Problem-solving model guided by stimulus-organism-response theory: State of mind and coping styles of depressed mothers after cesarean delivery

Abstract

BACKGROUND

The use of a problem-solving model guided by stimulus-organism-response (SOR) theory for women with postpartum depression after cesarean delivery may inform nursing interventions for women with postpartum depression.

AIM

To explore the state of mind and coping style of women with depression after cesarean delivery guided by SOR theory.

METHODS

Eighty postpartum depressed women with cesarean delivery admitted to the hospital between January 2022 and October 2023 were selected and divided into two groups of 40 cases each, according to the random number table method. In the control group, the observation group adopted the problem-solving nursing model under SOR theory. The two groups were consecutively intervened for 12 weeks, and the state of mind, coping styles, and degree of post-partum depression were analyzed at the end of the intervention.

RESULTS

The Edinburgh Postnatal Depression Scale and Hamilton Depression Scale-24-item scores of the observation group were lower than in the control group after care, and the level of improvement in the state of mind was higher than that of the control group (P < 0.05). The level of coping with illness in the observation group after care (26.48 ± 3.35) was higher than that in the control group (21.73 ± 3.20), and the level of avoidance (12.04 ± 2.68) and submission (8.14 ± 1.15) was lower than that in the control group (15.75 ± 2.69 and 9.95 ± 1.20), with significant differences (P < 0.05).

CONCLUSION

Adopting the problem-solving nursing model using SOR theory for postpartum depressed mothers after cesarean delivery reduced maternal depression, improved their state of mind, and coping level with illness.

Key Words: Stimulus-organism-response theory, Problem solving model, Cesarean section, Postpartum depression

Core Tip: Reasonable and effective nursing interventions play a pivotal role in alleviating an individual's psychological burden and elevating their overall state of mind. This is particularly crucial for postpartum mothers who are suffering from depression after undergoing a cesarean delivery, as it can significantly contribute to their emotional recovery and well-being.

INTRODUCTION

Postpartum depression is a common affective disorder type of disease in the puerperium of postpartum women. Women in the postpartum 6 week such experience irritability, depression, sadness, frustration, and other psychological states, and even some patients have symptoms such as hallucinations and negativity, which significantly affect the adaptive process of women's role transition, so that their self-efficacy is reduced, causing serious psychological problems and affecting their state of mind[1,2]. Nursing intervention is an important solution that affects the psychological state of an individual, and the use of reasonable and efficient nursing measures can improve the postpartum state of mind and improve the way of postpartum depressed mothers to cope with the disease. The total detection rate of postpartum depression among elderly women in China is 20.0%[3]. The prevalence of postpartum depression among women ranges from 5%–26% and is the main cause of disability and suicide in the first year of the postpartum period among women worldwide[4]. In recent years, the number of psychosocial and physiological studies on postpartum depression has increased with the increasing prevalence of postpartum depression. Improving the psychological function and perinatal outcomes of postpartum depressed mothers has been studied extensively reported. However, the processes and effects of each intervention method vary, and there is a lack of corresponding normative standards. The stimulus-organism-response (SOR) theory is an important branch of modern social psychology that was first proposed in 1988 by the social psychologist Tesser AI, and consists of three parts: Stimulus, organism, and behavioral response. It was widely used in the field of psychology to promote the individual self-esteem, improve the level of individual emotional management, and quality of life[5]. This theory believes that individual behavior is influenced by individual and social guidance, contradictory behaviors between the individual and the social environment, and emphasizes the systematic and dynamic nature of individual psychological problems, wherein the stimulus (S) indicates the external environmental factors of the organism (O), which acts as a mediator variable to represent the individual's change in psychological state, such as affective or cognitive responses, and the response (R) is the outcome of the individual's attitude or behavior variables. Mastery of SOR theory can provide an effective way to cope and deal with psychological problems. The use of conventional care alone lacks systematicity and specificity owing to the many risk factors that lead to postpartum depression, while holistic care is too general, resulting in sub-optimal problem solving. Therefore, this study adopted problem-solving nursing measures based on SOR theory and corresponding nursing interventions to improve the effectiveness of nursing interventions. In this study, we used women with postpartum depression after cesarean section as the case object, and analyzed the application effect of the problem-solving nursing model under the guidance of SOR theory.

MATERIALS AND METHODS

Eighty cases of postpartum depression after cesarean delivery admitted to the hospital from January 2022 to October 2023 were selected, and the inclusion criteria were: (1) All the included mothers underwent cesarean section in the hospital, which was caused by fetal malposition, low amniotic fluid and other factors, and was not owing to pregnancy complications; (2) singleton pregnancy; (3) conforming to the criteria for the determination of post-partum depression[6]; (4) each of them were in the first year of the postpartum period; and (5) all the mothers were informed of the specific details and contents of the study and signed a consent form. The exclusion criteria were as follows: (1) Prenatal ultrasound suggesting concomitant fetal malformations, fetal growth restriction, and other diseases; (2) newborns requiring resuscitation and treatment; (3) gestational hypertension, eclampsia, diabetes, and other diseases; (4) major physical dysfunctions; (5) mental disorders, such as anxiety and depression prior to the cesarean section; (6) malignancy; and (7) major adverse events, such as the death of a loved one.

The mothers were divided into two groups according to the random number table method, and there was no significant difference in the comparison of the basic information of each group (P > 0.05; Table 1).

Table 1 Comparing basic information of two groups.

Factor	Observation (n = 40)	Control (n = 40)	χ2	P value
Age (year)			0.503	0.478
≤ 35	25	28
> 35	15	12
Number of births			0.808	0.369
Primigravida	24	20
Menstruation	16	20
Education			0.774	0.679
Junior high and below	10	8
High school	23	22
College and above	7	10
Fetal gender			0.201	0.654
Male	22	20
Female	18	20
Profession			0.863	0.650
Fixed profession	12	15
Freelance	18	18
Unemployed	10	7
Weeks of pregnancy	39.92 ± 1.02	40.01 ± 1.05	0.151	0.698
BMI (kg/m2)	23.04 ± 1.84	22.96 ± 1.94	0.036	0.850

BMI: Body mass index.

Methods

The control group adopted conventional care; that is, instructed mothers to correctly apply antidepressant drugs; nursing staff communicate effectively with mothers, listening patiently to their psychological state, guiding them to analyze the reasons for the emergence of adverse psychological state, and encouraging them to cope with it positively; explaining to mothers the reasons for postnatal depression, and conducting psychological counselling; leading mothers to adapt to the role and gradually change; encouraging mothers to insist on breastfeeding, and increase touch and play activities between mothers and newborn babies to promote parent-child communication. Increase maternal and newborn babies’ touch and play activities to promote parent-child communication.

The observation group adopted the problem-solving nursing model under the guidance of the SOR theory based on the control group. (1) Formation of the SOR care team: The team consists of doctors, nurses and psychologists. The doctor is responsible for diagnosing and treating the mother's condition, the nurse is responsible for health promotion, and the psychologist is responsible for psychological counselling; (2) External stimulation: One-on-one communication is needed before the birth of the baby to understand the misconceptions about postnatal rehabilitation and infant feeding, and then to summarise the issues raised. Postnatal rehabilitation care includes postnatal observation and postnatal complications, as well as postnatal recovery and sleep quality. In addition, they need to communicate with patients in a warm manner, give them psychological comfort, and encourage them to vent their negative emotions; (3) Cognition and emotion: For the postpartum problems in the recovery process, we need to provide targeted care: before discharge, mothers can scan the code to join the home rehabilitation WeChat group, and real name system; for the problems arising in home rehabilitation group members regularly live broadcasting to implement health education, 40 min/session; and postpartum can be used to implement the study of WeChat public number, and in the public number of regular dissemination of relevant nursing information, during the process, mothers can according to their own needs, and the public information can be distributed. In the process, mothers can ask questions to the nursing staff according to their own needs, and then the nursing staff will give them targeted answers; (4) Peer education can be carried out on a regular basis, usually by inviting mothers who have successfully recovered, and then training them, allowing them to share their own experiences, and then letting other people learn about it; (5) Mothers need to be encouraged to learn how to take care of the newborns, to improve their own nursing skills and to enhance their sense of satisfaction, so that they can learn as soon as possible, and then they can be encouraged to learn how to care for the newborns; (6) Mothers need to be encouraged to learn how to care for newborns, to improve their own caregiving skills, and to increase their sense of self-satisfaction, so that they can enter the role of motherhood as soon as possible; and (7) After discharge from the hospital, the nursing staff should instruct the mothers to follow the rehabilitation support programme, carry out self-monitoring on a daily basis, and then summarize the rehabilitation status of the day and make improvements to the rehabilitation programme for the next day.

Problem assessment

The nursing staff communicated with the mother and her family to create a quiet and private environment, and the content of the problem assessment and survey was kept confidential to protect the mothers’ privacy. Nursing staff used unstructured interview methods to conduct the assessment and investigation, on-site audio recording and recording of the survey content, and initially asked "How do you feel recently?". The nursing staff used an unstructured interview method to conduct the assessment and survey and recorded the content of the survey by initially asking "How do you feel recently?", so that they could freely explain their feelings and gradually extend the topic to mother-in-law-daughter-in-law relationships, husbands and wives, family economy, childcare, postnatal rehabilitation, and other issues to clearly identify the relevant issues that may induce and aggravate postnatal depression, and to provide a reference basis for the next step of care.

External stimulation

According to information from the survey and assessment, common problems of home rehabilitation for mothers include cesarean section incision recovery, scientific childcare, postpartum physical recovery, and mother-in-law and husband-wife relationships. We assessed the degree of maternal awareness of postpartum depression by examining the distribution of health brochures, scientific lectures, and one-on-one communication methods. We briefly explained that the caesarean section has no obvious negative impact on later life, establishing a correct view of childbearing, explaining the erroneous thinking of favoring sons over daughters, and emphasizing the equality of men and women and knowledge of genetics. Mothers were guided to participate more in newborn care and early contact between mothers and their babies was emphasized. A relaxed and pleasant family atmosphere was encouraged by reducing the impact of external stimuli on the mother, such as crying babies and quarrels between husband and wife; encouraging the mother to participate in more work and recreational gatherings after her discharge from the hospital; and helping the mother to take on childcare work to divert the mother's attention and alleviate her psychological and physiological burdens.

Cognitive and emotional wellbeing

Strengthening couples’ health management by organizing one-on-one communication between mothers and their husbands; encouraging mothers to frankly explain their psychological state, demands, and dissatisfaction with daily life; and reminding husbands to listen to mothers' demands more often. For example, husbands are unable to play a coordinating role in mother-in-law-daughter-in-law relations, adopting an avoidant attitude and avoiding positive communication with their wives and mothers; husbands do not understand their wives and cannot share household chores in husband-and-wife relations; and both husbands and wives lack experience in parenting in terms of child-rearing; for example, they do not know what to do when their children are crying and are only fed up with the situation. Therefore, we have done a good job of health education for the husbands of women who have given birth, and we have provided them with scientific information and analysis of the postnatal emotional changes so that the husbands can accurately understand postnatal depression. At the same time, we have done a good job of training husbands and mothers in the skills of caring for their newborn babies, stressing the importance of breastfeeding, and mastering the basic measures of bathing and feeding newborn babies, so that the husbands can actively take on the basic tasks of crying, feeding milk powder, and changing nappies.

Psychological counselling: Mothers are given explanations of postpartum physical rehabilitation measures (such as postpartum yoga and postpartum gymnastics) and measures for the care of incisions after caesarean section to reduce the psychological burden on mothers through the distribution of manuals and the recording of rehabilitation videos. Understanding the psychological needs of mothers, discussing their feelings and experiences during pregnancy and childbirth, adopting narrative and reminiscence methods, using music, videos, photographs, and other materials to guide mothers to recall their past good experiences in life, the most unbeautiful work experiences, pleasant trips, my beloved relatives, and so on will help mothers build up their confidence in their future lives and cultivate a sense of responsibility, and enable them to positively cope with changes in their roles. Peer support work is organized with mothers who have good communication skills and have made a good transition to recovery, leading other mothers to learn about parenting and postnatal return to work measures. Maternal and child healthcare study manuals are distributed, and regular peer exchange and recreational activities are organized (such as shopping and watching movies) to gradually enable mothers to return to a normal life and divert their attention.

Positive thinking: Positive thinking, walking, meditation, yoga, and breathing training were combined with maternal recovery and emotional transformation. Initially, the medical staff investigated the maternal psychological state and influencing factors, led the maternal body scanning, positive thinking meditation, and positive thinking yoga through body scanning and meditation so that the mother could feel the present moment, accept the reality, and change its thinking mode; the nursing staff guided the maternal 3 min breathing exercises, lip-contracting respiration, abdominal respiration, and torso relaxation; and then to carry out positive thinking yoga, to learn the method of yoga, and to guide its; the nursing staff instructed the mothers to perform 3-minutes breathing exercises, lip-contraction breathing, abdominal breathing, and somatic relaxation.

Home-based rehabilitation care: A WeChat platform for mothers was created, called "Love Yourself”, and mothers are required to join the group, send the knowledge of parenting skills, post-partum depression, post-partum exercise and rehabilitation, post-partum diet, observation of the incision after caesarean section, prevention of complications, and so on to the group by combining graphics and texts, and answering the problems encountered by mothers, combined with videos and online live broadcasts. Furthermore, the group provides rehabilitation exercises and healthy diets in combination with videos and online live broadcasts and tries to meet the reasonable needs of mothers as much as possible. Peer experience sharing is arranged once a week in the group, with women who have successfully recovered sharing their experiences of postnatal rehabilitation, precautions, and psychological experiences, setting an example to motivate them to actively learn relevant rehabilitation skills and pregnancy knowledge.

Response

The two groups were continuously intervened for 12 week every weekend through WeChat and telephone follow-up to investigate the implementation of the home rehabilitation plan after the discharge of the mother; to instruct the mother to recall today's mental thoughts, behaviors, and the completion of the rehabilitation program before going to bed every day; to learn about the problems in the process of rehabilitation by summarizing and reflecting on them and to make improvements.

Observation indicators

Depression level: Survey and assessment was conducted before and after nursing care using the Edinburgh Postnatal Depression Scale (EPDS)[7]; the scale involves 10 questions, each question is 0–3 points, with a total score of 30 points; if the score ≥ 13 points, there is the possibility of depression; the Hamilton Depression Scale (HAMD) contains 24 items[8], with outcomes of no depression, mild, moderate, and severe depression, respectively with 0–7, 8–19, 20–35, and > 35 points, respectively.

Mood state: The Brief Mood State Scale[9] was used before and after care, involving tension-anxiety (9 items, 0-36 points), depression-frustration (15 items, 0-60 points), anger-hostility (12 items, 0-48 points), fatigue–sluggishness (7 items, 0-28 points), confusion (7 items, 0-28 points), and energy-vigor (8 items, 0-32 points); the higher the score, the more.

Coping styles: Surveys were conducted before and after nursing care and evaluated using the Medical Coping Style Questionnaire[10], a 20-item scale with each item counting 1-4 points: patients faced (8 items, 8-32 points), avoided (7 items, 7-28 points), and succumbed (5 items, 5-20 points) dimensions; the higher the score for each dimension, the more the individual tends to that type of coping style.

Statistical methods

Data within the study were statistically analyzed using SPSS version 26.0. Measured data were expressed in the form of (mean ± SD), meeting the normal distribution, the test of inter-group and intra-group data with independent and paired samples t, respectively; not meeting the normal distribution, expressed in the form of the median or for the interquartile spacing, the test of intra-group and inter-group data with paired and sample rank sum, respectively; count data were the rate (%), χ² test; P < 0.05 for the difference was statistically significant.

RESULTS

Before care, there was no significant difference in depression scores between the groups (P > 0.05); after care, depression scores were reduced between the groups, and EPDS and HAMD scores were lower in the observation group (P < 0.05; Table 2).

Table 2 Comparison of depression scores between the two groups (score, mean ± SD).

Group	EPDS		HAMD
	Before	After	Before	After
Observation (n = 40)	17.13 ± 2.18	8.14 ± 1.67	21.15 ± 4.28	11.48 ± 2.48
Control (n = 40)	16.92 ± 2.25	11.08 ± 1.95	20.96 ± 4.35	15.83 ± 3.16
t value	0.348	5.950	0.162	5.627
P value	0.729	< 0.001	0.872	< 0.001

EPDS: Edinburgh Postnatal Depression Scale; HAMD: Hamilton Depression Scale.

State of mind

Before nursing, there was no significant difference in the state of mind scores between the groups (P > 0.05), after which the state of mind between the groups improved; the observation group had the best degree of improvement (P < 0.05; Table 3).

Table 3 Comparison of mindfulness scores between groups (score, mean ± SD).

Group	Nervousness-anxiety		Depression-frustration		Anger-hostility		Tiredness-slowness		Bewilderment-confusion		Energy-vigor
	Before	After	Before	After	Before	After	Before	After	Before	After	Before	After
Observation (n = 40)	21.04 ± 3.89	8.14 ± 1.8a	40.25 ± 4.84	13.52 ± 2.4a	19.02 ± 2.87	6.15 ± 1.5a	15.05 ± 2.08	5.24 ± 1.28a	16.38 ± 2.15	6.89 ± 1.3a	9.08 ± 3.14	17.52 ± 1.6a
Control (n = 40)	20.96 ± 3.94	11.69 ± 1.9a	39.81 ± 4.96	16.98 ± 2.5a	18.73 ± 3.01	8.98 ± 1.6a	14.92 ± 2.12	7.18 ± 1.35a	16.10 ± 2.25	8.52 ± 1.4a	8.89 ± 3.20	13.24 ± 1.8a
t value	0.091	8.417	0.402	6.127	0.441	7.926	0.277	6.595	0.569	5.144	0.268	4.382
P value	0.927	< 0.001	0.689	< 0.001	0.660	< 0.001	0.783	< 0.001	0.571	< 0.001	0.789	< 0.001

^aP < 0.05 comparison with pre-care data between groups.

Level of coping

Before care, coping with the disease was compared between the groups (P > 0.05), after which coping improved in all groups, with the observation group showing the best level of improvement (P < 0.05; Table 4).

Table 4 Comparison of coping with illness between groups (score, mean ± SD).

Group	Face-to-face		Circumvent		Surrender
	Before	After	Before	After	Before	After
Observation (n = 40)	15.95 ± 3.18	26.48 ± 3.35a	19.12 ± 2.48	12.08 ± 2.50a	12.04 ± 2.68	8.14 ± 1.15a
Control (n = 40)	16.20 ± 3.25	21.73 ± 3.20a	18.92 ± 2.51	15.75 ± 2.69a	11.92 ± 2.75	9.95 ± 1.20a
t value	0.348	6.485	0.358	6.321	0.198	6.887
P value	0.729	< 0.001	0.721	< 0.001	0.844	< 0.001

^aP < 0.05 comparison with pre-care data between groups.

DISCUSSION

Postpartum depression is a common emotional problem that occurs specifically in women, mainly owing to endocrine and social factors, genetics, and adverse emotions during pregnancy[11]. Among them, cesarean section is the main mode of maternal delivery, with poor postpartum morphological recovery, destroyed physical integrity, lasting pain, long recovery time, and other conditions, that further affect the maternal psychological state, aggravating the degree of depression[12]. For postpartum depressed mothers, nursing intervention is the main solution. The SOR concept is a theoretical model for individual behavior caused by a variety of stimuli, and the stimulus is embodied in the individual's physiological and psychological factors, but also from external environmental factors, which produce a variety of behavioral motives[13]. Therefore, this study adopted the problem-solving nursing model under the guidance of the SOR theory, using the problem as the nursing orientation and combining the SOR theory with corresponding nursing interventions, which can standardize the nursing process and improve the level of clinical care.

This study showed that the EPDS and HAMD-24 item scores of the observation group were lower than those of the control group after nursing care (P < 0.05), indicating that the use of the problem-solving nursing model under the guidance of the SOR theory could alleviate the degree of maternal depression. There are few clinical reports about the effect of this kind of nursing program on postpartum depression; SOR theory is mainly used to analyze the psychology and behavior of consumers, and is gradually used in the analysis of social psychology. The use of the SOR theoretical model can be accurately and effectively analyze the individual psychological and behavioral analysis of the period of the new coronary pneumonia changes[14]. Therefore, we can understand the psychological problems of mothers, and based on the SOR theory through the assessment of the problem, we can analyze the external stimulus factors, and conduct the corresponding nursing solutions in the cognitive and emotional domains to improve the level of nursing interventions, create a good family atmosphere, improve the relationship between the husband and the wife, improve their parenting skills, enrich their experience of parenting, and avoid the state of depression owing to the cognitive deficiencies and insufficient nursing care.

State of mind is an emotional state that affects all experiences and significantly influences an individual's life, work, mental state, and behavioral performance. Post-traumatic stress disorder arising after cesarean section may contribute to the development of postpartum depression[15], which directly affects an individual's state of mind. Early symptoms of postpartum depressed mothers were sadness, fatigue, feelings of neglect, lack of interest in the baby, decreased appetite, and sleep disturbances[16]. In this study, tension-anxiety, depression-frustration, anger-hostility, fatigue-sluggishness, and confusion-confusion were lower and energy vitality was higher in the observation group than in the control group after nursing care (P < 0.05). The results indicate that the use of the problem-solving nursing model guided by SOR theory can improve the maternal state of mind. Through problem assessment and external stimulus analysis, intervention, combined with maternal disease characteristics and clinical information, the common problems in the process of maternal recovery were analyzed, and the mothers and husbands were helped to establish a correct view of childbearing; and to create a relaxing and pleasant family atmosphere to reduce the impact of external stimuli on the mothers, and to encourage the mothers to participate in more recreational activities, participate in the work, and so on. This alleviates the mothers' psychological and physiological burdens and strengthens the maternal psychological care to help establish the maternal state of mind. At the same time, strengthening maternal psychological care, helping mothers build confidence in their future lives, cultivating their sense of responsibility, and playing the role of role models to motivate mothers to form positive behaviors can reduce the state of maternal depression; through the connection of positive thoughts, breathing, body sensation, and observation of awareness, other methods can divert the attention of the mothers to alleviate the negative state of mind and to regulate the emotional state of the mothers[17].

Individuals can face stressful events and environments to resist negative emotions and avoid avoidance or withdrawal. The study showed that the level of coping with illness was significantly higher in the observation group than in the control group after care, indicating that the problem-solving nursing model guided by the SOR theory improves the level of maternal coping with illness[18]. This nursing programme strengthen the husband and wife's health management by coordinating the role of the husband to undertake household activities, and do a good job of husband and wife's parenting skills training, which can improve the maternal and husband's knowledge of the disease mastery level, and after discharge from the hospital through the WeChat platform to push the maternal postnatal rehabilitation exercise, healthy diet and other knowledge, to promote the maternal actively learn the relevant rehabilitation skills, and cope with postnatal depression. Furthermore, the positive thinking exercises can increase maternal coping with the disease level. These exercises were divided into 3-min breathing exercises and ice-holding exercises, which enabled the mothers to gradually complete the psychological state of acceptance, trust, and inaction to face the present, guide them to face and accept the disease directly, lower their perceptual pressure, and improve their coping with the disease.

In the future, we also need to increase the sample size by a certain amount in order to avoid limitations such as study design and potential confounders, which will strengthen the credibility of the study, and further research could enhance the generalisability of the findings and provide deeper insights into the mechanisms behind the observed effects.

CONCLUSION

Adopting the problem-solving nursing model guided by the SOR theory for postpartum depressed mothers after cesarean delivery can significantly reduce the degree of maternal depression, improve their state of mind, reduce maternal tension-anxiety, depression-frustration, anger-hostility, and fatigue-sluggishness negative state of mind, increase their energy-vitality level, and improve their coping level with illness, which can be an ideal care method for postpartum depressed mothers.