PROFESSIONAL ISSUES
Current nursing practice by hospitalbased stoma specialist nurses Jennie Burch
T
his research was undertaken as part of a Master’s degree.The study aim was to use a postal questionnaire to explore stoma care nursing and to answer the question: what is the current nursing practice for peristomal skin (skin around the stoma) problems among UK stoma specialist nurses? The rationale for undertaking this research was to account for a gap in the current knowledge— as it was uncertain what the current practice was—and to ascertain if it was evidence-based. The results were previously disseminated at a UK nursing conference in 2010.
Abstract
There are approximately 102 000 people with a stoma in the UK (Herlufsen et al, 2006). There are three main types of stoma. Faecal output stomas may be formed from the colon (colostomy) for conditions such as rectal cancer and diverticular disease. An ileostomy may be formed from the ileum for inflammatory bowel disease, for example. There is also the urinary output stoma (urostomy or ileal conduit) for diseases such as a bladder cancer or, in some cases, spina bifida (Burch, 2008). During the hospital stay, people with stomas are educated on peristomal skin care by the stoma specialist nurse, including what healthy peristomal skin should look like—ie. no visible skin changes. Unfortunately, sore peristomal skin can affect three in four people with stomas (Williams et al, 2010) and may cause leakage (Mitchell et al, 2007).
Introduction: Nurses frequently care for patients who have stomas. A common complication is sore peristomal skin (skin around the stoma). Aims and objectives: The study aim was to answer the research question: what is the current nursing practice for peristomal skin problems among UK stoma specialist nurses? The question was explored through investigation of descriptions, treatments and opinions of peristomal skin problems. Results were examined to ascertain if practice reflects the literature and if care was evidencebased. Methods: A questionnaire was posted in September 2009 to the stoma care nurses in all UK NHS hospitals (n=596). Results: The proportion of completed or partially completed questionnaires was 15% (89 of 596). Most of the responding nurses held a stoma-related qualification (86%), a degree (55%) and had specialised in stoma care for over 5 years (67%). Respondents used erythema to describe sore skin (80%). Stoma powder (98%) and convex appliances (98%) were the most commonly used treatments. The most common cause of sore skin was appliance leakage (61%). Conclusions: The study population was deemed suitably qualified and experienced to answer the research question. Many responses were reflected in the literature (predominantly opinion articles), reflecting a degree of reliability and validity. It could be concluded that stoma specialist nurses can accurately assess and use stoma accessories to treat sore skin, but due to the paucity of research, the care cannot be defined as evidencebased. More research is needed to determine universally accepted definitions and treatments for sore peristomal skin.
Background Search strategy
Key words: Stoma ■ Colostomy ■ Ileostomy ■ Urostomy ■ Research ■ Questionnaire
Stomas
The literature search included the terms colostomy, ileostomy, urostomy, ileal conduit, ostomy, stoma, peristomal, dermatitis, skin, disorder, problem and complication. Over a million results were reduced to 15 relevant articles by various exclusion criteria, including: ■■ Non-research articles ■■ Articles that were not a nursing intervention ■■ Articles not written in English. Several themes emerged from the literature: descriptions, treatments and general opinions of sore peristomal skin. These topics were used in the study questionnaire.
(Sweden) suggest definitions, including pseudo verrucose. Unfortunately, descriptions differ and these terms are rarely used in UK literature.
Treatments for sore peristomal skin In the literature search, only one research article on treating sore skin (with sucralfate) was discovered (Lyon et al, 2000). Other articles about treating sore peristomal skin were primarily narrative—expert opinions written by stoma specialist nurses.
© 2014 MA Healthcare Ltd
Descriptions for sore peristomal skin No standardised definitions for sore peristomal skin were found, and documented descriptions are frequently lacking and open to interpretation. Terms too are potentially interchangeable. Bosio et al (2007) (Italy) used classifications such as proliferative lesions and Persson et al (2010)
British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
Jennie Burch, a former stoma care nurse, is now an enhanced recovery nurse at St Mark’s Hospital, Harrow, Middlesex Accepted for publication: January 2014
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British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 16, 2015. For personal use only. No other uses without permission. . All rights reserved.
Opinions of sore peristomal skin Sore peristomal skin most commonly results from contact with faeces or urine (Ratliff et al, 2005).The cause may be an inappropriate appliance aperture size (Smith, 2002), neglect, appliance leakage or skin stripping (Park, 1999). The cause of sore skin was investigated in the questionnaire. Richbourg et al (2007) found that leaking occurred frequently, causing or perpetuating skin problems by impairing adhesion. Sore skin is a common complication (Robertson et al, 2005) occurring in three in four people with stomas (Smith et al, 2002) and is regularly encountered by stoma specialist nurses. It was further investigated in the questionnaire. Ratliff et al (2005) and Herlufsen et al (2006) have suggested that stoma type affects rates of sore skin. This was investigated with a Likert scale. The Likert scale offers the respondent a variety of choices where they mark the phrase that they consider most applies to each statement posed (including strongly agree, agree, disagree and strongly disagree).
Methods Design The research tool was designed from the literature to answer the research question and was both quantitative and qualitative. The research aim was achieved through the objectives: ■■ Describe sore peristomal skin ■■ Explain treatment options ■■ Investigate opinions. The author wrote the questionnaire and carried out the research project. The costs included stationary, postage, administrator costs and statistical advice. Funding came from the Barbara Saunders research fund via the Royal College Table 1. Respondents’ experience in stoma nursing Variable
Category
Number
Percentage
Qualifications*
Degree-level stoma-related course
39
49%
Diploma-level stoma-related course
29
37%
Master’s
24
30%
Degree
20
25%
Diploma
4
5%
Paediatric
2
3%
None
8
10%
10 years
76
86%
5 years
59
67%
Years as qualified nurse Years as specialist nurse
*Values will not add up to 100% because the questions invite more than one answer
S32
of Nursing. The respondents’ costs were nil, although completing the questionnaire took up to 30 minutes. The research instrument was a 62-question, purposedesigned, postal questionnaire. It was posted to all stoma specialist nurses in 596 UK hospitals. The questionnaire was tested for reliability and validity by a sample of nurses and academics who discussed and completed the draft questionnaire. Before the study, R&D and ethical approval were obtained from the hospital, and procedures were carried out in accordance with their guidelines. Written consent was not sought, as return of the questionnaire implied consent and questionnaires were anonymous. Responses were entered by a single person as predetermined, mutually exclusive codes into a purpose-designed Excel spreadsheet, to ensure reliable and consistent data (Fink, 2003). Advice was sought on statistical analysis.
Results A total of 109 questionnaires was returned; 15 were marked ‘insufficient postage’; and 5 were marked to the effect that no stoma specialist nurse worked in the hospital. Unless otherwise stated, responses are calculated from 89 completed or partially completed questionnaires.
Demographics The respondents’ job titles included the terms: stoma (83%, n=73), nurse (51%, n=45), clinical nurse specialist (45%, n=40) and others (9%, n=8). Respondents’ experiences in stoma nursing are described in Table 1.
Descriptions of sore peristomal skin Respondents were asked to describe peristomal skin problems. For sore skin, respondents used the terms ‘erythema/red’ (80%, 60/75) and ‘inflamed’ (19%, 14/75). Ulcerated skin was described as ‘broken’ (31%, 23/75) and ‘deep craters’ (21%, 16/75).
Treatment options Respondents were asked which treatments they used in practice from a table of 14 options (Figure 1) and to use free text to explain when they used each option: ■■ Filler paste: filled skin creases, 76% (56/74) ■■ Stoma powder: moist/wet skin, 64% (54/84) ■■ Convex appliances: retracted stoma, 62% (50/81). Treatments for different severities of sore skin were: ■■ Red skin: barrier film, 92% (82/89) ■■ Red, broken skin: barrier film, 65% (58/89) ■■ Red, wet skin: powder, 64% (57/89). Correlation between treatment choices for different severities of sore skin was mapped against respondents’ demographics. Respondents with a degree-level stoma-related qualification were more likely (p=0.04) to change the appliance type to treat red broken skin than respondents without.
General opinions Responses from the Likert scale showed that respondents agreed that patients who had had an ileostomy were more likely to have sore skin than those with colostomies. Also,
© 2014 MA Healthcare Ltd
Documented treatments include stoma accessories such as stoma powder (Voegeli, 2008), protective sheets, protective film barriers (Rudoni, 2009), protective paste (McCann, 2003), filler paste, convex appliances, seals/washers (Baxter and Lloyd, 2004) and belts attached to the stoma flange (Cronin, 2005). These and other treatment options were used in the questionnaire.
British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 16, 2015. For personal use only. No other uses without permission. . All rights reserved.
Respondents’ characteristics It was essential to evaluate if respondents were suitable for the research question. Most job titles contained ‘stoma’, showing that the sample population was purposeful. The majority of respondents held a stoma-related qualification (86%). Most of the subgroup of respondents without a specialist qualification had been in post for under 2 years (88%), a length of time comparable to their US counterparts (Colwell and Beitz, 2007). By the criteria of education and experience, the respondents were suitable to answer the research question.
Descriptions of sore peristomal skin In the literature, the terms for sore skin are rarely defined and appear interchangeable. The respondents’ descriptions, the researcher believes, are suitable and correlate with the literature. Although definitive descriptions of skin problems by use of the questionnaire results and the literature were impossible, there are now several skin assessment tools available (Martins et al, 2010; Williams et al, 2010; Jemec et al, 2011; Buckle, 2013).
© 2014 MA Healthcare Ltd
Treatment Respondents were asked about commonly documented treatments for peristomal skin problems. Half of the treatment options were used by at least 90% of respondents, implying that the questionnaire was appropriately planned and, more importantly, that the literature does reflect current practice. A convex appliance is a shaped flange that pushes into the abdominal wall and thus pushes out the stoma. A quarter of people who have had an ileostomy (Redmond et al, 2009) use convex appliances to resolve appliance leakage (Black, 2009), as suggested by respondents. Stoma powder was used by respondents on wet, broken skin, which is consistent with Boyles (2010), who suggests that powder soaks up moisture and protects skin. Stoma powder is used sparingly on wet peristomal skin to help dry the skin and thus allow the stoma appliance to adhere to the abdominal wall. Use of a stoma accessory is common: up to half of people who have ostomies needed one or more accessory to secure their appliance (Herlufsen et al, 2006). Thus it is essential
British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
80 60 40 20
ve
x n de =86 Ch r n an =8 ge 6 n Se =85 al Re n= siz 85 e n Be =82 Re lt n tra =8 1 in n Fil =7 9 le To r n pi =7 ca 6 l Sh n= 7 ee 1 Ba t n= rri er 71 Pa n=7 st 1 Su e n =6 ct io n 4 Dr n= ye 61 rn =5 2
0
w
The response rate of questionnaires was low (15%, 89/596). Low return rates (20%) are common with mailed questionnaires (Bourque and Fielder, 2003), but a rate of at least 50% is necessary for generalisation of results (Clifford, 1997). Although Colwell and Beitz (2007) only had a 24% return rate in their US study, when questioning UK stoma specialist nurses, Rudoni and Dennis (2009) received 44% of their questionnaires back.
100
Po
Discussion
120
Co n
respondents disagreed that patients with colostomies had more skin problems than those who had had a urostomy. The cause of sore skin was ‘most frequently’ (44%) ranked as an appliance leakage. According to the free text, the most common stomal complication was sore skin (55%, 46/84). The causes reported were appliance leakage (61%, 54/88) or a poorly fitting appliance (44%, 39/88).
Percentage of respondents using the treatment options
PROFESSIONAL ISSUES
Treatment options Figure 1. Percentage of treatment options used by respondents
to ensure that use of stoma accessories is evidence-based. Martins et al (2012) suggest that appropriate use of stoma accessories may save money—for example, by preventing appliances leaking. With the results from the questionnaires, it was not possible to determine whether more than one treatment was used concurrently or consecutively, which does happen. Nor was it possible to examine what influences nurses in their choice of treatment. Porrett et al (2011) and Thompson et al (2011) have clarified product usage, but a definitive, universally agreed treatment algorithm does not exist.
Opinions Literature and respondents suggest that stoma type affects the rates of sore peristomal skin developing, potentially because of corrosive enzymes in the ileostomy output (Taylor, 2012). However, caution should be taken when interpreting findings due to the low numbers of people who have had urostomies. Park et al (1999) report that two-thirds of patients with ostomies had sore skin due to appliance leakage. Ratliff et al (2005) found that an improperly fitting stoma appliance causes sore peristomal skin. The respondents cited appliance leakage as the most common cause of sore peristomal skin and a response to an open question also told of leaking appliances and poor fit. Comparing nurses’ responses with the literature shows that nurses are able to assess the cause of the peristomal skin problem accurately. It could be argued that open-access clinics or standardised follow-up is required to prevent, or assist with, peristomal skin problems. Furthermore, people who have had ileostomies are at greater risk of sore peristomal skin, as reported by stoma specialist nurses in this study and in Persson et al (2010). So it could be argued that these patients require more guidance on skin care than those who have ostomies.
Limitations The many limitations of this study include the literature search, the questionnaire and incomplete or missing data. Efforts were made to reduce bias and, although there were missing responses, they were not related to specific questions, suggesting that the questionnaire was generally understandable. Other limitations include the poor response rate, which, apart from incorrect postage (which meant that
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KEY POINTS n Complications such as sore skin and leaks can occur in relation to stomas n Causes of sore skin include leaking appliances as a result of faeces and urine touching the skin n Treatments for sore peristomal skin include stoma accessories, such as stoma powder n There is no standardised care of sore peristomal skin in relation to assessment and treatment
at least 15 questionnaires did not reach the nurses) may be due to nurses feeling that they did not have the time to complete an 8-side questionnaire.
Conclusion The questionnaire met the research aims: to describe current practice for peristomal skin problems and the different types of sore peristomal skin, treatments and opinions. Although respondents gave varying answers to the questions, consensus between their answers and the literature did emerge. It could also be concluded from their answers that respondents were able to assess and describe skin problems accurately. The vast majority of respondents use many of the available stoma accessories found in opinion articles, but limited conclusions can be drawn on treatment options. Skin assessment tools are available from many of the stoma appliance companies, such as described by Martins et al (2010), Williams et al (2010), Jemec et al (2011) and Buckle (2013), and there are also guides on treating peristomal skin problems (Porrett et al, 2011; Thompson et al, 2011). Further research is needed to establish universally agreed definitions and treatment algorithms, and to ensure that treatment is evidence-based. In terms of its relevance to clinical practice, it is reassuring that current care is reflected in the literature. A universally agreed treatment algorithm would lead to standardised practice and enable auditing of care to ensure patient satisfaction is maintained. It would also help service development. However, as patients who have had ileostomies are at greater risk of sore peristomal skin (Persson et al, 2010), this group might benefit from more training and follow-up BJN on skin care. Conflict of interest: none Baxter A, Lloyd PA (2004) Elimination: stoma care. In: Dougherty L, Lister S, eds. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6th edn. Blackwell, London
Black P (2009) Managing physical postoperative stoma complications. Br J Nurs 18(17): S4–S10 Bosio G, Pisani F, Lucibello L, et al (2007) A proposal for classifying peristomal skin disorders: results of a multicentre observational study. Ostomy Wound Manage 53(9): 38–43 Bourque LB, Fielder EP (2003) How to Conduct Self-administered and Mail Surveys. 2nd edn. SAGE, London Boyles A (2010) Stoma and peristomal complications: predisposing factors and management. Gastrointestinal Nursing. 8(7):26-36. Buckle N (2013) The dilemma of choice: introduction to a stoma assessment tool. Gastrointest Nurs 11(4): 26–32 Burch J (2008) Stomas: the past, present and future. In: Burch J, ed. Stoma Care. Wiley-Blackwell, West Sussex Clifford C (1997) Nursing and Health Care Research. 2nd edn. Prentice Hall, Hertfordshire Colwell JC, Beitz J (2007) Survey of wound, ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications. J Wound Ostomy Continence Nurs 34(1): 57–69 Cronin E (2005) Problem stomas and the use of convexity. Gastrointest Nurs 3(10): 33–40 Fink A (2003) How to Manage, Analyze, and Interpret Survey Data. 2nd edn. SAGE publishing, London Herlufsen P, Olsen AG, Carlsen B, et al (2006) Study of peristomal skin disorders in patients with permanent stomas. Br J Nurs 15(16): 854–62 Jemec GB, Martins L, Claessens I, et al (2011) Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool. Br J Dermatol 164(2): 330–5. doi: 10.1111/j.1365-2133.2010.10093.x. Lyon CC, Stapleton M, Smith MJ, Griffiths CE, Beck MH (2000) Topical sucralfate in the management of peristomal skin disease: an open study. Clin Exp Dermatol 25(8): 584–8 Martins L,Tavernelli K, Sansom W, et al (2012) Strategies to reduce treatment costs of peristomal skin complications. Br J Nurs 21(22): 1312–15 Martins L, Ayello EA, Claessens I, et al (2010) Theostomy skin tool: tracking peristomal skin changes. Br J Nurs 19(15): 960–4 McCann EM (2003) Common ostomy problems. In: Milne CT, Corbet LQ, Dubuc DL, eds. Wound, Ostomy and Continence Nursing Secrets. Hanley and Belfus Inc, Philadelphia Mitchell KA, Rawl SM, Schmidt CM, et al (2007) Demographic, clinical, and quality of life variables related to embarrassment in veterans living with an intestinal stoma J Wound Ostomy Continence Nurs 34(5): 524–32 Park JJ, Del Pino A, Orsay CP, et al (1999) Stoma complications. The Cook County Hospital experience. Dis Colon Rectum 42(12): 1575–80 Persson E, Berndtsson I, Carlsson E, Hallén A-M, Lindholme E (2010) Ostomy related complications and ostomy size—a two year follow-up. Colorectal Dis 12(10): 971–6. doi: 10.1111/j.1463-1318.2009.01941.x. Porrett T, Nováková S, Schmitz K, Klimekova E, Aaes H (2011) Leakage and ostomy appliances: results from a large scale, open-label study in clinical practice. Gastrointest Nurs 9(2 suppl): 19–23 Ratliff CR, Scarano KA, Donovan AM (2005) Descriptive study of peristomal complications. J Wound Ostomy Continence Nurs 32(1): 33–7 Redmond C, Cowin C, Parker T (2009) The experience of faecal leakage among ileostomists. Br J Nurs 18(17): S12–S17 Richbourg L, Thorpe JM, Rapp CG (2007) Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs 34(1):70–9 Robertson I, Leung E, Hughes D (2005) Prospective analysis of stomarelated complications. Colorectal Dis 7(12): 279–85 Rudoni C, Dennis H (2009) Accessories or necessities? Exploring consensus on usage of stoma accessories. Br J Nurs 18(18): 1106–12 Taylor L (2012) Peristomal sore skin: assessing the effect of an alginate wafer. Br J Nurs 21(16): S41–2, S44–6 Thompson H, North J, Davenport R, Williams J (2011) Matching the skin barrier to the skin type. Br J Nurs 20(16): S27–S30 Smith AJ, Lyon CC, Hart CA (2002) Multidisciplinary care of skin problems in stoma patients. Br J Nurs 11(5): 324–30 Voegeli D (2008) LBF® ‘no-sting’ barrier wipes: skin care using advanced silicone technology. Br J Nurs 17(7): 472, 474–6 Williams J, Gwilliam B, Sutherland N, et al (2010) Evaluating skin care problems in people with stomas. Br J Nurs 19(17): S6–S15
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Current nursing practice by hospitalbased stoma specialist nurses Jennie Burch
T
his research was undertaken as part of a Master’s degree.The study aim was to use a postal questionnaire to explore stoma care nursing and to answer the question: what is the current nursing practice for peristomal skin (skin around the stoma) problems among UK stoma specialist nurses? The rationale for undertaking this research was to account for a gap in the current knowledge— as it was uncertain what the current practice was—and to ascertain if it was evidence-based. The results were previously disseminated at a UK nursing conference in 2010.
Abstract
There are approximately 102 000 people with a stoma in the UK (Herlufsen et al, 2006). There are three main types of stoma. Faecal output stomas may be formed from the colon (colostomy) for conditions such as rectal cancer and diverticular disease. An ileostomy may be formed from the ileum for inflammatory bowel disease, for example. There is also the urinary output stoma (urostomy or ileal conduit) for diseases such as a bladder cancer or, in some cases, spina bifida (Burch, 2008). During the hospital stay, people with stomas are educated on peristomal skin care by the stoma specialist nurse, including what healthy peristomal skin should look like—ie. no visible skin changes. Unfortunately, sore peristomal skin can affect three in four people with stomas (Williams et al, 2010) and may cause leakage (Mitchell et al, 2007).
Introduction: Nurses frequently care for patients who have stomas. A common complication is sore peristomal skin (skin around the stoma). Aims and objectives: The study aim was to answer the research question: what is the current nursing practice for peristomal skin problems among UK stoma specialist nurses? The question was explored through investigation of descriptions, treatments and opinions of peristomal skin problems. Results were examined to ascertain if practice reflects the literature and if care was evidencebased. Methods: A questionnaire was posted in September 2009 to the stoma care nurses in all UK NHS hospitals (n=596). Results: The proportion of completed or partially completed questionnaires was 15% (89 of 596). Most of the responding nurses held a stoma-related qualification (86%), a degree (55%) and had specialised in stoma care for over 5 years (67%). Respondents used erythema to describe sore skin (80%). Stoma powder (98%) and convex appliances (98%) were the most commonly used treatments. The most common cause of sore skin was appliance leakage (61%). Conclusions: The study population was deemed suitably qualified and experienced to answer the research question. Many responses were reflected in the literature (predominantly opinion articles), reflecting a degree of reliability and validity. It could be concluded that stoma specialist nurses can accurately assess and use stoma accessories to treat sore skin, but due to the paucity of research, the care cannot be defined as evidencebased. More research is needed to determine universally accepted definitions and treatments for sore peristomal skin.
Background Search strategy
Key words: Stoma ■ Colostomy ■ Ileostomy ■ Urostomy ■ Research ■ Questionnaire
Stomas
The literature search included the terms colostomy, ileostomy, urostomy, ileal conduit, ostomy, stoma, peristomal, dermatitis, skin, disorder, problem and complication. Over a million results were reduced to 15 relevant articles by various exclusion criteria, including: ■■ Non-research articles ■■ Articles that were not a nursing intervention ■■ Articles not written in English. Several themes emerged from the literature: descriptions, treatments and general opinions of sore peristomal skin. These topics were used in the study questionnaire.
(Sweden) suggest definitions, including pseudo verrucose. Unfortunately, descriptions differ and these terms are rarely used in UK literature.
Treatments for sore peristomal skin In the literature search, only one research article on treating sore skin (with sucralfate) was discovered (Lyon et al, 2000). Other articles about treating sore peristomal skin were primarily narrative—expert opinions written by stoma specialist nurses.
© 2014 MA Healthcare Ltd
Descriptions for sore peristomal skin No standardised definitions for sore peristomal skin were found, and documented descriptions are frequently lacking and open to interpretation. Terms too are potentially interchangeable. Bosio et al (2007) (Italy) used classifications such as proliferative lesions and Persson et al (2010)
British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
Jennie Burch, a former stoma care nurse, is now an enhanced recovery nurse at St Mark’s Hospital, Harrow, Middlesex Accepted for publication: January 2014
S31
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 16, 2015. For personal use only. No other uses without permission. . All rights reserved.
Opinions of sore peristomal skin Sore peristomal skin most commonly results from contact with faeces or urine (Ratliff et al, 2005).The cause may be an inappropriate appliance aperture size (Smith, 2002), neglect, appliance leakage or skin stripping (Park, 1999). The cause of sore skin was investigated in the questionnaire. Richbourg et al (2007) found that leaking occurred frequently, causing or perpetuating skin problems by impairing adhesion. Sore skin is a common complication (Robertson et al, 2005) occurring in three in four people with stomas (Smith et al, 2002) and is regularly encountered by stoma specialist nurses. It was further investigated in the questionnaire. Ratliff et al (2005) and Herlufsen et al (2006) have suggested that stoma type affects rates of sore skin. This was investigated with a Likert scale. The Likert scale offers the respondent a variety of choices where they mark the phrase that they consider most applies to each statement posed (including strongly agree, agree, disagree and strongly disagree).
Methods Design The research tool was designed from the literature to answer the research question and was both quantitative and qualitative. The research aim was achieved through the objectives: ■■ Describe sore peristomal skin ■■ Explain treatment options ■■ Investigate opinions. The author wrote the questionnaire and carried out the research project. The costs included stationary, postage, administrator costs and statistical advice. Funding came from the Barbara Saunders research fund via the Royal College Table 1. Respondents’ experience in stoma nursing Variable
Category
Number
Percentage
Qualifications*
Degree-level stoma-related course
39
49%
Diploma-level stoma-related course
29
37%
Master’s
24
30%
Degree
20
25%
Diploma
4
5%
Paediatric
2
3%
None
8
10%
10 years
76
86%
5 years
59
67%
Years as qualified nurse Years as specialist nurse
*Values will not add up to 100% because the questions invite more than one answer
S32
of Nursing. The respondents’ costs were nil, although completing the questionnaire took up to 30 minutes. The research instrument was a 62-question, purposedesigned, postal questionnaire. It was posted to all stoma specialist nurses in 596 UK hospitals. The questionnaire was tested for reliability and validity by a sample of nurses and academics who discussed and completed the draft questionnaire. Before the study, R&D and ethical approval were obtained from the hospital, and procedures were carried out in accordance with their guidelines. Written consent was not sought, as return of the questionnaire implied consent and questionnaires were anonymous. Responses were entered by a single person as predetermined, mutually exclusive codes into a purpose-designed Excel spreadsheet, to ensure reliable and consistent data (Fink, 2003). Advice was sought on statistical analysis.
Results A total of 109 questionnaires was returned; 15 were marked ‘insufficient postage’; and 5 were marked to the effect that no stoma specialist nurse worked in the hospital. Unless otherwise stated, responses are calculated from 89 completed or partially completed questionnaires.
Demographics The respondents’ job titles included the terms: stoma (83%, n=73), nurse (51%, n=45), clinical nurse specialist (45%, n=40) and others (9%, n=8). Respondents’ experiences in stoma nursing are described in Table 1.
Descriptions of sore peristomal skin Respondents were asked to describe peristomal skin problems. For sore skin, respondents used the terms ‘erythema/red’ (80%, 60/75) and ‘inflamed’ (19%, 14/75). Ulcerated skin was described as ‘broken’ (31%, 23/75) and ‘deep craters’ (21%, 16/75).
Treatment options Respondents were asked which treatments they used in practice from a table of 14 options (Figure 1) and to use free text to explain when they used each option: ■■ Filler paste: filled skin creases, 76% (56/74) ■■ Stoma powder: moist/wet skin, 64% (54/84) ■■ Convex appliances: retracted stoma, 62% (50/81). Treatments for different severities of sore skin were: ■■ Red skin: barrier film, 92% (82/89) ■■ Red, broken skin: barrier film, 65% (58/89) ■■ Red, wet skin: powder, 64% (57/89). Correlation between treatment choices for different severities of sore skin was mapped against respondents’ demographics. Respondents with a degree-level stoma-related qualification were more likely (p=0.04) to change the appliance type to treat red broken skin than respondents without.
General opinions Responses from the Likert scale showed that respondents agreed that patients who had had an ileostomy were more likely to have sore skin than those with colostomies. Also,
© 2014 MA Healthcare Ltd
Documented treatments include stoma accessories such as stoma powder (Voegeli, 2008), protective sheets, protective film barriers (Rudoni, 2009), protective paste (McCann, 2003), filler paste, convex appliances, seals/washers (Baxter and Lloyd, 2004) and belts attached to the stoma flange (Cronin, 2005). These and other treatment options were used in the questionnaire.
British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 16, 2015. For personal use only. No other uses without permission. . All rights reserved.
Respondents’ characteristics It was essential to evaluate if respondents were suitable for the research question. Most job titles contained ‘stoma’, showing that the sample population was purposeful. The majority of respondents held a stoma-related qualification (86%). Most of the subgroup of respondents without a specialist qualification had been in post for under 2 years (88%), a length of time comparable to their US counterparts (Colwell and Beitz, 2007). By the criteria of education and experience, the respondents were suitable to answer the research question.
Descriptions of sore peristomal skin In the literature, the terms for sore skin are rarely defined and appear interchangeable. The respondents’ descriptions, the researcher believes, are suitable and correlate with the literature. Although definitive descriptions of skin problems by use of the questionnaire results and the literature were impossible, there are now several skin assessment tools available (Martins et al, 2010; Williams et al, 2010; Jemec et al, 2011; Buckle, 2013).
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Treatment Respondents were asked about commonly documented treatments for peristomal skin problems. Half of the treatment options were used by at least 90% of respondents, implying that the questionnaire was appropriately planned and, more importantly, that the literature does reflect current practice. A convex appliance is a shaped flange that pushes into the abdominal wall and thus pushes out the stoma. A quarter of people who have had an ileostomy (Redmond et al, 2009) use convex appliances to resolve appliance leakage (Black, 2009), as suggested by respondents. Stoma powder was used by respondents on wet, broken skin, which is consistent with Boyles (2010), who suggests that powder soaks up moisture and protects skin. Stoma powder is used sparingly on wet peristomal skin to help dry the skin and thus allow the stoma appliance to adhere to the abdominal wall. Use of a stoma accessory is common: up to half of people who have ostomies needed one or more accessory to secure their appliance (Herlufsen et al, 2006). Thus it is essential
British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
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The response rate of questionnaires was low (15%, 89/596). Low return rates (20%) are common with mailed questionnaires (Bourque and Fielder, 2003), but a rate of at least 50% is necessary for generalisation of results (Clifford, 1997). Although Colwell and Beitz (2007) only had a 24% return rate in their US study, when questioning UK stoma specialist nurses, Rudoni and Dennis (2009) received 44% of their questionnaires back.
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respondents disagreed that patients with colostomies had more skin problems than those who had had a urostomy. The cause of sore skin was ‘most frequently’ (44%) ranked as an appliance leakage. According to the free text, the most common stomal complication was sore skin (55%, 46/84). The causes reported were appliance leakage (61%, 54/88) or a poorly fitting appliance (44%, 39/88).
Percentage of respondents using the treatment options
PROFESSIONAL ISSUES
Treatment options Figure 1. Percentage of treatment options used by respondents
to ensure that use of stoma accessories is evidence-based. Martins et al (2012) suggest that appropriate use of stoma accessories may save money—for example, by preventing appliances leaking. With the results from the questionnaires, it was not possible to determine whether more than one treatment was used concurrently or consecutively, which does happen. Nor was it possible to examine what influences nurses in their choice of treatment. Porrett et al (2011) and Thompson et al (2011) have clarified product usage, but a definitive, universally agreed treatment algorithm does not exist.
Opinions Literature and respondents suggest that stoma type affects the rates of sore peristomal skin developing, potentially because of corrosive enzymes in the ileostomy output (Taylor, 2012). However, caution should be taken when interpreting findings due to the low numbers of people who have had urostomies. Park et al (1999) report that two-thirds of patients with ostomies had sore skin due to appliance leakage. Ratliff et al (2005) found that an improperly fitting stoma appliance causes sore peristomal skin. The respondents cited appliance leakage as the most common cause of sore peristomal skin and a response to an open question also told of leaking appliances and poor fit. Comparing nurses’ responses with the literature shows that nurses are able to assess the cause of the peristomal skin problem accurately. It could be argued that open-access clinics or standardised follow-up is required to prevent, or assist with, peristomal skin problems. Furthermore, people who have had ileostomies are at greater risk of sore peristomal skin, as reported by stoma specialist nurses in this study and in Persson et al (2010). So it could be argued that these patients require more guidance on skin care than those who have ostomies.
Limitations The many limitations of this study include the literature search, the questionnaire and incomplete or missing data. Efforts were made to reduce bias and, although there were missing responses, they were not related to specific questions, suggesting that the questionnaire was generally understandable. Other limitations include the poor response rate, which, apart from incorrect postage (which meant that
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KEY POINTS n Complications such as sore skin and leaks can occur in relation to stomas n Causes of sore skin include leaking appliances as a result of faeces and urine touching the skin n Treatments for sore peristomal skin include stoma accessories, such as stoma powder n There is no standardised care of sore peristomal skin in relation to assessment and treatment
at least 15 questionnaires did not reach the nurses) may be due to nurses feeling that they did not have the time to complete an 8-side questionnaire.
Conclusion The questionnaire met the research aims: to describe current practice for peristomal skin problems and the different types of sore peristomal skin, treatments and opinions. Although respondents gave varying answers to the questions, consensus between their answers and the literature did emerge. It could also be concluded from their answers that respondents were able to assess and describe skin problems accurately. The vast majority of respondents use many of the available stoma accessories found in opinion articles, but limited conclusions can be drawn on treatment options. Skin assessment tools are available from many of the stoma appliance companies, such as described by Martins et al (2010), Williams et al (2010), Jemec et al (2011) and Buckle (2013), and there are also guides on treating peristomal skin problems (Porrett et al, 2011; Thompson et al, 2011). Further research is needed to establish universally agreed definitions and treatment algorithms, and to ensure that treatment is evidence-based. In terms of its relevance to clinical practice, it is reassuring that current care is reflected in the literature. A universally agreed treatment algorithm would lead to standardised practice and enable auditing of care to ensure patient satisfaction is maintained. It would also help service development. However, as patients who have had ileostomies are at greater risk of sore peristomal skin (Persson et al, 2010), this group might benefit from more training and follow-up BJN on skin care. Conflict of interest: none Baxter A, Lloyd PA (2004) Elimination: stoma care. In: Dougherty L, Lister S, eds. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6th edn. Blackwell, London
Black P (2009) Managing physical postoperative stoma complications. Br J Nurs 18(17): S4–S10 Bosio G, Pisani F, Lucibello L, et al (2007) A proposal for classifying peristomal skin disorders: results of a multicentre observational study. Ostomy Wound Manage 53(9): 38–43 Bourque LB, Fielder EP (2003) How to Conduct Self-administered and Mail Surveys. 2nd edn. SAGE, London Boyles A (2010) Stoma and peristomal complications: predisposing factors and management. Gastrointestinal Nursing. 8(7):26-36. Buckle N (2013) The dilemma of choice: introduction to a stoma assessment tool. Gastrointest Nurs 11(4): 26–32 Burch J (2008) Stomas: the past, present and future. In: Burch J, ed. Stoma Care. Wiley-Blackwell, West Sussex Clifford C (1997) Nursing and Health Care Research. 2nd edn. Prentice Hall, Hertfordshire Colwell JC, Beitz J (2007) Survey of wound, ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications. J Wound Ostomy Continence Nurs 34(1): 57–69 Cronin E (2005) Problem stomas and the use of convexity. Gastrointest Nurs 3(10): 33–40 Fink A (2003) How to Manage, Analyze, and Interpret Survey Data. 2nd edn. SAGE publishing, London Herlufsen P, Olsen AG, Carlsen B, et al (2006) Study of peristomal skin disorders in patients with permanent stomas. Br J Nurs 15(16): 854–62 Jemec GB, Martins L, Claessens I, et al (2011) Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool. Br J Dermatol 164(2): 330–5. doi: 10.1111/j.1365-2133.2010.10093.x. Lyon CC, Stapleton M, Smith MJ, Griffiths CE, Beck MH (2000) Topical sucralfate in the management of peristomal skin disease: an open study. Clin Exp Dermatol 25(8): 584–8 Martins L,Tavernelli K, Sansom W, et al (2012) Strategies to reduce treatment costs of peristomal skin complications. Br J Nurs 21(22): 1312–15 Martins L, Ayello EA, Claessens I, et al (2010) Theostomy skin tool: tracking peristomal skin changes. Br J Nurs 19(15): 960–4 McCann EM (2003) Common ostomy problems. In: Milne CT, Corbet LQ, Dubuc DL, eds. Wound, Ostomy and Continence Nursing Secrets. Hanley and Belfus Inc, Philadelphia Mitchell KA, Rawl SM, Schmidt CM, et al (2007) Demographic, clinical, and quality of life variables related to embarrassment in veterans living with an intestinal stoma J Wound Ostomy Continence Nurs 34(5): 524–32 Park JJ, Del Pino A, Orsay CP, et al (1999) Stoma complications. The Cook County Hospital experience. Dis Colon Rectum 42(12): 1575–80 Persson E, Berndtsson I, Carlsson E, Hallén A-M, Lindholme E (2010) Ostomy related complications and ostomy size—a two year follow-up. Colorectal Dis 12(10): 971–6. doi: 10.1111/j.1463-1318.2009.01941.x. Porrett T, Nováková S, Schmitz K, Klimekova E, Aaes H (2011) Leakage and ostomy appliances: results from a large scale, open-label study in clinical practice. Gastrointest Nurs 9(2 suppl): 19–23 Ratliff CR, Scarano KA, Donovan AM (2005) Descriptive study of peristomal complications. J Wound Ostomy Continence Nurs 32(1): 33–7 Redmond C, Cowin C, Parker T (2009) The experience of faecal leakage among ileostomists. Br J Nurs 18(17): S12–S17 Richbourg L, Thorpe JM, Rapp CG (2007) Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs 34(1):70–9 Robertson I, Leung E, Hughes D (2005) Prospective analysis of stomarelated complications. Colorectal Dis 7(12): 279–85 Rudoni C, Dennis H (2009) Accessories or necessities? Exploring consensus on usage of stoma accessories. Br J Nurs 18(18): 1106–12 Taylor L (2012) Peristomal sore skin: assessing the effect of an alginate wafer. Br J Nurs 21(16): S41–2, S44–6 Thompson H, North J, Davenport R, Williams J (2011) Matching the skin barrier to the skin type. Br J Nurs 20(16): S27–S30 Smith AJ, Lyon CC, Hart CA (2002) Multidisciplinary care of skin problems in stoma patients. Br J Nurs 11(5): 324–30 Voegeli D (2008) LBF® ‘no-sting’ barrier wipes: skin care using advanced silicone technology. Br J Nurs 17(7): 472, 474–6 Williams J, Gwilliam B, Sutherland N, et al (2010) Evaluating skin care problems in people with stomas. Br J Nurs 19(17): S6–S15
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