Preparedness for colorectal cancer surgery and recovery through a person-centred information and communication intervention – A quasi-experimental longitudinal design

Autoři: Joakim Öhlén aff001;  Richard Sawatzky aff001;  Monica Pettersson aff001;  Elisabeth Kenne Sarenmalm aff001;  Cecilia Larsdotter aff007;  Frida Smith aff008;  Catarina Wallengren aff001;  Febe Friberg aff010;  Karl Kodeda aff011;  Eva Carlsson aff001
Působiště autorů: Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden aff001;  Palliative Centre, Sahlgrenska University Hospital Västra Götaland Region, Gothenburg, Sweden aff002;  School of Nursing, Trinity Western University, Langley, BC, Canada aff003;  Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada aff004;  Vascular Department, Sahlgrenska University Hospital, Gothenburg, Sweden aff005;  Research & Development Unit, Skaraborg Hospital, Skövde, Sweden aff006;  Department of Nursing science, Sophiahemmet University, Stockholm, Sweden aff007;  Center for Health Care Improvement, Department of Technology Management and Economics, Division of Service Management and Logistics, Chalmers University of Technology, Gothenburg, Sweden aff008;  Regional Cancer Center West, Sahlgrenska University Hospital, Gothenburg, Sweden aff009;  Faculty of Health Sciences, University of Stavanger, Stavanger, Norway aff010;  Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden aff011;  Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden aff012
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article


To meet patients’ information and communication needs over time in order to improve their recovery is particularly challenging for patients undergoing cancer surgery. The aim of the study was to evaluate whether an intervention with a person-centred approach to information and communication for patients diagnosed with colorectal cancer undergoing surgery can improve the patients’ preparedness for surgery, discharge and recovery during six months following diagnosis and initial treatment. The intervention components involving a novel written interactive patient education material and person-centred communication was based on critical analysis of conventional information and communication for these patients. During 2014–2016, 488 consecutive patients undergoing elective surgery for colorectal cancer were enrolled in a quasi-experimental longitudinal study. In three hospitals, first a conventional care group (n = 250) was recruited, then the intervention was introduced, and finally the intervention group was recruited (n = 238). Patients’ trajectories of preparedness for surgery and recovery (Preparedness for Colorectal Cancer Surgery Questionnaire—PCSQ) health related quality of life (EORTC QLQ-C30) and distress (NCCS Distress Thermometer) were evaluated based on self-reported data at five time points, from pre-surgery to 6 months. Length of hospital stay and patients’ behavior in seeking health care pre- and post-surgery were extracted from patient records. Longitudinal structural equation models were used to test the hypothesized effects over time. Statistically significant positive effects were detected for two of the four PCSQ domains (patients searching for and making use of information, and making sense of the recovery) and for the role functioning domain of the EORTC QLQ-C30. Patients in the intervention group were also more likely to contact their assigned cancer “contact nurse” (a.k.a. nurse navigator) instead of contacting a nurse on duty at the ward or visiting the emergency department. In conclusion, the overall hypothesis was not confirmed. Further research is recommended on written and oral support tools to facilitate person-centred communication.

Klíčová slova:

Cancer detection and diagnosis – Colorectal cancer – Communications – Critical care and emergency medicine – Nurses – Patients – Surgical and invasive medical procedures – Surgical oncology


1. Edvardsson D, Winblad B, Sandman PO. Person-centred care of people with severe Alzheimer's disease: current status and ways forward. Lancet Neurol. 2008;7(4):362–7. Epub 2008/03/15. doi: 10.1016/S1474-4422(08)70063-2 18339351.

2. Ekman I, Hedman H, Swedberg K, Wallengren C. Commentary: Swedish initiative on person centred care. BMJ. 2015;350:h160. doi: 10.1136/bmj.h160 25670185.

3. Favoriti P, Carbone G, Greco M, Pirozzi F, Pirozzi RE, Corcione F. Worldwide burden of colorectal cancer: a review. Updates Surg. 2016;68(1):7–11. Epub 2016/04/14. doi: 10.1007/s13304-016-0359-y 27067591.

4. Ricœur P. Oneself as another. Chigago: University of Chicago Press; 1994.

5. Leplege A, Gzil F, Cammelli M, Lefeve C, Pachoud B, Ville I. Person-centredness: conceptual and historical perspectives. Disabil Rehabil. 2007;29(20–21):1555–65. Epub 2007/10/09. doi: 10.1080/09638280701618661 17922326.

6. Kristensson Uggla B. Ricoeur, hermeneutics, and globalization. London: Continuum; 2009.

7. Ekman I, Swedberg K, Taft C, Lindseth A, Norberg A, Brink E, et al. Person-centered care—ready for prime time. Eur J Cardiovasc Nurs. 2011;10(4):248–51. Epub 2011/07/19. doi: 10.1016/j.ejcnurse.2011.06.008 21764386.

8. Friberg F, Andersson EP, Bengtsson J. Pedagogical encounters between nurses and patients in a medical ward—a field study. Int J Nurs Stud. 2007;44(4):534–44. Epub 2006/02/21. doi: 10.1016/j.ijnurstu.2005.12.002 16488418.

9. Hebert RS, Prigerson HG, Schulz R, Arnold RM. Preparing caregivers for the death of a loved one: a theoretical framework and suggestions for future research. J Pall Med. 2006;9(5):1164–71. doi: 10.1089/jpm.2006.9.1164 17040154.

10. Wenger E. Communities of practice: learning, meaning, and identity. Cambridge: Cambridge University Press; 1998.

11. Parnell TA, Editor. Health literacy in nursing: providing person-centered care. New York, NY: Springer Publishing Company; 2015.

12. Jarvis P. Towards a comprehensive theory of human learning. London: Routledge; 2006.

13. Öhlén J, Reimer-Kirkham S, Astle B, Håkanson C, Lee J, Eriksson M, et al. Person-centred care dialectics–Inquired in the context of palliative care. Nurs Phil. 2017;18(4):e12177. Epub 2017/05/13. doi: 10.1111/nup.12177 28497868.

14. Street AF, Horey D. The State of the Science: Informing choices across the cancer journey with public health mechanisms and decision processes. Acta Oncol. 2010;49(2):144–52. Epub 2009/12/17. doi: 10.3109/02841860903418532 20001494.

15. Brundage MD, Feldman-Stewart D, Tishelman C. How do interventions designed to improve provider-patient communication work? Illustrative applications of a framework for communication. Acta Oncol. 2010;49(2):136–43. Epub 2010/01/27. doi: 10.3109/02841860903483684 20100151.

16. Olsson LE, Jakobsson Ung E, Swedberg K, Ekman I. Efficacy of person-centred care as an intervention in controlled trials–a systematic review. J Clin Nurs. 2013;22(3–4):456–65. Epub 2012/12/13. doi: 10.1111/jocn.12039 23231540.

17. Britten N, Moore L, Lydahl D, Naldemirci O, Elam M, Wolf A. Elaboration of the Gothenburg model of person-centred care. Health Expect. 2017;20(3):407–18. Epub 2016/05/20. doi: 10.1111/hex.12468 27193725; PubMed Central PMCID: PMC5433540.

18. Naldemirci O, Lydahl D, Britten N, Elam M, Moore L, Wolf A. Tenacious assumptions of person-centred care? Exploring tensions and variations in practice. Health. 2016;22(1):54–71. Epub 2016/11/24. doi: 10.1177/1363459316677627 27879342.

19. Olsson LE, Hansson E, Ekman I. Evaluation of person-centred care after hip replacement-a controlled before and after study on the effects of fear of movement and self-efficacy compared to standard care. BMC Nurs. 2016;15(1):53. Epub 2016/09/13. doi: 10.1186/s12912-016-0173-3 27616936; PubMed Central PMCID: PMC5017008.

20. Ekman I, Wolf A, Olsson LE, Taft C, Dudas K, Schaufelberger M, et al. Effects of person-centred care in patients with chronic heart failure: the PCC-HF study. Eur Heart J. 2012;33(9):1112–9. Epub 2011/09/20. doi: 10.1093/eurheartj/ehr306 21926072; PubMed Central PMCID: PMC3751966.

21. Ulin K, Olsson LE, Wolf A, Ekman I. Person-centred care–An approach that improves the discharge process. Eur J Cardiovasc Nurs. 2016;15(3):e19–26. Epub 2015/02/05. doi: 10.1177/1474515115569945 25648848.

22. Fors A, Taft C, Ulin K, Ekman I. Person-centred care improves self-efficacy to control symptoms after acute coronary syndrome: a randomized controlled trial. Eur J Cardiovasc Nurs. 2016;15(2):186–94. Epub 2015/12/25. doi: 10.1177/1474515115623437 26701344.

23. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606–17. Epub 1997/05/01. doi: 10.1093/bja/78.5.606 9175983.

24. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–41. doi: 10.1016/s0002-9610(02)00866-8 12095591.

25. Eskicioglu C, Forbes SS, Aarts MA, Okrainec A, McLeod RS. Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg. 2009;13(12):2321–9. doi: 10.1007/s11605-009-0927-2 19459015.

26. Lv L, Shao YF, Zhou YB. The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Colorectal Dis. 2012;27(12):1549–54. Epub 2012/09/25. doi: 10.1007/s00384-012-1577-5 23001161.

27. Norlyk A, Harder I. Recovering at home: participating in a fast-track colon cancer surgery programme. Nurs Inq. 2011;18(2):165–73. Epub 2011/05/14. doi: 10.1111/j.1440-1800.2011.00519.x 21564397.

28. Norlyk A, Harder I. After colonic surgery: The lived experience of participating in a fast-track programme. Int J Qual Stud Health Well-being. 2009;4:170–80. doi: 10.1080/17482620903027726 20523886.

29. Rodin G, Mackay JA, Zimmermann C, Mayer C, Howell D, Katz M, et al. Clinician-patient communication: a systematic review. Support Care Cancer. 2009;17(6):627–44. Epub 2009/03/05. doi: 10.1007/s00520-009-0601-y 19259706.

30. Foster C, Haviland J, Winter J, Grimmett C, Chivers Seymour K, Batehup L, et al. Pre-surgery depression and confidence to manage problems predict recovery trajectories of health and wellbeing in the first two years following colorectal cancer: Results from the CREW Cohort Study. PLoS One. 2016;11(5):e0155434. Epub 2016/05/14. doi: 10.1371/journal.pone.0155434 27171174; PubMed Central PMCID: PMC4865190.

31. Carlsson E, Berndtsson I, Hallen AM, Lindholm E, Persson E. Concerns and quality of life before surgery and during the recovery period in patients with rectal cancer and an ostomy. J Wound Ostomy Continence Nurs. 2010;37(6):654–61. Epub 2010/11/06. doi: 10.1097/WON.0b013e3181f90f0c 21052026.

32. Wilson TR, Birks YF, Alexander DJ. A qualitative study of patient perspectives of health-related quality of life in colorectal cancer: comparison with disease-specific evaluation tools. Colorectal Dis. 2010;12(8):762–9. Epub 2009/04/04. doi: 10.1111/j.1463-1318.2009.01857.x 19341398.

33. Nordin K, Glimelius B. Reactions to gastrointestinal cancer—variation in mental adjustment and emotional well-being over time in patients with different prognoses. Psychooncology. 1998;7(5):413–23. Epub 1998/11/11. doi: 10.1002/(SICI)1099-1611(1998090)7:5<413::AID-PON318>3.0.CO;2-Q 9809332.

34. Winterling J, Wasteson E, Glimelius B, Sjödén PO, Nordin K. Substantial changes in life: perceptions in patients with newly diagnosed advanced cancer and their spouses. Cancer Nurs. 2004;27(5):381–8. Epub 2004/11/05. doi: 10.1097/00002820-200409000-00008 15525866.

35. Allvin R, Berg K, Idvall E, Nilsson U. Postoperative recovery: a concept analysis. J Adv Nurs. 2007;57(5):552–8. Epub 2007/02/08. doi: 10.1111/j.1365-2648.2006.04156.x 17284272.

36. Lithner M, Klefsgard R, Johansson J, Andersson E. The significance of information after discharge for colorectal cancer surgery–a qualitative study. BMC Nurs. 2015;14(1):36. Epub 2015/06/06. doi: 10.1186/s12912-015-0086-6 26045695; PubMed Central PMCID: PMC4456055.

37. Carlson LE, Feldman-Stewart D, Tishelman C, Brundage MD. Patient-professional communication research in cancer: an integrative review of research methods in the context of a conceptual framework. Psychooncology. 2005;14(10):812–28; discussion 29–30. Epub 2005/10/04. doi: 10.1002/pon.951 16200512.

38. Redman BK. Advanced Practice Nursing Ethics in Chronic Disease Self-management New York, NY: Springer Publishing Company; 2013.

39. Öhlén J, Carlsson G, Jepsen A, Lindberg I, Friberg F. Enabling sense-making for patients receiving outpatient palliative treatment: A participatory action research driven model for person-centered communication. Palliat Support Care. 2016;14(3):212–24. Epub 2015/08/04. doi: 10.1017/S1478951515000814 26235481.

40. Allvin R, Ehnfors M, Rawal N, Idvall E. Experiences of the postoperative recovery process: an interview study. Open Nurs J. 2008;2:1–7. doi: 10.2174/1874434600802010001 19319214.

41. Carlsson E, Pettersson M, Hydén LC, Öhlén J, Friberg F. Structure and content in consultations with patients undergoing surgery for colorectal cancer. Eur J Oncol Nurs. 2013;17(6):820–6. Epub 2013/09/10. doi: 10.1016/j.ejon.2013.07.002 24012188.

42. Friberg F, Lidén E, Håkanson C, Öhlén J. Communicating bodily changes: physicians' ways of enabling patient understanding in gastrointestinal cancer consultations. Palliat Support Care. 2015;13(3):661–71. Epub 2014/05/03. doi: 10.1017/S1478951514000352 24784141.

43. Pettersson ME, Öhlén J, Friberg F, Hydén LC, Carlsson E. Topics and structure in preoperative nursing consultations with patients undergoing colorectal cancer surgery. Scand J Caring Sci. 2017;31(4):674–86. Epub 2016/11/20. doi: 10.1111/scs.12378 27859450.

44. Smith F, Carlsson E, Kokkinakis D, Forsberg M, Kodeda K, Sawatzky R, et al. Readability, suitability and comprehensibility in patient education materials for Swedish patients with colorectal cancer undergoing elective surgery: a mixed method design. Patient Educ Couns. 2014;94(2):202–9. Epub 2013/12/03. doi: 10.1016/j.pec.2013.10.009 24290242.

45. Öresland S, Friberg F, Määttä S, Öhlén J. Disclosing discourses: biomedical and hospitality discourses in patient education materials. Nurs Inq. 2015;22(3):240–8. Epub 2015/04/08. doi: 10.1111/nin.12097 25847051.

46. Carlsson E, Pettersson ME. Communicative and pedagogical strategies in nurses' and surgeons' discharge consultations with patients undergoing surgery for colorectal cancer. J Adv Nurs. 2018;00:1–11. Epub 2018/07/19. doi: 10.1111/jan.13798 30019343.

47. Des Jarlais DC, Lyles C, Crepaz N. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health. 2004;94(3):361–6. Epub 2004/03/05. doi: 10.2105/ajph.94.3.361 14998794; PubMed Central PMCID: PMC1448256.

48. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321(7262):694–6. Epub 2000/09/15. doi: 10.1136/bmj.321.7262.694 10987780; PubMed Central PMCID: PMC1118564.

49. Brainard J, Hunter PR. Do complexity-informed health interventions work? A scoping review. Implement Sci. 2016;11(1):127. Epub 2016/09/21. doi: 10.1186/s13012-016-0492-5 27647152; PubMed Central PMCID: PMC5029105.

50. Sharp L, Westman B, Olofsson A, Leppanen A, Henriksson R. Access to supportive care during and after cancer treatment and the impact of socioeconomic factors. Acta Oncol. 2018;57(10):1303–10. Epub 2018/06/28. doi: 10.1080/0284186X.2018.1484157 29947281.

51. Nationella riktlinjer för bröst-, prostata-, tjocktarms- och ändtarmscancervård 2014: stöd för styrning och ledning (National guidelines for breast, prostate, colo and rectal cancer care 2014: support for direction and leadership). Stockholm, Sweden: Socialstyrelsen, 2014 978-91-7555-162-3.

52. Friberg F, Wallengren C, Håkanson C, Carlsson E, Smith F, Pettersson M, et al. Exploration of dynamics in a complex person-centred intervention process based on health professionals' perspectives. BMC Health Serv Res. 2018;18(1):441. Epub 2018/06/14. doi: 10.1186/s12913-018-3218-3 29895285; PubMed Central PMCID: PMC5998552.

53. Sawatzky R, Russell L, Friberg F, Carlsson EK, Pettersson M, Öhlén J. Longitudinal person-centered measurement: A psychometric evaluation of the Preparedness for Colorectal Cancer Surgery Questionnaire (PCSQ). Patient Educ Couns. 2016;100(5):827–35. Epub 2016/12/14. doi: 10.1016/j.pec.2016.11.010 27955903.

54. Carlsson E, Pettersson M, Öhlén J, Sawatzky R, Smith F, Friberg F. Development and validation of the preparedness for Colorectal Cancer Surgery Questionnaire: PCSQ-pre 24. Eur J Oncol Nurs. 2016;25:24–32. Epub 2016/11/21. doi: 10.1016/j.ejon.2016.09.002 27865249.

55. Derogar M, van der Schaaf M, Lagergren P. Reference values for the EORTC QLQ-C30 quality of life questionnaire in a random sample of the Swedish population. Acta Oncol. 2012;51(1):10–6. Epub 2011/10/04. doi: 10.3109/0284186X.2011.614636 21961499.

56. Bjordal K, de Graeff A, Fayers PM, Hammerlid E, van Pottelsberghe C, Curran D, et al. A 12 country field study of the EORTC QLQ-C30 (version 3.0) and the head and neck cancer specific module (EORTC QLQ-H&N35) in head and neck patients. EORTC Quality of Life Group. Eur J Cancer. 2000;36(14):1796–807. Epub 2000/09/07. doi: 10.1016/s0959-8049(00)00186-6 10974628.

57. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85(5):365–76. Epub 1993/03/03. doi: 10.1093/jnci/85.5.365 8433390.

58. Donovan KA, Grassi L, McGinty HL, Jacobsen PB. Validation of the distress thermometer worldwide: state of the science. Psychooncology. 2014;23(3):241–50. Epub 2014/08/28. doi: 10.1002/pon.3430 25160838.

59. Sarenmalm EK, Nasic S, Håkanson C, Öhlén J, Carlsson E, Pettersson ME, et al. Swedish Version of the Distress Thermometer: Validity Evidence in Patients With Colorectal Cancer. J Natl Compr Canc Netw. 2018;16(8):959–66. Epub 2018/08/14. doi: 10.6004/jnccn.2018.7027 30099372.

60. International Statistical Classification of Diseases and Related Health Problems 10th Revision. Accessed September 7, 2018.

61. ASA Physical Status Classification System. American Society of Anestesiologists. Accessed September 7, 2018.

62. NOMESCO Classification of Surgical Procedures. Nordic Medico-Statistical Committee. Accessed September 7, 2018.

63. TNM Classification of Malignant Tumours. Union for International Cancer Control. Accessed September 7, 2018.

64. Newsom JT. Longitudinal structural equation modeling: A comprehensive introduction. New York: Routledge, Taylor and Francis Group; 2015.

65. Heck RH, Thomas SL. An introduction to multilevel modeling techniques: MLM and SEM approaches using Mplus. Third edition. ed. New York, NY: Routledge, Taylor & Francis Group; 2015.

66. Muthén B, Muthén L. MPlus (version 8). Los Angeles, CA: Statmodel; 2017.

67. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6:1–55. 1998-03102-001.

68. Rubin DB. Multiple imputation for nonresponse in surveys. New York: Wiley; 1987.

69. Yadegari I, Bohm E, Ayilara OF, Zhang L, Sawatzky R, Sajobi TT, et al. Differential item functioning of the SF-12 in a population-based regional joint replacement registry. Health Qual Life Outcomes. 2019;17(1):114. Epub 2019/07/02. doi: 10.1186/s12955-019-1166-1 31266505.

70. Rezvan PH, Lee KJ, Simpson JA. The rise of multiple imputation: a review of the reporting and implementation of the method in medical research. BMC Med Res Methodol. 2015;15(1):30. Epub 2015/04/07. doi: 10.1186/s12874-015-0022-1 PMCID: PMC4396150.

71. Bell ML, Fairclough DL. Practical and statistical issues in missing data for longitudinal patient-reported outcomes. Stat Methods Med Res. 2014;23(5):440–59. doi: 10.1177/0962280213476378 23427225

72. Aaronson N, Alonso J, Burnam A, Lohr KN, Patrick DL, Perrin E, et al. Assessing health status and quality-of-life instruments: attributes and review criteria. Qual Life Res. 2002;11(3):193–205. Epub 2002/06/21. doi: 10.1023/a:1015291021312 12074258.

73. Pettersson ME, Öhlén J, Friberg F, Hydén LC, Wallengren C, Sarenmalm EK, et al. Prepared for surgery–Communication in nurses' preoperative consultations with patients undergoing surgery for colorectal cancer after a person-centred intervention. J Clin Nurs. 2018;27(13–14):2904–16. Epub 2018/02/16. doi: 10.1111/jocn.14312 29446494.

74. Kalia M. Biomarkers for personalized oncology: recent advances and future challenges. Metabolism. 2015;64(3 Suppl 1):S16–21. Epub 2014/12/04. doi: 10.1016/j.metabol.2014.10.027 25468140.

75. Mansour JC, Schwarz RE. Molecular mechanisms for individualized cancer care. J Am Coll Surg. 2008;207(2):250–8. Epub 2008/07/29. doi: 10.1016/j.jamcollsurg.2008.03.003 18656055.

76. van't Veer LJ, Bernards R. Enabling personalized cancer medicine through analysis of gene-expression patterns. Nature. 2008;452(7187):564–70. Epub 2008/04/04. doi: 10.1038/nature06915 18385730

Článek vyšel v časopise


2019 Číslo 12
Nejčtenější tento týden