To our knowledge, this is the first study in Sweden illuminating healthcare professionals’ experiences of assessing, treating and preventing constipation among older patients. Bowel health was considered an important part of the care of patients, but at the same time there was a lack of consensus on how to adequately assess, treat and prevent constipation.
Surprisingly, one of the key findings was that healthcare professionals experienced obstacles in the organization and relied on their own individual perceptions and attitudes, stating that they lacked an assessment tool. Saga, Seim, Morkved, Norton and Vinsnes (34) found that healthcare professionals often described difficulties in observing and identifying constipation, which also was found in this study. This may explain why healthcare professionals sometimes differ in their assessments and the limited utilization of assessment tools has been described (35, 36). The use of a constipation assessment scale has been demonstrated to be valuable in the assessment of constipation in nursing care and in different clinical settings (37). Improvement in evidence-based practice can be achieved through educating healthcare professionals in the use of assessment tools, standards and protocols as well as continuous follow up cycles to sustain their performance (36, 38).
The healthcare professionals emphasized the importance of clinical reasoning. Being able to interpret the patients’ symptoms and body language, and understand what the problem is, was highlighted by the participants and played an important role in the management of constipation. The importance of clinical reasoning is emphasized by Woolley (39), who considered that healthcare professionals need to develop specific skills in order to be able to provide an accurate diagnosis. Muller-Staub, de Graaf-Waar (40) described the usefulness of the nursing process as a systematic approach to the organization of nursing knowledge and clinical decision-making through assessing, diagnosing and identifying appropriate interventions, as well as following up and evaluating the effects of these interventions.
Creating opportunities for healthcare professionals to communicate with patients about bowel issues may be one way to increase awareness about patients’ subjective perceptions of constipation. This will open up for a dialogue between patients and healthcare professionals and might change clinical practice (21, 41, 42). Several healthcare professionals described the need to communicate with the patient about experiences of bowel function; however, it was healthcare professionals who decided which treatment options should be initiated. A person-centered approach where patient’s needs and subjective experience are taken into account has demonstrated better patient outcomes (43). To enable this, it is required that a person-centered approach is founded in the institutional leadership (44).
Another key finding of the present study was the different strategies that the participants reported for treating constipation. They described the importance of adhering to individual strategies as well as general strategies used on the ward, but they stated that pharmacological strategies were most commonly used and enabled individualized care. However, there seemed to be no consensus among the healthcare professionals’ choice of strategies and they also expressed uncertainty as to whether treatment was evidence based or not and thereby used their own individual strategies. This uncertainty was also found in previous studies (35, 45).
Day, Wills and Coffey (46) argue that individualized care is recommended and that a combination of several treatment options may be needed to treat constipation and, above all, they emphasize investigating which strategies the patients themselves use. Dimidi, Cox, Grant, Scott and Whelan (47) argue that numerous symptoms are identified by patients but are often not diagnosed by healthcare professionals according to diagnostic criteria or tools. This indicates that it is necessary to take the patient’s view into consideration when diagnosing the condition. The participants in this study also stated that the treatment should be individualized. However, they nevertheless proceeded to use pharmacological treatment as a first choice in a standardized manner and most of their actions were based on experience through clinical practice, which has also been described by others (48). It is not uncommon for healthcare professionals to rely on proven experience rather than evidence-based methods (49).
The healthcare professionals indicated that they were highly motivated to work with constipation in a preventive way, but were reliant on organizational resources, such as time and availability of staff, in order to meet the patients’ individual needs. Having enough knowledge and time to assess and prioritize the topic of constipation was also found to be important in a study by Saga, Seim, Morkved, Norton and Vinsnes (34) and might be related to organizational prioritization (41, 50). In the interviews, the healthcare professionals reported that it was important to be aware of patients’ risk factors and the consequences that constipation can lead to. A study by Goodman, Low and Wilkinson (51) previously found that healthcare professionals are aware of the importance of working preventively to avoid constipation. Such an awareness also emerged in this study through the participants’ descriptions of their ambitions to prevent constipation. However, despite the Swedish law on record keeping (52), this was something that was rarely documented by the healthcare professionals.
The healthcare professionals also highlighted the importance of a team-based approach. Teamwork was shown to reduce constipation among older patients when staff participated in a quality improvement method (53). However, Klein and Holowaty (54) found no reduction in constipation after the implementation of a Constipation Management Protocol, although the healthcare professionals became more observant of the patients’ normal bowel pattern and documentation improved. Lack of guidelines might be related to inadequate documentation, which has also been found in palliative care (55). Lee (56) argues that recordkeeping is important and in Sweden this is also mandatory by law. When preventive care processes, such as Senior Alert, have been implemented this has resulted in better structure and quality of care (57). Thus, the implementation of constipation risk assessment in the quality improvement register Senior Alert should be encouraged. When guidelines are used for best practice, there needs to be clearly identified clinical management and active communication between all members of the team (58) as well as effective team functioning (59).
All the participants were recruited from one medium-sized hospital with geriatric wards which may be a limitation. However, the participants’ represented a substantial variation in age, gender and work experience. The strength of this study was the use of a combination of focus groups and individual interviews, since rich data were provided about how healthcare professionals manage problems related to constipation. Another strength is that different professional perspectives were represented in relation to experiences of assessment, treatment and prevention, which may be valuable when implementing strategies and improving the care of older patients.