Impact of Intimate Partner Violence on Postoperative Psychological Adaptation and Nursing Outcomes in Female Enterostomy Patients: A Cohort Study

Summary

This prospective cohort study found that intimate partner violence was associated with poorer psychological adaptation, persistently elevated cortisol, reduced early stoma perfusion, lower nursing adherence, and more postoperative complications among women with enterostomies. Early screening and tailored cross-departmental support may improve recovery and quality of life.

Abstract

To assess the impact of intimate partner violence (IPV) on postoperative psychological adaptation and nursing outcomes in female patients with enterostomy across multiple departments, a prospective cohort study was conducted. Between January and December 2024, 188 women who underwent enterostomy in the Departments of Obstetrics and Gynecology, Colorectal Surgery, and General Surgery were enrolled and followed for 11 months. IPV exposure was evaluated within 1 week after surgery, and participants were categorized as an IPV group (n = 54) or a non-IPV group (n = 134). The IPV exposure rate was 28.7%. Compared with the non-IPV group, the IPV group had higher anxiety and depression scores, persistently higher serum cortisol levels at each postoperative time point, and lower early stoma mucosal blood supply scores. By the end of follow-up, the IPV group showed higher rates of stoma complications (38.9%) and readmission (24.1%), alongside poorer stoma-care compliance, lower nursing compliance scores, and lower scores across quality-of-life domains. Multivariable logistic regression analysis indicated that IPV exposure was independently associated with stoma complications (OR = 3.764, 95% CI 1.133 – 12.505, p = 0.030). These findings suggest that IPV amplifies postoperative stress responses and undermines rehabilitation in female enterostomy patients. Clinically, a cross-departmental screening pathway and tailored postoperative support for IPV-exposed patients may help improve recovery and nursing outcomes.

Introduction

Enterostomy is a critical therapeutic intervention for life-threatening intestinal conditions managed across various surgical specialties, including Obstetrics and Gynecology (e.g., gynecologic malignancies with bowel involvement), Colorectal Surgery (e.g., colorectal cancer), and General Surgery (e.g., severe intestinal obstruction)¹. By altering normal defecatory physiology and necessitating long-term use of stoma appliances, enterostomy can lead to psychological distress, including anxiety and depression, as well as difficulties in psychosocial adjustment—factors that may impede postoperative recovery and rehabilitation². Intimate partner violence (IPV) represents a significant global public health concern, capable of exacerbating symptom burden through chronic psychological stress and disruption of health-promoting behaviors. For women undergoing enterostomy, the postoperative period constitutes a particularly vulnerable phase, during which exposure to IPV may have an amplified impact on psychological adaptation and nursing-sensitive outcomes³.

Previous research has demonstrated that postoperative maladaptation is associated with diminished quality of life among patients with enterostomies²; reviews and editorials have also emphasized the substantial physical and psychological burden of IPV among women^4,5,6. Nevertheless, several knowledge gaps persist. Most existing studies have focused on single-department cohorts, limiting their ability to capture cross-departmental variations in the underlying indications for enterostomy⁷. Moreover, the association between IPV and postoperative outcomes in female enterostomy patients remains underexplored, with a paucity of prospective data available⁸. Finally, many published reports rely primarily on narrative descriptions, with insufficient incorporation of visual representations that could enhance the communication of recovery trajectories and key clinical outcomes⁹. Accordingly, this study aimed to characterize the dynamic association between IPV exposure and postoperative psychological adaptation in female enterostomy patients from a cross-departmental perspective and to examine its relationship with nursing outcomes. To facilitate clinical interpretation, the cohort construction, follow-up process, and time-course changes in key indicators were presented using flowcharts and trend graphs. The results are intended to inform collaborative identification of high-risk patients across departments and to support the development of targeted postoperative nursing strategies to strengthen psychological adaptation and improve rehabilitation outcomes.

Protocol

Statement of ethics
The study was approved by the ethics committee of First Affiliated Hospital of Xiamen University (Approval No. [2024]152). All the materials used in this study are listed in the Table of Materials.

Study design
A single-center, cross-departmental prospective cohort study was conducted in the Departments of Obstetrics and Gynecology, Colorectal Surgery, and General Surgery of First Affiliated Hospital of Xiamen University. Female patients who underwent enterostomy between January and December 2024 were eligible. Within 1 week after surgery, IPV exposure was assessed using the victimization items of the revised Conflict Tactics Scales (CTS2) together with a structured interview. Occurrence and frequency were analyzed separately. For occurrence scoring, each victimization item was coded as 0 when the act had not occurred and 1 when it had occurred at least once during the preceding 12 months; endorsement of at least one CTS2 victimization item, or disclosure of economic control during the structured interview, defined IPV exposure. Medical records of violence-related injuries, photographs, and police records were used as corroborative evidence but were not required for classification. The two researchers independently reached the same baseline classification for all 188 participants. Fifty-four participants met the binary exposure definition and were assigned to the IPV group, whereas 134 reported no qualifying exposure and were assigned to the non-IPV group; the resulting IPV exposure rate was 28.7% (54/188). For frequency scoring, the CTS2 response categories were converted to estimated frequencies of 0, 1, 2, 4, 8, 15, and 25 and summed across the victimization items. Among the 54 IPV-exposed participants, the observed frequency score ranged from 9 to 44; scores < 15, 15–30, and >30 were described as low, intermediate, and high frequency, respectively. These study-defined categories were used only for descriptive presentation and did not determine group assignment. Baseline group membership was retained throughout follow-up, irrespective of subsequent changes in reported IPV exposure. The study flow, cohort assembly, and follow-up schedule were summarized in Figure 1.

Sample size calculation
Sample size was estimated using PASS 15.0 software. Based on prior studies¹⁰, the authors assumed that the proportion of good stoma adaptation at 6 months would be 65% in the non-IPV group and 35% in the IPV group. With a two-tailed α of 0.05, power (1−β) of 0.90, and a 15% allowance for potential attrition, the minimum required sample size was 168.

Study participants
During the study period, 188 women who underwent enterostomy for colorectal cancer, gynecologic tumors involving the intestinal tract, intestinal obstruction, intestinal perforation, or other indications were assessed for eligibility. None was excluded because of a severe psychiatric or cognitive disorder (n = 0), severe major-organ dysfunction or an anticipated survival of less than 11 months (n = 0), a severe postoperative complication requiring emergency reoperation (n = 0), previous enterostomy or major organ transplantation (n = 0), or refusal or inability to complete the required follow-up and objective assessments (n = 0); consequently, all 188 women were enrolled. All 188 enrolled participants completed the 11-month follow-up, yielding an observed attrition rate of 0%. These patients were treated between January and December 2024 in the Departments of Obstetrics and Gynecology, Colorectal Surgery, and General Surgery; 30 participants were recruited from Obstetrics and Gynecology, 82 from Colorectal Surgery, and 76 from General Surgery. Potential participants were initially identified through screening of electronic medical records. Trained researchers then conducted face-to-face interviews to explain the study objectives and procedures. After providing written informed consent, eligible participants were enrolled, categorized according to their intimate partner violence (IPV) exposure status, and assigned individual follow-up files. Data on demographic characteristics, disease- and surgery-related variables, psychological assessments, objective physiological indicators, and nursing outcomes were systematically collected throughout the follow-up period.

Inclusion and exclusion criteria
Inclusion criteria: Age ≥18 years; conscious and oriented; capable of verbal communication and reading comprehension sufficient to complete questionnaires, assessments, and follow-up procedures; Undergoing first-time enterostomy (either permanent or temporary), with stable stoma morphology postoperatively and no immediate severe complications; Currently in an intimate partner relationship (married or cohabiting), with potential exposure to IPV; Willingness to participate and provision of written informed consent.

Exclusion criteria: Preoperative diagnosis of severe psychiatric disorders (e.g., schizophrenia, major depressive disorder) or cognitive impairment; Severe dysfunction of major organs (e.g., heart, liver, kidney) with an anticipated survival duration of less than 11 months; Presence of severe postoperative complications (e.g., stoma necrosis, severe infection) necessitating emergency reoperation; History of previous enterostomy or major organ transplantation; Refusal to participate, inability to comply with follow-up requirements, or unwillingness to undergo assessment of objective indicators.

Grouping
Within 1 week after surgery, IPV exposure was assessed using the revised Conflict Tactics Scales (CTS2)¹¹ combined with structured interviews. Where available, supporting materials (e.g., medical records documenting violence-related injuries and photographs of physical injuries) were collected. Baseline exposure status was determined from the participant’s CTS2 occurrence responses and disclosures made during the structured interview, whereas medical records, photographs, and police records were used solely as corroborative evidence and were not required for classification. Patients reporting any form of violence (physical violence, emotional violence, economic control, etc.) were allocated to the IPV group, while those reporting no IPV were allocated to the non-IPV group. The two researchers independently reached the same baseline exposure classification for all 188 participants; consequently, no case required consensus adjudication. Ultimately, 54 patients were included in the IPV group and 134 patients in the non-IPV group.

Outcome measures
Baseline data comparison table: Collected within 1 week after surgery. Objective indicators included age, surgical duration, intraoperative blood loss, stoma diameter, primary disease type, and surgical approach; subjective indicators included educational level and economic income. These variables were used to evaluate baseline comparability between groups. IPV occurrence and objective evidence table: Collected at baseline (within 1 week after surgery) and at 6 months postoperatively. In addition to IPV incidence and type, objective indicators (number of medical visits for violence-related injuries, cases with photographic evidence of injury, and records of police involvement) were recorded to strengthen the assessment.

Longitudinal psychological adaptation and objective physiological indicators: Collected at 1, 3, 6, 9, and 11 months postoperatively. Psychological outcomes were assessed using the 20-item self-rating anxiety scale (SAS) and the 20-item self-rating depression scale (SDS), both of which use four-point response options; higher standard scores indicate greater symptom burden, and scores of ≥50 and ≥53 were used to identify clinically relevant anxiety and depressive symptoms, respectively¹². Because only total scores were retained in the analytic dataset, cohort-specific internal-consistency coefficients were not calculated. Physiological indicators included serum cortisol (Cor) levels and stoma mucosal blood supply scores (0–3 points; 3 indicating normal blood supply, with lower scores indicating poorer perfusion).

Subjective and objective nursing outcome indicators: Collected at the 11-month follow-up endpoint. Objective outcomes included stoma complication incidence, readmission rate, stoma-care compliance rate (assessed by on-site evaluation; 1 = compliant, 0 = non-compliant), time to first postoperative ambulation, and length of hospital stay. Subjective outcomes included adherence to the postoperative nursing plan, assessed using a study-specific 12-item scale with four response options per item and a total score range of 12–48; scores ≥36 indicated higher adherence. The scale had not undergone formal external psychometric validation; therefore, the outcome was treated as exploratory. Quality of life was assessed using the EORTC QLQ-C30¹³ (five functional dimensions, including physical, emotional, and social functioning; higher scores indicate better quality of life).

Association between IPV frequency and objective stress indicators: CTS2 frequency scores were analyzed in relation to contemporaneous serum cortisol concentrations at 1, 3, 6, 9, and 11 months postoperatively among participants classified as IPV-exposed at baseline.

Objective diagnosis and intervention of stoma complications: Collected from 1 to 11 months postoperatively. The number and proportion of complications, diagnostic basis (physical examination and/or imaging), and the number of interventions for each complication type (e.g., peristomal dermatitis, stoma prolapse) were recorded.

Department-level comparisons of IPV exposure and objective stress indicators: Collected within 1 week after surgery to compare IPV exposure rates and mean Cor levels among departments.

Risk factors for adverse outcomes: Collected at the 11-month follow-up endpoint. Objective risk factors and IPV exposure status were included to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for adverse nursing outcomes (defined as the occurrence of complications).

Quality control
All researchers received standardized training on assessment tools and objective indicator testing procedures. Data were double-entered and cross-checked to improve accuracy. Outcome assessors were not formally blinded to IPV status; however, serum cortisol measurements were obtained using standardized laboratory procedures, and stoma complications were assessed according to prespecified clinical criteria. Follow-up completion was supported through text-message reminders and dedicated follow-up staff; all 188 participants completed the 11-month follow-up, and no participant was lost to follow-up. Objective indicator testing adhered to laboratory standards and clinical assessment criteria to reduce measurement error.

Statistical analysis
SPSS 26.0 was used for statistical analyses with a two-tailed α of 0.05. Categorical variables are presented as n (%) and compared using the χ² test. Continuous variables are presented as mean ± standard deviation (SD). Independent-samples t-tests were applied to normally distributed, homoscedastic data; the Mann-Whitney U test was used for non-normally distributed data. Repeated-measures analysis of variance was used to compare longitudinal changes in SAS, SDS, and serum cortisol, with group, time, and group-by-time effects evaluated. Residual distributions were examined graphically, homogeneity of variance was assessed using Levene’s test, and sphericity was evaluated using Mauchly’s test; Greenhouse–Geisser corrections were applied when sphericity was violated. When an omnibus longitudinal effect was significant, Bonferroni correction was applied to the five time-specific between-group comparisons within that outcome. The same correction was applied to the five correlations between CTS2 frequency scores and serum cortisol concentrations. No global adjustment was applied across distinct prespecified secondary outcomes, which were interpreted separately using exact two-sided p values. Because the stoma mucosal blood supply score was an ordinal measure ranging from 0 to 3, between-group comparisons at each postoperative time point were performed using the Mann–Whitney U test. Pearson correlation analysis was used to assess associations between CTS2 frequency scores and serum cortisol concentrations. Multivariate logistic regression was used to identify independent risk factors for adverse postoperative outcomes. All baseline and longitudinal variables included in the final analyses were complete for the 188 participants. Blank entries in conditional fields, such as complication type among participants without a stoma complication or supporting evidence among participants without IPV exposure, represented absence or non-applicability rather than missing data; therefore, no statistical imputation was performed.

Results

Comparison of baseline data between groups
Baseline characteristics are summarized in Table 1. No statistically significant between-group differences were observed in age, surgical duration, intraoperative blood loss, stoma diameter, patient source, surgical approach, or educational level; however, the distribution of monthly household income differed significantly between the groups (p < 0.05). Most baseline characteristics were comparable between the groups, although mo...

Discussion

This prospective cohort study investigated the association between intimate partner violence (IPV) exposure and postoperative recovery among female enterostomy patients across multiple departments. IPV exposure was identified in 28.7% of participants. Compared with the non-IPV group, individuals in the IPV group exhibited significantly higher anxiety and depression scores, elevated serum cortisol (Cor) levels at postoperative time points, and lower early stoma mucosal blood supply scores. By 11 months post-surgery, the I...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Medical Stoma Assessment Scale	Self-developed (validated)	N/A	Assessment of stoma mucosal blood supply
Microplate Reader	BioTek Instruments (Agilent)	ELx800	Used for ELISA absorbance measurement
Refrigerated Centrifuge	Eppendorf	5810R	Serum separation
Revised Conflict Tactics Scales (CTS2)	Western Psychological Services (WPS)	CTS2-Manual	Used to assess intimate partner violence exposure
Self-Rating Anxiety Scale (SAS)	Chinese Academy of Medical Sciences	N/A	Standardized questionnaire
Self-Rating Depression Scale (SDS)	Chinese Academy of Medical Sciences	N/A	Standardized questionnaire
Serum Cortisol ELISA Kit	Elabscience Biotechnology (China)	E-EL-H1585	Quantification of cortisol levels
Statistical Analysis Software	IBM SPSS Statistics	Version 26.0	Data analysis