Introduction

Atrial fibrillation (AF) is the most common clinical arrhythmia, affecting nearly 10 million people in China, the country with the highest AF prevalence in the world [1]. AF has a high morbidity, mortality, disability, and readmission rate, which not only causes significant symptom burden but also impairs patients’ psychological well-being [2,3]. According to studies, women with AF have worse symptoms, a lower quality of life, and a higher risk of stroke and death than men with AF [4]. Although Radiofrequency Ablation (RFCA) has shown promising results in reducing AF symptoms, there is still a risk of AF recurrence after surgery [5], and studies have shown that effective self-management can reduce disease burden and post-operative complications in patients with chronic disease [6]. Good self-management skills, and thus the ability to manage disease-related symptoms, physical and psychosocial changes, are required for effective self-management [7]. Furthermore, the recurrence of postoperative AF causes severe psychological distress (anxiety, depression, etc.), which leads to the recurrence of AF, creating a vicious circle [8]. Postoperative anxiety and depression are more severe in women patients [9] and have a negative impact on patients’ self-management [10]. Positive psychology has been shown in studies to have a positive predictive effect on patients’ self-management [11].

Positive psychology, pioneered at the end of the twentieth century by Martin Seligman [12], advocates focusing on people’s positive psychological qualities to guide them toward happiness and health by tapping into their latent, inherent, and constructive inner strengths. Positive psychology has broken the previous paradigm in which negative psychology was the primary research focus, and it plays an important role in improving health behaviors to improve quality of life [13]. Positive psychology has been shown in numerous studies [14,15] to play an important role in improving disease prognosis and promoting mental health. In recent years, psychological capital, an important concept in positive psychology theory [16], has received increased attention in psychology and organizational behavior. It refers to the positive psychological states that people have as they grow and develop, which include the four components of efficacy (or confidence), hope, optimism, and resilience [17]. According to research, psychological capital can mobilize positive psychological resources to respond positively when people face challenges, promoting individual health-promoting abilities [18,19].

There have been no studies that look at the relationship between psychological capital and self-management ability in AF patients. Given the severity of the condition, it is necessary to investigate the impact of positive psychology on self-management in women with AF. The goal of this study was to investigate the current status of psychological capital and self-management ability in women patients with AF after RFCA, as well as to analyze the impact of patients’ psychological capital on self-management ability, with the goal of analyzing female AF patients’ self-management ability from a positive psychology perspective and providing a foundation for future studies on gender differences in AF patients.

Methods

Study population

Women patients with atrial fibrillation aged 28 to 90 years were recruited and had regular follow-ups after their first radiofrequency ablation procedure. Inclusion criteria:(i) age ≥18 years; (ii) meeting the diagnostic criteria of atrial fibrillation [20]; (iii) performing RFCA for the first time and completing the operation successfully; Exclusion criteria: (i) combined with serious complications; (ii) combined with other malignant tumors, serious organic lesions; (iii) suffering from psychiatric disorders, unable to communicate properly or fill out questionnaires. All participants provided informed consent and took part volun- tarily.

Measures

General information questionnaire: The general information questionnaire including demographic data such as patients’ age, education, marital status, personal monthly income and disease-related data such as AF duration and European Heart Rhythm Association (EHRA) symptom class [21].

Self-management competence scale for patients with atrial fibrillation: Wenxiu et al [22] created this scale, which has 22 items, including management of the five dimensions of compliance behavior, bad hobbies, emotions and socialization, anticoagulant medications, and disease prevention and monitoring. The Likert 5-point scale yielded scores ranging from “not done” to “always done”, with total scores ranging from 22 to 110. The higher the score, the better the patient’s self-management ability. The Cronbach’s alpha coefficient of this scale was 0.811, and the Cronbach’s alpha coefficient of this scale in this study was 0.913.

The positive psychological capital scale: Zhang et al [23] developed this scale, which has 26 items and four dimensions of efficacy, resilience, optimism, and hope. The scale scores from “not at all=1” to “fully=7” with a total score of 26 to 182, with a score of less than 111 indicating poor psychological capital, 111 to 133 indicating moderate psychological capital, and more than 133 indicating strong psychological capital. Cronbach’s alpha coefficient was 0.910, indicating that the scale was reliable.

Statistical analysis

For normally distributed variables, (x ± s) is used; for non-normal variables, M (P25, P75) is used; and for qualitative information, frequencies and percentages (%) are used. The t-test was used to compare groups, and Spearman correlation was used to analyze correlations, both with a two-sided test and a test level of α=0.05.

Results

The characteristics of study population

Among the 227 women with AF in this study, ages ranged from 28 to 90 (67.04 ± 9.78) years; 204 (91.07%) were married, 23 (10.13%) were unmarried/divorced/widowed; education level: 30 (13.22%) were primary, 64 (28.19%) were secondary, 101 (44.49%) were college, and 32 (14.10%) were university; personal monthly income: <3000 yuan 60 cases (26.43%), 3000 yuan~6000 yuan 119 cases (52.42%), >6000 yuan 48 cases (21.15%); Other more detailed demographic characteristics and distribution are shown in Table 1.

Table 1: Demographic characteristics and distribution.

Self-management ability and psychological capital results

The normality of self-management ability and psychological capital variables was tested. Patients with atrial fibrillation had a total self-management behavior score of (75.37 ± 8.88), which included (23.50 ± 5.38) for compliance behavior management, (12.51 ± 1.65) for bad hobbies management, (16.44 ± 2.57) for emotions and socialization management, (10.28 ± 3.29) for anticoagulant medications management, and (12.65 ± 3.07) for disease prevention and monitoring management.

The total psychological capital score of patients with atrial fibrillation was (106.19 ± 20.13), with the resilience dimension (28.76 ± 8.04), the efficacy dimension (28.67 ± 10.05), the hope dimension (25.24 ± 6.60), and the optimism dimension (23.52 ± 6.54) contributing.

Correlations between self-management ability and psychological capital scores

In women patients with AF, self-management ability scores were significantly and positively correlated with psychological capital scores (r = 0.680, P < 0.01), where self-management ability was also positively correlated with each dimension of psychological capital, with statistically significant differences. Table 2 shows the results of an analysis of the relationship between self-management ability and psychological capital and its dimensions.

Table 2: ^αcorrelation between self-management ability with psychological capital.

Note: ^α: Spearman correlation.

Discussion

Women with AF have poor psychological capital

The total psychological capital score of atrial fibrillation patients after RFCA in this study was (106.19 ± 20.13), which was less than 111 points. It is clear that women with AF following RFCA have low psychological capital and a pessimistic outlook, which must be addressed. The reason for this analysis could be that recurrence of postoperative AF interferes with patients' normal lives and social activities [24], resulting in negative emotions such as pessimism and depression as a result of disappointment with the treatment outcome [25]. Negative emotions have been shown in studies to be risk factors for the recurrence of atrial fibrillation and to be extremely detrimental to patients' postoperative recovery [26]. As a result, medical and nursing staff should pay attention to women patients' emotional changes following RFCA, relieve their negative emotions as soon as possible, encourage female patients to actively cope with atrial fibrillation, and maintain an optimistic attitude. At the same time, their family members should be encouraged to provide adequate support and companionship to the patients and to tolerate their negative postoperative emotions. As a result, patients' positive postoperative psychological capital can be increased, and patients' early recovery after surgery can be promoted.

Female patients with AF have an intermediate level of self-management after RFCA

Currently, studies of self-management ability in patients with atrial fibrillation are limited to patients who are taking medications [27], and no studies have reported on patients' comprehensive self-management ability. The total score of patients' self-management ability in this study was (75.337 ± 8.88), and the score rate (actual score mean/total score) was 67.8%, indicating that the self-management ability of women patients with AF after radiofrequency ablation is at an intermediate level, with much room for improvement. The scores for anticoagulant medications management and disease prevention and monitoring management dimensions were low among them, indicating that the patients' postoperative anticoagulant medications management was poor and that it was difficult to effectively prevent and monitor atrial fibrillation. The reason for this is that the majority of the subjects in this study are elderly people, who frequently have multiple diseases and take more types of medications, and the adverse effects of anticoagulants (bleeding, hematuria, black stool, etc.) make patients feel panic and anxiety, which harms their quality of life [28], and they have more concerns during the process of taking medications and easily stop taking them or reduce the dosage by themselves [29], so the level of anticoagulant medications management is poor in this group. Furthermore, atrial fibrillation is characterized by abrupt onset and cessation as well as unpredictability [30], and patients are filled with uncertainty about atrial fibril- lation and thus cannot effectively cope with the onset and remission of AF [31]. This implies that health care professionals should provide female patients with AF and their families with good knowledge and guidance about the disease, explain the possible adverse reactions and risk factors leading to bleeding after surgery, instruct them on the methods of postoperative heart rate self-measurement and the triggers to avoid AF recurrence, and strengthen patients' control of AF after surgery to improve their self-management ability.

Psychological capital is a key predictor of women patients’ self-management

The total score of psychological capital and the scores of each dimension after RFCA in patients with AF were found to be positively correlated with the total score of self-management ability in women with AF in this study. Efficacy was positively correlated with patients' ability to self-manage among the four dimensions of psychological capital, which is consistent with previous findings [32] and suggests that female patients with higher levels of self-management confidence believe they can manage AF well and are thus more actively involved in disease self-management; on the other hand, patients with low self-management confidence are unable to actively cope with disease management after RFCA. Similar to Jenny et al.'s study [33], resilience was found to be positively correlated with patients' self-management ability in this study, indicating that patients who actively transformed and recovered from the same adversity of experiencing the trauma of RFCA and the painful experience of AF symptoms had greater self-management ability; conversely, AF patients who were unable to effectively self-recover after experiencing the trauma and painful experience had difficulty engaging in the study. Furthermore, hope was found to be positively related to patients' ability to self-manage, implying that the higher the level of patients' self-estimated goals prior to beginning postoperative self-management, the more conducive they are to generating the will to promote health and thus continuously improve self-management, which is consistent with previous research [34].

This study also found that optimism was positively correlated with self-management ability, most likely because the more positive AF patients' attitudes toward the disease and life after RFCA, the more likely they are to use positive coping methods to manage the disease, resulting in stronger self-management ability [35]. In conclusion, when caring for women with AF following RFCA, healthcare professionals should focus on positive psychological capital and help patients develop positive psychological qualities, which can be guided by positive psychology theory, and improve patients' self-efficacy or confidence, resilience, hope, and optimism through group psychological guidance [36], PERMA model intervention [37], and role model education [38], etc. To address patients' postoperative psychological issues while cultivating their positive and healthy psychological qualities, thereby promoting patients' self-management ability and early disease recovery.

Although this is the first study to look at the effect of post-operative psychological resilience on self-management ability in women AF patients, it has several limitations. First, because we used a cross-sectional study, we were unable to draw valid causal conclusions; second, this study included AF patients from only one hospital, resulting in a small sample size, and the results may not be generalizable to all AF patients in China. Finally, a self-report questionnaire was used to assess the postoperative self-management ability of AF patients in the absence of an objective evaluation index, and thus the influence of recall or social expectation bias may exist. This suggests that future studies on psychological resilience and self-management ability of female AF patients should include more objective evaluation indicators and boldly conduct multicenter longitudinal studies to determine the trajectory of changes in the influence of psychological resilience on AF patients' self-management ability.

Conclusion

The current study found that women AF patients have an intermediate level of self-management ability after radiofrequency ablation, and that their psychological capital can predict their level of self-management ability. As a result, the self-management ability of female patients should be assessed promptly after surgery, and targeted measures should be taken to improve the poor psychological capital of patients after surgery, particularly by cultivating positive qualities such as optimism, hope, self-confidence, and resilience to improve the positive psychological capital of patients and thus their self-management ability.

Declarations

Availability of data and materials: The data used in this analysis are relatively confidential and are available with the consent of the corresponding author and participants.

Competing interests: All of the authors of this article have disclosed potential conflicts of interest; none of the authors have declared any conflicts of interest.

Author’s contributions: CY and LF had complete access to all of the data in the study and accept responsibility for the data's integrity and the accuracy of the data analysis. Concept and design research: CY, LF, DYM, GJY, ZY, WLL. Data acquisition, analysis, or interpretation: DYM, GJY, XHX, ZY, WLL, LF, and CY. DYM, GJY, XHX, ZY, and WLL wrote the manuscript. All authors contributed to the critical revision of the manuscript for important intellectual content. DYM, GJY, ZY statistical analysis CY and LF received funding. CY, LF provide administrative, technical, and material assistance.

Funding: This study was supported by the Science and Technology Program of Qingdao City (2020-2-020-YY), and the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the paper.

Acknowledgements: We express our gratitude to all those who participated in this study.

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