Effect of multidimensional nursing on low anterior resection syndrome after sphincter preservation surgery for low rectal cancer.

INTRODUCTION
As reported in the Global Cancer Statistics, colorectal cancer is the third most commonly diagnosed malignancy and the second leading cause of cancer-related death globally. In China, both the incidence and mortality of colorectal cancer continue to rise each year, with rectal cancer comprising nearly 60% of all newly diagnosed cases[1,2]. With the evolution of surgical techniques, sphincter-preserving surgery has gradually replaced traditional abdominoperineal resection, thereby significantly improving patients’ quality of life and psychological well-being. However, > 80% of patients experience varying degrees of low anterior resection syndrome (LARS) after surgery, including symptoms such as frequent defecation, urgency, and fecal incontinence, which significantly affect patients’ physical and psychological health[3].
LARS pathogenesis is complex and involves factors including low anastomosis, anal sphincter damage, altered rectal compliance, and nerve conduction dysfunction[4,5]. Currently, there are some studies no standard treatment protocol exists. While interventions including pelvic floor muscle training, biofeedback, and dietary adjustments are commonly used in clinical practice, their effects are inconsistent. Therefore, systematically exploring targeted nursing strategies is of great clinical significance[6].
Multidimensional nursing, grounded in the Nursing Outcomes Classification (NOC) framework, offers an integrative approach that targets physical symptoms along with psychological and behavioral dimensions[7]. Compared with conventional care, which often focuses on routine physical management and symptom monitoring, multidimensional nursing includes individualized patient education, behavioral therapy, psychological support[8], and structured follow-up, thereby aligning more closely with the multifactorial nature of LARS[9]. This theoretical comprehensiveness suggests that multidimensional nursing may provide more sustained and holistic benefits in improving bowel function and enhancing quality of life[10,11].
However, few studies have applied multidimensional nursing specifically to LARS. Therefore, this study evaluated the effects of NOC-based multidimensional nursing on self-efficacy, symptom relief, and quality of life in patients with LARS after sphincter-preserving surgery, providing new insights into targeted postoperative care.

MATERIALS AND METHODS

General information
This study included a total of 120 patients with LARS after sphincter-preserving surgery for low rectal cancer who were admitted to our hospital between January 2022 and December 2024. The inclusion criteria were: (1) Diagnosis of low rectal cancer by pathological examination[12]; (2) Temporary enterostomy closure; (3) Ability to read and understand language and characters without comprehension disorders; and (4) Ability to provide informed consent. The exclusion criteria were: (1) Metastatic rectal cancer; (2) Complications with other intestinal diseases such as ulcerative colitis; (3) Complications with severe perianal diseases such as anal fissure and fistula, before surgery; (4) Cognitive impairment or complications with severe mental system diseases; and (5) Inability to eat orally. This study was approved by the Hospital’s Medical Ethics Committee.
The sample size was calculated as follows: According to the sample size (N) formula: N = Z² × [P × (1 - P)]/E², where the Z statistic was 2.09, E (error value) is 10%, and the P (probability value) was 0.5. The minimum N value obtained in this study was 109. Considering a 10% dropout rate, 120 patients were finally included. The random number table method was used to group the included participants into the control and observation groups (60 patients each). Baseline data did not differ significantly between the two groups (P > 0.05), indicating comparability (Table 1).

Methods
The control group received routine nursing interventions; that is, the nursing staff orally provided relevant and detailed information on LARS to the patients. This information included the clinical characteristics, potential hazards, and precautions to improve the patients’ cognitive level of disease knowledge. The patients’ psychological states were comprehensively evaluated. Targeted psychological counseling was provided to patients with negative emotions such as anxiety and depression. Postoperatively, they received personalized pelvic floor muscle training, with enhanced interventions focused on disease condition monitoring, medication management, dietary guidance, and daily living support.
The observation group received a NOC-based multidimensional nursing intervention as follows:

Establishment of the nursing team: The nursing team comprised one head nurse, one attending physician, one rehabilitation therapist, one dietitian, and six responsible nurses. The head nurse was the team leader responsible for formulating the nursing intervention plan, supervising its implementation, and coordinating all team members to thoroughly study relevant disease-specific nursing knowledge. The content included LARS causes, hazards, preventive measures, diagnostic results of the NOC system, and implementation steps for multidimensional nursing. Each intervention class lasted-30-40 minutes, with a total of six classes. All members successfully completed the assessment.

Nursing diagnosis: Members of the nursing team comprehensively evaluated each patient, including basic personal information such as educational level, dietary patterns (dietary preferences and sources), sleep, and psychological state, as well as disease data such as diagnosis results, chief complaints, vital signs, symptoms, and treatment methods. The nursing outcomes of patients with LARS after sphincter-preserving surgery for low rectal cancer were evaluated using the “Nursing Outcomes Classification and Standardized Nursing Language” diagnostic system[13]. According to the diagnostic results and nursing outcome classification, the corresponding nursing interventions mainly comprised four aspects: Lack of disease knowledge, negative emotions, symptom management, and nutritional disorders.

Implementation of the multidimensional nursing intervention: For patients reporting a nursing outcome of a lack of disease knowledge, the nursing goal was to enhance their understanding of LARS. Specifically, individualized “one-on-one” health education sessions were conducted to explain the nature of LARS, its treatment and nursing care, its impact on daily life and work, and effective coping strategies. Multimedia methods such as videos and PowerPoint presentations were used to increase engagement and reinforce learning. Following the sessions, interactive question-and-answer discussions were held to thoroughly address patient concerns. Weekly support group meetings were organized to encourage patients to promote active participation, experience-sharing, and peer learning. “Star” patients with good disease recovery or self-management ability were invited to speak and inspire confidence in treatment and recovery. Simultaneously, a WeChat group chat was established for ongoing communication. Nursing staff used this platform to provide daily medication reminders, share evidence-based LARS management strategies, and deliver educational content tailored to patients' reading and comprehension levels using images and video demonstrations.
For patients with the nursing outcome of negative emotions, the nursing goal was to reduce these negative emotions. Specifically by: (1) Empathetic: Communication: Nurses can maintain respectful and empathetic interactions, using active listening techniques such as nodding, smiling, and summarizing patient concerns to acknowledge and validate patients’ feelings; (2) Identifying emotional triggers: Through open-ended, interview-style conversations (e.g., What is overwhelming you? Do you feel it’s related to intestinal symptoms such as fecal incontinence, increased defecation frequency or abnormal flatulence? Is it affecting your social life or creating anxiety about disease prognosis?) (worrying that intestinal symptoms will lead to cancer recurrence), nurses can help patients explore the root causes of their emotional distress; and (3) Positive reinforcement and emotional support: The nursing staff provide reassurances to the patients (e.g., “It’s normal to feel anxious-many experience this post-surgery”, “These symptoms are temporary and manageable”, or “With treatment and good habits, your bowel function can improve”) so that patients understand that their state was caused by the disease and had nothing to do with themselves. Sharing successful recovery stories from similar patients helped instill hope and reduce fear. Additionally, family members are encouraged to actively participate in the care process, offering emotional support and companionship. This collaborative involvement aims to reduce patient dependence, foster resilience, and ease feelings of guilt or burden.
For patients with the nursing outcome of poor symptom management, the nursing goals were to improve their self-management and alleviate intestinal symptoms. Specifically: Symptom assessment: Anorectal manometry was conducted to evaluate anorectal physiological and pathological function. Symptom severity was assessed using the LARS scoring scale[14], with scores of 21-29 indicating mild LARS, and ≥ 30 indicating severe LARS (maximum score: 42). Symptom management patients with mild LARS were guided to perform pelvic floor muscle repair training [pelvic floor rehabilitation (PFR)], including Kegel and anal sphincter exercises. The exercise training time was reasonably controlled according to the patients' tolerance, generally 20-30 minutes per session, twice daily. After PFR training, stoma irrigation was performed once daily or 2-3 times weekly, beginning at an infusion rate of 200-300 mL/minute and gradually increasing to 1 L as needed. For patients with severe LARS, based on PFR and stoma irrigation interventions, biofeedback training was performed. Based on electromyographic findings, the nursing team selected appropriate biofeedback protocols using the InSIGHT PHNS-A system. Patients were guided through repeated anal contraction, relaxation, and defecation exercises for 20 minutes per session, three times weekly.
For patients with the nursing outcome of malnutrition, the nursing goal was to enhance nutritional support and improve nutritional status. Specifically: (1) Nutritional screening and assessment: The nursing staff collaborated with dietitians using the Nutrition Risk Screening 2002 (NRS2002) tool[15] which assesses disease severity, nutritional impairment, and age. A total score ≥ 3 indicated nutritional risk; and (2) Individualized nutrition planning: For patients with a total NRS2002 scale score < 3 points, based on the recommended intake in the "Dietary Guidelines for Chinese Residents"[16], personalized meal plans were developed to ensure a balanced distribution of nutrients such as protein (10%-35% of total energy), fat (20%-35%), and carbohydrates (45%-65%) was formulated. Patients were encouraged to follow regular, portion-controlled meal schedules. Patients with a total NRS2002 scale score ≥ 3 points received enhanced nutritional support, including oral or enteral immunonutrition containing glutamine, ω-3 polyunsaturated fatty acids, etc., was given. Parenteral nutrition was administered to intolerant patients.

Evaluation of nursing outcomes: The nursing team held group discussions once every 3 days to comprehensively evaluate improvements in nursing outcomes, including patients' lack of disease knowledge, negative emotions, and nutritional disorders. These evaluations focused on identifying unresolved issues or areas of insufficient care, enabling timely adjustments and optimization of the subsequent nursing management plan. Both the control and observation groups continued to receive their respective interventions until hospital discharge.

Observation indicators

Self-efficacy: To assess self-efficacy before and after the intervention, the Self-Management Efficacy Scale for Cancer Patients-Strategies Used by People to Promote Health (SUPPH), mentioned by Ibelo et al[17], was employed. This scale comprises three subscales: Decision-making (3 items), positive mindset (15 items), and stress management (10 items). Responses are rated on a 5-point Likert scale (1 to 5), where higher scores denote stronger self-efficacy. The internal consistency of the instrument is high, with Cronbach’s α ranging from 0.849 to 0.970.

Symptom relief: The LARS scoring scale developed by Emmertsen and Laurberg[14] was applied before and after the intervention. This scale considers five items: Flatus incontinence (0, 4, and 7 points), liquid stool incontinence (0, 1, and 3 points), defecation frequency (0, 2, 4, and 5 points), tenesmus (0, 9, and 11 points), and defecation urgency (0, 11, and 16 points). The score ranges from 0-42 points, with higher scores indicating more severe intestinal symptoms. The Cronbach's α coefficient of the scale is 0.96.

Quality of life: Quality of life was assessed both prior to and following the intervention using the European Organization for Research and Treatment of Cancer Quality of Life Core Scale (EORTC QLQ-C30) developed by the European Organization for Research and Treatment of Cancer[18]. This instrument measures five aspects of functioning-physical, emotional, role-related, social, and cognitive-as well as three symptom-related areas: Nausea and vomiting, fatigue, and pain. All dimension scores are linearly converted using the range transformation method, yielding values from 0 to 100, where a higher score reflects a better quality of life.

Nursing satisfaction: After completion of the nursing intervention, the patients completed a self-administered nursing satisfaction survey. Scores above 85, between 70-85, and below 70 were defined as very satisfied, satisfied, and dissatisfied, respectively. The total satisfaction percentage included both the very satisfied and satisfied groups.

Statistical analysis
Data analysis was conducted using IBM SPSS Statistics 26.0. For variables following a normal distribution, results are presented as mean ± SD. Group comparisons were carried out using independent samples t-tests, whereas within-group differences were evaluated using paired t-tests. Categorical variables were reported as counts and percentages (%), and differences between groups were assessed using the χ2 test. A P value less than 0.05 indicated statistical significance.

RESULTS

Comparison of self-efficacy between the two groups
Following the intervention, both groups exhibited improved scores in self-decision, positive attitude, and self-relief dimensions of the SUPPH scale compared to their pre-intervention levels. Moreover, the observation group achieved significantly higher scores in these domains than the control group during the same post-intervention period (P < 0.05; Table 2).

Comparison of symptom relief between the two groups
After the intervention, the LARS scores of the two groups decreased compared with those before the intervention. Compared with the control group, the LARS score of the observation group was significantly lower in the same period after the intervention (P < 0.05; Table 3).

Comparison of quality of life scores between the two groups
Following the intervention, both groups exhibited an upward trend in EORTC QLQ-C30 scores relative to their pre-intervention levels. Notably, the observation group demonstrated significantly greater improvements than the control group during the same post-intervention period (P < 0.05; Table 4).

Comparison of nursing satisfaction between the two groups
Table 5 presents the results of the satisfaction survey for the two groups (n = 60 participants each). The control group had a total satisfaction rate of 83.33%, with 53.33% being very satisfied and 30.00% satisfied. The observation group showed a higher total satisfaction rate of 95.00%, with 70.00% feeling very satisfied and 25.00% satisfied. The statistical test value was 4.227 with a P value of 0.040, indicating a significant difference in satisfaction between the two groups.

DISCUSSION

Multidimensional nursing based on NOC can improve the self-efficacy of patients with LARS after sphincter-preserving surgery for low rectal cancer
Self-efficacy refers to an individual's perception and belief in their ability to perform certain behaviors[19]. Patients with LARS following sphincter-preserving surgery for low rectal cancer often experience varying degrees of bowel dysfunction, including urgent defecation, frequent defecation, constipation, and fecal incontinence, which diminish their perceived control over bodily functions. Such experiences, particularly fecal leakage, can lead to feelings of vulnerability and inferiority, severely damaging their confidence and ultimately affecting their self-efficacy[20]. In the present study, the scores for self-decision-making, positive attitude, and self-stress reduction on the SUPPH scale showed upward trends in both groups of patients after the intervention compared with those at baseline. Compared with the control group, the scores for each item on the SUPPH scale were higher in the observation group were higher at the same time points after the intervention. Thus, NOC-based multidimensional nursing improved the self-efficacy of patients with LARS after sphincter-preserving surgery for low rectal cancer.
Conventional nursing interventions are often limited by a lack of connection and continuity. It was difficult to accurately assess the difference between the nursing effect and the expected goal, and these approaches often do not meet patients' physical and psychological needs, leading to patient dissatisfaction. The NOC is a standardized nursing language that quantifies various measurement indicators, thus more objectively and accurately reflecting patient status and providing a theoretical basis for the implementation of nursing measures[21-23]. Multidimensional nursing based on the NOC can address all aspects of managing patient health. Diversified health education offers accurate self-management guidance, enhances patient understanding of their condition, and empowers them to face the disease with more confidence and proactivity. This approach contributes to the establishment of health beliefs and promotes good self-management behaviors. For patients with the nursing outcome of negative emotions, structured, interview-style communication allows them to articulate the underlying causes of their distress. Through empathetic listening and guided dialogue, nursing staff can provide affirming suggestions and psychological support, helping patients to process their emotions constructively and help improve their self-efficacy.

Multidimensional nursing based on NOC can effectively relieve the intestinal symptoms of patients with LARS after sphincter-preserving surgery for low rectal cancer
LARS is a new symptom experienced by patients who have undergone sphincter-preserving surgery for low rectal cancer. It is mostly induced by damage to the rectal nerves and anatomical structures, the reduced volume of the “new rectum”, and an abnormal anorectal inhibitory reflex line, which lead to abnormal pelvic floor muscle function[24,25]. Patients may experience varying degrees of intestinal symptoms such as fecal incontinence, increased defecation frequency, and incomplete defecation. These symptoms are important factors affecting patient prognosis and mental health. Therefore, early interventions should be strengthened. Intestinal symptoms are an extremely private, embarrassing, and sensitive topic that is often not discussed except with people with similar symptoms or close family members and friends[26]. Therefore, in clinical practice, medical staff should encourage patients with LARS who have undergone sphincter-preserving surgery for low rectal cancer to actively participate in social activities and strengthen the family support system to help them better manage their intestinal symptoms.
This study analyzed the impact of NOC-based multidimensional nursing on the intestinal symptoms of patients with LARS after sphincter-preserving surgery for low rectal cancer. After the intervention, the LARS scores of the two groups of patients showed downward trends compared with those before the intervention. The lower LARS score in the observation group than that in the control group after the intervention indicated that this nursing approach can effectively relieve the intestinal symptoms in this patient population. Moreover, the comprehensive intervention of nursing outcomes from multiple aspects such as health education, psychological support, nutrition, and intestinal symptom management in NOC-based multidimensional nursing can allow a seamless handover of the nursing process to meet patients' needs for intestinal management. Dynamic evaluation of nursing outcomes, combined with timely adjustment and optimization of care plans, can enhance the scientific rigor and relevance of the interventions. This approach enables more comprehensive, individualized nursing in all aspects of disease management, improves overall rehabilitation outcomes, and significantly alleviates intestinal symptoms.

Multidimensional NOC-based nursing can improve the quality of life and nursing satisfaction of patients with LARS after sphincter-preserving surgery for low rectal cancer
Moon et al[27] reported relatively low scores on the overall quality of life, functional subscales, and various symptom subscales of patients with LARS. Other studies have reported the negative correlation of defecation function with patient quality of life after sphincter-preserving surgery for middle and low rectal cancer; that is, the more severe the degree of defecation dysfunction, the worse the overall quality of life of patients[28]. The results of this study showed upward trends in the scores for each item of the EORTC QLQ-C30 in both patient groups after the intervention compared with those before the intervention. Moreover, compared with the control group after the intervention, the scores for each item of the EORTC QLQ-C30 in the observation group were higher at the same time point, indicating that NOC-based multidimensional nursing can improve the quality of life of patients with LARS after sphincter-preserving surgery for low rectal cancer.
The findings of the present study demonstrated that multidimensional nursing interventions based on the NOC, emphasizing psychological support, cognitive-behavioral strategies, and personalized education, can effectively improve the patients' psychological resilience, enabling a more proactive approach to recovery and reintegration into daily life. Through reasonable diet selection and nutritional management, the nutritional intake needs of the normal physiological metabolism of the body can be met, which helps improve immune function and relieve intestinal symptoms. In addition, based on pelvic floor muscle exercises, biofeedback training can stimulate the surrounding sphincter muscles innervated by the same homologous nerve through the gluteus medius muscle, greatly improving patients' tolerance of increased colonic capacity and their ability to control defecation, thus reducing the frequency of defecation and improving their quality of life[29,30]. A single-center retrospective cohort study by Fiechter et al[31] showed that an intervention involving biofeedback physical therapy significantly improved the LARS symptom score (from 32.77 points to 22.92 points) in patients treated with low anterior resection, further improving their quality of life, supporting the findings of the present study. In addition, the nursing satisfaction rate of the observation group was higher than that of the control group. This may be related to the fact that multidimensional nursing based on the NOC helps to improve patient physical and psychological comfort and reduce the disease’s impact on the patients' emotions, interpersonal relationships, and social interaction abilities, thus helping patients to return to society as soon as possible.
Although the results of the present study demonstrated the positive impact of multidimensional NOC-based nursing on self-efficacy, symptom relief, and quality of life in patients with LARS after sphincter-preserving surgery, several limitations must be acknowledged. First, the study lacked long-term follow-up; thus whether the improvements in LARS symptoms and patient-reported outcomes were sustained over time remains unclear. Second, the intervention was only compared to routine care and not to other evidence-based interventions such as cognitive-behavioral therapy or pelvic floor rehabilitation alone, which limited the study’s ability to evaluate the relative efficacy of multidimensional nursing. Additionally, the single-center design and relatively small sample size may limit the generalizability of the findings. Future multicenter studies should incorporate larger cohorts and extended follow-up periods to validate these results and explore their comparative effectiveness with other structured rehabilitation models.

CONCLUSION
Among individuals experiencing LARS following sphincter-preserving surgery for low rectal cancer, nursing interventions grounded in the NOC system can enhance self-efficacy, alleviate bowel-related discomfort, and contribute to improved life quality and satisfaction with care. Nonetheless, the present study faces several limitations, such as a limited number of participants and insufficient long-term tracking of the intervention’s outcomes. As a result, certain NOC evaluation indicators may not comprehensively represent patients’ overall conditions. To address this, future investigations should aim to recruit larger cohorts, extend follow-up durations, and conduct in-depth analyses of NOC-based multidimensional care plans tailored to the clinical features of LARS patients undergoing sphincter-preserving procedures for low rectal cancer.