Definitions
Constipation was defined as the condition in which a person has difficulty in comfortably passing a sufficient amount of stool [23].
Study design and participants
We conducted a cross-sectional questionnaire survey of ward managers and staff nurses working in LTC wards in Japan from August to September 2018. We randomly selected 1,554 hospitals from 3,844 hospitals with LTC wards from a hospital database representing all of Japan in 2015 (Figure 1). Of these, we excluded 125 hospitals in disaster areas associated with torrential rainfalls in Western Japan and 247 hospitals without LTC wards in the Reporting on Medical Functions of Hospital Beds in 2016 [24]. We excluded two hospitals that were under intervention of another research program. Consequently, we extracted 1,180 hospitals with LTC wards in this study.
We sent self-administered, anonymous questionnaires to the ward managers and staff nurses of the 1,180 hospitals. We then asked the hospital nursing directors to distribute the questionnaires to the LTC ward managers and to one staff nurse within each ward who had a high level of familiarity regarding the state of patients’ bowel management. LTC ward managers and staff nurses who agreed to participate in the survey completed questionnaires and returned these by mail.
In the questionnaire, we explained the purpose and methods of the study, the voluntary nature of participation, and the right to refuse participation. Written informed consent was received from the nurses and ward managers involved in this study. This study was approved by the Research Ethics Committee of the university (No. 12037).
Measures
In this study, the questions posed to ward managers concerned the general characteristics of hospitals, wards, and inpatients; organizational factors; and ward manager demographic characteristics. The questions asked to staff nurses concerned their demographic characteristics, how constipation management was assessed, and the actual practice of constipation management.
Characteristics of hospitals, wards, and inpatients
Hospital characteristics included hospital ownership and total number of beds. Ward characteristics included the total number of beds in the ward, average length of patient stay, bed occupancy rate, number of hospitalized patients, number of full-time registered nurses, licensed practical nurses, care workers, and type of reimbursement (types 1 or 2). To be designated as type 1 wards, more than 80% of admitted patients should have high medical acuity levels, whereas in type 2 wards, only more than 50% need to have high acuity levels [9]. We investigated the number of patients using a diaper, those receiving nutrition through a gastric feeding tube, and those receiving total parenteral nutrition to understand the inpatient characteristics for activities of daily living.
Organizational factors
We inquired about the presence or absence of a certified nurse in wound, ostomy, and continence nursing; education availability for staff nurses (in-hospital and out-hospital study sessions); case conferences; the existence of committees; and nursing care plans for constipated patients.
The organizational climate was reported by staff nurses using a scale [25], rated on a 5-point Likert scale from 1 (never experienced) to 5 (always experience). This instrument comprises the following four subscales: sense of control, staff morale, intimacy, and learning atmosphere. Given that the existing learning opportunity was mostly for facilitating implementation of EBP [17], we only used the learning atmosphere subscale for the analyses. The internal consistency reliability of the learning atmosphere was acceptable (Cronbach’s alpha coefficient = 0.73).
Ward manager characteristics
The demographics of ward managers included age, sex, and qualification. Work-related variables were measured by years working in current workplace, types of workplace experience, experience in receiving education regarding constipation management (in-hospital study sessions, out-hospital study sessions, books or magazines, and academic conferences), and knowledge on stimulant laxative use. To examine the ward manager’s knowledge on laxative use, we asked whether the stimulant laxatives should be used every day, rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree).
We further examined the ward manager’s beliefs and preferences regarding use of laxatives. Regarding beliefs, we asked: “I believe we cannot manage constipation without laxatives.” For preference, we asked: “I want to manage constipation without relying on laxatives.” The answers were rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). To achieve face validity, we asked the nurses in LTC hospitals and the gastroenterologists if all questions were clearly worded and would not be misinterpreted.
Staff nurse characteristics
The characteristics of staff nurses, including age, sex, qualifications, and years working in their current workplace, were recorded.
Constipation assessment
Items regarding constipation assessment at the initial intake and on a daily basis were developed based on the nursing practice guidelines [10]. The initial assessment included the following six items: ability to sense the urge to defecate, medical history of laxative use, abdominal mass, bowel sounds, fecal impaction, and hemorrhoids. Daily assessment included the following seven items: frequency of bowel movements, time of bowel movement, amount of stool, abdominal mass, bowel sounds, stool consistency, and use of Bristol Stool Form Scale (BSFS) for assessing stool consistency. We asked the managers whether there was a recording field for each item in the nursing records and whether the nursing staff recorded each item for all, some, or none of the patients.
Constipation management
Items concerning constipation management were developed based on recommendations from the clinical/nursing practice guidelines for constipation [10,23,26]. Daily interventions included the following eight items: osmotic laxatives (magnesium oxide), stimulant laxatives (sodium picosulfate and senna), secretagogues (lubiprostone), Chinese herbal medicine, and medicine for external use and procedures (glycerin enema, suppository laxative, and digital disimpaction). Moreover, we inquired for the daily implementation of the following five non-pharmacological management practices: increased fluid intake, regular encouragement to use bathroom, increased physical activity, using dietary fiber products, and using probiotic products.
We asked the nursing staff to describe the daily constipation management practice in LTC wards based on the abovementioned pharmacological and non-pharmacological managements. In addition, we asked the nursing staff to select three patients with severe constipation and to describe the daily constipation management practice for each patient.
The following outcome variables were used: the total number of non-pharmacological management practices, whether dietary fiber and probiotic products are used in the ward, and non-use of stimulant laxatives on consecutive days. The total number of non-pharmacological management practices reflects effective constipation management with diverse options, because multiple [27] and individually tailored approaches [28] are reported to be effective. The efficacy of dietary fiber and probiotic products has been reported [29,30]; however, these products are infrequently implemented in the LTC setting [11]. These indicators were measured based on whether they were used daily (1) or not (0). Non-use of stimulant laxatives on consecutive days is recommended by the American Gastroenterological Association [26]. It was measured based on whether staff nurse used the stimulant laxatives on consecutive days for any patient out of the three selected patients (0) or not (1).
Data analysis
Data analyses were conducted by utilizing data for each ward as a unit of analyses; some data on individual patients were summed together to represent ward characteristics. The variables such as knowledge of laxative use and belief were reversed to high knowledge and belief for constipation management with a high score. First, we generated descriptive statistics. Second, we conducted bivariate analyses to examine associations between constipation management and ward manager's perceptions, organizational climate, and other variables.
Finally, we conducted multivariate analyses. We used the multiple linear regression analysis for the total number of non-pharmacological management practices and multiple logistic regression analysis for dietary fiber products, probiotic products, and non-use of stimulant laxatives on consecutive days.
The ward manager’s perception and organizational climate of the learning atmosphere were entered in the model using the force-entry method; other variables were entered using the forward selection for variables with P < .20. To control for ward patient characteristics (i.e., medical acuity and activities of daily living assistance needs), the number of hospitalized patients per LTC ward, those with a gastric feeding tube, and those receiving total parenteral nutrition were also applied using the force-entry method as independent variables. The significance level was P < .05 (two-tailed). All analyses were conducted using SPSS Statistics for Windows, version 25.0. (Armonk, NY: IBM Corp).