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Cancer Nursing:
doi: 10.1097/NCC.0b013e31826fc8eb
Articles

Effects of Enterostomal Nurse Telephone Follow-up on Postoperative Adjustment of Discharged Colostomy Patients

Zhang, Jun-e PhD, RN; Wong, Frances Kam Yuet PhD, RN; You, Li-ming MNSc, RN; Zheng, Mei-chun BN, RN; Li, Qiong BN, RN; Zhang, Bing-yan RN; Huang, Man-rong BN, RN; Ye, Xin-Mei BN, RN; Liang, Ming-juan RN; Liu, Jin-ling BN, RN

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Author Information

Author Affiliations: School of Nursing (Dr Zhang and Ms You), Cancer Center (Ms M-C Zheng), Third Affiliated Hospital (Ms B-Y Zhang), First Affiliated Hospital (Ms Huang), Sixth Affiliated Hospital (Ms Ye), and Second Affiliated Hospital (Ms Liang), Sun Yat-sen University, Guangzhou; School of Nursing, Hong Kong Polytechnic University, (Dr Wong); Guangdong Provincial People’s Hospital, Guangzhou (Ms Li); and Second Affiliated Hospital, Guangzhou Medical University (Ms Liu), China.

This study was supported by a grant from Guangdong Science & Technology Department, China (grant 2008B030301097).

The authors have no conflicts of interest to disclose.

Correspondence: Frances Kam Yuet Wong, PhD, RN, School of Nursing, Hong Kong Polytechnic University, Hunghom, Hong Kong, China SAR ( frances.wong@polyu.edu.hk).

Accepted for publication August 17, 2012.

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Abstract

Background:

People with a new colostomy encounter many difficulties as they struggle to adjust to their ostomies. Nurse telephone follow-up is a convenient way to ensure continuity of care. There is a paucity of studies testing if nurse telephone follow-up can enhance adjustment of postdischarged colostomy patients.

Objectives:

The purpose of this study was to evaluate the effect of enterostomal nurse telephone follow-up on the adjustment levels of discharged colostomy patients.

Methods:

This was a randomized controlled trial. Participants (n = 103) who had undergone colostomy operations in China were recruited and randomly assigned to the study or control group. Both the study and control groups received routine discharge care, whereas the study group received 2–3 nurse telephone calls in the follow-up period. The outcome measures included Ostomy Adjustment Scale, Stoma Self-efficacy Scale, satisfaction with care, and stoma complications.

Results:

Results of this study indicated that participants in the study group had significantly better ostomy adjustment, higher stoma self-efficacy, higher satisfaction with care, and less stoma complications compared with those in the control group.

Conclusions:

This study provided evidence to support that enterostomal nurse telephone follow-up can improve patient ostomy adjustment level and other related outcomes.

Implication for Practice:

Nurse telephone follow-up is an effective intervention to support the adjustment of stoma patients after hospital discharge.

Abdominoperineal resection with colostomy continues to be a primary surgical approach for many patients with colorectal cancer. In other words, these patients have to learn to live with a permanent stoma for the rest of their lives after surgical treatment. The number of stoma patients in the United States has been estimated at about 770 000 by the United Ostomy Associations of America, with an incidence of 100 000 patients per year.1 More than 13 000 patients undergo stoma surgery each year in the United Kingdom.2 The number of colostomy patients in mainland China has been estimated at 1 million, with an incidence of about 100 000 new patients per year.3

The sequelae of stoma surgery pose problems related to both physical and psychological functioning.4,5 The patient has to face the sight, appearance, smell, and equipment involved in managing the stoma. Richbourg et al6 identified difficulties that ostomates experienced after discharge from the hospital, and the top 5 reported problems were peristomal skin irritation (76%), pouch leakage (62%), odor (59%), reduction in previously enjoyed activities (54%), and depression/anxiety (53%). Eighty-eight percent of the patients (n = 34) reported that at least 1 problem had occurred after discharge from the hospital, with an average 3.6 problems per ostomate. Pringle and Swan7 interviewed 112 persons with permanent colostomies and found that 37% to 47% of ostomates experienced problems or worries related to sexual dysfunction, finance, work, family, and emotions.

Adjusting to these changes can be challenging.5 Enhancing adjustment in people with a colostomy is a prime focus of care.5 There has been a considerable amount of research investigating long-term patient adjustment to an ostomy.4,5,8–12 Stoma patients in general have difficulty adjusting and living with a stoma.6 Poor psychosocial adjustment to stoma surgery has been found to be correlated with depression and high mortality rates.4,13

Ideally, a patient requiring a colostomy will meet with an enterostomal nurse for preoperative education and stoma site marking prior to surgery, and postoperative ostomy education about stoma management techniques is usually provided in the hospital before discharge, but many ostomy patients still encounter stoma-related difficulties once they are home.6 With the increasing emphasis on cost containment in the contemporary healthcare environment, people with new ostomies are being discharged earlier after their initial surgical hospital stay.14 The shorter hospital stay reduces the time available to patients and their families to master skills of self-care in the hospital.14 Nurses play a major role in providing patients with adequate information and advice to support them in this critical transitional period from hospital to home.15 However, continuity of care for colorectal patients was perceived to be inadequate, particularly in addressing psychosocial problems, once patients were discharged to the home environment.15 There are 2 possible reasons. One is that there are time constraints in the follow-up consultation clinics.16 Another is that patients are reluctant to discuss nonphysical issues as they feel that it is not the healthcare professional’s role to assist them with psychosocial concerns.17

Nurse-led telephone follow-up care aiming at addressing the psychological and informational needs of patients is an effective way to ensure continuity of care and a convenient way to monitor patients’ progress after discharge.16,18 Studies using different patient groups revealed that nurse-led telephone follow-up is effective in enhancing self-efficacy among patients with chronic obstructive pulmonary disease19; coping behaviors for patients with breast, lung, or prostate cancer20; self-care behavior of patients with heart failure21; and quality of life in patients with breast cancer.22 It is convenient and economic, saves transportation time, increases patients’ accessibility to specialists, and improves patient self-management and satisfaction.14,18 The study by Bohnenkamp et al14 compared telenursing and traditional face-to-face follow-up of patients discharged with ostomies resulting from cancer treatment and found that telenursing patients indicated higher levels of satisfaction. However, there is a paucity of studies using postdischarge colostomy patients as subjects and adjustment as the main outcome.

Mistiaen and Poor23 argued that the type of healthcare provider was critical to the success of the telephone follow-up calls, and the use of specialty nurses in providing follow-up care is advocated.24 As for stoma care, it is suggested that the enterostomal nurses should phone the ostomates in the immediate weeks after discharge.6 Evidence showed that the enterostomal nurse made a difference for patients adjusting to life with an ostomy.13 Patients welcomed the nurses’ calls15 and felt that the nurses provided them with opportunities for open communication about stoma care and to resolve emotional conflicts about living with a stoma.4

In mainland China, there has been little attention given to the needs of postdischarged stoma patients. A recent study25 has used veteran stoma patients to conduct an expert patient program aiming to improve knowledge, self-management, and psychosocial adjustment of the more recent stoma patients. Results showed positive effects. However, this study targeted at the patients who had stoma surgery ranging from 8 months to 6 years.25 There is a need to provide transitional care to support patients immediately after discharge.26 A survey revealed that cancer patients in China hoped to have the telephone follow-up, if the service is available.27 At present, there are only 152 enterostomal nurses with internationally recognized certificates in mainland China.28 Telephonic nursing is a means that can help optimizing the care that can be provided by the limited number of enterostomal nurses for stoma patients in mainland China.

There is no empirical study that can be identified in the literature reporting the effects of telephone follow-up by an enterostomal nurse on patients’ adjustment level. This study was therefore launched to fill this knowledge gap. We asked what is the effect of a telephone follow-up by an enterostomal nurse on stoma patients’ adjustment and other related outcomes.

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Conceptual Framework

This study is guided by Bandura’s29 Social Learning Theory (SLT) to enhance the self-efficacy and adjustment of the stoma patients. Interventions can be designed to modify dysfunctional behaviors and alter one’s beliefs regarding the level and strength of self-efficacy.19,29 Self-efficacy refers to the confidence in one’s ability to perform relevant behaviors in a particular situation, and it has a major impact on adjustment to illness and health practices.30 Self-efficacy changes adaptation not only in its own right but also through its impact on other determinants such as motivation to achieve goals.30 Bandura29,30 asserts that self-efficacy brings about performance in activities and outcomes, and studies19,31,32 have provided evidence to support this claim. The strategies that can promote self-efficacy in the SLT include skill accomplishment, vicarious experiences, verbal persuasion, and emotional arousal.29 Skill accomplishment refers to the successful mastery of skills or performance of a task.31,32 Vicarious experience is the use of modeling, observing others such as peers.19,32 Verbal persuasion includes social persuasion or encouragement by family or professionals.19,32 Emotional arousal refers to signs such as the anxiety, stress, and mood states that may affect self-efficacy32 that need to be addressed in the intervention program.19,29 The use of these strategies will be translated into the telephone follow-up protocol to be discussed in Methods.

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Methods

Study Design

This was a randomized controlled trial. Colostomy patients in both the study group and the control group received routine discharge care, but only those in the study group received enterostomal nurse telephone follow-up after hospital discharge. Study participants completed data collection before discharge (baseline) and at 1 and 3 months after discharge.

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Participants and Setting

The research setting included 7 regional hospitals (1 cancer center and 6 comprehensive hospitals) located in Guangzhou, southern China. The study hospitals provided stoma outpatient services, and each had a full-time enterostomal nurse with at least 5 years’ stoma care experience. These 7 hospitals are under the same provincial administration and offered similar routine discharge care, including instructions for medications, basic health advice related to their condition, arrangements for outpatient follow-up, and referral to existing stoma patients for peer support.

Subjects were recruited over 11 months, from December 2008 to October 2009. The inclusion criteria for subject recruitment were (a) having a diagnosis of primary rectal cancer and permanent colostomy after surgery, (b) ability to speak Mandarin or Cantonese, (c) being alert and oriented, and (d) ability to be contacted by telephone after discharge. The exclusion criteria were (a) having other kinds of cancer, (b) alcohol or drug abuse, (c) suffering from psychiatric disease, (d) being discharged to an elderly care facility, (e) dying, and (f) inability to provide informed consent. The patients who agreed to participate and completed the baseline data were randomly assigned to either a telephone follow-up group or a control group, using the Research Randomizer.33 This software generated 30 sets of numbers with 2 numbers in each set (“1” belonged to the control group, and “2” to the intervention group). We provided the sets of random numbers for each of the study hospitals for use in sequence, and the unused numbers were discarded if the recruited subjects were less than 60 in the hospital.

The power of this study was estimated based on the primary outcome measure, the psychosocial adjustment score with a moderate effect size of 0.64.34 We estimated that a sample size of 94 (47 in each group) would be required for the study with an α of .05 and a power of 0.80.35 We planned to recruit 57 subjects in each arm to allow for a 20% dropout rates.

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Usual Care

Both the control and intervention groups received customary preoperative and postoperative care. Usual preoperative care involved patient education and stoma site marking by the enterostomal nurse. Patients after surgery would be visited by volunteers from the Ostomy Patients Club to share their experiences on ostomy self-care. At discharge, patients received instructions for medications, basic health advice related to their condition, and arrangements for outpatient follow-up.

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Telephone Follow-up Intervention

The telephone follow-up interventions were provided by an enterostomal nurse in each of the 7 study hospitals; that is, a total of 7 enterostomal nurses were involved, all of whom had more than 5 years of stoma care experience and possessed enterostomal nurse certificates. The enterostomal nurses explained the postdischarge follow-up calls to the patients in the study group prior to their discharge.

The structured, individualized educational and supportive telephone follow-up program was guided by a protocol developed and validated for this study. The first call took place within 3 to 7 days after discharge and the second within 14 to 20 days after discharge. An extra, third call on days 23 to 27 after discharge would be provided to strengthen the intervention effect if stoma self-care ability was still lower than 5 on the Stoma Self-care Scale (range, 0–10)36 at the second call. The calls were provided based on evidence from previous studies showing that a 2- to 4-time intervention for 1 month after hospital discharge is an adequate quantity dose to bring about effects.19,22,37 The telephone follow-up protocol was developed based on SLT29 and a previous study.19 Its main components were validated by a panel of experts, including 5 local experts in nursing and medicine specializing in colostomy care. The protocol consisted of 3 parts: assessment, management options, and evaluation. The assessment components included patients’ general clinical status, discomfort, stoma complications, stoma self-care ability, emotional condition, and self-efficacy. Then, based on the assessment results, the nurse used the sources of information of SLT29 in the telephone calls for management options. They were (a) self-care skills accomplishment (eg, reinforcing skills on stoma self-care), (b) vicarious experiences (eg, encouraging colostomy patients to attend the Ostomy Patients Club and learn from experiences of other colostomy patients), (c) verbal persuasion (eg, convincing patients that they can perform an activity and control their life), and (d) emotional arousal (eg, being sensitive to patients’ emotions, such as anxiety, distress, and maladaptation, and minimizing them where possible). Finally, the nurse made an evaluation and appropriate referral, such as clinical enterostomal nurse outpatient, general practitioner, surgical consultation, or emergency room as appropriate. With the patients’ consent, the conversation was recorded using a telephone recorder, and the intervention and advice provided were documented using self-designed telephone intervention recording sheets. This helped in evaluating whether the intervention was actually addressing issues relevant to health concerns and whether SLT was being applied in the conversation. Overall, 156 telephone intervention recording sheets were documented and validated by the first 3 authors. Content analyses of the telephone calls have been conducted and reported elsewhere.38

The enterostomal nurses were trained prior to the launching of the main study. They were provided with reading materials on SLT, and the first author explained the intervention protocol to them in detail. In order to ensure appropriate and consistent application of the intervention, 2 experienced investigators familiar with telephone intervention attended the cancer center to guide the intervention. Three cases were piloted to ensure that the protocols were fully comprehended and mastered by the enterostomal nurses.

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Instruments

There are 5 measurement tools as described in the following sections.

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DEMOGRAPHIC AND HOSPITAL LENGTH OF STAY

The variables on the demographics including age, gender, marital status, household income, and employment status were collected via face-to-face interview. The length of stay, collected from the hospital chart, is a proxy variable to reflect if all of the patients recover after surgery within the “normal” time frame. These measures have been validated and used in a previous study.39

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OSTOMY ADJUSTMENT SCALE

The Ostomy Adjustment Scale (OAS) was developed by Olbrisch.11 It was designed to measure patients’ subjective responses to living with an ostomy and their overall psychological, social, and sexual adjustment after ostomy surgery. There are 34 items. Examples of these items include “Though I had an ostomy, I could still live my life fully,” “With the presence of an ostomy, sometimes I feel unconfident,” and “I am confident that I know the proper methods in managing my ostomy.” The items were measured on a 6-point Likert scales, ranging from “totally disagree” to “totally agree.” There were 18 items that had reverse scores. The total scores ranged from 34 to 204, with higher scores indicating better adjustment.

The internal consistency of the OAS was tested with a Cronbach α of .87 to .90 and test-retest correlation of 0.72 to 0.82.10,11 Convergent validity was demonstrated with the OAS having a significant positive correlation with the 15-item quality-of-life scale (r = 0.40, P < .002) and a significant negative correlation with the 5-item depression index (r = −0.53, P < .0001).10 The reported reliability (Cronbach α = .85; test-retest r = 0.72) was confirmed in a study of Swedish patients with stomas.9 Translation validity was confirmed using forward and backward translation. We invited 5 experts, including 1 associate professor in surgical nursing, 2 certified enterostomal nurses, and 2 gastroenterologists, to examine the content validity for this questionnaire. The Content Validity Index of the Chinese version of the OAS was 0.91. The internal consistency was good, with a Cronbach α of .91 and a split-half reliability coefficient of 0.85, and the intraclass correlation among 15 colostomy patients for a 2-week interval was 0.90. The interrater reliability of the first author and research assistant who collected the data was assessed among 17 colostomy patients and yielded an interrater correlation of 0.95.

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STOMA SELF-EFFICACY SCALE

The Stoma Self-efficacy Scale (SSES) was developed by Bekkers et al40 to determine the self-efficacy of stoma patients. It contained 22 items that were rated on a 5-point Likert scale ranging from “not confident at all” to “slightly confident,” “fairly confident,” “highly confident,” and “extremely confident.” Higher scores indicated better stoma self-efficacy, that is, subjective presence of the ability to manage one’s stoma. The maximum score for the Stoma Self-efficacy Scale was 110, and the minimum score was 22. The Chinese version of the SSES had been validated, and the reliability confirmed with a Cronbach α of .97.41 In our study, the internal consistency was good, with a Cronbach α of .89, and the test-retest reliability (intraclass correlation) among 15 colostomy patients for a 2-week interval was 0.96. The interrater reliability of the first author and research assistant who collected the data was assessed among 17 colostomy patients and yielded an interrater correlation of 0.93.

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SATISFACTION WITH CARE

Patients’ satisfaction with care was evaluated by a single self-reported item scoring between 1 and 5, with 1 being “very satisfied” and 5 being “very unsatisfied.”

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STOMA COMPLICATIONS

The stoma complications were identified by an enterostomal nurse according to a preset checklist, which included the most common complications including stoma necrosis, mucocutaneous separation, skin irritation, bleeding, prolapse, peristomal hernia, stomal retraction, stomal stenosis, granuloma, and mechanical injury. The measure to each complication was “yes” and “no.” The presence of the complication was confirmed with the cross-checking of the clinical documentation with description of the signs and symptoms of the reported complication.

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Procedure

The study was approved by the ethics committees of the university and study hospitals. Patients who met the inclusion criteria were invited to participate. All participants received written and verbal information about the purpose of the study, benefits and risks, and confidentiality issues. Patients participated in the study on a voluntary basis, and their decision not to participate would not affect the care they would normally receive. Participants were asked to give written consent to confirm their voluntary participation. They were reassured that they could choose to withdraw from the study at any time without penalty. Their confidentiality was protected through the use of code numbers and the removal of all identifying information from the data excerpts. In order for the control group not to be disadvantaged, after the whole study was finished, the enterostomal nurse in each hospital would offer a telephone call to the patients in the control group to see if they had any concerns and provide advice as appropriate.

Baseline data were collected by the first author 1 to 2 days before patients were discharged. Of those who met the inclusion criteria, 121 agreed to participate in the study. The first author helped collect the data on demography, ostomy adjustment, self-efficacy, and satisfaction with care via face-to-face interview. The length of stay was collected from the patient medical records by the first author.

At 1 and 3 months after discharge, data were collected again via face-to-face interview when the patients returned to see the doctor at the outpatient clinics. A research assistant, who was independent from the hospital and was blind to the group assignment, helped collect the data except for stoma complication review, which was done by an enterostomal nurse in the hospital. Usually, there are 2 enterostomal nurses in the study hospital and the one who was not involved in the telephone intervention would be arranged to do the complication review. At the end of the study, 103 subjects completed the study. The Figure outlines the flow of the study.

Figure
Figure
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Data Analysis

Data were analyzed using SPSS for Windows version 17.0 (IBM SPSS Data Collection, New York). Demographic data and clinical characteristics were summarized as the means (SDs) for continuous variables, and as frequency counts (percentages) for categorical variables. Group comparisons were performed using 2-tailed t test for continuous variables and χ2 tests for categorical variables. The differences between baseline and posttest mean adjustment scores were calculated for each group with the use of the paired t test. A group comparison of the difference in baseline to posttest scores between groups was performed with the use of the independent-samples t test. One-way repeated-measures analysis of variance (ANOVA) was used to determine between-group (study vs control), within-group (3 times), and interaction (group × time) effects. The normality of the data was examined using the 1-sample Kolmogorov-Smirnov test. Statistical significance was preset at P < .05.

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Results

Participants’ Characteristics and Group Equivalence

The mean ages of the patients were 52.9 years (study group) and 55.3 years (control group), and there were more males (study, 59.6%; control, 70.6%) than females. The educational level varied, with over one-fifth having a level at primary school or below (study, 25.0%; control, 21.6%), and another one-fifth achieved the college level (study, 23.1%; control, 23.5%). More than 80% of them were married. Most of the patients had a monthly income that was basic, between RMB 1000 to 2000 (equivalent to US $151–$300). Many of them were either retired (study, 37.3%; control, 53.3%) or unemployed (study, 39.0%; control, 25.0%). The length of hospital stay between the 2 groups was similar (study, 16.4 days; control, 15.6 days). There was no significant difference between groups in the baseline data (Table 1).

Table 1
Table 1
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Effectiveness of Enterostomal Nurse Telephone Follow-up
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OSTOMY ADJUSTMENT

The OAS scores for each of the 2 groups were normally distributed at each time point. The ostomy adjustment was equivalent between the study and control groups at baseline. Both the study and control groups showed improvement over time, and there was significant within-group improvement in the OAS (F = 9.39, P = .003). However, the study group had numerically higher scores when compared with the control group, both at 1 month (study 130.85 vs control 123.77, t = 1.75, P = .083) and 3 months (study 136.11 vs control 124.32, t = 2.80, P = .006), although significance was achieved only by 3 months. There was a significant overall between-group difference (F = 3.96, P = .049). Table 2 shows the ANOVA result.

Table 2
Table 2
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STOMA SELF-EFFICACY

The SSES scores for each of the 2 groups were normally distributed at each time point. The SSES was equivalent between the study and control groups at baseline. Both the study and control groups showed improvement in SSES over time, and there was significant within-group improvement in SSES (F = 44.81, P = .000). The study group had a numerically higher score when compared with the control group, both at 1 month (study 70.17 vs control 66.92, t = 1.09, P = .281) and 3 months (study 77.52 vs control 70.02, t = 2.51, P = .014), and significance was achieved only by 3 months. There was no significant between-group difference (F = 1.29, P = .259). The interaction effect (group × time) in SSES was significant (F = 10.11, P = .002). Table 2 shows the ANOVA result.

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SATISFACTION WITH CARE

There was no significant difference between the control and study groups in the satisfaction level at baseline (study 1.52 vs control 1.73, t = 1.47, P = .144). However, at 1 month (study 1.44 vs control 2.12, t = 4.85, P = .000) and 3 months (study 1.45 vs control 2.04, t = 4.45, P = .000) after discharge, the study group had significantly greater satisfaction with care.

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STOMA COMPLICATIONS

The status of no stoma complications was equivalent between the study and control groups at baseline (study 80.8% vs control 76.5%, χ2 = 0.28, P = .868). The study group had a significantly better no-complication rate than the control group at 1 month (study 82.7% vs control 58.8%, χ2 = 7.12, P = .028) and 3 months (study 78.8% vs control 56.9%, χ2 = 6.24, P = .044). The top 3 most frequently reported types of complications were skin irritation, stomal retraction, and stomal stenosis (Table 3).

Table 3
Table 3
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Discussion

The present study provided evidence to support that enterostomal nurse telephone follow-up was effective to enhance postoperative adjustment of early discharged colostomy patients. Results from this study indicate that the study group had significantly better scores than did the control group on ostomy adjustment and stoma self-efficacy 3 months after discharge. This finding concurs with Wade’s13 study, which revealed that patients in districts that employed stoma-care nurses were less prone to affective disorder, more satisfied with information, and more proficient in self-care at 10 weeks. Our study using nurse telephone follow-up sustained enhanced adjustment effects up to 3 months. The findings are also consistent with previous findings that specialist stoma nurses’ support and education contributed significantly to positive adjustment in ostomy patients.4,12 The patients in the study group had significantly fewer stoma complications at 1 and 3 months after discharge compared with the control group. The overall complication rates are comparable to those found in other studies, ranging between 23.5%42 and 34%.43 The top complication on the list in this study is skin irritation, which is the same as reported by Richbourg et al.6 The patients in the study group were significantly more satisfied with their care. Findings in this study concur with results from another quasi-experimental design study, which also showed that the telenursing follow-up enhanced client satisfaction, even when compared with another home health group.14

Enterostomal nurse telephone follow-up may have influenced the patient adjustment level in several ways. First, telephone follow-up helps colostomy patients to deal with their stoma self-care problems, master their stoma self-care ability, and resolve issues relating to their activities of daily living. Some research results have shown that ostomy self-care is the most important variable predicting adjustment.12,44 Enhancing self-care is thus an essential nursing intervention to facilitate ostomy patients to resume normal living after colostomy surgery.12 Second, encouragement from the enterostomal nurse is designed to be reassuring for patients with a new stoma as they learn to live with a stoma independently. Evidence suggests the important role of self-efficacy in the process of adjusting to a stoma,5,12,40 and subjects in the study group achieved both increased stoma self-efficacy and adjustment. This notion of self-efficacy has been less emphasized among patients in the Chinese culture because Chinese patients tend to rely on the care of family members, particularly in the case of those who have spouses and children.45 The dependence on others hinders their process of adjustment to a stoma, so enterostomal nurses’ encouragement is of paramount importance at this time. Lastly, emotional and informational support from enterostomal nurses is designed to promote the adjustment to a colostomy. Talking about stressful life events in a supportive context, developing a trustful therapeutic relationship with an ostomy specialist, and receiving valuable information about stoma care and daily living contributed significantly toward positive adjustment to an ostomy.12,44 Although enterostomal nurses emphasized in the telephone follow-up about the importance of participating in Colostomy Patients Club and keeping in contact with other colostomy patients, a previous research showed that unfortunately the education and training of these external social resources for the patient with a colostomy are not a priority immediately after surgery, despite the significance of their role in the rehabilitation of the ostomy patients.12 We still believe that this education will play an important role in patients’ adjustment in the long run.

This study has chosen adjustment as the key outcome. The concept of adjustment is very complex and may be related to other factors such as quality of life, anxiety, and depression.46 This study has not encompassed all the relevant variables to unravel the possible complex relationship between adjustment and other relevant variables. We did a Pearson correlation test between the OAS and SSES, and indeed adjustment had a significant correlation with self-efficacy (1-month r = 0.72, P < .01; 3-month r = 0.56, P < .01). Further studies can help explore the relationships between adjustment and other related variables so as to provide more specific information to guide nursing intervention.

The OAS scores at 1 and 3 months after discharge for colostomy patients in this study were 127.34 (SD, 20.71) and 130.27 (SD, 22.10), respectively. The first author had previously conducted an exploratory study examining the adjustment level of colostomy patients in mainland China with an average span of 73.65 months after surgery,31 and the adjustment score was 130.56 (SD, 19.38). The OAS score of the study group at 3 months is thus comparable with that of veteran ostomy patients. The OAS of the study group at 3 months was similar to that in another study in Chile,12 which reported an OAS of 132.6. However, the scores are apparently lower than those reported in the United States (157.4)10 and in Sweden (178.6).9 The differences may result from the different economic, cultural, and healthcare contexts among these countries. Both China and Chile are developing countries, whereas the United States and Sweden are developed countries. Different cultural backgrounds may cause different attitudes toward a colostomy. Chinese people find it more difficult to accept the reality of having a colostomy, as suggested by the venomous curse “birth to a child with no rectum!” Higher acceptance of their stoma indicated better adjustment.5 Although stoma care in China has made tremendous progress in the last few years, ostomy adjustment is still at a relatively low level in China. Measures using nurse telephone follow-up, as shown in this study, contribute to better well-being of stoma patients. This study has set up a model of care that has implications for the larger context of healthcare in China.

The People’s Republic of China has provided free healthcare to the people when the new government was formed in 1949. In the 1980s, the country underwent economic reform, and the business ethos has influenced the healthcare market, resulting in some people not receiving healthcare because of the inability to pay. The Chinese government recognized the problem and has initiated a healthcare reform at the turn of the 21st century.47 China at present has 2 main insurance programs, the Government Health Insurance and Labor Health Insurance. The Government Health Insurance provides coverage to government employees as well university teachers and students. The Labor Health Insurance provides insurance to workers and retirees of state- and collective-owned enterprises. As for the people in the rural area, there is a safety net built for the rural population with the implementation of the New Cooperative Medical Scheme in 2003.48 With the efforts of the central government, the individual out-of-pocket healthcare expenses have now decreased from 40.4% in 2008 to 35.5% in 2010, and the claim can go up to 70%.49 This study has established a model of care that addresses the directives of the current healthcare reform in China that aims to achieve affordable, accessible, available, and quality healthcare for people in China.50 Telephone follow-up by nurses is an efficient intervention that is low cost and easily accessible to patients who need support for adjustment after treatment.

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Limitations of the Study

We acknowledge that there are at least 2 limitations to this study. The study followed discharged colostomy patients only up to 3 months; thus, the sustained effect of the intervention in this study needs to be further tested. The study also suffered from a second limitation, that is, the use of 7 different enterostomal nurses to provide the intervention. Although a standard protocol was developed and piloted, we could not control any individual differences that might have occurred in care.

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Conclusions

This study has established evidence to suggest that enterostomal nurse telephone follow-up was effective in improving the adjustment level, self-efficacy, and satisfaction with care, reducing the stoma complications of discharged colostomy patients as compared with those who received only routine discharge care. Enterostomal nurse telephone follow-up can enhance the adjustment level by improving patients’ stoma self-care ability, confidence, and competence to deal with their own stoma and providing emotional and informational support. The adjustment level of colostomy patients in China is still relatively low compared with those in developed countries. Health professionals in China should pay more attention to postdischarge transitional care and adopt effective and potentially low-cost measures such as nurse telephone follow-up to achieve accessible care to the people they serve.

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References

1. 1. United Ostomy Associations of America. UOAA discussion board. http://www.ostomy.org/forum/viewtopic. Accessed December 22, 2010.

2. Baxter A, Salter M . Stoma care nursing. Nurs Stand. 2000; 14:(19): 59

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Keywords:

Colostomy adjustment; Continuity of care; Randomized controlled trial; Telephone follow-up

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