Effect of whole-process management based on planned behavior theory on postoperative recovery of acute appendicitis patients

Abstract

BACKGROUND

The theory of planned behavior (TPB) and whole-course nursing are mainly used for patients with cancer, chronic diseases, and other conditions that require long-term rehabilitation. There are few studies on diseases, such as acute abdomen, for which patients urgently need surgery. Owing to the particularity of acute abdomen and limited preoperative preparation, patients and their families may not fully realize the significance of postoperative rehabilitation and the development of good treatment behavior. Therefore, this study used acute appendicitis as an entry point to explore the influence of TPB and the whole-process management of acute abdominal disease.

AIM

To examine the impact of TPB-based whole-process management on postoperative rehabilitation and complications in patients with acute appendicitis.

METHODS

A total of 180 patients enrolled between July 2023 and June 2024 were randomly assigned via computer-generated sequence into two groups in a 1:1 ratio, with 90 cases each. In the control group, 17 cases withdrew, leaving 73 cases that ultimately received routine care. In the experimental group, 6 cases withdrew, leaving 84 cases that ultimately received full-process TPB management. The postoperative rehabilitation and complications were compared between the two groups.

RESULTS

The first exhaust time, bowel sound recovery time, first defecation time, first postoperative ground movement time, and postoperative hospital stay were shorter in the experimental group than in the control group (P < 0.05). The Visual Analog Scale scores of the experimental group were lower than those of the control group at 6 hours, 12 hours, 24 hours, and 48 hours postoperatively (P < 0.05). The total incidence of complications was lower in the experimental group than in the control group (P < 0.05). The total satisfaction rate of the experimental group was higher than that of the control group (P < 0.05). In both groups, patients 48 hours postoperatively had lower Self-Rating Anxiety Scale scores than those preoperatively. The Self-Rating Anxiety Scale score of the experimental group at 48 hours was lower than that of the control group (P < 0.05).

CONCLUSION

Whole-process management based on the TPB can shorten the postoperative recovery time in patients with acute appendicitis and reduce the incidence of pain and complications.

Key Words: Theory of planned behavior; Whole process management; Acute appendicitis; Postoperative rehabilitation; Complications

Core Tip: The theory of planned behavior, which is widely applied in China as well as globally, is underutilized in acute surgical conditions in clinical nursing. While commonly used for long-term rehabilitation in China, there is minimal research on its application in urgent surgeries such as acute abdominal diseases. Domestic studies primarily focus on preoperative full-course nursing for cancers (e.g., cervical and breast cancers) requiring extensive preparation, thereby neglecting acute cases such as appendicitis with rapid surgical turnover. This study pioneered the theory of planned behavior-based full-process management for patients with acute appendicitis and evaluated its impact on postoperative recovery and complication rates.

INTRODUCTION

Acute appendicitis is one of the most common acute abdominal emergencies, affecting 7%-10% of patients in the emergency department[1,2]. Based on clinical manifestations and pathological anatomy, appendicitis can be categorized into several types, including acute uncomplicated, acute gangrenous, perforated, acute suppurative, and periappendiceal abscess[3]. Currently, surgery is the primary treatment for appendicitis. However, surgery can easily cause physiological and psychological stress in patients and increase the risk of postoperative complications, such as incision infection and bleeding. This prolongs the recovery period and exacerbates the economic difficulties faced by patients and their families. Therefore, nursing interventions during intensive care are important.

Whole-course nursing involves focusing on all possible situations of a patient throughout the treatment period, placing patients at the center, and understanding their needs in an all-around manner to provide personalized care[4]. The theory of planned behavior (TPB) is a cognitive psychology theory based on the expected value model. By adjusting the patient’s attitude, subjective norms, and perceptual behavior, the patient’s behavior and outcomes may improve under the guidance of the TPB; it uses the nursing staff as well as the patient’s family members and friends to intervene in the patient’s postoperative diet, exercise, and psychology[5]. Therefore, we aimed to evaluate the effects of TPB-guided whole-process management on postoperative rehabilitation and complications in patients with acute appendicitis.

MATERIALS AND METHODS

Study participants

This study enrolled patients with acute appendicitis who were admitted to our hospital for surgery between July 2023 and June 2024. Patients were included if they met the following criteria: (1) Diagnosed with acute appendicitis by radiograph or computed tomography, laboratory examination and clinical features, and met the surgical indications[6]; (2) Age ≥ 18 years; (3) Normal listening and speaking function, and normal understanding ability; and (4) Underwent laparoscopic appendectomy. The exclusion criteria were as follows: (1) Severe liver, heart, and kidney dysfunction or malignant tumors; (2) Mental illness; (3) Other infectious diseases; and (4) Bleeding tendency or coagulation dysfunction. Ultimately, a total of 180 patients were enrolled in the study.

The participants were randomly assigned via computer-generated sequence into two groups in a 1:1 ratio, with 90 cases each. In the control group, 17 patients withdrew, leaving 73 participants who received routine care. In the experimental group, 6 patients withdrew, leaving 84 participants who received full-process TPB management. The control group included 31 males and 42 females, aged 24-75 years, with a mean age of (54.52 ± 10.84) years. The course of disease was 5-30 hours, with a mean course of (17.92 ± 7.41) hours. Of these, 36 cases were uncomplicated, 28 suppurative, and 9 gangrenous appendicitis. The experimental group comprised 48 males and 36 females, aged 24-74 years, with an average age of (55.49 ± 11.27) years. The course of disease was 6-32 hours, with an average course of (17.63 ± 7.13) hours. There were 45 patients with uncomplicated appendicitis and 32 with suppurative appendicitis. Seven cases of gangrenous appendicitis were noted. No significant differences were found in the general characteristics between the two groups (P > 0.05). All participants signed an informed consent form and the study was reviewed and approved by the hospital ethics committee.

Nursing intervention

The control group received the routine nursing care. Before the operation, the participants were provided with a surgical explanation, health education, and preoperative preparation. An aseptic technique was performed during surgery. Participants were followed-up after the operation with postoperative vital sign monitoring and health education.

Experimental group

The TPB-guided whole-course nursing in the experimental group included several specific contents, which are described as follows. First, a whole-course nursing group based on TPB guidance was established, including two physicians, one head nurse, two supervisor nurses, and four primary nurses. The head nurse organized these staff to undergo TPB and whole-course nursing training; they assumed their posts after completing the training.

Second, a preoperative behavior intervention was conducted. In the behavior attitude intervention, when patients were admitted to the hospital, the nursing group immediately explained their knowledge of acute appendicitis to patients. This allowed the patients to fully understand the pathogenic factors of acute appendicitis, precautions in daily life, surgical procedures, and postoperative care. When the patients asked questions, the staff were to be patient and avoid inappropriate language. The other intervention in this step was the subjective normative intervention. One primary family member was invited to participate in a preoperative education program. A postoperative ‘rehabilitation family support manual’ was issued to family members to clarify their roles in diet supervision, activity encouragement, and emotional support. The medical staff emphasized to patients that “the medical team and family jointly expect you to carry out the rehabilitation plan”, strengthening the pressure of social norms. The last intervention in this step was the perceived behavior control intervention. The Postoperative Rehabilitation Self-Efficacy Scale (Chinese version) was used to evaluate the patients’ confidence in ambulation and pain management (0-10 points), and a step-by-step demonstration was provided for low-score items.

Third, intraoperative nursing was conducted. The staff prepared the surgical items, soothed patients’ emotions, and mitigated stress responses caused by emotional overreactions. Close attention was paid to the patient’s vital signs during surgery. The operating room temperature was adjusted to 26 °C, and electric blankets and other insulation materials were provided. Fourth, a postoperative behavioral intervention was conducted. Postoperative precautions were explained to the patients; video and repeated oral education were utilized to deepen their understanding. Questions from patients were also answered in a timely and patient manner, to correct any incorrect cognitions about postoperative rehabilitation matters. The subjective behavior of the patients was also standardized in this intervention. This involved standardizing the patient’s dietary structure, ensuring they drink warm water 6 hours after surgery, and gradually transitioning their diet to a regular one. The provision of greasy, spicy, and irritating foods was avoided. Instead, vegetables and fruits rich in dietary fiber were included in the patient’s diet. Fewer but more frequent meals were provided to patients to avoid increasing gastrointestinal burden. Depending on their condition, the postoperative patients were guided to gradually regain mobility and resume physical activity. Family members filled in the family support log every day to record the number of diet/activity reminders (0-5 times) and the implementation status of the patients (yes/no). In positioning nursing, according to the patient’s anesthesia type, the patient is guided into the appropriate position. The semi-sitting position can be used within 6 hours after the operation. Regarding wound care, wound status and vital signs were continuously monitored after surgery. Regular cleaning and disinfection of the ward, as well as daily disinfection of the wound, were also carried out. These steps limited the number of visitors and prevented cross-infection. In pain nursing, regular assessment of pain level in patients were conducted after surgery. For patients with mild pain, nurses may provide psychological hints, music therapy, attention transfer, and other therapies to improve the pain threshold and reduce pain. For mild pain [Visual Analog Scale (VAS) 1-3], oral ibuprofen (400 mg, every 6 hours) or acetaminophen (500 mg, every 8 hours) was administered. For moderate pain (VAS 4-6), intravenous parecoxib sodium (40 mg, every 12 hours) or tramadol (50 mg as needed, with a minimum 6-hour interval) was administered. For severe pain (VAS ≥ 7), morphine (2-4 mg intravenous injection titration, adjusted based on response) or fentanyl (25-50 μg intravenous injection bolus) was administered. The patient’s preferred relaxation music was selected, three times a day (9:00, 14:00, 20:00) from 6 hours after surgery, 30 minutes each time, with a volume of ≤ 50 dB. The patients were prescribed analgesics according to medical instructions based on their level of pain intensity. Several steps were carried out to prevent postoperative complications. Changes in the patients’ body temperature were closely monitored after the operation. The staff observed whether the wound is red, swollen, painful, and fluctuating, and judged whether there is an infection. The staff also assisted patients in getting out of bed as soon as possible.

Lastly, a postoperative follow-up was conducted. One to two telephone follow-ups were conducted to inquire about the patient’s current recovery and provide corresponding health guidance. Patients in both groups were admitted to the hospital for a total of 2 weeks until the end of follow-up.

Observed indexes

The observed indexes in this study are described as follows: (1) Postoperative recovery index: The time to first exhaustion, defecation, ambulation, and hospitalization were recorded; (2) Pain: Wound pain was assessed at 6 hours, 12 hours, 24 hours, and 48 hours postoperatively using the VAS[7]. A 10-cm long ruler was used to measure the VAS score. One end of the ruler was marked with 0 points to indicate no pain, and the other end was marked with 10 points to indicate extreme pain; (3) Postoperative complications: Records were made on whether a patient has a postoperative incision infection, postoperative bleeding, intestinal adhesion, intestinal obstruction, or other complications; (4) Nursing satisfaction rate: Patients’ scores regarding nursing care were collected using a 0-100 scoring system. More than 90 points indicated “very satisfied”, 60-89 points “satisfied”, and less than 60 points indicated “dissatisfied”. The satisfaction rates of the two groups were compared; and (5) The psychological state of the patients in the two groups was evaluated 24 hours before and 48 hours after the operation. Anxiety levels were evaluated using the Self-Rating Anxiety Scale (SAS). The scoring standard was 20 items, with each item being 1-4 points; the full score was 100 points, and ≥ 50 points indicated anxiety.

Statistical analysis

Data was analyzed using the SPSS software (version 20.0). The data were tested for normality. Measurement data conforming to the normal distribution were expressed as (mean ± SD), and paired samples or two independent samples t-tests were used. The count data are expressed as (%), and the χ² test was used. P < 0.05 was considered statistically significant.

RESULTS

The postoperative recovery-related indicators of the patients in the two groups are summarized in Table 1. The experimental group demonstrated shorter first exhaust time, bowel sound recovery time, first defecation time, first ambulation time, and postoperative hospitalization time compared to the control group, with all differences being statistically significant (P < 0.05).

Table 1 Postoperative recovery-related indicators of patients with acute appendicitis, mean ± SD.

Group	n	The first exhaust time (hour)	Bowel sound recovery time (hour)	First defecation time (hour)	First ambulation time (hour)	Postoperative hospitalization time (days)
Experimental group	84	12.54 ± 2.41	8.96 ± 1.34	16.85 ± 3.06	7.86 ± 1.42	4.32 ± 0.52
Control group	73	13.64 ± 2.74	9.66 ± 1.75	18.85 ± 3.42	8.75 ± 1.84	5.41 ± 0.52
t		2.700	2.807	3.874	3.445	13.082
P value		0.008	0.006	< 0.001	0.001	< 0.001

A comparison of postoperative pain between the two groups is summarized in Table 2. The VAS scores of the experimental group at 6 hours, 12 hours, 24 hours, and 48 hours after surgery were lower than those of the control group (P < 0.05). The postoperative complications in the two groups are summarized in Table 3. The total postoperative complication rate in the experimental group was 3.57%, including one case of incisional infection, one of postoperative bleeding, and one of intestinal adhesion. The total rate in the control group was 12.33%, with five cases of incision infection, two of postoperative bleeding, one of intestinal adhesion, and one of intestinal obstruction. The difference in the total postoperative complication rates between the two groups was statistically significant (P < 0.05; Table 3).

Table 2 Comparative analysis of postoperative pain between the experimental and control groups, mean ± SD.

Group	n	6 hours after surgery (score)	12 hours after surgery (score)	24 hours after surgery (score)	48 hours after surgery (score)
Experimental group	84	4.17 ± 0.51	3.52 ± 0.50a	2.85 ± 0.36a,b	1.94 ± 0.36a,b,c
Control group	73	4.82 ± 0.63	4.85 ± 0.52	4.12 ± 0.58a,b	3.51 ± 0.53a,b,c
t		7.185	16.247	16.838	21.907
P value		< 0.001	< 0.001	< 0.001	< 0.001

^aP < 0.05 vs 6 hours after operation.

^bP < 0.05 vs 12 hours after operation.

^cP < 0.05 vs 24 hours after operation.

Table 3 Comparative analysis of postoperative complications between the experimental and control groups, n (%).

Group	n	Incision infection	Postoperative bleeding	Intestinal adhesion	Ileus	Total rate
Experimental group	84	1 (1.19)	1 (1.19)	1 (1.19)	0 (0)	3 (3.57)
Control group	73	5 (6.85)	2 (2.74)	1 (1.37)	1(1.37)	9 (12.33)
χ2						4.243
P value						0.039

A comparison of patient nursing satisfaction between the two groups is summarized in Table 4. The experimental group had an overall satisfaction rate of 98.81%, with 52 patients very satisfied, 31 satisfied, and 1 not satisfied. The control group had an overall satisfaction rate of 90.41%, with 24 patients very satisfied, 42 satisfied, and seven not satisfied. The overall satisfaction rate of the experimental group was significantly higher than that of the control group (P < 0.05; Table 4). The SAS scores of the patients in the two groups are summarized in Table 5. The SAS scores of both groups of patients 48 hours after the operation were lower than those before the operation. The SAS score of the experimental group at 48 hours was lower than that of the control group (P < 0.05).

Table 4 Comparative analysis of nursing satisfaction between the experimental and control groups, n (%).

Group	n	Very satisfied	Satisfied	Not satisfied	Total satisfaction rate
Experimental group	84	52 (61.90)	31 (36.90)	1 (1.19)	83 (98.81)
Control group	73	24 (32.88)	42 (57.53)	7 (9.59)	66 (90.41)
χ2					6.235
P value					0.013

Table 5 Comparison of Self-Rating Anxiety Scale scores between the experimental and control groups, mean ± SD.

Group	n	24 hours before surgery (score)	48 hours after surgery (score)
Experimental group	84	52.71 ± 6.84	42.37 ± 5.13a
Control group	73	53.13 ± 7.25	48.55 ± 6.93a,b
χ2		0.373	5.141
P value		0.710	0.001

^aP < 0.05 vs 24 hours before operation.

^bP < 0.05 vs the experimental group.

DISCUSSION

Acute appendicitis is commonly encountered in emergency departments and is a common indication for emergency abdominal surgery. The time from its onset to surgery is short and patients often have insufficient psychological preparation and awareness of the disease, leading to negative emotions, such as anxiety, fear, and insecurity, and psychological stress[8]. The TPB, proposed by American psychologist Icek Ajzen, is based on the rational hypothesis of people’s behavior. It postulates that individuals will process and analyze information before acting and rationalize their actions. These reasons constitute the motivation for behavior, specifically behavioral intention, which is a direct determinant of behavioral implementation[9,10]. The whole-process risk management approach suggests that the condition is a dynamic process and that the occurrence of risk events may also be closely related to changes in the condition. This patient-centered model understands the specific situation of the patient through regular assessments to take relevant measures. It can improve the utilization rate of time and effectively reduce the incidence of adverse events, such as pressure injuries and falls.

This study demonstrated that through whole-process management based on TPB guidance, the postoperative recovery time of patients was shortened, and postoperative pain was reduced. The TPB covers five core elements: Behavioral attitude, subjective norm, perceived behavioral control, behavioral intention, and actual behavior. This theory holds that behavioral intention is a key predictor of behavior, and is influenced by behavioral attitudes, subjective norms, and perceived behavioral control. At the same time, perceived behavioral control not only affects behavioral intentions but also directly affects behavior[11].

In the process of intervention, TPB-based nursing helps patients initially understand the etiology and surgical process of acute appendicitis through brief preoperative health education, such that they can initially prepare for surgery and avoid stress responses due to insufficient psychological preparation. After the patient is awake, the nursing measures and precautions after appendicitis are explained in detail to help the patient realize the importance of disease management, help the patient to establish an attitude, mobilize the subjective initiative, reduce avoidance and yield psychology, and motivate the patient to actively face the disease treatment and rehabilitation; these reduce the patient’s fear and unawareness of the disease, thereby improving the patient’s treatment compliance and shortening the patient’s postoperative recovery time[12,13].

Wang and Gu[14] demonstrated that nursing models based on the Health Belief Model and TPB can benefit patients undergoing limb fracture surgery by reducing swelling, alleviating pain, promoting symptom resolution, accelerating rehabilitation, and enhancing self-care management. Whole-course nursing can combine a patient’s disease and individual characteristics and implement nursing measures before, during, and after surgery. Compared to routine nursing, its content is more comprehensive and can better ensure the continuity and integrity of nursing activities[15,16]. Intraoperative heat preservation measures can effectively prevent tissue damage caused by low-temperature environments, and reduce the inflammatory response associated with postoperative rewarming[17]. The patients were kept supine for > 6 hours after surgery to avoid dizziness, nausea, and vomiting after anesthesia[18]. Providing warm water to patients 6 hours after surgery can help activate gastrointestinal function, reduce the risk of intestinal adhesions, protect the intestinal barrier, decrease the likelihood of infection, and minimize the need for antibiotics, ultimately leading to cost savings[19,20]. Guiding patients’ early postoperative activities can promote intestinal peristalsis, which not only helps accelerate the recovery process but also effectively reduces the risk of postoperative complications.

This study indicated that nursing satisfaction was higher in the experimental group and the SAS score 48 hours after the operation was lower than that in the control group. Pre and postoperative education guided by whole-process management and the TPB theory can alleviate patients’ negative emotions, such as tension and anxiety, enhance nurse-patient communication, and boost patient trust in the medical team[21]. Patients are provided with various types of nursing care after surgery to shorten the postoperative recovery time, reduce postoperative pain, decrease the incidence of postoperative complications, decrease hospitalization time, and improve the quality of life after surgery. In whole-process management, patients are still followed up after discharge, encouraging them to lead a healthy life such that they feel the care and attention of the medical staff. Therefore, under the whole-process management intervention of TPB, patients’ satisfaction with nursing has improved.

This study had several limitations. First, because of the geographical limitation of patients’ residences, most of the studies were based on the principle of nearby treatment and did not involve hospitals in other regions and different levels, which may lead to selection bias. Second, the follow-up period was set at 2 weeks, and the main evaluation was perioperative indicators. However, postoperative complications, such as intestinal adhesion and incisional hernia, may occur later. Future studies should further expand the sample size and extend the follow-up to 3-6 months after surgery to monitor the occurrence of delayed complications. Third, although the overall data showed that the TPB intervention was effective, it was not stratified by pathological type (i.e., simple/suppurative/gangrenous). Increasing the sample size may achieve the efficacy test of pathological subgroups. Fourth, this study only analyzed the impact of the consultation mode on patients and did not quantify the economic value of the TPB whole-process management. A Markov model should be used to determine its resource input-output ratio, which may lead to a better promotion of the TPB-guided whole-process management in clinical practice.

CONCLUSION

Whole-process management based on TPB guidance can shorten the postoperative recovery time in patients with acute appendicitis and reduce the incidence of pain and complications. It is not only suitable for patients with acute appendicitis but also provides theoretical support and practical guidance for the nursing of patients with other acute abdominal conditions, such as cholecystitis and intestinal obstruction.