In this study, we investigated the constipation management and assessment practices in LTC wards in Japan. Practicing constipation management was associated with organizational factors and ward manager. To the best of our knowledge, this is the first study to describe the practice of constipation management/assessment in LTC wards.
In almost all LTC wards, nurses assessed the daily frequency of bowel movements, but other characteristics of elimination (e.g., stool consistency and amount) were not as extensively examined. Given that nurses determined the presence of constipation based on bowel movement frequency in many cases,32 it is habitually recorded in LTC hospitals. Conversely, the implementation of other assessments varied from 10% to 68% despite the nursing guideline recommendation of the importance of multiple assessments.10 Although 50% of ward nurses assessed stool consistency, only 20% used BSFS, suggesting a lack of assessment with standardized tools in LTC wards. Adding a recording field for assessment with a standardized tool, such as BSFS, could facilitate constipation assessment and result recording.
In almost all LTC wards, nurses used laxatives daily, which was consistent with previous studies.7,33 Contrary to the recommendation of clinical guidelines,12,23 70% of ward nurses used stimulant laxatives on consecutive days, indicating that healthcare providers in LTC settings do not use them properly.
LTC ward nurses did not implement non-pharmacological management as frequently as the use of laxatives. They reported increased fluid intake and regular encouragement to use the bathroom. Meanwhile, only 20%–30% of ward nurses implemented the intake of dietary fiber and probiotic products, a relatively new but costly approach, which has been reported in a previous study.11 Given that LTC wards in Japan are financed by the pay per capita system, LTC ward staff may face financial challenges regarding the introduction of such a novel approach for constipation management.
Certain characteristics of LTC ward managers, including their perception of constipation management and their knowledge of stimulant laxative use, were associated with practicing constipation management. Ward manager support has been shown to enhance nurses’ evidence-based practice.16 Therefore, to facilitate effective constipation management, LTC ward managers should have the knowledge of and perceive the importance of constipation management.
The existence of nursing record fields for constipation assessment, including the standardized assessment tool, and a nursing care plan for constipation were also associated with the practice of constipation management. The result is consistent with that of a previous study reporting that care planning for laxative use was related to its actual use.33 Thus, modifying the organizational recording system to include a standardized assessment tool, such as BSFS, and standardized care planning for constipation management could promote effective constipation management.
The conference and organizational climate were associated with the use of non-pharmacological management and implementation of probiotic and dietary fiber products, rather than laxative use. The results suggest that while the use of medication could be changed only by intervention from the ward managers and the recording system, non-pharmacological constipation management, which is time-consuming and costly, would need an additional approach to promote discussion and care in the organization.
Based on the study results, we recommend two major strategies targeted at ward managers and hospital organization to improve constipation management in LTC hospitals. For LTC ward managers, interventions to facilitate and support successful constipation management34 might be useful to change their beliefs on use of laxatives. For the organization, changing the recording system (e.g., integrating evidence-based assessment/management into the nursing record), conducting audits and regularly providing feedback during case conferences,35 and increasing learning opportunities (e.g., organizing training sessions in the hospitals) may contribute to promoting effective constipation management.
This study has several limitations. First, the cross-sectional design prevented us from concluding a causal relationship among variables. Second, we only asked one staff member about the organizational climate; therefore, it may not have been adequately assessed. Finally, we could not determine the constipation management for each individual patient. Patients’ physical conditions and causes of constipation vary. In future studies, we should clarify the constipation management for each patient to determine effective strategies according to their individual condition.