ORIGINAL ARTICLE

Effects of planned group interactions on the social adaptation of individuals with an intestinal stoma: a quantitative study Hatice K Karabulut, Leyla Dincß and Ayisße Karadag

Aims and objectives. To investigate the effects of a planned group interaction method on the social adjustment of individuals with an intestinal stoma. Background. Individuals with a stoma often experience physiological, psychological and social problems that affect their social adaptation. Design. Quasi-experimental. Methods. The population included ileostomy and colostomy patients registered at the Gazi University Health Research and Implementation Centre Stoma therapy Unit between September 2011–June 2012. They were assigned to experimental (n = 23) and control (n = 27) groups based on their willingness to attend planned group interaction meetings. Experimental group members participated in the ‘planned group interaction method’ for six weeks. Control group members only received routine care services. Weekly group interaction meetings lasted for average of 90 minutes. The Ostomy Adjustment Inventory and Psychosocial Adjustment to Illness Scale-Self-Report Scale were administered to experimental group members on three occasions: prior to the first group meeting, after the six-week meeting process ended and during the first month after group meetings ended. Control group evaluations were conducted simultaneously. Results. Experimental group members’ ostomy adjustment mean scores after planned group interaction meetings gradually increased. No changes occurred in the control group’s average scores. The experimental and control groups’ average psychosocial adjustment scores eventually changed and showed a tendency towards adjustment. Experimental group members aged 51–60 and 61–70, who were married, had primary and higher education, had permanent stomas, had stomas for periods between 12 months or less and 61 months and longer and had sufficient stoma care knowledge demonstrated higher adjustment values (p < 0
05). Furthermore, experimental group members reported they received psychological support during interactions and learned how to solve problems encountered in stoma care and daily life. Conclusions. Planned group interactions effectively enhanced the social adjustment of patients with a stoma. Relevance to clinical practice. Group interaction methods should be included in nursing care practices for individuals with a stoma. Authors: Hatice K Karabulut, MSN, PhD, RN, Research Assistant, Nursing Department, Faculty of Health Sciences, Gazi University, Ankara; Leyla Dincß, PhD, RN, Professor, Faculty of Nursing, Hacettepe University, Ankara; Ayisße Karadag, ET/WOCN, PhD, RN, Professor, Nursing Department, Faculty of Health Sciences, Gazi University, Ankara, Turkey

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What does this paper contribute to the wider global clinical community?

• Planned

•

•

group interaction method is effective on social adjustment of individuals with a stoma. Individuals with lower educational levels and females had higher scores than participants who possessed higher educational levels, suggesting the influence of educational levels on social adjustment. Having permanent or temporary stoma influences the social adjustment.

Correspondence: Hatice K Karabulut, Research Assistant, Nursing Department, Faculty of Health Sciences, Gazi University, 06500 Ankara, Turkey. Telephone: +90 3122162609. E-mail: [email protected]

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813, doi: 10.1111/jocn.12541

Original article

Effects of group interactions on people with stoma

Key words: clinical nurse specialist, psychosocial adjustment, stoma, stoma care Accepted for publication: 5 December 2013

Introduction An intestinal stoma is a surgically constructed artificial opening in the abdominal wall that permits waste passage after colostomy or ileostomy. Stomas are frequently constructed for patients diagnosed with colorectal cancer, inflammatory intestinal diseases and trauma (Kann & Cataldo 2002, Silva et al. 2003, Husain & Cataldo 2008, Lizarondo et al. 2008, Butler 2009). The International Agency for Research on Cancer (IARC) (2008) reports that, globally, one million cases per year that were diagnosed as colorectal cancer involved intestinal stoma surgery. In Europe, new cases totalled 412,900 in 2006 (Ferlay et al. 2007). According to statistics provided by The Ministry of Health of Turkey (2010), colorectal cancer is one of the 10 most frequent types of cancer. It ranks fourth (0
0208%) among males and third (0
0135%) among females. However, the exact number of patients who had stoma surgery is unknown because of the insufficiencies of hospital recording systems and the rarity of stomatherapy units in Turkey. Although, in many cases, stoma surgery is a life-saving procedure, it may cause a variety of physical, social and psychological problems (Karada
g et al. 2003, Black 2004, Brown & Randle 2005, Williams 2011). The most common problems included uncontrolled gas and stool emissions, malodour, faeces leakage and skin irritations. Therefore, patients’ body images may become disturbed, and their family relations, social and sexual lives might be negatively affected (Bekkers et al. 1997, Harris et al. 2004, Woodhouse 2005).

Background Individuals with a stoma can experience psychological problems such as distorted body image, decreased selfesteem, nervousness, anger, anxiety and depression (Burch 2005, Woodhouse 2005). White and Hunt (1997) determined that almost 20% of patients experienced psychological problems after stoma surgery. Wade (1990) indicated that one-third of all patients experienced depression. Nugent et al. (1999) determined that 35% of colostomy patients and 45% of ileostomy patients were diagnosed with anxiety. These studies indicate that individuals with a stoma may develop psychological disorders. Changes in physical appearance may affect individuals’ sexual lives. Many individuals with a stoma worry about © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

their sexual lives. Persson and Hellstrom (2002) discovered that most patients believed their sexual appeal decreased after stoma surgery. Nugent et al. (1999) determined that 45% of colostomy patients and 43% of ileostomy patients experienced sexual difficulties. Addis (2003) revealed that 80% of individuals with a stoma experienced sexual problems. These sexual problems might also have resulted from psychological reasons, such as patients’ fears when they open bags, fears of faecal leakage or fears of malodour during sexual intercourse. They might also be physiological in origin (e.g. nerve injuries). The physical, psychological and sexual problems of individuals with a stoma can affect their social adaptation. These individuals tend to restrict and alienate themselves from social activities because they fear their altered physical appearances and bowel control problems may lead to social difficulties (Watt 1977, Brown & Randle 2005). Some studies revealed that because of uncontrolled passage of faeces or gas through stomas, individuals’ social activities (e.g. attending movies, playing sports, engaging in entertaining activities, attending worship, performing religious ablutions and prayers), as well as their work lives, have been negatively affected (Herek et al. 2003, Black 2004, Simmons et al. 2007). Following stoma surgery, individuals experienced resignation, decreased working hours, decreased productivity and increased job changes (Kuzu et al. 2002, Herek et al. 2003, Karada
g et al. 2003, Ayaz 2007, Karada
g & Baykara 2009). In Turkey, studies focused on the psychological problems of individuals with a stoma are limited. Karada
g et al. (2003) revealed that most patients displayed strong tendencies to isolate themselves, to become introverted and to prefer solitude because they feared stoma leakage and malodour. Karada
g et al. (2003) argued that the physiological problems of individuals with a stoma could be minimised or eliminated by the provision of training and counselling in hospitals. However, their psychological, social and sexual problems continued to occur. To encourage individuals with a stoma to cope with problems, in addition to addressing physiological problems, care, training and counselling services must incorporate social and psychological aspects. These services must be continued and aligned with patients’ needs during postoperative periods. Thus, patients’ abilities to adapt to such changes that affect their social lives will improve.

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Enterostomal therapy (ET) nurses play important roles because they ensure social adaptation in individuals with a stoma. Nursing interventions that address patients’ social adaptation include the maintenance of individual training and counselling services to help them increase their awareness of their own power, to connect them with their social support systems and to improve their use of those systems and to ensure the reinforcement of that support by enlisting the aid of their families and friends. Social adaptation can also be facilitated by support groups that bring individuals with stomas together. These groups help patients realise they are not alone. They can share their feelings, thoughts and problem-solving suggestions and increase social support. In Turkey, individuals with a stoma have received customised care, training and counselling services from ‘Certified Stoma and Wound Care Nurses’ in stomatherapy units since 2000. Although patients’ physiological problems can be resolved to a large extent by these services (Karada
g et al. 2005, T€ uzer 2007), patients’ psychosocial and sexual problems either continue to occur or resolve over longer periods (Karada
g et al. 2003, Ayaz 2007). The introduction of patients who experience similar problems in stomatherapy units is a widely adopted practice. We have provided stomatherapy services for more than 10 years. Our experiences demonstrate that patients who adapt to lives with stomas can make important contributions when they share problems and solutions with individuals who recently had a stoma. However, a review of the literature revealed that no studies examined whether planned group interactions can increase such individuals’ social adaptation. Therefore, the current study attempts to address these issues.

Methods Research design The current study is a segment of a larger study that employed a qualitative and quantitative quasi-experimental design to examine the effects of a planned group interaction method on the social adaptation in individuals with a stoma. The current study describes the quantitative portion of the larger study.

The population and sample The current study was performed in the Gazi University Health Research and Implementation Centre (GUHRIC) Stomatherapy Unit between 1 September 2011–1 June 2012. The GUHRIC Stomatherapy Unit was the first

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stomatherapy unit developed in Turkey. It was established in 2000. The unit consists of a team that includes a general surgeon, two stoma and wound care nurses and three academician nurses. One of those nurses possesses a Wound Ostomy Continence Nursing certificate. During the preoperative period and continuing throughout treatment, this nurse provides training, counselling and care services to patients diagnosed with wound, ostomy, incontinence and fistula problems and their relatives. A purposive sample was drawn from patients who have been followed by the GUHRIC Stomatherapy Unit since 2007. The inclusion criteria were patients: (1) who had surgery at least three months prior and who had temporary or permanent ileostomies or colostomies; (2) who attended postsurgery check-ups at least once per year; (3) who were over 18 years old; (4) who resided within the boundaries of Ankara Province; and (5) who provided written consents. To meet parametric test assumptions, we planned to recruit 30 patients for the experimental group and 30 patients for the control group. However, seven patients withdrew because of health problems that occurred during the planned interaction sessions. Three control group patients were unable to complete the data collection process. Thus, the study sample contained 50 patients (23 experimental group members and 27 control group members).

Data collection The following instruments were used to collect data: Questionnaire form for individuals with an intestinal stoma This form was developed based on a review of the literature (Silva et al. 2003, Brown & Randle 2005, Karada
g et al. 2005). It consists of two sections. The first section includes 12 questions focused on individuals’ socio-demographic characteristics (age, gender, marital status, education status, income level and so on). The second section includes 13 questions related to types of stoma patients, reasons for stoma surgery, stoma duration, stoma care and the extent to which patients engage in daily life activities. Ostomy Adjustment Inventory (OAI) This scale is a self-evaluation scale comprised of 23 items and four subfactors. It was developed by Simmons et al. (2009) to assess ostomy patients’ psychosocial adjustment. Each item is evaluated on a Likert-type scale (0–4 range). Higher scores indicate better adjustment. Twelve items (2, 5, 7, 8, 10, 11, 12, 13, 16, 17, 18 and 21) are negative sentences that are evaluated reversely (see Appendix 1). A validity and reliability study of the scale was performed on 570 individuals © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

Original article

with a stoma. The Cronbach’s value amounted to 0
93. The correlation value (r) in the test–retest assessment was 0
83 (Simmons et al. 2009). Karada
g et al. (2011) performed a validity and reliability study of the scale in Turkey. The correlation value (r) in the test–retest assessment was 0
76. Psychosocial Adjustment to Illness Scale-Self-Report (PAIS-SR) This scale was developed by Derogatis and Lopez in 1983 to assess patients’ psychosocial adjustment to illness. PAISSR consists of 46 items and seven subfactors. Subfactors include headings such as healthcare orientation, vocational environment, family environment, sexual relations, extended family relations, social environment and psychological distress. Four defining statements are used to determine patients’ varying levels of adjustment for each area. Patients must select the statement that best defines their own personal experiences. Each item is scored on a scale that ranges between 0–3. Largely negative changes that occurred since patients’ illnesses began are assigned three points. Positive changes or no changes are assigned 0 points. Possible minimum and maximum scores range between 0–138 points. Low scores indicate patients’ ‘good psychosocial adjustment’ to illness, whereas high scores indicate patients’ ‘poor psychosocial adjustment’ to illness. Studies that employed the PAIS-SR indicated the following results: scores below 35 indicated patients’ good psychosocial adjustment; scores between 35–51 indicated patients’ moderate psychosocial adjustment; and scores above 51 indicated patients’ poor psychosocial adjustment (Adaylar 1995). Adaylar (1995) examined the validity and reliability of PAIS-SR in Turkey. He determined that the reliability coefficients for subgroups ranged between 0
80– 0
95. The reliability coefficient was 0
94 for the entire scale.

Development of the planned group interaction programme As reported by Zabalegui et al. (2005) that Katz and Bender (1976) had defined a planned support group as a structured group that contains several members who suffer from the same problem. The group provides common support through interpersonal interactions. A review of the literature did not reveal any studies focused on planned group interactions for individuals with a stoma. However, the use of planned group modalities with cancer patients has positively affected participants and decreased depression rates (Zabalegui et al. 2005). Therefore, for the current study, a planned group interaction programme was developed that may serve as model for individuals with a stoma. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

Effects of group interactions on people with stoma

The current study’s authors work actively with individuals with a stoma. They provide stoma care training programmes. One author is nationally certified. The other author received an International Wound Ostomy Continence Nursing certificate. Prior to beginning this study, the first author enrolled in a course entitled ‘Principles and Techniques of Psychological Counselling with Groups’. She also enrolled in a postgraduate course in Guidance and Psychological Counselling provided by the Gazi University Educational Sciences Institute during the fall semester of the 2010–2011 academic year to develop the contents of the planned group interaction programme. She also participated as an observer in a 10-session group therapy programme for colostomy patients provided cooperatively by the Gazi University Stomatherapy Unit and the Psychiatry Department. The general purposes and contents of the planned group interaction programme were determined based on the above-mentioned information, the authors’ experiences and a review of the literature (Ott 1996, Fukui et al. 2000, Zabalegui et al. 2005, Pistrang et al. 2008). Studies suggest that, to ensure successful group interactions, the number of group participants should range between a minimum of six and a maximum of 12 participants. The preferred frequency of meetings is once per week. On average, the duration of € most programmes ranges between 6–10 weeks (Ozen & _ G€ ulacßtı 2006, Akboy & Ikiz 2007). Therefore, in the current study, the planned group interaction programme met for six weeks of sessions and one session per week. The authors then formulated the objectives for and the agenda of each session. The objective of the first session was to provide information related to the process and to administer data collection instruments. The remaining session agendas focused on ‘Stoma-related physiological problems and their impacts on daily life’, ‘Stoma-related psychological problems’, ‘Negative impacts of stomas on patients’ sex lives and spousal relationships’, ‘Impact of a stoma on an individual’s communication with his close and far circles’ (family, relatives, friends and so on.). In contrast, the agenda for the final session focused on ‘Individuals’ stomarelated social activity problems’, ‘Future plans for life with stomas (business/professional life, education and so on.)’ and ‘Impact of group process on adjusting to life with stomas and suggestions related to the process’.

Ethical considerations The study protocol received official approval and ethical clearance from the Ethical Committee of Hacettepe University and the GUHRIC Chief Physician’s Office. Patients

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registered with the GUHRIC Stomatherapy Unit who met the sampling criteria were contacted by phone, informed of the research and asked whether they would participate. Patients who verbally agreed to participate in the planned group interaction process were invited to the stomatherapy unit, where they were informed of the research purposes. Those patients then signed informed consents. Based on patients’ preferences and their ability to participate in planned interaction sessions, patients were assigned to experimental or control groups.

Implementation of research with the experimental group The ‘planned group interaction method’ was employed with the experimental group. Sessions were held in the meeting hall once per week for six weeks. On average, each meeting lasted 90 minutes. Based on this method, interaction meetings, subjects, interview frequency and total number of interviews were determined in advance. Each group contained between 7–10 patients. The researcher served as the group leader of the planned group interaction meetings. The group leader informed participants of the agenda for each planned group session using methods and techniques such as prepared lectures accompanied with PowerPoint presentations, demonstrations performed on a stoma model with care materials, round table group discussions and ‘question and answer’ sessions. The group leader facilitated interactions among participants to help them identify problems associated with stomas, to help them explore their feelings, thoughts and behaviours and to help them discover and share suggestions to achieve problem resolution. A stoma care nurse who was familiar with the patients also participated in the group interaction meetings. The researcher concluded each meeting by summarising the day’s discussion subject. The first planned group interaction group commenced on 16 November 2011 and ended on 21 December 2011. Ultimately, nine patients participated, because one participant left the group. The second planned interaction group commenced on 12 January 2012 and ended on 2 March 2012. Ultimately, seven patients participated. Three individuals left the group because of health problems. The third planned interaction group commenced on 5 April 2012 and ended on 17 May 2012. Ultimately, seven patients participated because two initial patients began chemotherapy and one patient’s illness worsened. Thus, the experimental group that completed the planned interaction programme included 23 participants. The first evaluation of data collection forms and scales completed by the experimental group

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members was performed after the first meeting. The second evaluation of those scales was performed after the group meetings (week 6) ended. The third evaluation was performed during the first month after the group meetings ended.

Implementation of research with the control group Some individuals were unable to participate in the planned group interaction programme. Yet, they hoped to contribute to the study. These individuals were included in the control group. No interventions were performed with control group members during the study. However, these individuals received regular care services in the stomatherapy unit. Control group members completed data collection forms and scales on a schedule similar to the experimental group’s schedule. Therefore, the first evaluation of forms and scales was performed during the first interview conducted with members. The second and third evaluations of forms and scales were conducted during week 6, as well as one month after the first interviews were conducted.

Data analysis Data were analysed using the SPSS for Windows, version 11.5 program [Statistical Package for the Social Science (SPSS), Inc., Chicago, IL, USA]. Participants’ PAIS-SR and OAI scores were acquired during the first, second and third monitoring sessions. To discover the impacts of the planned group interaction method on participants’ scores for psychosocial adjustment to illness and adjustment to stomas, Friedman’s and Kruskal–Wallis analytical methods were applied. In addition, the researchers applied the Mann– Whitney U-test, which had been used previously to compare the differences that occur between individuals’ scale scores based on their dependent variables (e.g. socio-demographic and illness attributes).

Results Sample characteristics Results related to participants’ socio-demographic attributes Participants’ average ages were 55
52  9
85 for the experimental group and 53
81  9
97 for the control group. Males constituted 52% of the experimental group and 67% of the control group. The majority of participants in both the experimental and control groups were married and had © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

Original article

Effects of group interactions on people with stoma

children. With respect to educational status, 39% of experimental group members were university graduates. However, 41% of control group members were primary school graduates. More than half of both the experimental and control group members did not work (see Table 1). Results related to participants’ stoma attributes In the experimental group, 73
9% of members had permanent stomas, in comparison with 55
6% of control group members. The results revealed that 40
8% of control group members had stomas for ≤12 months. However, 43
5% of experimental group members had stomas for 13– 60 months. In both groups, more than half of all members performed their own stoma care. In the experimental group, 55
6% of the members believed their knowledge of stoma care was sufficient, in comparison with 37
0% of control group members (see Table 2). Mean scores of participants on the Ostomy Adjustment Inventory and Psychosocial Adjustment to Illness Scale The OAI average scores for the experimental group increased gradually when they were measured in weeks 6

Table 1 Distribution of participants’ socio-demographic characteristics

Socio-demographic characteristics Age 50≤ 51–60 61–70 Gender Female Male Marital status Married Single Parental status Parent Nonparent Educational background Primary school Secondary school University Working status Working Not working Income level perception Sufficient Insufficient

Experimental group (n = 23)

Control group (n = 27)

n

%

n

%

5 11 7

21
7 47
8 30
5

10 9 8

37
0 33
4 29
6

11 12

47
8 52
2

9 18

33
3 66
7

19 4

82
6 17
4

21 6

77
8 22
2

20 3

87
0 13
0

22 5

81
5 18
5

6 8 9

26
1 34
8 39
1

11 10 6

40
8 37
0 22
2

3 20

13
0 87
0

10 17

37
0 63
0

11 12

47
8 52
2

15 12

55
6 44
4

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

and 10, in comparison with measurements made in week 1. This represents a statistically significant change (p < 0
05). However, no significant changes occurred in the control group’s average scores (see Fig. 1). Lower PAIS-SR scores appeared to be related to higher adjustment levels. The results revealed that the experimental group members’ average PAIS-SR scores decreased gradually when measurements were made in weeks 6 and 10, in comparison with measurements made in week 1. This represents a statistically significant change (p < 0
05). However, although the control group members’ average scores

Table 2 Distribution of participants’ stoma-related attributes

Stoma-related attributes

Experimental group (n = 23)

Control group (n = 27)

n

n

%

12 15

44
4 55
6

4 5 15 3

14
8 18
5 55
6 11
1

24 1 2

88
9 3
7 7
4

11 8 8

40
8 29
6 29
6

15 12

55
6 44
4

7 20

25
9 74
1

4 23

14
8 85
2

14 13

51
9 48
1

10 17

37
0 63
0

11 16

40
7 59
3

%

Stoma nature Temporary 6 26
1 Permanent 17 73
9 Stoma type End ileostomy 6 26
1 Loop ileostomy 2 8
7 End colostomy 13 56
5 Loop colostomy 2 8
7 Reason for stoma Cancer 22 95
7 Injury 0 0
0 Inflammatory 1 4
3 intestinal disease Stoma duration (months) 12≤ 8 34
8 13–60 10 43
5 61≥ 5 21
7 Received therapy during the last 3 months Received 9 39
1 Not received 14 60
9 Coexistent disease Yes 10 43
5 None 13 56
5 Health problem that complicates stoma care Yes 5 21
7 None 18 78
3 Stoma care performed by Him/herself 12 52
2 Him/herself 11 47
8 by assistance Stoma care knowledge perception Sufficient 13 55
6 Insufficient 10 43
4 Stoma and problems surrounding it Yes 9 39
1 None 14 60
9

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HK Karabulut et al.

also decreased over time, the change was not statistically significant (p > 0
05) (see Fig. 2).

45

Mean scores of participants on the Psychosocial Adjustment to Illness Scale, based on socio-demographic characteristics and stoma attributes Significant differences were found between average scores for males and females, individuals age 50 and below, married individuals, primary school and university graduates and nonworking individuals in the experimental group based on measurements made in weeks 6 and 10, in

80

67.39

70

OAI average score

60

53.04

70.91

51.07

50

36.33

35.3

35

31.04

30 25 20 15 10 5 0

Test

Control

Figure 2 Distribution of Psychosocial Adjustment to Illness Scale-Self-Report average scores of experimental and control group members with intestinal stomas.

comparison with measurements made in week 1 (p < 0
05) (see Table 4). On the other hand, from the viewpoint of stoma features, the results revealed that experimental group members who had permanent and temporary stomas and who had stomas for 12 months or less and/or 61 months or longer had significant average PAIS-SR scores (p < 0
05). In addition, the experimental group members’ average PAIS-SR scores trended towards adjustment with respect to members’ knowledge of stoma care and their ability to perform their own care (p < 0
05) (see Table 4).

Week 10

In this quasi-experimental study, we investigated the effects of a planned group interaction method on social adaptation of individuals with an intestinal stoma. The majority of participants were middle-aged and married with children. More than half were male. A review of the literature revealed that the average age of individuals with stomas was higher than the average age of the stoma patients included in our sample. In addition, most individuals with stomas were married males (Piwonka & Merino 1999, Cheunga et al. 2003, Nishigaki et al. 2007, Simmons et al. 2007, 2009, Cheng et al. 2012). Our participants were relatively younger because many received late diagnoses of colorectal cancer. In contrast with Western countries, cancer screening and early diagnosis services in Turkey are insufficient. This finding is also consistent with our findings

53.22 53.07

20 10

Control

Figure 1 Distribution of Ostomy Adjustment Inventory averages of experimental and control group members with an intestinal stoma.

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39.96

Discussion

30

Test

Week 10

Week 1 Week 6

40

0

Week 6

44.92 41.3

40

PAIS-SR average score

Mean scores of participants on the Ostomy Adjustment Inventory, based on socio-demographic characteristics and stoma attributes The results revealed that significant differences were apparent between the average OAI scores of both the experimental and control groups with respect to their sociodemographic and stoma attributes, based on the results of measurements made in weeks 6 and 10, in comparison with measurements made in week 1 (p < 0
05). Therefore, the experimental group demonstrated higher average scores than the control group for both males and females, all age groups, married individuals and for all education levels (p < 0
05) (see Table 3). From the perspective of patients’ stoma attributes, experimental group members with permanent and temporary stomas and control group members who had temporary stomas had higher average OAI scores (p < 0
05) (see Table 3).

Week 1

50

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813 57
33  17
52 47
94  9
63 49
70  14
60 49
33  12
91 54
75  12
85 51
57  13
74 49
33  12
35 59
54  13
08 43
90  9
35 47
50  11
70 46
60  8
89 53
70  14
86 43
83  9
00 56
86  13
47 45
45  8
00 51
25  9
98 58
62  18
60 54
33  16
28 48
46  10
07 52
00  12
15 50
07  14
77

49
00  15
86 56
75  17
03 55
80  20
84 54
54  18
10 48
71  11
85 53
10  14
73 52
75  26
72 51
00  15
73 50
12  15
98 57
00  18
68 61
66  22
27 51
75  15
90 38
00  8
85 58
35  15
45 43
87  12
71 57
20  19
95 59
40  8
50 61
00  16
30 47
92  15
16 58
08  17
00 47
54  14
94

67
25  17
67 67
54  14
53

72
88  13
19 63
85  16
89

65
37  14
27 65
60  19
73 74
20  8
98

64
33  14
69 68
47  16
57

74
66  19
08 66
30  15
62

69
16  14
67 64
50  14
11 68
77  19
28

54
07  9
74 52
30  8
68

54
00  8
36 52
60  9
91

50
54  9
12 57
75  7
00 52
37  10
25

51
58  8
54 54
53  9
63

49
80  9
21 55
23  8
70

59
63  6
00 46
80  8
45 52
16  7
54

53
00  9
15 54
00  9
79

51
70  11
47 53
11  8
92 55
25  6
34

64
80  25
78 70
00  13
82 65
14  11
81 68
89  12
88 60
25  27
76

58
11  9
59 50
77  8
04

Control X  SD

67
18  17
31 67
58  15
22

Experimental X  SD

Control X  SD

Experimental X  SD

69
33  18
12 72
63  10
44

77
66  7
50 66
57  16
73

71
00  9
05 67
20  20
11 78
20  6
05

67
50  10
94 72
11  15
95

76
66  18
58 70
05  14
43

76
16  11
26 67
75  11
22 70
22  19
36

73
00  10
57 61
00  27
54

67
20  26
09 73
54  11
51 69
42  9
60

71
36  16
78 70
50  13
29

Experimental X  SD

Week 10

54
85  11
91 51
15  7
31

54
58  9
94 51
86  10
14

49
00  9
19 58
25  10
18 53
50  9
33

52
00  6
88 53
93  12
05

46
20  7
71 57
11  8
99

58
90  9
14 46
30  9
22 53
66  5
31

53
09  10
16 53
00  10
11

51
20  11
30 52
66  8
80 55
87  10
07

60
00  9
73 49
61  8
31

Control X  SD

0
00 0
00

0
00 0
00

0
00 0
00 0
01

0
00 0
00

0
06 0
00

0
00 0
00 0
00

0
00 0
06

0
02 0
00 0
00

0
00 0
00

Experimental Pd

0
55 0
44

0
71 0
47

0
22 0
20 0
34

0
01 0
68

0
36 0
26

0
90 0
63 0
56

0
55 0
62

0
67 0
39 0
96

0
39 0
65

Control Pk

Differences between groups by measurement weeks

Pd: Difference among the experimental group individuals’ average scores by socio-demographic attributes, by measurement weeks; Pk Difference among the control group individuals’ average scores by socio-demographic attributes, by measurement weeks. Significant p-values are displayed in bold (p < 0
05 and p < 0
01).

Gender Female Male Age 50≤ 51–60 61–70 Marital status Married Single Educational background Primary school Secondary school University Work status Working Not working Stoma nature Temporary Permanent Stoma duration (months) 12≤ 13–60 61≥ Stoma care knowledge perception Sufficient Insufficient Ability to perform stoma care Him/herself Him/herself by assistance

Socio-demographic and stoma attributes

Week 6

Week 1

Table 3 Distribution of Ostomy Adjustment Inventory average scores of experimental and control group members by socio-demographic and stoma attributes

Original article Effects of group interactions on people with stoma

2807

2808 43
66  29
82 45
55  24
80 51
80  31
04 36
11  27
51 46
25  15
47 46
61  28
01 39
00  18
02 39
45  28
23 37
50  13
01 67
33  28
99 45
10  22
78 44
82  28
41 48
16  24
67 42
33  27
60 44
72  18
59 55
37  33
72 34
75  25
26 50
16  32
92 40
73  19
03 42
57  27
06 47
46  25
66

42
09  24
29 40
58  25
27 50
80  38
61 34
90  15
10 44
57  24
90 40
26  21
01 46
25  40
30 54
16  23
50 37
00  21
88 36
55  26
17 42
00  36
00 41
20  23
33 48
16  19
69 38
88  25
76 46
87  19
31 43
90  31
12 27
20  8
70 28
88  13
84 49
28  26
50 39
16  29
61 43
63  17
83

33
08  31
83 37
72  25
62

19
44  13
19 45
50  31
28

44
00  27
95 38
50  32
55 15
00  3
74

34
16  12
81 35
70  32
59

21
33  17
00 37
40  29
54

32
83  16
64 42
00  36
80 31
00  28
30

35
92  26
75 44
30  19
64

39
66  25
96 40
20  22
33

46
18  23
79 40
12  24
63 31
25  22
25

48
16  21
80 33
40  23
48

36
60  22
01 41
94  24
83

38
27  26
02 34
60  19
09 52
00  25
16

40
66  24
98 37
50  19
36

47
60  30
89 30
11  14
26 41
50  19
67

50
20  48
68 27
09  15
08 37
57  26
42 33
84  26
09 42
25  42
22

43
22  26
66 38
33  22
46

Control X  SD

33
00  26
75 37
41  30
99

Experimental X  SD

Control X  SD

Experimental X  SD

30
91  30
41 31
18  27
40

15
88  8
73 40
78  32
43

39
25  29
76 33
30  32
16 13
40  2
50

24
66  11
48 33
29  32
30

11
66  7
50 33
95  29
27

29
00  17
27 36
75  35
93 27
33  29
03

29
73  25
48 37
25  43
99

47
20  51
08 23
36  13
13 31
57  24
38

30
09  27
44 31
91  30
35

Experimental X  SD

Week 10

30
28  21
26 42
84  17
29

36
91  22
09 35
86  19
18

41
63  17
08 32
87  21
04 32
50  23
87

38
33  17
25 34
73  22
62

36
70  19
31 36
11  21
17

36
27  24
45 32
50  15
60 42
83  19
79

36
04  19
88 37
33  22
86

36
40  22
83 31
11  15
55 42
12  22
00

40
11  22
04 34
44  19
47

Control X  SD

0
01 0
00

0
00 0
01

0
01 0
06 0
01

0
00 0
00

0
06 0
00

0
01 0
23 0
00

0
00 0
06

0
00 0
54 0
10

0
00 0
03

Experimental Pd

0
09 0
59

0
15 0
36

0
55 0
01 0
84

0
07 0
27

0
56 0
06

0
62 0
43 0
16

0
10 0
54

0
15 0
31 0
39

0
34 0
13

Control Pk

Pd: Difference among the experimental group individuals’ average scores by socio-demographic attributes, by measurement weeks; Pk: Difference among the control group individuals’ average scores by socio-demographic attributes, by measurement weeks.

Gender Female Male Age ≤50 51–60 61–70 Marital status Married Single Educational background Primary school Secondary school University Working status Working Not working Stoma nature Temporary Permanent Stoma duration (months) 12≤ 13–60 61≥ Stoma care knowledge perception Sufficient Insufficient Ability to perform stoma care Him/herself Him/herself by assistance

Socio-demographic and stoma attributes

Week 6

Week 1

Differences between groups by measurement weeks

Table 4 Distribution of Psychosocial Adjustment to Illness Scale average scores of experimental and control group members by socio-demographic and stoma attributes

HK Karabulut et al.

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

Original article

that indicated that the majority of our participants had stoma surgery because of cancer. Similar to our research findings, earlier studies stated that colorectal cancer was the most prevalent disease that required stoma surgery (Piwonka & Merino 1999). More than half of the individuals who participated in the current study had permanent stomas. Almost half of those individuals were receiving chemotherapy and/or radiotherapy. Almost half of all participants in the experimental group had stomas for between 13–60 months. Individuals in the control group had stomas for 12 months or less. Previous studies indicated that individuals who had stomas primarily had colostomies. To a lesser extent, some individuals had ileostomies (Wade 1990, Kelman 1997). Studies conducted by Simmons et al. (2009, 2007) also demonstrated that most individuals had colostomies, that stoma duration varied between 1 year–59 years and that almost half of those individuals received chemotherapy and/ or radiotherapy. In the current study, experimental group members’ average OAI scores increased gradually during and after planned group interaction sessions. However, control group members’ average scores did not change significantly over time. In addition, experimental group members’ average scores were higher than control group members’ average scores. This indicated the effectiveness of the planned group interaction method on social adjustment of individuals with a stoma. The results of the current study are consistent with the results of several other studies that evaluated interventions aimed at the facilitation of stoma patients’ adaptation. Martin (1994) stated that new stoma patients in an experimental group who received nursing interventions demonstrated higher adaptation scores (82
42) during weeks 6 and 8 of the post-operative period, in comparison with the control group (78
58). Cheng et al. (2012) discovered that the adaptation scores of patients who participated in a specialist-patient programme demonstrated significantly higher adaptation scores after programme completion (53
37), in comparison with scores achieved before the programme began (47
59). The results of the current study, as well as the results of the above-mentioned studies, indicate that planned professional support might ensure adaptation in individuals with a stoma. The current study’s results revealed that, although experimental group members’ average PAIS-SR scores demonstrated moderate adaptation levels during the first week, members’ adaptation increased over subsequent weeks. However, control group members’ average PAIS-SR scores did not change significantly over time. Thus, the absence of a significant difference between the average scores of the © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

Effects of group interactions on people with stoma

experimental and control groups might demonstrate that experimental group members’ PAIS-SR scores during the monitoring period that followed group interactions remained at a certain level. In other words, adaptation difficulties continued to occur. This might explain why group members’ average PAIS-SR scores demonstrated limited changes over time. The fact that no significant differences occurred between the average scores of members of both the experimental and control groups might have occurred because members experienced lifelong anxiety, members suffered from adaptation problems that developed when they received cancer diagnoses, as well as from the fact that the adaptation process can take a long time. Bekkers et al. (1997) noted that patients’ psychosocial adjustment to illness takes a long time. In particular, when body integrity is affected, adjustment problems can continue over time, despite the fact that patients are healing physically. The current study’s results revealed significant differences existed between experimental group and control group members’ adjustment scores on both scales with respect to socio-demographic attributes such as gender, age, marital status, educational status and working status. Other studies in the literature demonstrated that socio-demographic variables, such as age, gender, education, occupation and so on, exert important impacts on adaptation in individuals with a stoma (Piwonka & Merino 1999, Brown & Randle 2005). Based on our observations in the stomatherapy unit, we believe that gender-based stoma adaptation differences that occur arise because females are more acquiescent than males when they are ill. Females are also more capable of performing self-care activities without assistance. In addition, most male members of the current study’s experimental group stated they were unable to care for themselves for long periods without assistance. Most received assistance from their wives. Therefore, it is possible to state that, in comparison with females, males’ lower adaptation levels were related to males’ inability to care for themselves without assistance. With respect to the impacts of age on adaptation, it appeared that, for older individuals, fewer external factors affected adaptation. Only illness and their ability to care for themselves appeared to be important. Piwonka and Merino (1999) conducted a study focused on individuals with stomas. They examined the impacts of age on social adaptation and determined that the time elapsed after surgery, body image, social support and a limited number of post-operative complications were the most important factors that affected the adaptation of individuals below 62 years of age. For individuals older than 62, only the ability to perform stoma care and body image were

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HK Karabulut et al.

important factors. One study noted that spousal support is an important factor that affects individuals’ adaptation (Wade 1990). In addition, family, children, friends and social supports also exert positive influences on adaptation (Piwonka & Merino 1999). The current study discovered that participants who possessed lower educational levels demonstrated higher scores than participants who possessed higher educational levels. This may have occurred because participants with lower educational levels might more easily accept catastrophic situations (e.g. diseases) because they believe fatalistically that they are God’s children. Thus, they believe they can adapt more rapidly to diseases. As educational levels increased, individuals tended to protect and improve their health. When they received disease diagnoses, those individuals accepted professional support so that they could learn to adapt. In the current study, experimental group members’ higher educational levels might be considered an indicator of this tendency. From the viewpoint of working status, the absence of environments in which individuals with a stoma can perform stoma care in comfort and privacy, particularly in work environments, can increase patients’ struggles to adapt to life with stomas. Additionally, working individuals tended to decrease the length of time they engaged in social activities because of higher workloads and because of the time required for stoma care. They preferred to delay or abandon these activities. In contrast, nonworking individuals were able to allot additional time for social activities because they were not restricted in any way. They were more comfortable performing stoma care in their home environments. The results of the current study imply that nonworking experimental group members received support from the planned group interaction programme. Thus, their adaptation levels increased. In the current study, individuals who demonstrated higher adaptation levels had permanent stomas, had stomas for 61 months and longer, had sufficient stoma care knowledge and were able to perform stoma care without assistance. Stoma surgery affects individuals’ living standards. Therefore, whether stomas are permanent or temporary, the length of time individuals live with stomas, as well as individuals’ knowledge of stoma care, can significantly influence their adaptation levels. Individuals who have permanent stomas attempt to adapt to these situations as quickly as possible because they understand that they will live with stomas for life. They also demonstrate better understanding of care-related information and practices. Individuals who have temporary stomas neither need to adapt to these situations, nor perform stoma care by themselves because their stomas will eventually be closed. Some

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studies have noted that stoma types, individuals’ ability to perform stoma care and the time elapsed after surgery are important variables that may ensure positive adaptation (Piwonka & Merino 1999, Simmons et al. 2009).

Conclusion The results of the current study indicate that the planned group interaction programme facilitated social adaptation in individuals with a stoma. The OAI average scores of experimental group members increased gradually when measurements were made during the sixth and tenth weeks, in comparison with measurement made during the first week. In addition, these average scores were higher than control group members’ OAI average scores. The PAIS-SR average scores of experimental group members decreased significantly during weeks 6 and 10 of the planned group interaction sessions. This indicates that patients’ adaptation improved. However, no significant differences occurred between the experimental and control groups with respect to average scores. Based on the results of this study, we suggest that planned group interaction programmes should be included in ET nurses’ practices to ensure the adjustment of individuals with a stoma to stomas and illness.

Relevance to clinical practice Stoma has great impact on quality of life of an individual due to loss of an important body function, stoma-related complications and changes in the body’s appearance and functional ability. Individuals with stoma experience difficulties in psychological and social adjustment. Nursing care encompasses not only physical care, but the psychological, cultural, sexual and social needs of the individuals with stoma. Results of this study indicated that a planned group interaction guided by a stoma nurse facilitates the social adjustment of individuals with an intestinal stoma. Further studies of the effects of planned group interactions on a greater number of individuals with a stoma would make significant contributions to the literature.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethi cal_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

Original article

Effects of group interactions on people with stoma

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Appendix 1: Ostomy Adjustment Inventory-23 (OAI-23) The statements below relate to how you feel about your stoma. For each statement, please insert a U in one of the boxes, ‘strongly agree’ to ‘strongly disagree’ to indicate your agreement with the statement. Please try to answer all of the questions.

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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2800–2813

Original article

Effects of group interactions on people with stoma

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