Through analysis of the interview data using the “Structure-Process-Outcome” model, we identified seven overarching themes along with an additional 22 subthemes. The respective main themes and corresponding interview data can be found in Table 3 and Supplementary Table 1.
Table 2. General Information of Study Participants
Categories
|
Frequency (n)
|
Proportion (%)
|
General Information on Cervical Cancer Patients
|
Age
|
|
|
≤30
|
1
|
14.2
|
31~40
|
3
|
42.9
|
41~50
|
3
|
42.9
|
Employment Status
|
|
|
Employed
|
3
|
42.9
|
Unemployed
|
4
|
57.1
|
Marital Status
|
|
|
Single
|
0
|
0.0
|
Married
|
7
|
100.0
|
Education
|
|
|
College
|
3
|
42.9
|
Bachelor’s and above
|
4
|
57.1
|
General Information on Nursing Personnel
|
Age
|
|
|
26~35
|
5
|
41.7
|
36~45
|
5
|
41.7
|
46~55
|
2
|
16.7
|
Sex
|
|
|
Male
|
0
|
0.0
|
Female
|
12
|
100.0
|
Education
|
|
|
College
|
2
|
16.7
|
Bachelor’s
|
7
|
58.3
|
Master’s
|
3
|
25.0
|
Work Experience
|
|
|
6~10 years
|
5
|
41.7
|
11~15 years
|
5
|
41.7
|
>15 years
|
2
|
16.7
|
Table 3
Nursing Structure, Process, and Outcome Indicators
Categories
|
Themes
|
sub- themes
|
Structure
|
Optimisation and allocation of human resources
|
Optimising nurse-patient ratio
|
|
|
Establishing a multi-disciplinary Enhanced Recovery After Surgery (ERAS) team
|
|
|
Defining nurses‘ roles in the ERAS program
|
|
Equipment and environmental support
|
Enhancing facility and equipment
|
|
|
Creating private communication spaces
|
|
|
Creating an ERAS-supportive environment
|
|
Improvement of the ERAS institutional system
|
Developing and updating nursing procedures
|
|
|
Formulating performance evaluations
|
|
Enhancement of team expertise and professional ethics
|
ERAS nursing philosophy training
|
|
|
ERAS nursing practice and application training
|
|
|
Professional competence
|
|
|
Humanistic care competence
|
|
|
Team collaboration competence
|
Process
|
Improvement of health education efficiency
|
Creating educational tools
|
|
|
Conducting multi-disciplinary education
|
|
|
Strengthening sexual health education
|
|
Patients’ psychological state and care
|
Fear and anxiety
|
|
|
Loneliness
|
|
|
Suffering
|
|
|
Positivity
|
|
|
Psychological care
|
Outcome
|
Patient Outcome Management
|
Patient outcome reporting and audit
|
3.1 Optimisation and allocation of human resources
3.1.1 Optimising nurse-patient ratio
Some nurses (2/12) believe that a reasonable nurse-patient ratio is important in ensuring the quality of cervical cancer perioperative recovery care. They mentioned the need for an adequate number of nurses to ensure the timeliness and safety of nursing tasks.
As the number of patients increases and the demand for services grow, the implementation of the ERAS nursing program adds to the workload of nurses, doctors, anaesthetists, etc., requiring more nurses to handle the increased workload (N3).
If there are not enough nurses and the workload is too high, we might not have the time to strictly implement some ERAS nursing measures, which could impact the quality of care and lead to errors. Patients might also complain because of a lack of patience from nurses (N7).
3.1.2 Establishing a multi-disciplinary ERAS team
Nurses mentioned the importance of effective collaboration among surgical physicians, anesthesiologists, rehabilitation therapists, nutritionists, psychiatrists, and nursing staff for the successful implementation of ERAS nursing (3/12).
The collaboration and assessment by surgeons and anesthesiologists are essential throughout a patient’s perioperative period, and their cooperation impacts the implementation of the ERAS nursing program (N2).
In our department, we often consult experts from rehabilitation, nutrition, and psychiatry for multi-disciplinary assessments and treatments tailored to patients’ needs (N5).
3.1.3 Defining nurses‘ roles in the ERAS program
Clarifying the nurses’ roles within the multi-disciplinary ERAS team is crucial. Some nurses recommend appointing someone responsible for communication and coordination among team members (2/12). Others propose that specialised nurses can effectively prevent and improve postoperative complications in cervical cancer patients, shortening the recovery process (3/12).
Effective communication within the whole team is crucial. Someone should be responsible for unifying treatment and nursing information, like the head nurse who collects information and arranges implementation plans to avoid confusion (N12).
The presence of specialised nurses can aid postoperative recovery for cervical cancer patients. For instance, in our department, we have specialised nurses for lower limb lymphedema and pelvic floor rehabilitation, providing professional guidance for preventing and treating complications (N7).
3.2 Equipment and environmental support
3.2.1 Enhancing facility and equipment
Nurses emphasise the importance of providing sufficient facilities and equipment in obstetrics and gynaecology wards and operating rooms to meet the needs of ERAS treatment and care (2/12).
The recovery stage following ERAS surgery is critical. Our department has rehabilitation equipment like acupuncture tools and percutaneous acupuncture stimulation devices used every day (N4).
3.2.2 Creating private conversation spaces
One cervical cancer patient (1/7) recommends having private spaces for conversations in the ward.
This hospital does have separate spaces for conversations, and I find that important (P4).
3.2.3 Creating an ERAS-Supportive Environment
Nurses mention the need to create a supportive environment for the development of ERAS nursing (2/12).
If the hospital, department, or even the entire medical environment actively advocates for the ERAS concept, the development of ERAS nursing will progress rapidly (N7).
There are still relatively few well-established ERAS hospitals, leaving ample room for development. Hospitals and departments need the right culture, ideas, and funds to support the implementation of new protocols (N9).
3.3 Improvement of the ERAS institutional system
3.3.1 Developing and updating nursing procedures
Nurses recommend that evidence-based standardised ERAS nursing protocols and processes suitable for the Chinese medical environment are essential for high-quality ERAS care (3/12).
ERAS nursing guidelines and protocols, both domestic and international, are continuously evolving. Similarly, our nursing processes and protocols need timely adjustments and updates (N3).
ERAS nursing in gynaecologic oncology is less mature compared to other fields. We need more evidence-based research to guide the clinical development and optimisation of ERAS nursing processes specific to cervical cancer patients (N7).
3.3.2 Formulating performance evaluations
Nurses proposed the need to establish corresponding assessment schemes to motivate ERAS team members to engage actively in treatment and nursing practices (2/12).
Defining assessment criteria ensures clear roles and responsibilities (N10).
The development of a performance assessment scheme not only standardises the behaviour of nursing staff but also serves as a motivation for everyone (N11).
3.4 Enhancement of team expertise and professional ethics
3.4.1 ERAS philosophy training
Nurses recommend actively conducting ERAS multi-disciplinary team training to update treatment and nursing philosophies (4/12).
Apart from fostering communication and cooperation among ERAS team members, optimising certain nursing measures might raise concerns about increased workload and the challenge of changing habits. Hospitals and departments actively promoting and training ERAS philosophy help integrate this philosophy into our work, making it more readily accepted (N10).
3.4.2 ERAS nursing practice and application training
Nurses mention the need for standardised training in implementing ERAS nursing for cervical cancer patients (3/12).
Medical staff may be familiar with ERAS nursing philosophy, but actual practice might vary. This variability in practice necessitates operational-level training for ERAS team members to understand how to coordinate and improve effectively, avoiding chaos in our work (N4).
ERAS nursing covers various aspects, including early mobility, complication management, pain management, etc. Comprehensive training is required to tackle these challenges (N7).
3.4.3 Professional competence
Most postoperative cervical cancer patients believe that the professional competence of nursing staff is crucial for the quality of care. Nurses with strong theoretical knowledge and skilled nursing techniques can accurately identify symptoms and problems, effectively improving patients’ physical symptoms (4/7).
When something happens, our first thought is to find a nurse. Their high technical level reassures us that they can promptly resolve any issues, which certainly makes us feel more at ease (P6).
The competence of doctors and nurses determines my recovery and treatment outcomes. Their competence is what matters most to me (P7).
Nursing staff also acknowledge that a strong foundation in theoretical knowledge and practical skills is essential for providing high-quality care (3/12). In this study, nurses mention that mastering basic cervical cancer nursing theory and practices, along with ERAS nursing knowledge and skills, is important (2/12).
In nursing, professional skills directly affect patient safety and recovery. Ensuring accurate and error-free operations is fundamental (N5).
...ERAS nursing knowledge provides us with the best postoperative recovery practices. Combining the two maximises the effectiveness of patients’ treatment outcomes (N3).
3.4.4 Humanistic care competence
Postoperative cervical cancer patients indicate that the professional attitude of nursing staff affects their healthcare experience. They highly appreciate patient and proactive nurses (3/7). One patient mentioned it’s easier to establish a cooperative relationship with these nurses (1/7).
Nurses with good attitudes and patience are rare and possess excellent professional qualities. I feel respected and will respect them in return (P3).
The nurses are friendly; they inquire about my day and how I feel and offer advice. They are serious and patient. With such a great team, I will certainly cooperate well (P2).
Nurses also believe that developing and enhancing humanistic care abilities help establish a good nurse-patient relationship and increase patient satisfaction with care (2/12).
We often say we should actively care for patients and listen patiently. Practising these approaches reduces conflicts, and patients are more satisfied (N2).
Establishing an emotional connection with patients is crucial. Through deep communication, we can make them feel we genuinely care about their emotional needs, not just treatment issues (N3).
3.4.5 Team collaboration competence
Nurses express that high-quality ERAS nursing relies on teamwork and collaboration among team members. Effective communication and collaboration can improve team efficiency and ensure the successful implementation of ERAS nursing plans (4/12).
Close cooperation and information exchange among teams are key factors in the success of ERAS. This friendly cooperation atmosphere makes our work more comfortable and efficient (N12).
3.5 Improvement of health education efficiency
3.5.1 Creating educational tools
Nursing staff emphasise the importance of strengthening health education to improve the quality of cervical cancer ERAS nursing. The effectiveness of health education can be maximised by creating various forms of educational tools and combining bedside education while also improving work efficiency and reducing nursing staff burden (4/12).
...I think it is best to create lists, booklets, videos, etc., to help patients better understand and remember what they should and should not do (N4).
We have produced videos on postoperative ankle pump exercises displayed on bedside screens. We’ve also made brochures about lower limb lymphedema care and more. These tools help patients and families understand self-management priorities, reduce patient questions, and lighten our workload (N5).
Some patients also express difficulty in understanding bedside health education from nurses, and because of time gaps between education and implementation, some content may be forgotten. They need more detailed nursing tools for guidance (3/7).
Nurses sometimes share a lot at once, and we cannot remember everything. Sometimes, nurses are busy, and we do not have time to ask questions. Having (printed) instructions would be great (P4).
3.5.2 Conducting multi-disciplinary education
Nursing staff suggest that multi-disciplinary ERAS team members should assess patients’ conditions and provide health education on aspects like diet, exercise, and psychology (4/12).
Patients receive comprehensive care and support through the collaboration of a multi-disciplinary ERAS team. In addition to the surgery, the ERAS team must focus on patients’ mental, nutritional, and exercise aspects, providing personalised treatment and guidance (N3).
3.5.3 Strengthening sexual health education
Nursing staff believe there is a need to enhance sexual health education for postoperative cervical cancer patients (5/12). A nurse believes that providing educational materials can help patients and their spouses reduce the psychological burden during communication (1/12). A patient hopes medical staff will proactively provide guidance (1/7).
Patients often feel embarrassed or consider sexual health less important than their illness. They seek less information about postoperative sexual health from medical staff, and healthcare professionals may also be less proactive because of privacy concerns. This situation should raise our attention; we should focus on patients’ sexual health needs and provide guidance (N4).
We can provide pamphlets to patients, avoiding embarrassment and offering useful information (N9).
I hope nurses can actively address my sexual health concerns during treatment and recovery. Understanding what’s normal, how to handle potential issues, and what to pay attention to are all very important to me (P5).
3.6 Patients psychological state and care
3.6.1 Fear and Anxiety
Most postoperative cervical cancer patients fear cancer recurrence and serious postoperative complications, affecting their family and social roles. Hence, this triggers fear and anxiety (5/7).
The thought of not knowing when I will need another surgery terrifies me. It feels like I cannot do anything anymore (P3).
As a mother and wife, I worry that changes in my body might affect my family relationships. I don’t want my family to feel guilty or worried because of me (P4).
3.6.2 Loneliness
Some patients feel lonely because of inadequate understanding and support (4/7).
Even though my family is around, they cannot truly understand my inner feelings. Sometimes their words and actions make me feel even lonelier (P2).
I do not want to be seen as a patient or a burden to my family. I rarely talk to them about my issues, but that makes me feel like I’m dealing with everything alone (P5).
3.6.3 Suffering
Other patients express that the prolonged treatment is causing them significant distress (3/7).
The suffering from treatment isn’t just physical; it’s also psychological. I experience low mood, and anxiety, which adds to my distress (P3).
3.6.4 Positivity
Some patients embrace the illness’s changes and actively seek treatment and support (2/7).
I have always been resilient, and I believe I can get through this phase. The doctors and nurses here are doing their best to help me. Despite the difficulties of treatment, I am determined to keep going (P4).
3.6.5 Psychological care
Healthcare professionals state ERAS team members should communicate with patients, promptly identify negative psychological states, and provide psychological support and guidance (4/12).
Patients post-cervical cancer surgery might struggle with physical changes initially, with fears of recurrence and concerns about treatment costs. Various issues can arise, and we need to focus on their psychological well-being, seeking consultation from psychologists if necessary (N4).
3.7 Patient outcome management
3.7.1 Patient outcome reporting and audit
During the interview, nursing staff expressed the need to continuously gather patient information, understand patient prognosis and outcomes, and audit the effectiveness of cervical cancer ERAS nursing implementation to optimise the ERAS nursing protocol and ensure patient safety (3/12).
Gathering patient prognosis information and organising ERAS members to analyse and discuss the effectiveness of ERAS care implementation—identifying which nursing measures are effective and which ones aren’t, and devising improvements—can significantly enhance the quality of ERAS care (N3).