Constipation is a great concern for patients as it can provoke multiple problems and lower patient quality of life.1–3
It is estimated that constipation affects 14% of the total population, with a medical cost of more than $250,000 annually. Therefore, constipation is a significant issue that, if ignored, can lead to both physical and psychological difficulties.4
Owing to discomfort, patients often use laxatives. Studies indicate that the incidence rate of constipation in the population is 3% to 27%,5
with a prevalence of 79% in hospital settings. However, this condition is often a neglected aspect of patient care in acute clinical practice.6
The parameter most often used to define constipation of “three bowel movements weekly” is not sufficiently sensitive. However, there is scant literature on the prevalence or incidence of constipation in acute care. Likewise, there are no published reports on the duration of constipation after thoracolumbar fracture surgery. At present, many physical factors are acknowledged as being associated with gastrointestinal disruption, including surgery, diet, immobilization, narcotic use, lack of privacy, and a change in the toileting routine. All these factors can lead to changes in defecation patterns. However, psychosocial factors are rarely considered. Nurses should be aware of not only physical factors that can affect the duration of postoperative constipation but also psychosocial factors.
Self-efficacy is defined as the individual’s belief in and perception of their capability to perform a particular behavior. Beliefs about personal efficacy, therefore, are not dependent upon one’s wishes; achieving healthy behavior requires basic health knowledge, as well as volitional and motivational factors that can guide the self-regulatory process. Many people who have difficulty with defecation understand that they should consume a fiber-rich diet, drink sufficient water, engage in more physical activity, and stop their reliance on laxatives. Nevertheless, these individuals often continue to eat few fiber-rich foods, drink little water, engage in low levels of physical activity, and continue their use of laxatives. Previous studies7–9
show that perceived self-efficacy is important in each step of the process of health behavior change, including changes in the habits of diet and physical activity. Moreover, self-efficacious individuals are more confident about changing unhealthy behaviors and apply greater effort in maintaining the desired behavior. This study aimed to analyze the relationship between intention formation and actual behavior change when it comes to postoperative constipation.
Anxiety and depression are related to the occurrence of constipation; however, our understanding is limited to long-term constipation and little is known about postoperative constipation. The psychological effect of anxiety and depression owing to postoperative constipation has not been well characterized. Moreover, according to the Bandura’s theory of self-efficacy, involving four basic aspects of developing self-efficacy, controlling psychological responses owing to emotional status is a central approach.9
In other words, anxiety and depression are typically functions of the confidence with which patients approach unhealthy behaviors.
Before implementation of well-designed interventions in nursing practice, it is necessary to understand the duration of constipation and to obtain information about its related psychological factors in the first postoperative phase. No studies have been conducted investigating the association between duration of postoperative constipation and psychosocial factors. Therefore, in this study, we aimed to describe the duration of constipation at 30 days after thoracolumbar fracture surgery and to examine the relationships with self-efficacy and psychological factors, such as anxiety and depression.
The results of international studies have demonstrated that anxiety and depression are associated with the incidence of constipation,14,15
but there are no reports on the association of anxiety and depression and the duration of postoperative constipation. The current findings provide new and valuable information about the relationship between self-efficacy and the incidence of postoperative constipation.16
This is the first study to date reporting the duration of constipation in the first 30 days after thoracolumbar fracture surgery, and examining the relationships with self-efficacy and psychological factors (anxiety and depression). The two main findings of this study were that 89% of our postoperative patients had dry or hard stools or difficulty evacuating during the first several postoperative days, and a normal defecation pattern was re-established in most patients by approximately 13 days after surgery. The frequency of postoperative constipation was higher than that in previous reports, which may be because other studies did not report the use of measures to facilitate defecation (laxatives, digital stimulation, irrigation, and enemas). From our research, we could clarify the difference in duration of postoperative constipation and incidence of constipation. A large proportion (63.9%) of our patients who underwent thoracolumbar fracture surgery reported constipation at hospital admission. With prolonged hospitalization prior to surgery, the frequency of constipation increased; however, in the first 3 postoperative days, the frequency of constipation remained high and then declined. By 30 days after surgery, 9.3% of patients had not yet re-established a normal defecation pattern. Therefore, the duration of postoperative constipation can more precisely reflect patients’ gastrointestinal function than the incidence of constipation.
In the present study, patients demonstrated medium to high levels of self-efficacy, perhaps because most patients were middle-aged adults. In this study, patients who attained higher health behavior self-efficacy had shorter durations of postoperative constipation. Abusabha17
claimed that among the aspects of self-efficacy, self-esteem, outcome expectancy, health values, self-control, self-efficacy can predict and explain more than 50% of health behavior variation. The incidence and duration of constipation, however, depends largely on a proper diet (increased fruit, vegetable, and water consumption), physical activity level, and use of narcotics. Patients with high self-efficacy may tend to consume more fruits, vegetables, and water, exercise more, and use narcotics as little as possible. In addition, patients with high self-efficacy are less likely to use laxatives and more likely to rely on other measures to promote gastrointestinal function. These patients have more confidence in fighting constipation. This result further supports Bandura’s viewpoint that efficacy beliefs play a central role in regulating health behavior.
The present study results demonstrated that the duration of postoperative constipation was positively correlated with anxiety and depression, which means that anxiety and depression in these patients becomes more serious the longer postoperative constipation persists. Recently, mental disorders have been recognized as one of the most important factors causing constipation, which has become the focus of much research. In humans, there is a well-recognized association between emotional or psychological factors (including anxiety and depression) and gastrointestinal function. Emmanuel18
reported that psychological factors probably affect gut function through the autonomic efferent neural pathway. In countries that attach little importance to psychology, like China,19,20
there are very few reports with important results regarding the relationship between constipation and psychological factors. However, in patients with thoracolumbar fractures, postoperative anxiety or depression may be caused by many factors, such as economic issues, the condition of postoperative recovery, loss of work time, and limited social activity. These factors can increase patients’ anxiety or depression such that their postoperative constipation syndrome becomes more severe.
The results of this study support that psychological factors are closely related to self-efficacy levels. In our patients with postoperative constipation after thoracolumbar fracture surgery, those with higher levels of self-efficacy had lower levels of anxiety and depression. This coincides with previous findings regarding the close relationship between individual self-efficacy and mental health, as well as Bandura’s theory regarding self-efficacy. Generally, individuals with higher self-efficacy have more confidence in overcoming difficulties. Such people will actively seek methods to solve their problems and will apply greater effort in doing so. These individuals are also more skilled at controlling the development of a situation. In contrast, individuals with lower self-efficacy are prone to developing anxiety or depression when faced with difficulties. These individuals behave more negatively and doubt their own abilities, often giving up efforts to cope with the situation.
A recent study21
showed that self-efficacy can moderate the association between subjective physical health and depressive symptoms. When self-efficacy is low, physical health is more negatively correlated with depressive symptoms. Based on the results of the present study, the duration of postoperative constipation was negatively correlated with self-efficacy and anxiety or depression negatively related to self-efficacy. Therefore, we can speculate that self-efficacy might be a mediator between postoperative constipation and anxiety or depression. Thus, to shorten the duration of postoperative constipation, self-efficacy should be increased, to alleviate postoperative emotions of anxiety or depression.
Based on Bandura’s theory of self-efficacy,9
expectations of personal efficacy depend upon four main sources of information: vicarious experiences, verbal persuasion, performance accomplishments, and physiological states. We can help patients to attain the greater self-efficacy using these four sources.
With respect to performance accomplishments, strong efficacy expectations can be established via repeated successes, thereby reducing the negative effect of occasional failures.22–25
Nursing staff can assist patients to set goals according to individuals’ levels of dietary intake, physical activity, and painkiller use rate. For example, nurses can help patients who eat fewer fiber-rich foods to adopt a certain level of intake of fiber-rich foods every day. In patients with extended hospitalization time, the quantity of fiber-rich foods can be increased gradually, thereby improving their experience of success and promoting improvement in their self-efficacy. Many expectations are derived from vicarious experiences. Patients watch others perform activities that have positive consequences, which can generate the expectation that the patient can also succeed, if they persist. Patients with postoperative constipation can learn from the experiences of other postoperative patients who have normal defecation patterns. Verbal persuasion is widely used to influence human behavior because this method is very easy to implement. Nursing staff can explain methods to relieve constipation using verbal persuasion in the form of health education. Topics to address can include eating more fiber-rich fruits and vegetables, drinking more water, engaging in more physical activity, using fewer painkillers, and training in how to toilet in bed, prior to surgery. As for physiological states, individuals partly rely on physiological arousal in evaluating their anxiety and vulnerability to stress. As high levels of arousal can weaken performance, individuals can expect greater success when they are not experiencing high arousal levels, as compared with when they are irritated and agitated. In assessing the defecation pattern of patients, psychological states must also be assessed, to guarantee that patients can maintain low levels of anxiety or depression, thus improving their self-efficacy.