The prevalence of colorectal cancer is the second highest after stomach cancer in Korea [1]. Advanced diagnostic and medical technologies have raised the rate of early detection of colorectal cancer, and its five-year relative survival rate increased from 54.8% in 1993~1995 to 76.3% in 2010~2014 [2]. These increases suggest that there are many patients who are in need of managing their disease process continuously, resulting in demands for various nursing interventions for psychosocial adjustment in their communities. However, clinical outcome measures are mostly confined to laboratory results, complication rates, and death, which often overlook those aspects of functioning and fall short of providing a complete picture of how patients' lives have been affected by the disease and its sequelae [3].

As a traumatic event, cancer causes patients to face a variety of stressful situations from the moment of diagnosis such as fear and anxiety of death, high-risk recurrence and metastasis, and uncertainty about the future [4]. Moreover, colorectal cancer survivors mostly suffer from frequent bowel movements, fecal incontinence, and difficulty in activities of daily living, and some are obliged to have a stoma [5]. These changes in appearance and physical functions result in psychological atrophy and social isolation [6].

Although cancer causes traumatic impacts on lifestyle [4, 6], during the process of overcoming, some survivors experience positive growth with respect to their life values and report affirmative changes in relationships with others, indicating posttraumatic growth [7]. Posttraumatic growth has been reported in a certain portion of individuals undergoing traumatic episodes of natural disaster, sexual assault, or military attacks [7]. Recently, these positive changes are notable in individuals enduring treatment of life-threatening illness. The posttraumatic growth in cancer survivors contributes to an improved lifestyle [8]. However, there are few studies of posttraumatic growth among colorectal cancer survivors in Korea. On the one hand, although cancer survivors should maintain health-promoting behaviors continuously to minimize the after-effects of treatment and to prevent recurrence and metastasis [9, 10], little is known about the relationship between their healthy behaviors and psychosocial adjustment to daily life. It is important to understand the psychosocial adjustment of colorectal cancer survivors through multidimensional approaches [3]. However, there is a lack of studies of psychosocial adjustment in Korean colorectal cancer survivors [11].

The purpose of this study was to identify the factors associated with psychosocial adjustment in Korean colorectal cancer survivors after surgery. The study addressed the following research objectives:

The present study attempted to investigate the factors associated with psychosocial adjustment in Korean colorectal cancer survivors among posttraumatic growth, health-promoting behavior, and general characteristics. The score of posttraumatic growth in this study was relatively low as 2.97 compared to 3.18 in individuals with gynecologic cancer [16] and 3.38 in those with general cancer [9]. This might result from the burden of caring for fecal incontinence or stoma following colorectal cancer surgery, along with a lack of support group activities in this study.

The level of health-promoting behavior in colorectal cancer survivors was relatively higher as 2.70 than the 2.61 of individuals with breast cancer [17], 2.65 of those with uterine cancer [16], and 2.34 of healthy adults [18]. These results may indicate that colorectal cancer survivors actively engage in health-promoting behaviors to overcome their illness and to prevent aftereffects more than other cancer survivors or healthy persons.

The level of psychosocial adjustment in this study was relatively higher as 3.58 compared to 3.05 of those with permanent colostomy [19]. This may indicate that colorectal cancer survivors after surgery more proactively try to cope, compared to those living with stoma. Nurses need to actively provide effective solutions for patients during the adjustment period after surgery, because patients receiving authoritative information from a medical team rather than outside sources actively participated in the required management [20]. The level of psychosocial adjustment was lower in individuals within two years of treatments compared to those with a longer period of treatment. This result also indicates that patients in the early period of treatment may require more nursing interventions, whereas those in the long-term follow-up period need support for adjusting to society and regaining their careers.

Health-promoting behavior was the strongest factor facilitating psychosocial adjustment, followed by level of activities of daily living, posttraumatic growth, and not having a stoma. Nurses need to develop an intervention program that promotes health-promoting behaviors such as physical exercise and healthy lifestyles, because colorectal cancer survivors experience hardships during the treatment process. To reduce the health risks and challenges facing cancer survivors, interventions to encourage physical exercise and screening for cancer recurrence and secondary disease should be implemented [21]. Adopting a health-promoting approach based on empowerment is important, not just for improving care, but also for increasing perceptions of control that may reduce negative cancer beliefs [22].

In this study, the difficulty in activities of daily living decreased the level of psychosocial adjustment. Although there is a lack of studies examining psychosocial adjustment based on the level of activities of daily living in Korean colorectal cancer survivors, higher levels of physical, mental, and social discomfort related to cancer may decrease quality of life and psychosocial adjustment. A study of breast cancer survivors found that physical disability was significantly associated with psychosocial well-being [23].

Posttraumatic growth was reported by colorectal cancer survivors and promoted their psychosocial adjustment in this study. Previous studies of breast cancer survivors also highlighted the importance of psychological intervention focusing on depressive symptoms, distress, and spirituality, which are associated with posttraumatic growth [24, 25]. A study of patients with colorectal cancer identified resilience, coping, and importance of religion as influencing factors on posttraumatic growth [26]. The current methodological study of posttraumatic growth inventory for general cancer patients found that the new possibilities for cancer treatments and an active life were the strongest factors accounting for posttraumatic growth [27]. The development of medical technology will provide more opportunities. Hence, nursing interventions should include strategies for posttraumatic growth, to facilitate psychosocial adjustment.

Having a stoma is an important task in adapting to a changed appearance and lifestyle. For some colorectal cancer patients, the change of location of the excretory orifice to the surface of the abdomen and the sight of this excretion and stoma may be the biggest shock to them. The psychological stress from changes in the passageway of bowel movements, uncontrollable smells, and the noise of passing gas is a serious challenge for cancer survivors. Previous studies found that colorectal cancer survivors with colostomy had a lower quality of life and experienced depression and anxiety due to a diminished body image [28, 29]. Because survivors with stomas experience hardships in adjusting to physical changes, psychosocial adjustment often takes a significant amount of time for them. Therefore, the comprehensive stoma programs are necessary for these survivors to obtain a positive body image and to restore themselves psychologically, as well as to reintegrate social relationships.

Nurses have responsibilities for encouraging colorectal cancer survivors to use positive life transformations to maintain an optimal level of health and to increase their level of psychosocial adjustment. Thus, nurses should have a comprehensive understanding of the possibilities for physical, psychological, and spiritual improvements, which one can accomplish through cancer management. In addition, nurses should develop intervention programs to explore efficient strategies that can increase continuous and systematic psychosocial adjustment. The study findings suggest that more research is needed to identify and facilitate posttraumatic growth for colorectal cancer survivors, to increase the level of psychosocial adjustment.

Among Korean colorectal cancer survivors after surgery, the level of psychosocial adjustment increased through health-promoting behavior and posttraumatic growth; and decreased due to difficulty in activities of daily living and having a stoma. The psychosocial adjustment program for colorectal cancer survivors after surgery should include various nursing strategies to promote health-promoting behaviors and level of activities of daily living. As patients also experience posttraumatic growth, which was important for their survival and quality of life, nurses need to understand the nature of posttraumatic growth and develop intervention strategies for facilitating affirmative growth during colorectal cancer management. Medical technology also needs to develop new approaches related to stoma management, considering malodor control and appearance improvement for psychosocial adjustment.

Several limitations existed in this study. The study used a cross-sectional design, and the causal relationship between independent and dependent variables should be carefully inferred. However, the significant factors such as health-promoting behavior, difficulty in activities of daily living, posttraumatic growth, and having a stoma are theoretically ahead of psychosocial adjustment, and those factors may be useful for nursing interventions, to facilitate the psychosocial adjustment of colorectal cancer survivors. As we included participants with colorectal cancer without discriminating between colon cancer and rectal cancer, a further comparative study may be able to identify the characteristics of the relationships among variables between patients with colon cancer and those with rectal cancer.