Oral squamous cell carcinoma (OSCC) that originates within the oral mucosa is a widely occurring type of cancer in the head and neck area. It makes up roughly 90% of oral malignancies and negatively impacts appearance, speech, swallowing, and taste sensation [1]. Oral cancer is acknowledged as one of the most prevalent malignant tumours, presenting considerable economic and clinical challenges on a global scale. Although treatment approaches have progressed, the five-year survival rates for patients diagnosed have not significantly improved over the decades, mainly because the disease is often diagnosed at a later stage [2]. A significant number of patients undergoing extensive resections of the oral cavity, pharynx, or larynx due to oral cancer are older adults, specifically those over 65 and tend to be frail. They often present with comorbidities, including heart disease, brain blood vessel disorders, and diseases that affect the blood vessels in the legs, as well as chronic lung disease (hypertension), diabetes, or low red blood cell count-frequently tied to lifestyle risk factors such as excessive alcohol consumption, tobacco usage, and sometimes other forms of substance misuse [3].

Oral cancer can be treated using chemotherapy, radiation therapy, and surgical methods. Generally, surgical treatment is considered the most effective and immediate option for the majority of cases. The selection of therapy is affected by two primary factors: the patient and the characteristics of the tumour. Several aspects, including the tumour’s size, location, proximity to bone, and level of infiltration, impact the surgical strategy [4]. A thorough analysis of the support required following surgery for oral cancer revealed a considerable range of consequences that arise after treatment. These include dry mouth, difficulty swallowing, speech difficulties, tooth loss, persistent pain, concerns about body image, anxiety or depression, restricted jaw movement, and inadequate nutrition [5].

Anxiety is a formidable emotional state that is defined by significant discomfort, trepidation regarding future events, and both voluntary and involuntary modifications in the body, which influence its chemical and biological systems [6]. Reports indicate that anxiety and fear are commonly experienced by patients upon their hospital admission for surgery. Thus, the interplay of physical changes and mental reactions associated with surgery and hospital stays can endanger the health of patients. Moreover, individuals who are set to undergo cancer surgery find themselves in a particularly challenging situation, as the cancer itself leads to significant emotional strain. The negative effect of anxiety in both the perioperative and postoperative stages on patients' recovery is well recognized, as it can result in poor outcomes following the surgical procedure [7].

Despite multiple studies that underscore anxiety in oral cancer patients, there is a substantial shortfall in research related to postoperative anxiety in India. This awareness inspired us to perform our study, which sought to examine the effects of nursing interventions on alleviating postoperative anxiety for these patients.

Participants and Settings

This investigation covered 300 patients, with a breakdown of 177 males and 123 females, from the surgical department of the Atal Bihari Vajpayee Regional Cancer Centre (ABV-RCC) in Agartala, Tripura, India. The patients had oral surgery due to a diagnosis of oral cancer during the period from 2022 to 2024. The evaluation was performed at the ABV-RCC, following the ethical review board's approval (DBU/RC/2023/2338). Each participant gave written acceptance of their participation before being asked to participate.

Demographic Characteristics

The categorization of participants was based on various criteria, including age, gender, religious beliefs, educational background, employment status, monthly income, marital status, types of surgeries performed, cancer stage, presence of tumor metastasis, and the site of the primary tumor.

Comprehensive Nursing Intervention

As a key component of nursing intervention, patients were provided with a variety of exercises, which encompassed swallowing, mouth-opening, stretching, and both active and passive range of motion exercises, in addition to relaxation techniques. They were encouraged to concentrate on maintaining correct posture and to integrate neck stretches, chin tucks, and shoulder blade squeezes into their everyday routines. The experimental group engaged in an educational intervention that outlined the advantages of thyme honey, dental hygiene, and counselling, delivered via a PowerPoint presentation and a video. This educational session spanned 30 minutes, whereas the nursing intervention lasted between 10 to 15 minutes. The program was conducted 9 to 10 times over a continuous five-day period, arranged at the participants' convenience. On the other hand, only standard hospital care was given to the control group.

Assessment of Anxiety

In this analysis, the severity of anxiety was assessed using the Beck Anxiety Inventory (BAI) questionnaire, which includes 21 items evaluated on a 4-point Likert scale, with scores from 0 to 3. A score of 0 corresponds to "Not at all," while a score of 3 indicates "Severely-it bothered me a lot." Each individual's total score can range from 0 to 63 points. Anxiety levels are divided into categories of 0-7, 8-15, 16-25, and 26-63, representing very low, mild, moderate, and severe anxiety, respectively.

Recruitment and Sampling

The lottery method was incorporated as a facet of the probability approach under the umbrella of simple random sampling (Figure 1).

Figure 1: Flowchart of the Randomization Process.

Measurements and Outcomes

Both the experimental and control groups were compared to conduct a comparative analysis of demographic characteristics. The Beck Anxiety Inventory (BAI) questionnaire was utilized to gauge the anxiety levels of the participants.

Analysis         

The evaluation encompassed both Karl Pearson’s correlation and Wilcoxon’s test, understanding that a p-value beneath 0.05 demonstrates statistical significance.

In the current investigation involving 300 participants, males made up 59% (n = 177, 95% CI: 53.1 – 64.5) and females represented 41% (n = 123, 95% CI: 35.4 – 46.8), yielding a sex ratio (M: F) of 1.44:1. Demographic characteristics for the experimental and control groups are summarized in Table 1. The mean and standard deviation for the anxiety level among postoperative patients are illustrated in Table 2.  Figure 2 displays the mean and standard error of the mean of the anxiety scale of the experimental and control groups.

Table 1: Demographic characteristics of the participants (n=300).

Table 2: Mean and SD of pre and post-test level of anxiety among postoperative patients with oral cancer (n=300).

Figure 2: Mean of the anxiety scale of experimental and control groups.

Oral cancer can induce major emotional and social distress, as its occurrence and treatment compromise oral abilities like chewing, swallowing, and speaking, along with causing facial disfigurement. Evidence suggests that oral dysfunction leads to specific reductions in quality of life (QoL) related to the disease and its location. Additionally, postoperative disfigurement is linked to symptoms of anxiety. Indeed, over 40% of patients suffer from psychological impacts after being diagnosed with oral cancer which resembles post-traumatic stress disorder.

Furthermore, the way a patient copes after diagnosis is related to their QoL post-surgery [8]. As awareness of the influence of mental health on cancer recovery increases, healthcare providers are encountering more challenges in addressing anxiety and depression. It is vital to analyze the psychosocial factors that lead to these symptoms to provide effective psychological support and enhance the QoL for patients. Mental health issues, especially anxiety and depression, are prevalent among cancer patients. The anxiety that these individuals experience can be attributed to a variety of factors. Research has identified a significant link between depressive symptoms and various characteristics, such as age, gender, and education level. Additionally, there is a strong and enduring connection between stigma and adverse mental health conditions in cancer patients, which includes depression, anxiety, and feelings of demoralization [9].

The extent of tissue injury and the reconstructive measures needed are dictated by the stage of cancer, which is generally related to the size of the surgical site. More complicated surgical operations can cause greater fatigue in patients, which can detrimentally affect their QoL and heighten the risk of emotional struggles like anxiety and depression. The physical and psychological difficulties that occur after surgery are a result of surgical incisions, the stress of the illness, and the interventions conducted [10]. Psychological symptoms and syndromes like anxiety, depression, and fatigue are commonly found in individuals with HNC. Inadequate evaluation of these psychological aspects, especially anxiety and fatigue, has been associated with higher mortality rates and a substantially lower QoL [11]. Consequently, precise evaluation tests are essential for comprehending the reasoning behind the selection and adjustment of particular medical treatments to fulfil the unique needs of patients [12]. This research employed the BAI scale, a frequently used questionnaire for measuring anxiety in oncology contexts. Prior investigations have verified that this scale serves as a dependable and valid assessment of anxiety [13].

Healthcare providers face a major challenge in managing anxiety, and educating both patients and their families is an essential aspect of the caregiving process to enable them to identify and address this issue effectively. In-depth research has demonstrated the significant importance of nursing interventions in lowering anxiety levels. Nonetheless, there is a deficiency of studies that focus specifically on the effects of these interventions on patients who underwent surgery for oral cancer.

Our findings underscore the critical need for comprehensive nursing interventions to reduce post-operative anxiety in this demographic. Our analysis indicates that nursing interventions have markedly diminished postoperative anxiety in oral cancer patients in the experimental group relative to the control group. In addition, these interventions have proficiently improved patients' knowledge and self-care competencies. The all-encompassing nursing intervention model facilitates the recovery of patients from oral cancer and the management of cancer pain by empowering them to recognize and understand their condition, transform their outlook, foster confidence in their healing journey, participate actively in their treatment, and lessen anxiety. In contrast to standard nursing practices, comprehensive nursing arranges its methods to prioritize patient needs, clarifies the philosophy and responsibilities of nursing, offers superior, evidence-based care, and adapts the individualized nursing plan based on the patient's changing requirements, thus ensuring a caring nursing experience that encourages healing.

This study reveals that nursing interventions are very effective in significantly lowering post-surgical anxiety in oral cancer patients. Moreover, there is a significant gap in research concerning the psychological, physical, and social factors affecting the health of patients post-oral cancer surgery. Adopting a comprehensive nursing intervention within standard care practices can greatly ease post-surgical anxiety in patients undergoing oral cancer treatment.

Limitations

Our investigation has particular constraints that must be acknowledged. It was performed at a single location, and the follow-up timeframe was confined to five days, which may have impacted the outcomes. Moreover, it is suggested to replicate this research in diverse areas of the country, as levels of patient anxiety could differ based on varying lifestyles and support mechanisms.

Data Availability

All data from this study is available with the corresponding author, which will be shared upon request.

Ethics Approval Statement

The study was conducted in accordance with the Declaration of Helsinki, and this research was approved by Desh Bhagat University’s Institutional Review Board (DBU/RC/2023/2338). The research was conducted at Atal Bihari Vajpayee Regional Cancer Centre, Agartala, Tripura, India

Patient Consent Statement

Informed consent was obtained from all individual participants included in the study.

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