Sharper follow-up after upper GI cancer surgery: a contact nurse–led, individualized rehabilitation model
Wenche Melander, Oscar ÅkessonAbstract
Introduction
Patients undergoing surgery for oesophageal or gastric cancer frequently present complex and fluctuating rehabilitation needs. Despite this, the optimal structure for postoperative follow-up remains insufficiently defined. Participants in this study had previously taken part in an individualized rehabilitation intervention led by a contact nurse, who served as a consistent clinical anchor throughout recovery.
Methods
A phenomenological hermeneutic qualitative design was used, aiming to explore the meaning of the contact nurse–led rehabilitation intervention. Interviews were conducted with participants who had completed the intervention (n = 13).
Results
Preliminary findings indicate that the contact nurse played a pivotal role in ensuring that follow-up was tailored to patients’ clinical, functional, and psychosocial needs. Using the Assessment for Rehabilitation Needs the contact nurse systematically identified rehabilitation needs, coordinated evidence-based support, and provided continuous follow-up. This included targeted information, self-management strategies, and timely involvement of rehabilitation professionals or medical specialists. Patients described the model as responsive, coherent, and closely aligned with their postoperative trajectory, emphasizing the value of having a safe, knowledgeable point of contact.
Discussion
A structured, team-integrated approach to rehabilitation anchored by a contact nurse, enables task shifting in which clinical encounters are driven by patient needs rather than fixed schedules. This model supports early identification of rehabilitation needs, strengthens continuity across the surgical and rehabilitative pathway, and enhances patients’ sense of safety during recovery. Integrating individualized assessment with coordinated multidisciplinary input may optimize postoperative outcomes and survivorship care.