J Wound Ostomy Continence Nurs. 2016;43(1):57-61. Published by Lippincott Williams & Wilkins
OSTOMY CARE
The Impact of Preoperative Stoma Marking on Health-Related Quality of Life A Comparison Cohort Study Linda S. McKenna Elizabeth Taggart Joyce Stoelting Geri Kirkbride Gordon B. Forbes
■ ABSTRACT PURPOSE: The purpose of this study was to compare
health-related quality of life (HRQOL) in patients receiving preoperative stoma marking by a certified wound, ostomy and continence nurse (CWOCN) to patients who did not receive preoperative marking. DESIGN: Quasi-experimental, nonrandomized comparison cohort study. SUBJECTS AND SETTING: The sample comprised 59 patients immediately following creation of a fecal stoma during an 18-month period between 2008 and 2010. The experimental group consisted of 35 patients with a mean age of 49.7 years who received preoperative stoma site marking by a CWOCN. Six of those 35 patients (17%) received preoperative ostomy education and stoma site marking. The control group consisted of 24 patients with a mean age of 60.1 years who did not receive preoperative stoma site marking or preoperative ostomy education. The study setting was a 500-bed Midwest Magnetdesignated teaching hospital. METHODS: Data collection occurred at 2 points: within 72 hours before hospital discharge and 8 weeks after discharge. The Stoma Quality of Life (Stoma-QOL) instrument was used to measure HRQOL. Two CWOCNs and 3 RNs, all members of Memorial’s Ostomy & Wound Services, administered the Stoma QOL within 72 hours before hospital discharge. The 2 CWOCNs followed a scripted message to collect functional lifestyle factors and administer the Stoma-QOL, for the second time at 8 weeks after discharge. RESULTS: Groups were compared using analysis of covariance to control for age; analysis demonstrated significantly higher HOQOL in the marked group compared to the unmarked group (F = 4.9, P = .031). CONCLUSION: Findings demonstrated that patients who underwent stoma site marking reported higher HRQOL than those who did not.
KEY WORDS: CWOCN, Functional lifestyle factors, HRQOL,
Quality of life, Stoma marking
■ Introduction Approximately 120,000 people undergo fecal or urinary diversion each year in the United States and Canada.1 Wound, Ostomy and Continence (WOC) nurses provide care for people throughout the course of their ostomy experience. Findings supported that patients requiring a fecal stoma experienced postoperative complications that impacted health-related quality of life (HRQOL), such as peristomal skin irritation and pouch leakage.1,2,4,7,8,9,21 Stoma site marking is possibly one of the most impactful services provided by WOC nurses. Nevertheless, evidence concerning the effect of stoma site marking on postsurgical outcomes is limited.3,5,7 Studies suggest that stoma site marking, along with preoperative education and Linda S. McKenna, MSN, RN, CWOCN, Ostomy, Wound and Skin Services, University of Wisconsin Hospital and Clinics, Madison, Wisconsin. Elizabeth Taggart, BSN, RN, CWOCN, Memorials Ostomy & Wound Service, Memorial Medical Center, Springfield, Illinois. Joyce Stoelting, MSN, RN, CWS, Memorials Ostomy & Wound Service, Memorial Medical Center, Springfield, Illinois. Geri Kirkbride, PhD, RN, Patient Safety Nurse Coordinator, Memorial Medical Center, Springfield, Illinois. Gordon B. Forbes, PhD, Professor Emeritus, Milikin University, Decatur, IL Research team members: Imran Hassan, MD; Tammy Berry, RN; Carol Midiri, RN, CWS; Rosalie Mottar, RN, BSN; Kay E. Gaehle, RN, PhD, Memorial Medical Center, Springfield, Illinois. The authors declare no conflict of interest. Correspondence: Linda S. McKenna, MSN, RN, CWOCN, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, E5/540, Mail Code 8340, Madison, WI 53792 ([email protected]). DOI: 10.1097/WON.0000000000000180
Copyright © 2016 by the Wound, Ostomy and Continence Nurses Society™
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ongoing care by a WOC or ostomy nurse specialist, reduces stoma and peristomal complications,3,6,12,14–19 enhances acceptance of a new body image,13,16,24 and promotes selfcare,7,16,20 self-management of complications,11,13,23 and HRQOL.1,22 The purpose of this study was to compare HRQOL in patients who received stoma marking prior to surgery by a certified wound, ostomy and continence nurse (CWOCN) to a cohort of patients who did not receive preoperative marking.
■ Methods A nonrandomized, quasi-experimental design was used for the study. Patients in the intervention group received preoperative stoma marking by a CWOCN and patients in the control group did not. The study site serves a large, rural population; hence, the majority of the participants (n = 29 or 83%) in the experimental (marked) group received stoma site marking only on the day of surgery as they did not wish to make a separate trip for preoperative ostomy education. Seventeen percent (n = 6) of the experimental group (marked) participants received both preoperative stoma site marking and ostomy education. The study site was a 500-bed Midwest Magnetdesignated teaching hospital, where approximately 75 colostomy or ileostomy procedures are completed each year. Convenience sampling was used to enroll patients who underwent ileostomy or colostomy, during an 18-month period between 2008 and 2010. Inclusion criteria were individuals who were English speaking and able to answer questions during the interview process and had no previous history of an abdominal stoma. Patients were excluded from the study if they were transferred unexpectedly to the ICU, hospitalized for greater than 10 days, scheduled for a stoma takedown within 8 weeks, or experienced postoperative complications such as wound dehiscence, evisceration, or stoma necrosis below the fascia. The institutional review board approval was applied for and granted by the Springfield Committee for Research Involving Human Subjects prior to study participant enrollment.
Instruments Multiple data were collected for this study including demographic information, presence of coexisting conditions, and functional lifestyle factors such as self-care, use of assistive devices, and ability to independently manage stoma care. Health-related quality of life was measured using the Stoma Quality of Life (Stoma-QOL) developed by Prieto and colleagues.25 This instrument contains 20 items that query 4 domains contained within Maslow’s pyramidal hierarchy, sleep, sexual activity, relations with family and close friends, and relations with others. Scores range from 0 to 80, with a score of 0 indicating the lowest possible HRQOL. The Stoma-QOL’s reliability has an internal consistency of 0.92. Test/retest reliability analysis yielded a Spearman rank correlation coefficient of 0.88.
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These scores indicate an instrument that has high overall internal consistency and high test/retest reliability.2,25
Study Procedures Patients undergoing fecal ostomy surgery in our facility are referred to Memorial’s Ostomy and Wound Service (MOWS). Referral sources include colorectal, trauma, cardiovascular, transplant, gynecology/oncology, and general surgeons. The MOWS team is made up of 2 CWOCNs, 2 CWS, and 1 RN with special training in ostomy care. The majority of study participants who underwent nonemergent surgery received preoperative stoma marking by a CWOCN. Those individuals undergoing emergent surgery did not receive stoma site marking but were referred for postoperative management and ostomy education. Patients meeting inclusion criteria were provided an explanation about the study by 1 of 5 nurse members of the research team; a scripted message was used to ensure consistency when delivering this message. Participants in the experimental group received standard preoperative marking by a CWOCN following procedures outlined in the ASCRS and WOCN Joint Position Statement on the Value of Preoperative Stoma Marking for Patients Undergoing Fecal Ostomy Surgery.3 All patients received routine postoperative care and education by a MOWS team member using our standard ostomy teaching plans. Patients were provided a minimum of 3 teaching sessions. Minimal skills sets taught during these sessions include opening and emptying the pouch of stool and gas, as well as cleaning and closing the pouch. Patients and family members observed and assisted in at least 1 pouch change but were not expected to demonstrate proficiency in this skill because most of our patients receive home health care. Convenience sampling was used to enroll subjects in both the experimental (marked) and control (unmarked) groups. Demographic information and coexisting conditions were obtained from chart review. At 2 points during the study, MOWS nurses collected additional data from subjects in both groups. The first interview occurred within 72 hours prior to discharge; the Stoma-QOL was administered during this face-to-face interview. The second interview occurred 8 weeks following hospital discharge, during a scheduled telephone call; a CWOCN followed a scripted message to collect functional lifestyle factors and administer the Stoma-QOL for the second time. Ninety percent of patients in both groups received home nursing and all study subjects were given the opportunity to follow up with the MOWS nurses for ostomy pouching problems or issues.
■ Data Analysis Data were compared for equivalency and differences between groups using t tests and analysis of covariance. An alpha level of .05 was used to determine statistical significance. Data were analyzed using SPSS software version 17 (Statistical Package for the Social Sciences, Chicago, Illinois).26
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TABLE 1.
Demographic and Clinical Characteristics Marked
Unmarked
35
24
49.7 (15.5)
60.1 (14.1)
Male (27)
15
12
Female (32)
20
12
Diverticulitis
4
9
Irritable bowel syndrome
6
1
Bowel ischemia/perforation
1
3
Variable Sample size, N (59) Mean age (SD)
Type of coexisting illness
59
coexisting illness, 56% (n = 33) had a single comorbid condition, 14% (n = 8) had 3 conditions, and 6% (n = 4) had 4 or more conditions. Twenty-six patients (44%) had cancer and several had been diagnosed with more than one type of malignancy.
Stoma-QOL Analysis of covariance, with age as the covariant, was used to examine group differences based on Stoma-QOL scores. Because information on age was not available for 1 patient, this analysis included only 23 persons in the comparison (unmarked) group. Neither the effect of time (F = 2.3; P = 0.13) nor group (F = 0.01, P = 0.91) was statistically significant by themselves. However, an increase in Stoma-QOL at the 8-week period following hospital discharge interval was significantly greater in the marked group than in the unmarked group (F = 4.90; P = .031), indicating a significant increase in HRQOL among patients who received preoperative stoma marking.
Spinal cord injury
3
0
Cancer [Type]
17
11
[Colon]
[6]
[3]
[Rectal]
[6]
[4]
[Ovarian]
[3]
[3]
Functional Lifestyle Factors
[Other]
[2]
[1]
Participants were asked about lifestyle factors that might influence HRQOL 8 weeks after hospital discharge. Most participants (92%; n = 54) returned to their own home, including 10 (17%) who lived alone. Fifty-three participants (89%) stated that they were able to provide self-care related to cooking, bathing, toileting, and walking. Group differences related to stoma self-care functional lifestyle factors are displayed in Table 2. The majority of study participants reported a high level of function with stoma alone self-care; 53 (90%) indicated that they were able to empty their ostomy pouch without assistance, and 46 (78%) stated that they were able to change their ostomy pouch independently. Although more patients in the marked group indicated higher levels of stoma self-management when compared to patients in the unmarked group, the differences were not statistically significant (Figure 1).
■ Results Demographic and pertinent clinical information of the sample (N = 59) is summarized in Table 1. No significant differences were found between the groups for gender, coexisting conditions, or functional lifestyle factors. In contrast, a statistically significant difference in age was found between the marked and unmarked groups (t(56) = −2.52, P = .011). Data concerning comorbid conditions were obtained from chart review. No significant differences were found between the marked group (M = 1.36, SD = 1.44) and unmarked group (M = 1.42, SD = 1.10) groups, t(57) = −0.458, P = .65. While 22% (n = 13) of all patients had no TABLE 2.
Functional Lifestyle Factors at 8 Weeks Following Surgery Stoma functional lifestyle factors N (59)
Marked (n = 35)
Unmarked (n = 24)
90% (n = 53)
94% (n = 33)
83% (n = 20)
With assistance
5% (n = 3)
6% (n = 2)
4% (n = 1)
Unable
5% (n = 3)
0 (n = 0)
13% (n = 3)
78% (n = 46)
86% (n = 30)
67% (n = 16)
With assistance
8% (n = 5)
3% (n = 1)
17% (n = 4)
Unable
14% (n = 8)
11% (n = 4)
17% (n = 4)
Self-care Empty ostomy pouch: χ2(2) = 4.63, P = .10 Independent
Change ostomy pouching system, χ2(2) = 4.15, P = .12 Independent
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STOMA-QOL Scores 60.6
60
56.6
55 52.5 50
Unmarked
48.8
Marked
45 Time 1
Time 2
FIGURE 1. Stoma-QOL Scores. At 8 weeks after fecal ostomy
surgery, subjects in the experimental (marked) group had significantly higher (P = .031) stoma-QOL scores than subjects in the control (unmarked) group. Stoma-QOL indicates Stoma Quality of Life.
■ Discussion We found a statistically significant increase in HRQOL among patients who received preoperative stoma marking. This finding adds to a growing body of evidence that preoperative stoma marking enhances postoperative HRQOL. Our findings are similar to those reported by Person and associates,27 Mahjoubi and colleagues,28 and Millan’s group,29 who also reported that patients receiving preoperative stoma marking had lower rates of anxiety and significantly higher HRQOL scores than unmarked patients. However, none of these authors reported a statistically significant difference in HRQOL for subjects who received preoperative education as compared to subjects who did not receive preoperative ostomy teaching. The majority of our study participants underwent ostomy surgery due to a cancer diagnosis; therefore, the cancer diagnosis itself may have impacted HRQOL. Having a diagnosis of cancer can be an additional stressor for ostomy patients.14 Carlsson and colleagues30 evaluated 57 patients with new ostomies associated with treatment of rectal cancer and reported higher levels of anxiety immediately following surgery related to the uncertainty of a cancer diagnosis and fear of what their new lives would entail.30 Cotrim and Pereira’s31 cross-sectional, descriptive study of 153 patients and 96 informal caregivers also found that a colorectal cancer diagnosis was associated with increased anxiety and depression. However, the increase in anxiety and depression was not based on scores from a validated instrument. Coping strategies are essential for managing emotional responses. In our study, the majority of participants returned home with a family support system. GustavssonLilius and colleagues32 reported results of a longitudinal research study that focused on psychosocial consequences of cancer, including the impact of partner support on patient optimism, hopelessness, and HRQOL. Their findings suggest that female cancer patients who perceive high lev-
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els of partner support were more optimistic and had a higher HRQOL than women reporting lower levels of support from their partners. Lee and colleagues33 reported findings from a randomized control trial involving 74 cancer patients, demonstrating that those receiving formal training in coping strategies had an improved sense of optimism as a result of participating in an intervention, which examined the fearful aspects of cancer. Although fewer than half of the patients in our study had a diagnosis of cancer, these findings suggest that anxiety and HRQOL can be affected by a cancer diagnosis. Lifestyle functions related to HRQOL can also be impacted by stoma location. Sun and colleagues34 found that many individuals with ostomies faced challenges related to bowel function, activity limitations, and clothing restrictions due to the placement of the stoma. Their findings suggest that a poorly located ostomy required more diligent constant monitoring to avoid leakage and embarrassing accidents, which participants found emotionally exhausting and stressful. This study site serves a large, rural population; as a result, 83% of patients in the experimental (marked) group received stoma site marking only on the day of surgery as they did not wish to make a separate trip for preoperative ostomy education. We found several studies that suggest that preoperative ostomy education contributes to shorter hospital stays and quicker mastery of stoma care.5,10,29,35,36 For example, de la Quintana and associates37 reported results of a prospective, longitudinal, multicentered study that looked at the benefits of ostomy education, apart from stoma marking, and found that structured ostomy education performed either pre- or postoperatively had a positive effect on HRQOL.
■ Limitations Limitations of this study include a single study site and inability to randomize group assignment. In addition, postoperative HRQOL was remeasured at 8 weeks, whereas a measurement at a more distant time might produce different results. Although the Stoma-QOL is a valid and reliable instrument, Pittman and colleagues1 found that all existing instruments have limited value in the clinical setting as a diagnostic measure of HRQOL. Further research is needed to determine if these findings will remain consistent if evaluated in a randomized, multisite study with follow-up longer than an 8 week postoperative period. It is also of interest to explore whether the addition of preoperative ostomy education influences HRQOL in patients receiving stoma siting. Finally, we acknowledge that the influence of a cancer diagnosis leading to a fecal ostomy, lack of controlling preoperative ostomy education, and measuring HRQOL only during the immediate postoperative period may have influenced study results.
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■ Conclusion Study results strongly suggest that stoma site marking increase HRQOL during the early postoperative period. Based on results of this study, we recommend that CWOCNs educate physicians and staff about the importance of stoma site marking, and ensure that marking is a priority prior to ostomy surgery.
18. 19.
20.
21.
■ References 1. Pittman J, Rawl SM, Schmidt CM, et al. Demographic and clinical factors related to ostomy complications and quality of life in veterans with an ostomy. J Wound Ostomy Continence Nurs. 2008;35:493-503. 2. Pittman J, Kozell K, Gray M. Should WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery? J Wound Ostomy Continence Nurs. 2009;36:254265. 3. Berry K, Carmel J, Gutman N, et al. ASCRS and WOCN joint position statement on the value of pre-operative stoma marking for patients undergoing fecal ostomy surgery. 2007;34:627628. 4. Nichols TR. Quality of life in US residents with ostomies as assessed using the SF36v2. J Wound Ostomy Continence Nurs. 2015;42:71-78. 5. Colwell J, Gray M. Does pre-operative teaching and stoma site marking affect surgical outcomes in patients undergoing ostomy surgery. J Wound Ostomy Continence Nurs. 2007;34:492496. 6. Salvadalena G, Hendren S, McKenna L, et al. WOCN society and ASCRS position statement on preoperative stoma site marking for patients undergoing colostomy or ileostomy surgery. Stoma. 2015;8:10. 7. Erwin-Toth P, Barrett P. Stoma site marking: a primer. Ostomy Wound Manag. 1997; 43:18-25. 8. Colwell JC, Beitz J. Survey of wound, ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications: a content validation study. J Wound Ostomy Continence Nurs. 2007;34:57-69. 9. Doughty D B. The state of ostomy care: tremendous progress, continued challenges. J Wound Ostomy Continence Nurs. 2001; 28:1-2. 10. Haugen V, Bliss DZ, Savik K. Perioperative factors that affect long-term adjustment to an incontinent ostomy. J Wound Ostomy Continence Nurs. 2006;33:525-535. 11. Richbourg L, Thorpe J, Rapp C. Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs. 2007;34:70-79. 12. Chaudhri S, Brown L, Hassan I, Horgan A. Pre-operative intensive, community-based vs. traditional stoma education: a randomized, controlled trial. Dis Colon Rectum. 2005;48:504-509. 13. Black P. Psychological, sexual and cultural issues for patients with a stoma. Br J Nurs. 2004;13:692-697. 14. Comb J. Role of the stoma care nurse: patient with cancer and colostomy. Br J Nurs. 2003;12:852-856. 15. Karada A, Mentes B, Uner A, Irkorucu O, Ayaz S, Ozkan S. Impact of stoma therapy on quality of life in patients with permanent colostomies or ileostomies. Int J Colorectal Dis. 2002;18:234-238. 16. Readding L. Stoma siting: what the community nurse needs to know. Br J Comm Nurs. 2003;8:504-511. 17. Bass EM, Del Pino A, Tan A, Pearl RK, Orsay CP, Abcarian H. Does pre-operative stoma marking and education by the enter-
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ostomal therapist affect outcome? Dis Colon Rectum. 1997; 40:440-442. Rozen BL. The value of a well-placed stoma. Cancer Pract. 1997;5:347-352. Ma N, Harvey J, Steward J, Andrews L, Hill A. The effect of age on the quality of life of patients living with stomas: a pilot study. ANZ J Surg. 2007;77:883-885. Persson E, Gustavsson B, Hellstrom A, Lappas G, Hulten L. Ostomy patients’ perceptions of quality of care. J Adv Nurs. 2005;49:51-58. Harris R, Daly K, Jones L, Kiff E. Stoma formation for functional bowel disease. Colorectal Dis. 2004;6:280-284. Gulbiniene J, Markelis R, Tamelis A, Saladzinskas Z. [The impact of preoperative stoma siting and stoma care education on patient’s quality of life]. Medicina (Kaunas, Lithuania). 2003;40:1045-1053. Barr E. Assessment and management of stomal complications: a framework for clinical decision making. Ostomy/Wound Manag J. 2004;50:50-67. Johnson J. Self-regulation theory and coping with physical illness. Res Nurs Health. 1999;22:435-448. Prieto L, Thorsen H, Juul K. Development and validation of a quality of life questionnaire for patients with colostomy or ileostomy. Health Qual Life Outcomes. 2005;3:62. SPSS Inc. (2008). SPSS Statistics for Windows, Version 17.0. Chicago, IL: SPSS Inc. Person B, Ifargan R, Lachter J, Duek SD, Kluger Y, Assalia A. The impact of preoperative stoma site marking on the incidence of complications, quality of life, and patient’s independence. Dis Colon Rectum. 2012;55:783-787. Mahjoubi B, Goodarzi KK, Mohammad-Sadeghi H. Quality of life in stoma patients: appropriate and inappropriate stoma sites. World J Surg. 2010;34:147-152. Millan M, Tegido M, Biondo S, Garcia-Granero E. Pre-operative stoma siting and education by stoma therapists of colorectal patients: a descriptive study in twelve colorectal surgical units. Colorectal Dis. 2010;12:88-92. Carlsson E, Berndtsson I, Hallén AM, Lindholm E, Persson E. Concerns and quality of life before surgery and during the recovery period in patients with rectal cancer and an ostomy. J Wound Ostomy Continence Nurs. 2010 ; 37 : 654661. Cotrim H, Pereira G. Impact of colorectal cancer on patient and family: implications for care. Euro J Oncol Nurs. 2008;12:217226. Gustavsson-Lilius M, Julkunen J, Hietanen P. Quality of life in cancer patients: the role of optimism, hopelessness, and partner support. Qual Life Res. 2007;16:75-87. Lee V, Robin Cohen S, Edgar L, Laizner AM, Gagnon AJ. Meaning-making intervention during breast or colorectal cancer treatment improves self-esteem, optimism, and self-efficacy. Soc Sci Med. 2006;62:3133-3145. Sun V, Grant M, McMullen CK, et al. Surviving colorectal cancer: long-term, persistent ostomy-specific concerns and adaptations. J Wound Ostomy Continence Nurs. 2013;40: 61-72. Zimnicki KM. Preoperative stoma site marking in the general surgery population. J Wound Ostomy Continence Nurs. 2013; 40:501-505. Danielsen AK, Burcharth J, Rosenberg J. Patient education has a positive effect in patients with a stoma: a systematic review. Colorectal Dis. 2013;15:e276-e283. de la Quintana JP, Pastor JC, Prados HI, et al. A prospective, longitudinal, multicenter, cohort quality-of-life evaluation of an intensive follow-up program for patients with a stoma. Ostomy/wound Manage. 2010;56:44-52.
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OSTOMY CARE
The Impact of Preoperative Stoma Marking on Health-Related Quality of Life A Comparison Cohort Study Linda S. McKenna Elizabeth Taggart Joyce Stoelting Geri Kirkbride Gordon B. Forbes
■ ABSTRACT PURPOSE: The purpose of this study was to compare
health-related quality of life (HRQOL) in patients receiving preoperative stoma marking by a certified wound, ostomy and continence nurse (CWOCN) to patients who did not receive preoperative marking. DESIGN: Quasi-experimental, nonrandomized comparison cohort study. SUBJECTS AND SETTING: The sample comprised 59 patients immediately following creation of a fecal stoma during an 18-month period between 2008 and 2010. The experimental group consisted of 35 patients with a mean age of 49.7 years who received preoperative stoma site marking by a CWOCN. Six of those 35 patients (17%) received preoperative ostomy education and stoma site marking. The control group consisted of 24 patients with a mean age of 60.1 years who did not receive preoperative stoma site marking or preoperative ostomy education. The study setting was a 500-bed Midwest Magnetdesignated teaching hospital. METHODS: Data collection occurred at 2 points: within 72 hours before hospital discharge and 8 weeks after discharge. The Stoma Quality of Life (Stoma-QOL) instrument was used to measure HRQOL. Two CWOCNs and 3 RNs, all members of Memorial’s Ostomy & Wound Services, administered the Stoma QOL within 72 hours before hospital discharge. The 2 CWOCNs followed a scripted message to collect functional lifestyle factors and administer the Stoma-QOL, for the second time at 8 weeks after discharge. RESULTS: Groups were compared using analysis of covariance to control for age; analysis demonstrated significantly higher HOQOL in the marked group compared to the unmarked group (F = 4.9, P = .031). CONCLUSION: Findings demonstrated that patients who underwent stoma site marking reported higher HRQOL than those who did not.
KEY WORDS: CWOCN, Functional lifestyle factors, HRQOL,
Quality of life, Stoma marking
■ Introduction Approximately 120,000 people undergo fecal or urinary diversion each year in the United States and Canada.1 Wound, Ostomy and Continence (WOC) nurses provide care for people throughout the course of their ostomy experience. Findings supported that patients requiring a fecal stoma experienced postoperative complications that impacted health-related quality of life (HRQOL), such as peristomal skin irritation and pouch leakage.1,2,4,7,8,9,21 Stoma site marking is possibly one of the most impactful services provided by WOC nurses. Nevertheless, evidence concerning the effect of stoma site marking on postsurgical outcomes is limited.3,5,7 Studies suggest that stoma site marking, along with preoperative education and Linda S. McKenna, MSN, RN, CWOCN, Ostomy, Wound and Skin Services, University of Wisconsin Hospital and Clinics, Madison, Wisconsin. Elizabeth Taggart, BSN, RN, CWOCN, Memorials Ostomy & Wound Service, Memorial Medical Center, Springfield, Illinois. Joyce Stoelting, MSN, RN, CWS, Memorials Ostomy & Wound Service, Memorial Medical Center, Springfield, Illinois. Geri Kirkbride, PhD, RN, Patient Safety Nurse Coordinator, Memorial Medical Center, Springfield, Illinois. Gordon B. Forbes, PhD, Professor Emeritus, Milikin University, Decatur, IL Research team members: Imran Hassan, MD; Tammy Berry, RN; Carol Midiri, RN, CWS; Rosalie Mottar, RN, BSN; Kay E. Gaehle, RN, PhD, Memorial Medical Center, Springfield, Illinois. The authors declare no conflict of interest. Correspondence: Linda S. McKenna, MSN, RN, CWOCN, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, E5/540, Mail Code 8340, Madison, WI 53792 ([email protected]). DOI: 10.1097/WON.0000000000000180
Copyright © 2016 by the Wound, Ostomy and Continence Nurses Society™
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ongoing care by a WOC or ostomy nurse specialist, reduces stoma and peristomal complications,3,6,12,14–19 enhances acceptance of a new body image,13,16,24 and promotes selfcare,7,16,20 self-management of complications,11,13,23 and HRQOL.1,22 The purpose of this study was to compare HRQOL in patients who received stoma marking prior to surgery by a certified wound, ostomy and continence nurse (CWOCN) to a cohort of patients who did not receive preoperative marking.
■ Methods A nonrandomized, quasi-experimental design was used for the study. Patients in the intervention group received preoperative stoma marking by a CWOCN and patients in the control group did not. The study site serves a large, rural population; hence, the majority of the participants (n = 29 or 83%) in the experimental (marked) group received stoma site marking only on the day of surgery as they did not wish to make a separate trip for preoperative ostomy education. Seventeen percent (n = 6) of the experimental group (marked) participants received both preoperative stoma site marking and ostomy education. The study site was a 500-bed Midwest Magnetdesignated teaching hospital, where approximately 75 colostomy or ileostomy procedures are completed each year. Convenience sampling was used to enroll patients who underwent ileostomy or colostomy, during an 18-month period between 2008 and 2010. Inclusion criteria were individuals who were English speaking and able to answer questions during the interview process and had no previous history of an abdominal stoma. Patients were excluded from the study if they were transferred unexpectedly to the ICU, hospitalized for greater than 10 days, scheduled for a stoma takedown within 8 weeks, or experienced postoperative complications such as wound dehiscence, evisceration, or stoma necrosis below the fascia. The institutional review board approval was applied for and granted by the Springfield Committee for Research Involving Human Subjects prior to study participant enrollment.
Instruments Multiple data were collected for this study including demographic information, presence of coexisting conditions, and functional lifestyle factors such as self-care, use of assistive devices, and ability to independently manage stoma care. Health-related quality of life was measured using the Stoma Quality of Life (Stoma-QOL) developed by Prieto and colleagues.25 This instrument contains 20 items that query 4 domains contained within Maslow’s pyramidal hierarchy, sleep, sexual activity, relations with family and close friends, and relations with others. Scores range from 0 to 80, with a score of 0 indicating the lowest possible HRQOL. The Stoma-QOL’s reliability has an internal consistency of 0.92. Test/retest reliability analysis yielded a Spearman rank correlation coefficient of 0.88.
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These scores indicate an instrument that has high overall internal consistency and high test/retest reliability.2,25
Study Procedures Patients undergoing fecal ostomy surgery in our facility are referred to Memorial’s Ostomy and Wound Service (MOWS). Referral sources include colorectal, trauma, cardiovascular, transplant, gynecology/oncology, and general surgeons. The MOWS team is made up of 2 CWOCNs, 2 CWS, and 1 RN with special training in ostomy care. The majority of study participants who underwent nonemergent surgery received preoperative stoma marking by a CWOCN. Those individuals undergoing emergent surgery did not receive stoma site marking but were referred for postoperative management and ostomy education. Patients meeting inclusion criteria were provided an explanation about the study by 1 of 5 nurse members of the research team; a scripted message was used to ensure consistency when delivering this message. Participants in the experimental group received standard preoperative marking by a CWOCN following procedures outlined in the ASCRS and WOCN Joint Position Statement on the Value of Preoperative Stoma Marking for Patients Undergoing Fecal Ostomy Surgery.3 All patients received routine postoperative care and education by a MOWS team member using our standard ostomy teaching plans. Patients were provided a minimum of 3 teaching sessions. Minimal skills sets taught during these sessions include opening and emptying the pouch of stool and gas, as well as cleaning and closing the pouch. Patients and family members observed and assisted in at least 1 pouch change but were not expected to demonstrate proficiency in this skill because most of our patients receive home health care. Convenience sampling was used to enroll subjects in both the experimental (marked) and control (unmarked) groups. Demographic information and coexisting conditions were obtained from chart review. At 2 points during the study, MOWS nurses collected additional data from subjects in both groups. The first interview occurred within 72 hours prior to discharge; the Stoma-QOL was administered during this face-to-face interview. The second interview occurred 8 weeks following hospital discharge, during a scheduled telephone call; a CWOCN followed a scripted message to collect functional lifestyle factors and administer the Stoma-QOL for the second time. Ninety percent of patients in both groups received home nursing and all study subjects were given the opportunity to follow up with the MOWS nurses for ostomy pouching problems or issues.
■ Data Analysis Data were compared for equivalency and differences between groups using t tests and analysis of covariance. An alpha level of .05 was used to determine statistical significance. Data were analyzed using SPSS software version 17 (Statistical Package for the Social Sciences, Chicago, Illinois).26
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TABLE 1.
Demographic and Clinical Characteristics Marked
Unmarked
35
24
49.7 (15.5)
60.1 (14.1)
Male (27)
15
12
Female (32)
20
12
Diverticulitis
4
9
Irritable bowel syndrome
6
1
Bowel ischemia/perforation
1
3
Variable Sample size, N (59) Mean age (SD)
Type of coexisting illness
59
coexisting illness, 56% (n = 33) had a single comorbid condition, 14% (n = 8) had 3 conditions, and 6% (n = 4) had 4 or more conditions. Twenty-six patients (44%) had cancer and several had been diagnosed with more than one type of malignancy.
Stoma-QOL Analysis of covariance, with age as the covariant, was used to examine group differences based on Stoma-QOL scores. Because information on age was not available for 1 patient, this analysis included only 23 persons in the comparison (unmarked) group. Neither the effect of time (F = 2.3; P = 0.13) nor group (F = 0.01, P = 0.91) was statistically significant by themselves. However, an increase in Stoma-QOL at the 8-week period following hospital discharge interval was significantly greater in the marked group than in the unmarked group (F = 4.90; P = .031), indicating a significant increase in HRQOL among patients who received preoperative stoma marking.
Spinal cord injury
3
0
Cancer [Type]
17
11
[Colon]
[6]
[3]
[Rectal]
[6]
[4]
[Ovarian]
[3]
[3]
Functional Lifestyle Factors
[Other]
[2]
[1]
Participants were asked about lifestyle factors that might influence HRQOL 8 weeks after hospital discharge. Most participants (92%; n = 54) returned to their own home, including 10 (17%) who lived alone. Fifty-three participants (89%) stated that they were able to provide self-care related to cooking, bathing, toileting, and walking. Group differences related to stoma self-care functional lifestyle factors are displayed in Table 2. The majority of study participants reported a high level of function with stoma alone self-care; 53 (90%) indicated that they were able to empty their ostomy pouch without assistance, and 46 (78%) stated that they were able to change their ostomy pouch independently. Although more patients in the marked group indicated higher levels of stoma self-management when compared to patients in the unmarked group, the differences were not statistically significant (Figure 1).
■ Results Demographic and pertinent clinical information of the sample (N = 59) is summarized in Table 1. No significant differences were found between the groups for gender, coexisting conditions, or functional lifestyle factors. In contrast, a statistically significant difference in age was found between the marked and unmarked groups (t(56) = −2.52, P = .011). Data concerning comorbid conditions were obtained from chart review. No significant differences were found between the marked group (M = 1.36, SD = 1.44) and unmarked group (M = 1.42, SD = 1.10) groups, t(57) = −0.458, P = .65. While 22% (n = 13) of all patients had no TABLE 2.
Functional Lifestyle Factors at 8 Weeks Following Surgery Stoma functional lifestyle factors N (59)
Marked (n = 35)
Unmarked (n = 24)
90% (n = 53)
94% (n = 33)
83% (n = 20)
With assistance
5% (n = 3)
6% (n = 2)
4% (n = 1)
Unable
5% (n = 3)
0 (n = 0)
13% (n = 3)
78% (n = 46)
86% (n = 30)
67% (n = 16)
With assistance
8% (n = 5)
3% (n = 1)
17% (n = 4)
Unable
14% (n = 8)
11% (n = 4)
17% (n = 4)
Self-care Empty ostomy pouch: χ2(2) = 4.63, P = .10 Independent
Change ostomy pouching system, χ2(2) = 4.15, P = .12 Independent
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STOMA-QOL Scores 60.6
60
56.6
55 52.5 50
Unmarked
48.8
Marked
45 Time 1
Time 2
FIGURE 1. Stoma-QOL Scores. At 8 weeks after fecal ostomy
surgery, subjects in the experimental (marked) group had significantly higher (P = .031) stoma-QOL scores than subjects in the control (unmarked) group. Stoma-QOL indicates Stoma Quality of Life.
■ Discussion We found a statistically significant increase in HRQOL among patients who received preoperative stoma marking. This finding adds to a growing body of evidence that preoperative stoma marking enhances postoperative HRQOL. Our findings are similar to those reported by Person and associates,27 Mahjoubi and colleagues,28 and Millan’s group,29 who also reported that patients receiving preoperative stoma marking had lower rates of anxiety and significantly higher HRQOL scores than unmarked patients. However, none of these authors reported a statistically significant difference in HRQOL for subjects who received preoperative education as compared to subjects who did not receive preoperative ostomy teaching. The majority of our study participants underwent ostomy surgery due to a cancer diagnosis; therefore, the cancer diagnosis itself may have impacted HRQOL. Having a diagnosis of cancer can be an additional stressor for ostomy patients.14 Carlsson and colleagues30 evaluated 57 patients with new ostomies associated with treatment of rectal cancer and reported higher levels of anxiety immediately following surgery related to the uncertainty of a cancer diagnosis and fear of what their new lives would entail.30 Cotrim and Pereira’s31 cross-sectional, descriptive study of 153 patients and 96 informal caregivers also found that a colorectal cancer diagnosis was associated with increased anxiety and depression. However, the increase in anxiety and depression was not based on scores from a validated instrument. Coping strategies are essential for managing emotional responses. In our study, the majority of participants returned home with a family support system. GustavssonLilius and colleagues32 reported results of a longitudinal research study that focused on psychosocial consequences of cancer, including the impact of partner support on patient optimism, hopelessness, and HRQOL. Their findings suggest that female cancer patients who perceive high lev-
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els of partner support were more optimistic and had a higher HRQOL than women reporting lower levels of support from their partners. Lee and colleagues33 reported findings from a randomized control trial involving 74 cancer patients, demonstrating that those receiving formal training in coping strategies had an improved sense of optimism as a result of participating in an intervention, which examined the fearful aspects of cancer. Although fewer than half of the patients in our study had a diagnosis of cancer, these findings suggest that anxiety and HRQOL can be affected by a cancer diagnosis. Lifestyle functions related to HRQOL can also be impacted by stoma location. Sun and colleagues34 found that many individuals with ostomies faced challenges related to bowel function, activity limitations, and clothing restrictions due to the placement of the stoma. Their findings suggest that a poorly located ostomy required more diligent constant monitoring to avoid leakage and embarrassing accidents, which participants found emotionally exhausting and stressful. This study site serves a large, rural population; as a result, 83% of patients in the experimental (marked) group received stoma site marking only on the day of surgery as they did not wish to make a separate trip for preoperative ostomy education. We found several studies that suggest that preoperative ostomy education contributes to shorter hospital stays and quicker mastery of stoma care.5,10,29,35,36 For example, de la Quintana and associates37 reported results of a prospective, longitudinal, multicentered study that looked at the benefits of ostomy education, apart from stoma marking, and found that structured ostomy education performed either pre- or postoperatively had a positive effect on HRQOL.
■ Limitations Limitations of this study include a single study site and inability to randomize group assignment. In addition, postoperative HRQOL was remeasured at 8 weeks, whereas a measurement at a more distant time might produce different results. Although the Stoma-QOL is a valid and reliable instrument, Pittman and colleagues1 found that all existing instruments have limited value in the clinical setting as a diagnostic measure of HRQOL. Further research is needed to determine if these findings will remain consistent if evaluated in a randomized, multisite study with follow-up longer than an 8 week postoperative period. It is also of interest to explore whether the addition of preoperative ostomy education influences HRQOL in patients receiving stoma siting. Finally, we acknowledge that the influence of a cancer diagnosis leading to a fecal ostomy, lack of controlling preoperative ostomy education, and measuring HRQOL only during the immediate postoperative period may have influenced study results.
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■ Conclusion Study results strongly suggest that stoma site marking increase HRQOL during the early postoperative period. Based on results of this study, we recommend that CWOCNs educate physicians and staff about the importance of stoma site marking, and ensure that marking is a priority prior to ostomy surgery.
18. 19.
20.
21.
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