Care Planning for Ostomates: What Should Nurses Consider?

CHAPTER ONE

1.0 Introduction

This work is in three chapters. This chapter will provide a brief background of stomas and the rationale for this choice of topic. The methodology deployed in the selection of the primary articles and extraction of the themes will be explained. The second chapter of this work will analyse the emergent themes and summarise the findings from these relative to the goals of the review. The final chapter will suggest recommendations from the analysis conducted, identify implications for care planning and offer suggestions for professional practise.

1.1 Aims and objectives

This literature review seeks to inform nursing care planning for ostomates from a divergent patient perspective. By analysing and drawing on these perspectives, this work hopes to provide insights that will enhance the delivery of holistic care to ostomates by adding to existing knowledge and practice. Finally, this work hopes to stimulate research into any potential areas in which existing care planning processes might not be adequately addressing ostomates’ needs.

1.2 Background

Hubbard et al (2017) define a stoma as an artificial opening or passageway in the bowel which diverts the flow of faeces or urine onto the surface of the abdomen. The word ‘stoma’ comes from the Greek word meaning ‘mouth’ or ‘opening’. The formation of a stoma is necessitated by the treatment of certain conditions that result in bowel malfunction, the most common being cancer (Claessens et al, 2015). Stomas may be permanent or reversible. The three main types of stoma are colostomy, ileostomy        and urostomy (Burch, 2017).

Stomas are becoming quite commonplace in line with increasing rates of gastrointestinal diseases (Norbury, 2016). The Colostomy Association estimated in 2017 that 13,000 patients in the UK were undergoing stoma formation annually with approximately 1 in 500 people living with a stoma (Colostomy Association, 2017).  There are an estimated 120,000 people living with an ostomy in the UK, of which 65,000 have a colostomy, 45,000 have an ileostomy and 10,000 a urostomy (Rippon et al, 2017).

A specialist organisation, the Association of Stoma care Nurses (ASCN), was formed in the UK in 2013 to address the rise in nursing demand for ostomates and to provide an expert clinical resource for specialist stoma care nurses (SCNs). Stoma care should however not be deemed to be the exclusive preserve of SCNs (Edis, 2015).

1.3 Rationale

This student’s experiences and observations of patients’ distress and frustrations whiles interacting with ostomates during placements encouraged this review in order to relay the patient voice to care planners. Nurses believe the existing care provisions for ostomates are adequate, but the evidence from ostomates would contradict this. Insights about the challenges faced by ostomates will enhance the planning of their care (McCormack and McCance, 2017). The care planning process for ostomates tends to focus on the physical well-being of the patients, possibly neglecting psychosocial needs that also can potentially affect their recovery and quality of life post-stoma (Perry-Woodford, 2013; Walker, 2013).

Quality of life (QoL) can be defined as a multidimensional concept comprising subjective appraisals of both positive and negative aspects of life (Fayers and Machin, 2013). Despite difficulties in its measurement, it is an important indicator of the success of nursing interventions (Walker, 2013).

1.4 Methodology

This work will be a literature review. Machi & McEvoy (2016) defines a literature review as an interpretative piece of work offering an assessment of the scope and quality of existing studies in a specific subject area. Aveyard (2014) define it as a topic-specific classification and study of literature. A total of ten (10) articles will be utilised in this review and three emergent themes identified and analysed to aid a deeper understanding of practical ostomate perspectives and requirements with regards to care provision and support.

1.5 Article Sources and Parameters

EbscoHost was used as the primary search engine to scan existing health science research databases (these include Academic Search Premier, CINAHL Plus with Full Text, MEDLINE and the Psychology and Behavioural Sciences Collection). To increase the relevance and quality of articles, the search criteria was set to identify only the most relevant and up-to-date articles. A time limit of 5 years was applied and only full-text English-language articles with relevance to the topic were selected (Ellis, 2013).

Primary research related to the topic was also selected. Countries were not excluded as this student believes the quality of patient’s voice is not dependant on country. Secondary and unpublished research related to the topic were excluded.

The keyword ‘stoma’ yielded 2,296 results. In refining the search the following specific keywords and key phrases were used for further searches:

Sexual dysfunction	Colostomy	Urostomy	Complications	Sexuality	Health related quality of life
Stoma	Ostomy	Quality of life	Adaptations	Well-being	Social
Body Image	Ostomies	Ostomy care needs	Physical psychosocial	Sexual dysfunction	Ostomy management

The abstract of the article was read to determine whether it was a research article and related to the topic (Aveyard and Sharp, 2013).

Ten articles were finally selected. Three were from the United Kingdom (Smith et al 2017, Russell 2017 and Hubbard et al 2017), two were from Turkey (Yilmaz et al 2017, Ozturk et al 2015), two from Brazil (Costa et al 2014, Paula et al 2012), one from India (Umesh & Dharmabandu 2017), one from Denmark (Feddern et al 2015) and Claessens et al 2015 originated from four European countries namely Netherlands, Australia, Belgium and Denmark.

Three themes emerged after careful analysis of these articles that indicated three areas in which ostomates encountered challenges post-stoma that affected their Quality of Life (QoL): Activities of Daily living (4 articles), Body image (3 articles) and Sexual health (3 articles). Common variables include appliance usage and complications, changes in body image and functionality, hernia risk, impact on social relationships, leakages, physical activity and sexuality. These emergent themes and their implications for care planning form the subject of the next chapter. The matrix of the research articles can be found in the appendix to this work.

CHAPTER TWO

This chapter will systematically discuss and critically appraise the emergent themes from the selected literature. The Critical Appraisal Skill Programme (CASP) tool which facilitates the assessment of the trustworthiness, relevance and credibility of published literature will be applied (CASP, 2017) with an emphasis on research design, ethics, methodology and sampling.

2.1 Activities of Daily Living

Activities of Daily Living can be defined as activities which engage a person’s time and energy resources. They comprise three main areas – self maintenance, productivity and leisure – and vary through a lifespan (Mlinac and Feng, 2016). Ostomates face challenges with their practical activities of daily living, adversely affecting their quality of life (QoL). These range from the fear of leakage and associated problems like ballooning and smell, hernias, impairment of physical activity and appliance problems. Four studies will be discussed under this theme: (Claessens et al (2015), Feddern et al (2015), Hubbard et al (2017) and Russell 2017.

Claessens et al, (2015) sought to better understand the stoma-appliance related challenges faced by ostomates and evaluate their impact on the everyday life of the ostomates by conducting a study called the “Ostomy Life Survey”.

They emailed an online questionnaire to approximately 14,000 ostomates between February and March 2014. The design of the questionnaire involved 193 SCNs from 10 countries (Belgium, Canada, Denmark, France, Germany, Slovakia, Sweden and the Netherlands, UK, and US). Four main topics were selected: appearance of the stoma bag, ballooning, discretion, leakage and any challenges two-piece users may have with the coupling (a mechanical or adhesive connection between the baseplate and the stoma bag). Questions were asked for each topic about users’ worries, experiences and how their daily lives were impacted. Each question presented predefined response options and the opportunity to write an individual answer.

Participant recruitment was through databases or nurse’s records and contacts and their consent was collected through a link within the introductory email (Salmons, 2014). The sole exclusion criteria was a requirement that the participants be at least 18 years of age. This was to gain as wide a participation as possible, a potential outcome of online research recruitment (Moule and Goodman, 2014). This method of participant recruitment meant volunteer sampling, which carries a high risk of bias, was deployed (Cronin et al, 2015). Individuals who volunteer for such studies usually have strong views about the subject matter and may thus be unrepresentative of the population (Moule and Goodmann, 2014).

A total of 4,138 people from 11 countries provided responses. Data processing was through a market research software system with each country weighted equally. All statistical tests were two-sided, adjusted for confounding effects such as age country and gender, and carried out at the 5% level of significance.

This study found that stoma formation adversely impacted the everyday life of ostomates with several mental, physical and social impairments. Being dependent on a stoma appliance and the attendant challenges could generate additional concerns, troubles, and a feeling of conspicuousness.

The strengths of this study are in its design, the range of respondents and the statistical tools applied. The use of online questionnaires can provide a relatively simple and straight-forward means of studying attitudes, values, beliefs and motives (Polit and Beck, 2014). Their adaptability makes the collection of generalisable data from across most populations possible and much of the collected data can be standardised (Moule and Goodman, 2014). This study can be said to have gathered a rich depth of information and awareness about ostomates’ experiences and challenges living with stoma from an international divergent perspective. Its findings can thus be argued to be of relevance to this study.

The researchers make no acknowledgement of limitations of their study but the use of email and social media to conduct research raises ethical issues (Townsend and Wallace, 2016) and automatically excludes respondents who are not users of the internet and social media or do not trust privacy assurances given (Evans et al, 2015). It is also an impersonal method, missing out on aspects of respondents like body language and facial expressions (Aveyard and Sharp, 2013). There is no indication of the questionnaire being validated, but the design process can be argued to have added validity to the responses (Harvey and Land, 2017). Further, key information about data loss and ethics are unavailable. This will suggest issues with generalizability, reliability, and validity and there is little within the article to indicate how these limitations were addressed (Polit, 2014; Leung, 2015).

Feddern et al (2015), conducted a cross-sectional study to investigate problems related to stomas and how stomas affected the general QoL in rectal cancer patients having surgical treatment between May 2001 and April 2007 in Denmark.

The data was collected using a 23-item questionnaire survey developed by a panel of experts who thoroughly reviewed available literature, conducted pilot testing and revised the questionnaire after patient evaluation. Eligible participants were identified in a database managed by the Danish Colorectal Cancer Group, holders of national rectal cancer patient records. Participants needed to have undergone curative surgery for non-disseminated rectal cancer from May 2001 to April 2007. Any patients who were less than 18 years, had disseminated or recurrent disease, previous cancer (excluding spinocellular and basocellular carcinoma of the skin), mental dementia and could not read and understand the Danish language were excluded. 644 (88%) out of 732 patients surveyed provided informative answers.

Differences between groups were tested with the Mann–Whitney U test and the chi-squared test. The impact of the stoma on the patient’s QoL and its association with gender, type of surgery, radio (chemo) therapy, age at survey and interval from surgery was assessed by performing ordinal logistic regression. All statistical tests were performed at a threshold significance of 5%.

This study found that stomas had diverse impacts on the quality of life of ostomates, but was unable to establish clear causations from gender, type of surgery, the interval from surgery or the use of chemo-radiotherapy. Many patients were troubled by appliance leakage or odour.

A strength of this study is the use of a questionnaire survey with the previously mentioned advantages (Polit and Beck, 2014). The method of data analysis was rigorous, with the use of multistage sampling (Garg, 2016), and the detailed findings provided insights into the daily lives, challenges and coping mechanisms of ostomates. This provides rich data for the perspectives of this review (Polit, 2014).

The use of a non-validated questionnaire is a major limitation of this study as it makes comparison with other studies challenging (Polit, 2014). It is however quite descriptive of the various types of problems encountered by stoma patients. The absence of a recognised psychologist in the design and analysis teams suggests an important aspect of ostomates’ challenges was missed. Given the size and reach of the sample, a record of interrater reliability would have assisted the reader reach a decision about the reliability of the findings (Jirojwong et al, 2014). Data was lost in this study (< 100%) response level and there was no mention of the possible reasons behind the data loss and how it was managed. There was no evidence of maintaining confidentiality and anonymity of patients, gaining consent, or obtaining committee approval. These are essential ethical principles to be upheld in all research (Moule, 2015).

Hubbard et al, (2017) conducted a pilot cross-sectional survey in the UK over three months to determine stoma-related quality of life research priorities for ostomates. They administered an online questionnaire using the Bristol Survey On-line, an online survey development, deployment and analysis service for researchers. The questionnaire comprised nine stoma-related quality of life topics drawn from available literature which were refined from initial feedback. The inclusion of an open-ended question enabled participants indicate any additional issues and concerns that they considered important. The inclusion criterion was UK resident ostomates over 16 years of age from whom consent was gained. The distributions of the priority scores for the research topics were analysed, with group differences explored using either the Kruskal–Wallis or the Mann–Whitney U-tests.

This study found that the most important research priority was leakage and appliance problems followed by hernia risk. The rankings of research priorities between both sexes, age, the stoma-causing disease, type and duration of stoma all had statistically significant differences.

The strengths of this study lie in its design and the nature of responses acquired. The insertion of the open–ended question was a quality tool that assisted gaining insight into the challenges faced by ostomates in this area. The authors suggested that the research priorities this study found may be an indicator of insufficient support for these concerns, given the length of time respondents had lived with stomas and the demographics of the respondents.

This study is however limited by sample size (225 respondents). The use of social media meant the total population size was undetermined, so it was impossible to tell if the sample was representative, and thus if findings could legitimately be generalised (Townsend and Wallace, 2016). The online method used meant it was impossible to ascertain if respondents were really UK resident ostomates (Townsend and Wallace, 2016). Also, the clinical characteristics of the respondents could not be determined. There was also a possible selection bias – the organisations advertising the survey were United Kingdom charities – thus respondents may have only been those who had accessed charitable support. The authors therefore recommend caution in the usage of their findings.

Russell (2017) presented results from a UK-wide survey investigating the physical activity of ostomates. In particular, the survey looked at exercise and physical activity, general attitudes and opinions about exercise, whether advice about physical activity had been received or not and other general questions about parastomal hernia and quality of life.

The survey was designed to gather quality data using a mix of open and closed questions, 3 and 5 point rating scales and sought to avoid the use of leading questions. Each question was optional and questions could be skipped if desired. The survey was kept open for a period of 3 weeks. The title adopted – ‘Living with a stoma, your experience’- was intentionally non-leading. The words ‘exercise’ or ‘physical activity’ were omitted to encourage a wider range of respondents. The survey was distributed online via Survey Monkey (www.surveymonkey.co.uk), shared through a database of 10,000 patients and on social media through charitable associations and organisations. A total of 2,631 people responded to the survey. The survey data was analysed by SQN (www.synequanon.com) using a range of statistical tests including Chi-squared, Kruskal-Wallis and Spearman’s correlation. The author also undertook a number of one-to-one interviews with stoma patients and nurses to gather additional qualitative data.

The research utilised a self-reporting methodology, which is well known for possible exaggeration, under/over-reporting and bias (Ellis, 2013). This was countered with careful question design and the incorporation of a small pilot study conducted using a team of patient advocates. The survey was also reviewed by an internal clinical affairs team and a colorectal surgeon. The project gained NHS Ethics Approval (Camden and Kings Cross Committee). This survey will however be limited by the previously discussed factors affecting social media research methods (Townsend and Wallace, 2016).

The results of this survey indicated that physical activity levels among ostomates drop significantly after stoma surgery and the vast majority of people living with a stoma do not meet UK health guidelines for physical activity. The primary reason was fear of developing further complications like parastomal hernia. Those with a cancer diagnosis or a parastomal hernia were even less active.

The significance of the findings within this theme for care planning is that ostomates are living with concerns such as ballooning, hernias, leakage and coupling failure which relate to the use of stoma appliances and limit their social and physical activities, thereby adversely impacting their QoL. This also has psychological implications which have to be taken into consideration when planning care.

2.2 Body image

Body image is described as a person’s perception of their physical appearance its effects on their self-esteem (Houston, 2017). This change may adversely affect patients’ self-esteem, making them feel less attractive, insecure and lacking in confidence which subsequently threatens existing relationships (Aktas & Baykara, 2015). This makes it an essential factor in QoL studies. Under this theme, three articles shall be reviewed – Costa et al, (2014); Jayarajah & Samarasekera, (2017) and Smith et al, (2017).

Costa et al (2014) conducted an analytic, descriptive and prospective clinical study which assessed subjective wellbeing and body image in patients with an intestinal ostomy. This study, conducted between December 2010 and May 2013 in an outpatient clinic in the State of Minas Gerais in Brazil, was based on a non-probability convenience sample. Seventy (70) adult patients with an intestinal stoma were asked to complete a questionnaire, complete the Brazilian version of the Body Investment Scale (BIS) and a Subjective Well-Being Scale. Ethical approval was obtained from Research Ethics committee of the Sapucai Valley University and the study was performed in accordance with the ethical standards of the World Medical Association Declaration of Helsinki (World Medical Association, 2014). Informed consent was obtained and respondent anonymity ensured.

This study found that patients were generally unhappy and dissatisfied with their life. Respondents scored low on the body image and touch components of the BIS, indicating negative feelings about their body as well as distress and dissatisfaction with their life.

This study was able to assess the changes in ostomates’ body image according to a recognised scale, making its findings relevant for the purpose of this review. The ethical standards maintained and methodology applied add further strength to their findings.

This study has limitations in the area of sampling – convenience sampling is highly vulnerable to selection bias and influencing factors that are unregulated by the researcher as well as a high level of sampling error (Polit and Beck, 2014). Also, the validity of the responses in this study can be argued to have been limited by the use of a Likert-scale (Ellis, 2013).

Jayarajah and Samarasekera, (2017), sought to identify the factors influencing the adaptation to altered body image in ostomates by conducting an analytical, descriptive cross-sectional study among 41 ostomy patients who were treated at a single tertiary care unit in the National Hospital of Sri Lanka, Colombo over a period of one year. This study excluded patients who had ostomy creation through emergency surgery or had a history of psychiatric illnesses. Data was collected through an interviewer-administered questionnaire while patients were awaiting consultation during clinic visits to minimize discrepancies. Information gathered included demographic characteristics, details of the disease and surgery-related details. A modified body image disturbance questionnaire (BIDQ) was used to assess their perceptions of body image.

Data was analysed using Independent Samples t-test (unpaired), Chi-square test, and Spearman’s correlation. Statistical testing was performed at <0.05 significance level.

This study found that body image disturbance was common across the sample with higher outcomes in younger and overweight patients. Males appeared to be worse affected, with a significant level of depressive symptoms across the sample. This study emphasised that there was a significant association between stomas and psychological parameters such as depression, anxiety and reduced self-efficacy.

The weakness of this study lies in its small sample size, lack of ethical clarity and subsequently its limited grounds for generalisability (Polit and Beck, 2014).

Smith et al, (2017), conducted an in-depth idiographic analysis of the experience of living with an ileostomy among patients in online stoma support groups in the UK. This study used the interpretative phenomenological analysis (IPA), a widely used qualitative method on health psychology, which they assessed to be very effective for the purposes of the study (Smith, 2011). Three of the authors were very experienced IPA researchers and they recruited a purposive stratified sample to ensure a balanced representation of age and gender. Informed consent was acquired and participants were informed of their freedom to terminate interviews or withdraw their data if they wished. Interviews were undertaken in person or via Skype/phone, were audio recorded and transcribed verbatim and field notes made afterwards. Ethical clearance was gained from the relevant university and all data was anonymised to protect confidentiality. The authors adopted processes consistent with good practice in hermeneutic phenomenology to ensure rigor.

This study had found that stomas had debilitating consequences for the sense of self of ostomates. Ostomates struggled with body image issues and some had to find ways to redefine disability and difference in order to boost their self-esteem. Stomas impacted on relationships and ostomates experienced a fear of rejection. Body issues were challenging for both sexes.

The strengths of this study lie in the skill of the authors in the methodology used. The nuanced, detailed findings created a resonance, allowing the reader gain a detailed and coherent view of the ostomates’ experiences. The authors also checked their work against Smith’s (2011) guidelines for high quality IPA. The methodology used can be argued to strengthen the reliability and validity of the findings.

The limitations of this study lies in its sample size (21 participants) and subsequently its generalisability. Being an interview conducted from online sources, it suffers the challenge of ensuring validity of sample responses and population purity (Townsend and Wallace, 2016).

The significance of the findings within this theme for care planning are that stomas have a psychological impact on ostomates with adverse effects on their body image, sense of self and subsequently their relationships.

2.3 Sexual Health

Kimura et al, (2016), state that sex is much more than a physical act; but rather an intrinsic part of being with biological, psychological and social aspects that intertwine, thereby affecting self-image, self-worth, feelings and relationships. Problems in this area are generally either physiological or psychological and affects both sexes, severely diminishing QOL (Houston, 2017).

All three articles reviewed under this theme – Ozturk et al, (2015); Boccara de Paula et al, (2012) and Yilmaz et al (2017) – were qualitative studies. Bunard et al, (2011) argue that the value of qualitative research lies in its ability to study personal, subjective thoughts and personal meanings attached to personal experiences, not necessarily generalisability. It can thus be argued to be suited to this subject matter.

Ozturk et al, (2015) investigated the sexual problems male or female patients could encounter following temporary or permanent colostomies and how these problems related to self-esteem. They conducted a retrospective case study with a sample size of 42 patients and a control group of similar size selected on the basis of simple randomization, excluding individuals with psychological diagnosis, a history of psychological treatment or dormant sex lives. 17 of the patients had undergone permanent colostomies.

Data was collected by means of evaluation questionnaires given to participants in their homes. Informed consent was gained from participants and all participants completed the Rosenberg Self-Esteem Scale (RSE) and sociodemographic information forms. Female participants completed the Female Sexual Function Index (FSFI) and male participants the International Index of Erectile Function (IIEF).

Data thus collected was analysed on SPSS 15.0 software, with the Shapiro-Wilk test used to analyse homogeneity and non-parametric tests like the Mann Whitney-U test also deployed. The questionnaire results were first evaluated between the study and control groups and then between the permanent and temporary colostomy patients.

This study found statistically significant sexual functional problems in patients of either gender who had colostomy histories. Sexual desire and satisfaction was most affected in male patients and sexual arousal most affected in female patients. No demographic risk factor (age, education level, continuing to work normally, etc.) was determined to affect the sex lives of patients who were sexually active pre-stoma. They also found more significant functional decreases in male patients within the sample, though the female patients had higher sexual dysfunctions when the ostomy was temporary.

This study has its limitations. Retrospective case studies suffer from the risk of bias. The researcher and their prior assumptions cannot be easily detached from the phenomenon under study (Leung, 2015). Although randomization of the control group was used to reduce this factor, it cannot be said to have been completely eliminated. There was no evidence of the method of validation used in the design of the questionnaire (Harvey and Land, 2017). The researchers acknowledge the control group was selected from the staff of the hospital and existing relationships and discussion of the study amongst the control group cannot be ruled out (Ozturk et al, 2015). Personal relations can however be argued to improve trust and subsequently, honesty of responses in qualitative research (Leung, 2015). The findings may have also been influenced by the course of treatment followed by the participants and progressive morbidity levels. The size of the sample and the choice of population raises concerns about the validity of any generalisations of the study findings (Leung, 2015).
Further, the researchers sought to justify their sample sizes by stating that the size of their sample was satisfactory in comparism to other similar studies. No data was lost in this study, a 100% response rate (Polit, 2014), and respondent burden was eliminated by ensuring a suitable lead time (one week) and ensuring that respondents fully understood the questions being asked through the use of translators where necessary (Sullivan-Bolyai and Bova, 2014). The extent of analysis was significant and multiple tools were applied (Leung, 2015). Finally, the researchers point to their work being one of the few studies in this regard. It is also worth noting that they gained ethical approval from the hospital board. The identified limitations do not in themselves negate the validity of the findings, though care needs to be taken in extrapolation (Leung, 2015).

Boccara de Paula et al, (2012), sought to identify social representations of intestinal ostomates regarding sexuality pre and post stoma production. They conducted an exploratory, descriptive, qualitative study using the Social Representation Theory (SRT) within the local population of a medium-sized city in the state of Sao Paolo, Brazil, who were service users of a University Hospital. SRT is a flexible conceptual framework that enables researchers understand and explain the way individuals and groups elaborate, transform and communicate their social realities (Rateau et al, 2012). The social representations with regards to sexuality experiences post-stoma were based on meanings attributed to the body, associated with daily life and present in the social imagery. Other factors such as surgery-resultant physiological changes, the existence of a partner and the quality of relationships affect this social representation.

Data was collected by means of private individual interviews with 15 ostomates, eight of them female, who had had stoma for over a year and had given informed consent. Ethical permission was gained from the University board. All the interviews were recorded and fully transcribed.  A group of techniques for communication analysis which seek explicit or hidden knowledge, realities and significations behind respondent answers was deployed. The initial categorisation was generated by extensive reading of the transcribed interviews which led to identification of key expressions. Speech cutting was then applied in addition to verification of how often the speeches fitted the identified categories. The results were then sorted into subgroups, for subsequent definitive categorisation. The validity of an interview depends on the extent to which the respondent’s opinions are truly reflected (Polit and Beck, 2014) and this methodology could be argued to have ensured both the opinions and perspectives of interviewees were adequately communicated (Alshenqeeti, 2014).

This study found that intestinal stoma interfered in the sexuality experience. This was despite factoring in individual life stories, quality of relationships and sexual perceptions of participants.

This study has strengths that stem from the use of interviews in qualitative research. Interviews potentially produce rich data that could supplement findings from alternate sources (Doody and Noonan, 2013; Polit and Beck, 2014). Interviewing is expected to broaden the scope of understanding investigated phenomena, as it is a more naturalistic and less structured data collection tool (Alshenqeeti, 2014). A standard set of questions were asked of all respondents and the environment of the study was conducive to honest answers and observations, reducing bias and improving reliability (Polit and Beck, 2014). The exhaustive reading and personal answers provided to questions and relayed in the study enhances the value of the study to the personal nature of patient’s experiences and the perspectives of this review (Jirojwong and Welch, 2014).

Though the researchers acknowledge no limitations to their work, this study is limited by a dependence on human and manual interactions with insufficient detail about statistical tools applied (Polit and Beck, 2014). There is very little detail about the sample selection and the exclusion criteria. For a qualitative study, this raises issues around reliability, validity and generalisation and would appear to decrease the value of this study’s findings in academic circles.

Yilmaz et al (2017) conducted a descriptive, cross-sectional study to evaluate the effects of stoma on sexuality and QOL among patients of a general surgery clinic of a university hospital in the western region of Turkey between May 2015 and 2016. Eligibility requirements included patients willing to participate, be more than eighteen years of age, with a colostomy for at least four months, who were married and/or with a sexual partner and in otherwise good physical and mental health with no rectal nerve damage or receiving radio or chemotherapy. This study utilises methodologies deployed in the two previous studies and draws on the finding of Ozturk et al (2015), within which the instruments of the IIEF and the IFSF were also deployed. Data was collected via face to face interviews using the instruments of a Personal Information Form, the IIEF and the IFSF measures in addition to the Stoma Quality of Life Scale (SQOLS). Statistical analyses were then performed using descriptive statistics from SPSS v.15.0. The Kolmogorov-Smirnov test was used to assess the distribution of data and the Spearman’s correlation coefficient and the Mann-Whitney U test were also applied.

This study found that a majority of patients reported problems with their sexual lives post-stoma. QOL and daily activities were affected negatively after creation of the stoma, with the SQOLS scores of patients with a temporary stoma being better than those with a permanent stoma. 54% of male patients had severe ED and all female patients experienced sexual dysfunction.

The strengths of this study are in the rigorous methodology and the comparability of its findings with similar studies performed in alternative settings (Leung, 2015)

The researchers acknowledge the findings of this study can only be generalised to patients representing the characteristics of the sample group. However, generalisability could be assessed from the methodological qualities of the study and the rigour with which it was conducted (Leung, 2015). A rigorous methodological approach would offset some generalisability criticisms of a qualitative study. Further, the view of sexuality as a taboo in the sample environment (Turkey) may have compromised the honesty of answers and findings. Finally, the participants were not assessed prior to the stoma and participants who had stomas for longer than four months could have lent more validity to the experiences relayed. These limitations would also suggest the findings of this study would be treated with caution by academics and generalisations drawn from it would not be easily justifiable.

The implications of the findings within this theme for care-planning are that stomas adversely affect sexual function and arousal and this is a source of unhappiness for ostomates.

CHAPTER THREE

3.1. Recommendations and Implications for Clinical Care

With increasing number of patients undergoing stoma surgery, this aspect of care provision will assume increasing importance. Having completed this literature review, this student suggests a number of recommendations with relevance for clinical practise that are in line with the objectives and recommendations of the ASCN Stoma Care National Clinical Guidelines (ASCN, 2016).

Nurses should view the three main categorisations of stressors identified in this review as distinct areas to be addressed in ostomate care-planning which should include collaboration with other relevant health workers to ensure a positive, holistic impact on the quality of life of ostomates (Ozturk et al, 2015).

Education of patients and their families should cover challenges likely to arise post–stoma in the areas identified by this review and how these challenges will be addressed by care-planning and post-stoma treatments. Clarifying any misconceptions and alleviating anxiety will enhance patient post-operative coping and recovery (Feddern et al, 2015).

Post-surgery, the provision of appropriate nursing interventions such as relaxation techniques to alleviate possible post-operative stressors (Jayarajah and Samarasekera, 2017) and long-term counselling and support facilities such as a 24-hour helpline for ostomates and their families and regular appointments with SCNs will produce positive care outcomes (Hubbard et al, 2017).

Assessments should be designed that will identify body image disturbances during hospitalisation to pre-empt the development of psychological problems (Smith et al, 2017). Support could vary from acknowledging and addressing patient psychological stressors to facilitating the verbalising of their frustrations (Costa et al, 2014).

The creation of social platforms such as stoma support groups and organised outings for ostomates will ensure continuity of care and support in community settings. In addition, a home visitation program for stoma care will enhance the ostomates’ long-term adjustment in their communities and preserve their relationships (Smith et al, 2017).

The inclusion of psychosocial management techniques into routine ostomates nursing care would help minimize the negative impact of stressors affecting ostomates’ psychological health post-stoma (Jayarajah and Samarasekera, 2017).

Patients should be assisted in adapting to and identifying alterations in sexual self-concept (Yilmas et al, 2017). Techniques that have been found to make a difference to sexual practice post–stoma, like the self-irrigation technique, should be integrated into ostomates’ support programmes (Boccara de Paula et al, 2012).

The identification of leakage, appliance problems and hernia risk as important research priorities suggests that despite obvious efforts addressing these within care plans, patients still feel a need for additional support in these areas. The adoption of a more interactive process in care planning, delivery and follow-up will enable patient’s voice to improve care processes (Hubbard et al, 2017).

3.2. Strengths

A strength of this review is that its findings are supported by the wider literature and the identification of psychosocial aspects of care as requiring consideration will go a long way to improve the QoL and support systems of ostomates. In addition, this review brings an international flavour to the topic of ostomates care planning and suggests that the experiences and needs of ostomates worldwide follow a consistent pattern, further emphasising the usefulness of its findings.

3.3. Limitations

This review has its limitations. The number of articles used (10) is a comparatively small number given the extent and volume of stoma patients. Each individual article has their own limitations, which when considered in total do not negate the overall findings of the review, but must be considered in the case of a more forensic assessment. Finally, it is worth noting that this review has been conducted by a relative novice.

The selected literature has its limitations as well. All the studies utilised targeted the experiences of patients after discharge. Relatively little is known about the hospitalisation experiences among ostomates immediately post-surgery or indeed whiles in a hospital setting. This review would suggest more research is needed to explore the impact of stoma surgery on patient health during hospitalisation and the immediate post-surgical setting. Also, none of the studies directly investigated the impact of psychological stress of stoma formation on ostomates. There was a strong indication that this is an area of concern and distress for ostomates. In addition, there was no standard time setting across the studies reviewed. Data collection timescales varied from weeks to years after surgery. The accuracy of participants’ recollections may be affected by the time lapse between the actual experience and data collection.

3.4. Conclusion

This literature review has identified three main stressors affecting patients’ quality of life following stoma surgery: activities of daily living, body image and sexual health. This review makes care planning recommendations in line with the guidance from regulatory bodies to enhance the delivery of holistic care to ostomates. Further research is however needed into the establishment of criteria for holistic care for ostomates and the implications for care planning. This would result in patient satisfaction and positive health outcomes.