Journeying towards life with a stoma can be a cause for concern for many people facing ostomy surgery. Giving the right information to the right person at the right time can help alleviate some of the worries experienced, so it is a vital part of the stoma care nurse's (SCN) role to be able to recognise and respond to the educational needs of those in their care. The aim of this article is to identify the opportunities to deliver education and the subjects often discussed. Initially, the preoperative stage will be discussed, followed by the immediate postoperative period within the hospital setting, before moving on to the long-term postoperative period after discharge. Finally, barriers to delivering this education will be highlighted.
Preoperative preparation
Patients preparing for life with a stoma will often be anxious and need help to adjust to, and accept, its presence (Lim et al, 2015). A preoperative meeting is organised with the SCN to help prepare for surgery. During this meeting, the SCN will ask questions about which lifestyle and personal needs the patient feels it is important to discuss at this juncture, as well as identifying any concerns that need addressing. Typical topics discussed during the preoperative meeting include:
Information leaflets and booklets are provided to reinforce the messages given during this meeting, along with contact details for the SCN, other people with a stoma who are happy to discuss their own experiences and support groups, if deemed helpful.
Post-surgery
The aim is to see the patient on the first day after surgery to begin education. The goals of stoma care that were discussed preoperatively are revisited. It may be possible to identify psychological issues and anxieties that the patient may have from verbal or non-verbal cues. It is important to deal with these issues promptly, using reassurance and giving them any other support they may need. During the inpatient stay, topics discussed preoperatively are readdressed and any new concerns talked through.
A pouch change demonstration is given, with rationales provided for each stage of the process. The patient is encouraged to take part but initially may observe. The pouch is removed using adhesive remover spray to protect the skin from stripping. Then, using water and wipes or tissue, the stoma and peristomal skin are cleaned and dried.
The peristomal skin condition is assessed using the Ostomy Skin Tool (Martins et al, 2010), which identifies and scores discolouration, erosion and tissue overgrowth of the peristomal skin in terms of area covered and severity (Coloplast, 2019b).
An appropriate pouch is chosen based on the type of stoma, its position, output and level of protrusion, and the body profile. The stoma is then measured to enable the creation of a template for the hole that is cut into the adhesive part of the pouch—this must be a snug fit so that the skin is protected from damage caused by the output from the stoma.
Teaching continues at least daily until competence and confidence are achieved, with the aim of reaching these goals by the time the patient is medically fit for discharge. On discharge, more written information is given to support the verbal discussions, as well as details regarding follow-up.
Post-discharge
Follow-up appointments are held at regular intervals in the immediate post-discharge period. As well as providing a chance to check the condition of the stoma and peristomal skin, these appointments offer time to build on information touched upon in previous meetings, as well as to address any new concerns that have developed since the patient left hospital. The topics identified earlier, namely: work, exercise, travel, sexuality and diet, become even more important as life with a stoma becomes a reality. Essential information, such as how to order products, is given. Specific advice, tailored to meet the patient's needs, is given on all of these subjects in an attempt to help them achieve a healthy, fulfilling lifestyle.
Body image can be an issue as the person comes to terms with the changes to their body and this can have an impact on their psychological wellbeing, as well as affecting relationships with others (Jayarajah, and Samarasekera, 2017). Signposting towards clothing companies such as Vanilla Blush, which manufactures clothing with ostomy patients in mind, can help improve confidence and normalise life with an ostomy. Encouraging open discussions with the SCN, family and friends can help overcome psychological hurdles. Referrals can be made for counselling or input from other specialties if needed.
Barriers to delivering education
Every person with an ostomy is different and their needs should be considered individually. Ideally, adults will become independent with their stoma care needs, but obstacles can be identified and addressed in the postoperative teaching sessions (Burch, 2008). The use of different tools, stoma care products and supporting materials may be needed to achieve independence and acceptance.
Older people may encounter additional problems with manual dexterity/strength, poor eyesight and short-term memory loss. It is important to address these obstacles and identify possible solutions, such as choosing the right products and providing prompt sheets. The involvement of family members or carers to assist in the more difficult aspects of care may be necessary. Training may take longer as these patients have to identify different strategies to perform the pouch change and may need more practice.
A person with poor vision who was fully independent before surgery should be able to look after their stoma (Burch, 2008). However, if they required help with personal care before, then training and support will need to be provided to family members or carers.
Learning disabilities and dementia can also affect the ability to cope with a stoma, depending on the extent of the disability. If the person lived on their own or with minimal assistance before surgery, they should be able to become independent with their stoma care (Burch, 2008). However, training may take longer, and other training approaches may be required.
The support and participation of carers or family members in the educational setting is vital. Another strategy for people with learning disabilities is to use Buttony, a cuddly toy with a red button on the abdomen (Cleasby, 2016). These teddy bears, originally developed for use with children, are a different way to normalise life with an ostomy. When dressed, the bear looks like any other teddy bear, but under the clothes is a tiny ostomy bag that, when removed, reveals a small button-shaped stoma.
Language barriers may also impact on educational provision. Without the opportunity to fully discuss the stoma formation and the possible impact of this in the preoperative assessment, the patient will be unable to share any concerns or understand the planned surgery and its outcome (Cooper-Gamson, 2017). The same issues will be encountered in the postoperative setting. Illness and other stressful healthcare situations can have a negative impact on anyone's ability to communicate effectively but this is especially true in patients whose first language is not English. This can affect people who may usually cope well with English but may find it more difficult and revert to their native language in stressful situations. There are several strategies available. These include use of an online or telephone medical translator service, the help of family members or the use of a local cultural advocate or official translator in person during the preoperative and discharge education sessions. Another strategy is to use supportive material provided in the person's first language and safe websites where they can navigate securely, choosing their own language.
Conclusion
The SCN can help to ensure that the journey into and through life with an ostomy is a healthy and fulfilling one. Education and information-giving is vital in achieving these targets, as well as overcoming any barriers faced, and this is carried out at several stages throughout the patient's journey.