerated gastrointestinal recovery, a lower incidence of stoma complications, and improved self-care and psychosocial adaptation at 3 months. These findings suggest that integrating structured psychological support into routine ostomy management may offer benefits for both physical and psychosocial rehabilitation.

INTRODUCTION

Permanent colostomy is a surgical procedure that creates an opening in the abdominal wall to divert feces from the colon, most commonly performed after abdominoperineal resection for low rectal cancer or other pelvic malignancies[1]]. Patients undergoing permanent colostomy must adapt to fundamentally altered body image and excretory function, often encountering significant physical and psychological challenges, including ostomy-related complications, decreased mobility, and reduced quality of life[2,3].

Modern advances in perioperative management, such as minimally invasive surgery, the enhanced recovery after surgery protocol, and special ostomy care programs, mainly pay attention to technical details of stoma sites, pouching techniques, and prevention of complications but still have a high morbidity rate for ostomatism[4,5]. Furthermore, traditional nursing primarily addresses patients’ bodily conditions and fails to explore their emotions that are troubled due to damage to the body[6]. Consequently, many patients struggle with poor self-care ability, persistent anxiety, and social isolation, which may hinder functional recovery and increase complication rates[7]. Joint effort is urgently necessary for physical rehabilitation and emotional adjustment.

Psychosocial stressors are known to influence the process of wound recovery in surgery. The hypothalamus-pituitary-adrenal axis is impaired by continuous exposure to stress or depression for an extended period, leading to increased blood corticosterone levels, weakened immunity, and delayed tissue reconstruction[8,9]. Positive psychological intervention methods may lower blood cortisol concentrations; stimulate patients’ initiative to participate in treatment, and help individuals recover from injury more quickly and sustainably[10,11]. Narrative therapy (NT) helps people change their perspectives towards illness by constructing an extensive life story of theirs[12]. Although the connection between narrative reconstruction and physiological recovery is complex and multifactorial, new psycho-neuroimmunological research suggests that reducing internalized shame and social isolation may promote enhanced surgical outcomes by modulating inflammatory responses and encouraging early mobilization[13,14]. Although several studies have been conducted on the application of NT combined with ostomy care to accelerate post-operative recovery, how to reduce ostomy complications remains unknown.

This retrospective cohort study was designed to examine whether a combination of NT and standard ostomy care (NTSOC) is more effective than traditional standard ostomy care (SOC) for improving post-operative recovery after elective permanent colostomy surgery. A three-stage story-based teaching plan was integrated into the postoperative nursing schedule. Guided by the biopsychosocial perspective, this approach focuses on the physical changes, emotional experiences, and mental states of patients with ostomy. The demonstration of NTSOC provides reference materials for implementing an inter-disciplinary after-operation plan, enhancing patients’ quality of life, and contributing to a more balanced distribution of the overall healthcare burden.

MATERIALS AND METHODS

Study design

This study is a retrospective cohort study aimed at evaluating the effect of NTSOC on postoperative activity recovery and stoma complications in patients undergoing permanent colostomy. Patients who underwent elective permanent colostomy at the General Surgery Department of the First People’s Hospital of Linping District from June 2022 to June 2025 were included. They were divided into an NTSOC group and an SOC group on the basis of whether they received NT postoperatively.

Ethical statement

This study only used anonymized data from patients who completed treatment for permanent colostomy. All data were de-identified before analysis to ensure that individual patients could not be traced. The research process did not have any effect on patients’ subsequent treatments, and it complied with the ethical principles of the Declaration of Helsinki. This study was reviewed and approved by the First People’s Hospital of Linping District’s Ethics Committee. Given the retrospective nature of the study, the requirement for informed consent was waived.

Treatment methods

All patients underwent elective permanent colostomy. The SOC group received routine stoma care, which specifically included preoperative stoma site marking and preoperative education by a stoma therapist, informing patients of the surgical procedure and purpose of the stoma and teaching them basic nursing knowledge. During the postoperative hospital stay, daily stoma assessment (e.g., color, edema, and blood supply) was performed, and the responsible nurse guided patients and their families in learning stoma pouch change techniques, covering operating steps, cutting techniques, and application methods. Peri-stomal skin care guidance was provided, including cleaning, protection, and complication prevention. Dietary guidance was offered to help patients identify gas-producing and odor-producing foods, maintain adequate fluid intake, and adjust dietary fiber. Common stoma complications, such as dermatitis, stenosis, prolapse, and parastomal hernia, were explained, along with recognition and management methods. Upon discharge, a stoma care manual was provided, and outpatient follow-up was scheduled.

The NTSOC group received all the standard stoma care described above, along with NT. This therapy was initiated when the patients were medically stable, conscious, and able to communicate effectively after surgery (on postoperative days 2 or 3), conducted once a week for 30 minutes each session, for a total of eight sessions. The sessions were delivered by two designated stoma therapists (intrastromal therapy nurses) who completed a structured 4-week training program in narrative counseling techniques led by a clinical psychologist. The training included theoretical instruction, roleplaying, and case supervision to ensure uniform treatment competency across all practitioners. During hospitalization, it was delivered one-on-one at the bedside; after discharge, it was continued via video calls. The implementation of NT followed a five-step framework. First, externalization of the problem was performed to help patients separate stoma-related issues from themselves. Second, deconstruction was used to analyze the roots of patients’ stigma and anxiety, identifying the effect of negative social labels. Third, through rewriting, patients were guided to discover overlooked positive coping events and “sparkling moments”. Fourth, reframing was conducted to facilitate a transformation in self-identity from “burden” to “survivor or manager”. Finally, witnessing was arranged, inviting family members to participate, jointly witness the patient’s changes, and plan for life after discharge. This protocol aimed to assist patients in reconstructing a positive narrative about their stoma and their own lives.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) Age ≥ 18 years; (2) Undergoing elective permanent colostomy due to colorectal cancer or other diseases; (3) Normal cognitive function, without mental illness or consciousness disorders, able to understand and cooperate with the completion of treatment; and (4) Complete clinical data, including demographic information, surgical records, postoperative follow-up data, and other results.

The exclusion criteria were as follows: (1) Undergoing emergency stoma surgery; (2) Combined with severe vital organ failure (e.g., heart, liver, or kidneys) or expected survival < 6 months; (3) Pre-existing severe mental illness (e.g., schizophrenia or major depression) or cognitive impairment (e.g., dementia) before surgery; and (4) Loss of key data after surgery due to deterioration of condition, transfer to another hospital, or other reasons.

Data collection

Baseline and clinical data: The baseline and clinical data collected in this study were all sourced from the First People’s Hospital of Linping District’s electronic medical record system. Patients’ demographic information and clinical data were uniformly extracted from the medical record system. Preoperative hemoglobin and albumin levels were the test results from the last fasting venous blood sample collected after admission and before surgery. Hemoglobin was measured using an automatic hematology analyzer (model BC-6800, Shenzhen Mindray Bio-Medical Electronics Co., Ltd., China). Albumin was measured using an automatic biochemical analyzer (model AU5800, Beckman Coulter, Inc., CA, United States), with serum albumin quantitatively determined by spectrophotometry.

Surgery-related characteristics: Surgery-related data, including operative time, intraoperative blood loss, stoma diameter, surgical method, and stoma location, were uniformly extracted from the patients’ surgical records. The surgical records were completed by the attending surgeon immediately after surgery and archived in the electronic medical record system.

Early postoperative recovery: Data on early postoperative recovery indicators were uniformly extracted from the electronic nursing records and inpatient medical record system. The time to first bowel sound recovery, first flatus, and first postoperative defecation were recorded in the nursing record sheet by the responsible nurse after auscultating abdominal bowel sounds at regular intervals (every 6 hours) and inquiring about the patient’s flatus and defecation.

The time to first liquid diet intake was defined as the time when a medical order for “liquid diet allowed” was issued and the patient actually ingested liquid food orally for the first time. It was recorded immediately by the responsible nurse after feeding or guidance. The time to first sitting up, first out-of-bed activity, and first independent walking after surgery were extracted on the basis of the specific time points of the patient’s out-of-bed activities recorded in the nursing records. All the above activities were performed with the assistance or guidance of medical staff. The length of hospital stay was calculated as the actual number of calendar days from the day of surgery to the day of discharge, obtained from the discharge summary in the electronic medical record system.

Self-care ability: Patients were assessed using the Exercise of Self-Care Agency (ESCA) scale at two time points. Preoperative assessment was conducted after admission but before the start of routine preoperative health education, and postoperative 3-month assessment was conducted during outpatient follow-up 3 months after discharge. The ESCA scale contains 43 items covering four dimensions: Self-care skills, self-concept, self-nursing responsibility, and health knowledge level[15]. The scale uses a Likert 5-point scoring method, with each item assigned a score from 4 to 0 corresponding to “very like me” to “very unlike me”, of which 11 items are reverse-scored. The total score ranges from 0 to 172. A higher total score indicates a stronger self-care ability of the patient.

Incidence of stoma complications: Data on stoma complications within 3 months postoperatively were collected through outpatient follow-up, electronic medical record review, and nursing records. All patients were followed up at the stoma clinic at 1 month and 3 months after surgery. Clinical assessment of the stoma and peristomal skin was performed by uniformly trained stoma therapists, including evaluation of stoma color, edema, blood supply, integrity of the mucocutaneous junction, peristomal skin condition, and presence of abnormal bulging. At each assessment, the stoma therapist removed the stoma pouch and observed the stoma and peristomal skin with the patient in sitting and lying positions. The findings were recorded in detail.

Peristomal dermatitis was defined as inflammatory changes in the peristomal skin, such as erythema, erosion, maceration, or ulceration. Fecal dermatitis was defined as prolonged contact and irritation of the peristomal skin by stoma effluent (especially loose or liquid stool), leading to disruption of the skin barrier and manifested as redness, pain, itching, superficial ulceration, or even erosion. The diagnosis was based on clinical visual assessment by the stoma therapist, combined with patient complaints and medical history.

Parastomal hernia was defined as a palpable or visible bulge caused by abnormal protrusion of abdominal contents through the abdominal wall defect at the stoma site. Diagnosis was primarily based on physical examination, with observation and palpation of the peristomal area in supine and standing positions to assess for protrusion of abdominal contents or a reducible mass.

Stoma stenosis was defined as progressive narrowing of the stomal opening due to scar tissue hyperplasia or inflammatory contracture at the stoma orifice, manifested as thinning of the effluent, difficulty in passage, or patient complaints of abdominal distension and straining during defecation. Diagnosis was based on clinical visual and digital examination by the stoma therapist, combined with patient complaints. Stoma prolapse was defined as excessive outward protrusion of the bowel through the stoma, with the stoma length significantly increased (by more than 2 cm) or swelling worsened compared with the early postoperative period.

Psychosocial adaptation of patients with ostomy: At the 3-month follow-up, the Ostomy Adjustment Inventory-20 (OAI-20) was used to assess the level of psychosocial adaptation. OAI-20 comprises 20 items grouped into three dimensions: Persistent concerns, acceptance, and positive outlook on life[16]. A 4-point Likert scale was adopted, with each item scored from 1 (strongly disagree) to 4 (strongly agree) in accordance with the patient’s own perception. The persistent concerns dimension consists of seven items, all of which are reverse-scored (each item is negatively worded); a higher score indicates a higher level of anxiety and distress related to stoma-associated problems. The acceptance dimension consists of five items; a higher score indicates a greater degree of acceptance of the stoma and fewer internal conflicts. The positive-outlook-on-life dimension consists of eight items; a higher score indicates that the patient is better able to maintain a positive and optimistic attitude and actively participates in social activities.

Stigma: The Social Impact Scale (SIS) was used to assess the level of stigma related to the stoma immediately after surgery (postoperative days 3-5, after the patient’s condition stabilized) and at the 3-month follow-up. SIS comprises 24 items divided into four dimensions: Social rejection, economic insecurity, internalized shame, and social isolation[17]. A 4-point Likert scale was adopted, with each item scored from 1 (strongly disagree) to 4 (strongly agree) in accordance with the patient’s perceived level of stigma.

Statistical analysis

All statistical analyses were performed using R software (version 4.3.3, R Core Team, Vienna, Austria). The normality of continuous variables was assessed using the Shapiro-Wilk test. All continuous variables conformed to a normal distribution (P > 0.05 for all). Thus, they were expressed as mean ± SD, and comparisons between two groups were performed using independent sample t-test. Categorical variables were expressed as n (%), and comparisons between two groups were performed using Pearson’s χ² test. When the expected frequency was less than 5, Fisher’s exact test was used. All tests were two-tailed, and a P value < 0.05 was considered statistically significant.

Post-hoc power analysis was performed for the primary outcome measures by using G*Power software (version 3.1.9.7, Heinrich Heine University Düsseldorf, Germany). With the achieved sample sizes (SOC: n = 76; NTSOC: n = 72) and a two-sided alpha level of 0.05, the study had 92.7% power to detect the observed difference in total stoma complication rates (effect size h = 0.68).

RESULTS

Baseline demographic and clinical characteristics

A total of 148 eligible patients were enrolled in this study, including 76 in the SOC group and 72 in the NTSOC group. Table 1 presents the baseline demographic and clinical characteristics of both groups. No statistically significant differences were observed between the two groups regarding age (P = 0.514), gender distribution (P = 0.762), body mass index (P = 0.603), educational level (P = 0.734), marital status (P = 0.522), reason for surgery (P = 0.270), preoperative hemoglobin levels (P = 0.732), preoperative albumin levels (P = 0.738), prevalence of diabetes mellitus (P = 0.726), or hypertension (P = 0.927). These results indicate that the two groups were well-matched at baseline across a range of demographic and clinical variables.

Table 1 Baseline demographic and clinical characteristics, n (%)/mean ± SD.

Indicators	SOC group (n = 76)	NTSOC group (n = 72)	t/χ2	P value
Age (years)	58.34 ± 7.29	59.10 ± 6.86	0.655	0.514
Gender (male/female)	42 (55.26)/34 (44.74)	38 (52.78)/34 (47.22)	0.092	0.762
Body mass index	23.16 ± 3.11	22.88 ± 3.44	0.522	0.603
Education level			0.617	0.734
Primary school or below	16 (21.05)	19 (26.39)
High school	35 (46.05)	30 (41.67)
University or above	25 (32.89)	23 (31.94)
Marital status			1.302	0.522
Single	21 (27.63)	16 (22.22)
Married	50 (65.79)	48 (66.67)
Divorced or widowed	5 (6.58)	8 (11.11)
Reason for surgery (colorectal cancer/other)	64 (84.21)/12 (15.79)	65 (90.28)/7 (9.72)	1.216	0.270
Preoperative hemoglobin (g/L)	118.45 ± 10.33	119.02 ± 9.87	0.343	0.732
Preoperative albumin (g/L)	36.78 ± 4.12	36.55 ± 4.01	0.335	0.738
Diabetes mellitus	11 (14.47)	9 (12.50)	0.123	0.726
Hypertension	29 (38.16)	28 (38.89)	0.008	0.927

SOC: Standard ostomy care; NTSOC: Narrative therapy combined with standard ostomy care.

Intra-operative and stoma-related characteristics

Table 2 outlines the intraoperative and stoma-related characteristics for participants in the SOC group compared with those in the NTSOC group. No difference was found between the groups in terms of operation time (P = 0.504), intraoperative blood loss (P = 0.196), stoma diameter, surgical approach, distribution, and stoma location (all P > 0.05). Therefore, these two groups had no significant differences in the assessed operating and stoma-related indicators.

Table 2 Intraoperative and stoma-related characteristics, n (%)/mean ± SD.

Indicators	SOC group (n = 76)	NTSOC group (n = 72)	t/χ2	P value
Surgery duration (minutes)	165.46 ± 22.83	168.12 ± 25.45	0.669	0.504
Intraoperative blood loss (mL)	110.50 ± 20.35	115.25 ± 24.12	1.298	0.196
Stoma diameter (cm)	2.65 ± 0.42	2.69 ± 0.45	0.609	0.544
Surgical approach (laparoscopic surgery/open surgery)	48 (63.16)/28 (36.84)	45 (62.50)/27 (37.50)	0.007	0.934
Stoma location			0.100	0.951
Through rectus abdominis	71 (93.42)	68 (94.44)
Pararectus	4 (5.26)	3 (4.17)
Through umbilicus	1 (1.32)	1 (1.39)

SOC: Standard ostomy care; NTSOC: Narrative therapy combined with standard ostomy care.

Postoperative early recovery outcomes

Table 3 shows the gastrointestinal function recovery outcomes after surgery for the SOC and NTSOC groups. The time to first bowel sound recovery was significantly shorter in the NTSOC group (P = 0.001). The NTSOC group also had a significantly shorter time to first fluid intake (P < 0.001). In addition, the time to first flatus passage was significantly decreased in the NTSOC group (P = 0.002), thus highlighting a more rapid return of bowel function. Finally, the time to first postoperative bowel movement was significantly earlier in the NTSOC group than in the SOC group (P = 0.003), indicating a better recovery of gastrointestinal function. These findings collectively suggest that patients in the NTSOC group experienced significantly accelerated postoperative gastrointestinal recovery compared to those in the SOC group.

Table 3 Postoperative gastrointestinal function recovery, mean ± SD.

Indicators	SOC group (n = 76)	NTSOC group (n = 72)	t	P value
Time to first bowel sounds recovery	46.76 ± 9.06	42.28 ± 7.53	3.259	0.001
Time to first fluid intake (hours)	56.43 ± 8.26	48.24 ± 6.57	6.654	< 0.001
Time to first flatus passage (hours)	48.93 ± 10.29	43.95 ± 8.62	3.180	0.002
Time to first postoperative bowel movement (hours)	71.57 ± 12.61	65.83 ± 10.48	3.001	0.003

SOC: Standard ostomy care; NTSOC: Narrative therapy combined with standard ostomy care.

As shown in Table 4, the postoperative activity recovery and hospital stay durations between the SOC and NTSOC groups were examined. The NTSOC group achieved first sitting up significantly earlier than the SOC group (P = 0.007), indicating a faster initial mobilization. Similarly, the time to first ambulation was significantly shorter for the NTSOC group (P = 0.015), suggesting quicker initiation of movement post-surgery. Furthermore, the time to first independent walking postoperatively was significantly reduced in the NTSOC group (P = 0.012), highlighting an enhanced ability to regain full mobility sooner. Additionally, the length of hospital stay was significantly shorter for the NTSOC group than for the SOC group (P = 0.016). These findings suggest that the NTSOC approach may offer substantial benefits in terms of accelerating patient recovery and improving hospital efficiency.

Table 4 Postoperative activity recovery and hospital stay, mean ± SD.

Indicators	SOC group (n = 76)	NTSOC group (n = 72)	t	P value
Time to first sitting up (hours)	18.74 ± 4.57	16.97 ± 3.23	2.730	0.007
Time to first ambulation (hours)	25.31 ± 6.11	23.14 ± 4.56	2.459	0.015
Time to first independent walking postoperatively (days)	3.75 ± 1.14	3.31 ± 0.97	2.548	0.012
Length of hospital stay (days)	12.37 ± 2.31	11.46 ± 2.19	2.439	0.016

SOC: Standard ostomy care; NTSOC: Narrative therapy combined with standard ostomy care.

Self-care agency

As shown in Figure 1, the ESCA scores pre-operation vs 3-month postoperative values for the SOC and NTSOC groups were compared. Preoperatively, the ESCA scores of the two groups did not vary notably (P = 0.746), and therefore, their baseline levels of self-care agency were similar before surgery. However, by 3 months after surgery, the NTSOC group had an obvious increase in ESCA scores compared with the SOC group (P < 0.001). The ESCA scores of the NTSOC group were relatively higher, implying that NTSOC may be more beneficial in enhancing patients’ own-care skills during recovery.

Figure 1 Exercise of Self-Care Agency Scale scores before surgery and at 3 months postoperatively. SOC: Standard ostomy care; NTSOC: Narrative therapy combined with standard ostomy care.

Stoma-related complications

Table 5 shows stoma-related complications within 3 months after surgery in both groups. The SOC group had significantly higher frequencies of peristomal dermatitis and fecal dermatitis than the NTSOC group (P = 0.011, P = 0.032). Meanwhile, no significant differences were observed at each stage for parastomal hernia and stoma obstruction/protrusion (P = 0.651 and 0.501, respectively). Overall, the rates of all stoma complications in the SOC group were more likely than those in the NTSOC group (P < 0.001). These results showed that the number of stoma-related complications was lower in the NTSOC group. Thus, NTSOC may be an advantageous strategy for preventing these problems at this stage after surgery.

Table 5 Stoma-related complications within 3 months postoperatively, n (%).

Indicators	SOC group (n = 76)	NTSOC group (n = 72)	χ2	P value
Peristomal dermatitis	13 (17.11)	3 (4.17)	6.419	0.011
Fecal dermatitis	11 (14.47)	3 (4.17)	4.586	0.032
Parastomal hernia	3 (3.95)	1 (1.39)	0.205	0.651
Stoma stenosis/protrusion	2 (2.63)	0 (0.00)	0.454	0.501
Total incidence rate	29 (38.16)	7 (9.72)	16.241	< 0.001

SOC: Standard ostomy care; NTSOC: Narrative therapy combined with standard ostomy care.

Psychological adaptation

As shown in Figure 2, the OAI-20 subscale scores at 3 months post-operatively for both groups were compared. The SOC group scored significantly higher than the NTSOC group on the “persistent concern” item, indicating that these patients were under greater stress and had been worrying about their stoma problems for a long period. On the contrary, the NTSOC group showed significantly higher scores for acceptance (P < 0.05) and positive outlook of life, indicating strong psychological adaptation ability and more optimistic attitude towards life following surgery. These findings suggest that the NTSOC approach may be more effective in facilitating psychological adaptation and promoting a positive outlook among patients with a stoma. The enhanced adjustment can help improve overall mental health and quality of life after surgery.

Figure 2 Ostomy Adjustment Inventory-20 subscale scores at 3 months postoperatively. SOC: Standard ostomy care; NTSOC: Narrative therapy combined with standard ostomy care.

Stigma perception

Table 6 demonstrates the immediate postoperative and 3 months postoperative SIS subscale scores of the two groups. Immediately after surgery, no significant difference was found for all sub-items: Sense of social isolation (P = 0.706), economic insecurity (P = 0.513), internalized shame (P = 0.705), and perceived social exclusion (P = 0.666). However, at the 3-month follow-up, significant differences emerged. The NTSOC group reported significantly lower scores for Sense of Social Isolation (P = 0.033), internalized shame (P = 0.004), and perceived exclusion from society (P = 0.004), different from the SOC group. Despite a general decline in economic insecurity in the NTSOC group, this difference was not statistically significant at P = 0.091. The findings showed that NTSOC is expected to be an effective means to help reduce the negative social and psychological effects from this surgery, thereby improving people’s general psychological state.

Table 6 Social Impact Scale subscale scores immediately postoperatively and at 3 months postoperatively, mean ± SD.

Indicators	SOC group (n = 76)	NTSOC group (n = 72)	t	P value
Immediate postoperative
Sense of social isolation	21.53 ± 4.16	21.78 ± 4.17	0.378	0.706
Economic insecurity	12.24 ± 2.64	12.52 ± 2.46	0.655	0.513
Internalized shame	15.36 ± 3.19	15.16 ± 3.25	0.379	0.705
Perceived social exclusion	24.81 ± 4.59	24.49 ± 4.41	0.433	0.666
3-month follow-up
Sense of social isolation	15.54 ± 4.29	14.21 ± 3.18	2.153	0.033
Economic insecurity	11.25 ± 2.61	10.55 ± 2.44	1.699	0.091
Internalized shame	11.34 ± 3.37	9.84 ± 2.83	2.922	0.004
Perceived social exclusion	19.53 ± 4.71	17.34 ± 4.26	2.962	0.004

SOC: Standard ostomy care; NTSOC: Narrative therapy combined with standard ostomy care.

DISCUSSION

This retrospective cohort study compared postoperative outcomes in patients undergoing permanent colostomy who received NTSOC vs those who received SOC alone. The results showed that the addition of NT was associated with faster postoperative gastrointestinal function recovery, enhanced early mobility, shortened hospital stay, improved self-care ability, reduced ostomy-related complications, better psychosocial adaptation, and decreased postoperative stigma at 3 months. The findings suggest that integrating structured psychological interventions into routine ostomy management may yield benefits in physical and psychosocial rehabilitation.

The NTSOC group showed more rapid gastrointestinal and functional recovery than the SOC group. The NT protocol aims at problem externalization; it removes stigma and creates a favorable sense of self to reduce fear caused by serious abdominal surgery[18]. Postoperative ileus is thought to be exacerbated by sympathetic nervous system activation and increased cortisol levels, and anxiety, fear, or feelings of helplessness in patients with ostomy may further contribute to this process[19]. Many previous reports have shown that chronic stress can weaken the hypothalamus-pituitary-adrenal system, increase blood cortisol levels, and disrupt normal repair functions of wounds or digestive dysfunction and others[20]. By providing patients with a structured platform to process and reframe their experiences, NT may help reduce internalized shame and anxiety, which may, in turn, contribute to mitigating neuroendocrine stress responses[21]. Reducing anxiety and enhancing self-efficacy are core goals of NT. Patients who feel less stigmatized about their ostomy and more confident in self-management are more likely to be active and engage in physical rehabilitation[22]. Improved bowel motility may reduce abdominal pain and facilitate early activity. Cognitive behavioral intervention can help patients improve gastrointestinal motility, as reported by others. The results of the present study are consistent with this conclusion. If NT helps mitigate the fight-or-flight response, it may promote parasympathetic dominance and thereby support enteric nervous system activity and bowel function recovery[23]. The findings of the present study are consistent with those of Wang and Pan[24], who reported that resilience-oriented psychological support significantly improved pain control and reduced inflammatory markers in patients with colorectal cancer.

The reduced incidence of ostomy-related complications, particularly dermatitis, further highlights the therapeutic potential of NTSOC. Complications such as peristomal dermatitis often stem from a combination of mechanical factors like improper pouching and psychosocial factors[25]. By enhancing self-care abilities, as reflected in higher postoperative self-care scores, NT can enable patients to more diligently follow ostomy care instructions, recognize early signs of complications, and seek medical advice promptly[26]. This finding echoes previous research showing that higher health literacy and self-efficacy are associated with lower complication rates in chronic disease management[27]. While this observed association is consistent with the hypothesis of the present study, the improvement in self-care ability may only partly explain the reduced complication rate. Mediation analysis was not performed, and the causal pathway between self-care enhancement and complication reduction, though plausible, remains to be formally tested in future prospective studies with appropriate mediation frameworks.

The better psychosocial adaptation effects in the NTSOC group correspond to the main goals of NT[28]. By encouraging patients to view ostomy formation as an independent aspect of their lives rather than a defining feature of identity, and to regard it as a tool for living, their identity construction may become more life-centered[29]. The results of the present study are consistent with those of previous systematic reviews that found narrative-based interventions improved quality of life and reduced anxiety in patients with ostomy[30]. By the end of 3 months post-operation, the feelings of stigmatization were reduced through NT. Interestingly, economic insecurity showed less improvement, likely because it affects people’s finances more directly, so its root cause cannot be addressed through NT.

Clearly, improving the physical recovery index helps enhance mental health and create an upward-feedback system for this improvement. Early activities and reduced complications can increase patients’ sense of control and confidence. Consequently, this enhanced sense of control and self-efficacy may reduce stigma and promote social reintegration[31]. The bi-directional relationship of these two kinds of effects has also been found in the psychoneuroimmunological field[32]. For example, a research result showed that the application of psychological intervention decreased the inflammatory markers following surgery, accelerated patients’ recovery, and reduced stress[33].

This study has several limitations. First, it is a single-center retrospective study, which carries potential selection bias and limits the generalizability of the findings. The allocation to the NTSOC group vs the SOC group was not randomized. Although the baseline characteristics were well-matched, unmeasured confounding factors, such as patients’ psychological traits, coping styles, or social support, may have influenced the decision to receive NT and the observed outcomes. Second, the observation period was only 3 months; it cannot assess long-term effects such as ostomy-related complications after a year, stable self-management habits, and permanent improvement of quality of life. Third, performance or detection bias may be present when measuring subjective outcomes like psychological adaptation due to lack of blinding. Fourth, NT was administered by one team; thus, its effect could possibly be inconsistent among different therapist training backgrounds and patient cultures. Finally, this study did not obtain objective biological indicators to examine the proposed psychoneuroimmunological pathway directly.

Future studies should employ prospective, randomized controlled designs and include larger sample sizes and multicenter data to validate these findings. Blinded outcome assessments, longer follow-up periods, and the inclusion of biological markers could help strengthen causal inference and mechanism understanding. Additionally, exploring which components of the five-step NT are most effective could provide a basis for streamlining intervention protocols. Cost-effectiveness analyses are warranted to support the adoption of this intervention in routine clinical practice.

CONCLUSION

NTSOC is associated with faster postoperative activity recovery, lower incidence of stoma complications, greater self-care ability, better psychosocial adaptation, and reduced stigma levels in patients undergoing permanent colostomy.