INTRODUCTION
Colorectal cancer is the third most common cause of cancer-related death.1 Taiwanese citizens have begun to adopt Westernized dietary and lifestyle habits; the colorectal cancer incidence in Taiwan is now correspondingly higher than those of all other cancer types. In addition, the incidence of colorectal cancer in younger age groups has increased. Mortality from colorectal cancer increased from 19.5 (people/year/million people) in 2007 to 21.2 in 2011. This number increased to 24.3 in 2016 statistics.2 These reports have demonstrated that colorectal cancer poses a substantial threat to human life.2
Colorectal cancer is primarily treated through surgery. Following colostomy, patients commonly encounter problems with stoma care, including fecal leakage, abrasion of the peristomal skin, formation of the granulation tissue, and hernia. To support patients in adjusting to their condition, they should receive self-care-related information and skill training during their hospital stay after colostomy,3 which might include instructions on colostomy care provided either verbally or via handout.
Taiwanese researchers have examined the effects of multimedia patient education interventions on those scheduled for spinal surgery4 and on those who have undergone cardiac catheterization.5 These education programs were mostly designed to reduce anxiety. However, research on the efficacy of multimedia patient education regarding postoperative stoma care for patients with colorectal cancer is lacking in Taiwan. Therefore, the present study adopted multimedia patient education as an intervention and explored its effectiveness in improving the self-care knowledge and skills of patients who underwent colostomy.
With the adoption of Westernized dietary habits, Taiwanese people tend to consume more meat than high-fiber vegetables and fruits. Consequently, they experience constipation, which results in abnormal proliferation of colonic epithelial cells.6 In addition to dietary habits and lifestyle, heredity is also a primary factor in colorectal cancer.7,8
Colorectal cancer is classified into four stages, each of which corresponds to a distinct standard treatment method. In the stage where the tumor is confined to the intestinal wall, most patients must undergo surgical excision; this tends to involve colostomy, which in turn creates challenges for stoma self-care. The most common colostomy-related stoma care problems, as discussed earlier, pose psychological challenges, including negative emotions, as well as difficulties in managing daily activity for the patients and their family.3,9 Therefore, patient education regarding stoma care is imperative. Recent unpublished data (Chung SY, 2015) indicated that patients with colorectal cancer in Taiwan do not exhibit sufficient colostomy self-care knowledge or skills and should receive relevant training before discharge from hospital.
Self-care comprises personal practices that must be acquired; these practices include behaviors related to health maintenance or disease management and strategies for attaining personal health and comfort. Self-care is a process of personal decision-making for engaging in healthy behaviors and seeking healthy conditions. To achieve self-care, a patient must understand the requirements of these practices, participate in appropriate activities to strengthen their self-care capacity,10 be fully aware of their health status, take initiative to identify problems, exhibit the ability to solve problems, and avoid incurring additional medical costs.11
Under clinical circumstances, in-hospital time for appropriate patient education is insufficient because of short hospital stays and limited medical resources. Moreover, conventional patient education methods cannot meet patients’ physical, emotional, and economic needs.12–14 Patients who receive inadequate education might be poorly prepared to engage in postoperative stoma care after hospital discharge.15
Multimedia-based methods are a new form of teaching.16 Studies from Taiwan and abroad have confirmed that the use of multimedia materials for patient education is more effective than conventional patient education methods.17,18 Multimedia technology can overcome time and space limitations, satisfy the needs of patients and family regarding self-care after hospital discharge, and ensure consistency in patient education content.17 In addition, multimedia DVDs allow not only repeated viewing of self-care procedures but also flexible, independent learning. In clinical applications, the use of multimedia DVDs produces positive learning effects and can reduce the likelihood of incomplete or inconsistent patient education, which may occur when clinical nurses serve as educators.4,19
Mulhall et al20 administered multimedia patient education as an intervention for patients with chronic obstructive pulmonary disease. Patients were instructed regarding correct techniques for using inhaled medications. The researchers assessed the patients after 3 to 6 months and found that the intervention exhibited long-term efficacy but did not reduce respiratory symptoms. Laszewski et al21 used a multimedia patient education strategy as an intervention to prevent the occurrence of radiation dermatitis in patients receiving preventive radiotherapy. The researchers assessed the results at weeks 1 and 3 and found that multimedia patient education materials produced more satisfactory results than did written materials. Further, Huang et al22 confirmed that a multimedia diabetes education program improved patients’ knowledge regarding diabetes and insulin injection, insulin injection skills and self-efficacy, and satisfaction with the program. The researchers claimed that health care providers could enhance the quality of patient care by offering multimedia health education regarding diabetes.
Lo et al23 used a multimedia education strategy for patients with stoma to improve their knowledge and attitude. Culha and colleagues24 found that self-care education can increase stoma knowledge in patients with stoma. Dalmolin et al25 observed that people with colostomy and their families learned by watching videos, and the families also developed their own methods for colostomy care.
The aforementioned studies have confirmed the effectiveness of multimedia patient education for imparting self-care knowledge and skills to patients with a variety of conditions. Therefore, the present study examined the effectiveness of multimedia patient education for improving the self-care knowledge and skills of patients who underwent colostomy.
METHODS
A quasi-experimental design was used in this study, and a structured questionnaire26 was distributed to maximize data collection. The experimental group received multimedia patient education, whereas the control group received standard general nursing instructions (ie, written and verbal instructions).
Both groups received stoma care education once before and after surgery. Researches collected study data related to the self-care knowledge and skills of both groups through a pretest on the day prior to patient hospitalization, posttest 1 on the first day the patients passed gas after surgery (this is the day that the nurses reinforce ostomy care in clinical practice), posttest 2 on the day prior to hospital discharge, and posttest 3 during the first clinic visit after hospital discharge.
Site and Sampling
Purposive sampling was performed. The recruitment site was the general surgery ward of a regional teaching hospital in northern Taiwan. The recruitment criteria were as follows: adults (1) 20 years or older, (2) who had received a diagnosis of colorectal cancer and undergone colostomy, (3) who could communicate in Mandarin Chinese or Taiwanese Hokkien, and (4) who consented to participate in this study. Patients who were too weak to complete the questionnaire or refused to participate were excluded from the study.
G*Power 3.1.9.4 (Heinrich-Heine-Universität Düsseldorf, Germany) was used in sample estimation (effect size = 0.7, α error = .05, and power = 0.80). The ideal sample size for both the experimental and control groups was estimated to be 34. Finally, a total of 63 patients were recruited (33 for the experimental group and 30 for the control group). No participant withdrew during the research.
Research Tools
The research tools were multimedia DVDs used for patient education and a questionnaire.
Multimedia DVDs for Patient Education
The use of DVDs as a resource for patient education has been verified in previous studies27 in which materials were designed based on written health education materials used at that time, expert opinion, and clinical experience. In this study, three surgical ward nurses performed and filmed demonstrations. The nurses recorded a video of approximately 10 minutes. The video was designed according to scales of self-care knowledge and skills and consisted of several sections: preparation of items for postoperative stoma care, procedures for stoma care, information on common problems, and additional guidance regarding stoma care. The intervention group could review the DVD as frequently as they wished during their postoperative hospital recovery. However, this study dictated the review of colostomy care on the third day after surgery. Therefore, the researcher reinforced colostomy care through the DVD.
The video was evaluated by a team of experts in colostomy care using the content validity index to determine the extent to which it addressed all the aspects of interest that it intended to measure.28 The content validity index was 0.95, suggesting that the video’s content was appropriate.
Questionnaire
A structured questionnaire with two sections was developed based on clinical experience and a relevant study by Su et al.27 The first section collected demographic information (ie, sex, age, education level, religion, marital status, and current health status). The second section pertained to the respondent’s stoma care knowledge and skills (which references quality-of-life factors in patients with colorectal stoma, as discussed by Su et al27). The structured questionnaire used by Su et al27 was suitable for these research purposes and targets. Investigators obtained consent from authors to use their questionnaire, which involves two scales: the self-care knowledge scale and the self-care behavior scale.
The self-care knowledge scale comprises 23 items grouped into three dimensions: diet, stoma care, and self-care activities. Higher scores indicate greater knowledge regarding postoperative stoma care in patients with colorectal cancer. The self-care behavior scale comprises 19 items that are rated on a 5-point scale. Higher scores suggest more positive behaviors related to postoperative stoma care in patients with colorectal cancer.
The internal consistency of each scale was tested (Cronbach α = .80). Reliability was also analyzed for the self-care knowledge scale (overall Cronbach α = .77) and the self-care behavior scale (overall Cronbach α = .81).
Ethical Considerations
Sampled patients from the hospital officially joined the study as research participants after their consent was obtained. In the event that they encountered any discomfort or stress during the research process, the participants were allowed to terminate their participation or cease completion of the questionnaire at any time. Their rights to receive appropriate treatment were not affected by their withdrawal from the study. During the research process, none of the participants terminated their participation, and none of the sampled patients refused to be recruited.
Data Collection
During the data collection process, the researchers attended a colorectal cancer group meeting to exclude unsuitable research candidates. To avoid interference in the recruitment process, the experimental group was recruited before the control group. The participants’ data were retrieved, coded, filed, and then analyzed using SPSS 20.0 (IBM Corp, Armonk, New York). A χ2 test was performed to examine the homogeneity of groups in terms of their demographic data. An independent-sample t test was conducted to compare the pretest performance (ie, regarding self-care knowledge and skills) of participants in both groups. One-way analysis of covariance was employed to compare performance on the pretests and posttests and after the participants underwent the intervention.
RESULTS
More than half of the participants were men (n = 39) and were aware of relevant support groups (n = 45). Most of the participants had completed junior high school or lower levels (n = 46), had received a temporary colostomy (n = 60), generally took care of their stoma by themselves or with partial help from family (n = 57), had never experienced fecal leakage (n = 50), and had never participated in stoma care-related activities (n = 48). The test results revealed nonsignificant intergroup differences (P > .05; Table 1), suggesting adequate homogeneity in terms of demographic data. The length of hospital stay between the groups was also not significantly different: both groups of participants remained in the hospital for approximately 7 days.
Table 1. -
PARTICIPANT DEMOGRAPHICS
| Variable
a
|
Experimental Group (n = 33) |
Control Group (n = 30) |
P
|
| Age, y, mean ± SD |
64.6 ± 13.3 |
66.7 ± 11.1 |
.26 |
| Sex |
.11 |
| Male |
23 (69.7) |
16 (53.3) |
|
| Female |
10 (30.3) |
14 (46.7) |
|
| Education level |
.24 |
| Junior high school or less |
29 (89.9) |
23 (76.7) |
|
| Senior high school or more |
4 (12.1) |
7 (23.3) |
|
| Colostomy type |
.50 |
| Temporary |
32 (97.0) |
28 (93.3) |
|
| Permanent |
1 (3.0) |
2 (6.7) |
|
| How do you usually receive stoma care? |
.75 |
| Self-administration |
17 (51.5) |
17 (56.7) |
|
| Partial help from family |
12 (36.4) |
11 (36.7) |
|
| Family administered |
4 (12.1) |
2 (6.7) |
|
| Do you know of any support groups for patients with a colostomy? |
.18 |
| Yes |
26 (78.8) |
19 (63.3) |
|
| No |
7 (21.2) |
11 (36.7) |
|
| Have you ever attended such groups? |
.50 |
| No |
24 (72.7) |
24 (80.0) |
|
| Yes |
9 (27.3) |
6 (20.0) |
|
| Frequency of fecal leakage |
.55 |
| Never |
27 (81.8) |
23 (76.7) |
|
| Rarely |
6 (18.2) |
6 (20.0) |
|
| Occasionally |
0 (0) |
1 (3.3) |
|
aAll values n (%) unless otherwise noted.
Scores for Self-care Knowledge and Skills
Pretest results revealed scores of 0.56 ± 0.16 and 0.60 ± 0.17 for the experimental and control groups, respectively, in terms of self-care knowledge and scores of 1.31 ± 0.57 and 1.27 ± 0.64, respectively, for self-care skills. Thus, no significant differences in postoperative self-care knowledge and skills were detected between the groups (P > .05), confirming their pretest homogeneity (Table 2).
Table 2. -
PRETEST COMPARISON BY GROUP
| Knowledge and Skills |
Experimental Group (n = 33), Mean ± SD |
Control Group (n = 30), Mean ± SD |
P
|
| Self-care knowledge |
.56 ± .16 |
.60 ± .17 |
.41 |
| Diet |
.71 ± .32 |
.68 ± .29 |
.66 |
| Stoma care |
.59 ± .16 |
.64 ± .19 |
.21 |
| Self-care activities |
.32 ± .26 |
.39 ± .28 |
.34 |
| Self-care skills |
1.31 ± .57 |
1.27 ± .64 |
.81 |
| Gas and smell control |
1.28 ± .65 |
1.22 ± .86 |
.75 |
| Self-care activities |
1.48 ± 1.08 |
1.38 ± .98 |
.72 |
| Stoma care |
1.30 ± .70 |
1.32 ± .77 |
.90 |
| Coloclysis |
1.25 ± .67 |
1.13 ± .79 |
.53 |
| Active learning |
1.15 ± .61 |
1.23 ± .91 |
.67 |
The analysis of covariance results revealed a significant difference in results for posttest 2 (on the day prior to hospital discharge) between the experimental and control groups. The results indicated that the performance of the experimental group in self-care knowledge was superior to that of the control group.
In all posttests, the experimental group obtained higher scores for the five self-care skills (ie, gas and smell control, self-care activities, stoma care, coloclysis [colostomy irrigation], and active learning) than did the control group (P < .05; Table 3), suggesting the efficacy of multimedia patient education.
Table 3. -
ANALYSIS OF COVARIANCE OF POSTTEST SCORES
| Knowledge or Skill |
Pretest
a
|
Experimental Group Versus Control Group, Mean ± SD |
| Posttest 1 |
Posttest 2 |
Posttest 3 |
| Self-care knowledge |
.58 |
.21 ± .02 > .16 ± .02 |
.30 ± .01 > .26 ± .01b
|
.30 ± .01 = .30 ± .01 |
| Diet |
.70 |
.91 ± .03 > .84 ± .03 |
.97 ± .02 > .93 ± .02 |
.98 ± .01 > .97 ± .01 |
| Stoma care |
.62 |
.80 ± .02 > .78 ± .02 |
.85 ± .01 > .84 ± .02 |
.85 ± .02 < .89 ± .02 |
| Self-care activities |
.35 |
.61 ± .05 > .55 ± .05 |
.83 ± .02 > .74 ± .22b
|
.84 ± .02 > .76 ± .02d
|
| Self-care skills |
1.29 |
1.12 ± .08 > .82 ± .09c
|
2.17 ± .09 > 1.22 ± .09d
|
2.53 ± .07 > 1.64 ± .08d
|
| Gas and smell control |
1.25 |
2.34 ± .10 > 2.09 ± .10 |
3.43 ± .13 > 2.65 ± .13d
|
3.87 ± .07 > 2.95 ± .08d
|
| Ability to perform daily living activities |
1.43 |
2.60 ± .12 > 2.20 ± .13b
|
3.43 ± .14 > 2.54 ± .14d
|
3.60 ± .16 > 3.04 ± .17b
|
| Stoma care |
1.31 |
2.48 ± .11 > 2.08 ± .11c
|
3.55 ± .10 > 2.33 ± .11d
|
3.92 ± .07 > 2.86 ± .08d
|
| Coloclysis |
1.19 |
2.26 ± .12 > 2.09 ± .13 |
3.41 ± .12 > 2.54 ± .12d
|
3.86 ± .08 > 2.89 ± .08d
|
| Active learning |
1.19 |
2.26 ± .11 > 2.05 ± .12 |
3.38 ± .09 > 2.60 ± .10d
|
3.80 ± .12 > 2.92 ± .13d
|
aPosttests were conducted after pretest homogeneity was adjusted for equal variances.
bP < .05
cP < .01
dP < .001
DISCUSSION
The participants’ demographic characteristics aligned with the 2015 demographic statistics released by the Executive Yuan in Taiwan (according to which the male-to-female ratio of patients with colorectal cancer is 1.24:1, and most individuals with this cancer are aged 60–70 years).29
Based on pretest scores, the experimental group exhibited superior performance in self-care knowledge and skills to that of the control group; however, the differences were not significant, indicating considerable homogeneity between the groups. This finding is similar to results reported by Shao et al,30 who conducted a thorough exploration of the effects of DVDs combined with nursing instruction on the knowledge, attitudes, and self-care behaviors of patients diagnosed with first-onset coronary heart disease. The researchers identified no significant differences between pretest scores of the studied groups.
In posttest 2, the experimental group obtained significantly higher average scores for self-care skills (2.17 ± 0.09; P < .001) and self-care knowledge (0.30 ± 0.01; P < .05) than did the control group. This result is in accordance with Abbaszadeh and colleagues,31 who studied the effects of patient education videos on preventing the recurrence of myocardial infarction.
Ihrig et al32 investigated the perspective of physicians when using multimedia patient education as an intervention preceding prostatectomy. The researchers claimed that because the multimedia support did not involve time restrictions, the patients benefited in terms of self-care knowledge. That study revealed that multimedia patient education was more effective than conventional patient education because multimedia education was easier to understand, visually entertaining, and more conducive to helping patients understand complex topics.32
When performing postoperative stoma self-care, patients tend to experience anxiety and insecurity because of insufficient experience. Therefore, the method that medical practitioners use for patient education is crucial. Further, DVD resources can improve patient engagement and positive actions in their colostomy care.23,33 When provided with repeated opportunities for practice, patients reduce the probability of encountering unfamiliar stoma care procedures.3,34
In the present study, no significant intergroup differences were identified for self-care knowledge and skills at posttest 1 (on the first day the patients passed gas following surgery) and self-care knowledge at posttest 3 (during the first clinic visit after hospital discharge). This result can be attributed to the fact that posttest 1 was conducted on the third or fourth day following surgery, corresponding to the time during which the patients were most likely to experience postoperative pain. Therefore, at the time of posttest 1, the patients considered postoperative pain control their top priority. At posttest 3 (ie, the first clinic visit), they had become familiar with self-care information, which contributed to nonsignificant differences in test results. Scores for posttest 2 exhibited significant differences because the patients were focused on preparing for discharge from hospital on the following day. The pretest results indicated that the patients had low scores for “self-care activities” (under self-care knowledge) and “gas and smell control” (under self-care skills).
Limitations
Because of time constraints, limited labor resources, and a small sample size, this study did not generate concrete and generalizable inferences. The study needed 34 participants in each group to be sufficiently powered, but this was not achieved. Further, this study sampled only patients from the general surgery ward of a regional teaching hospital in northern Taiwan. Therefore, the results may not be widely generalizable.
In addition, most of the participants in the present study received a temporary colostomy. Therefore, the researchers recommend further study with a greater number of participants and encourage sampling at multiple facilities to generate study results of greater generalizability for application. Further, the researchers recommend use of a longitudinal research methodology in which posttests are administered at intervals of 2 months after hospital discharge to ascertain the long-term effects of multimedia patient education on patients with colorectal cancer who have undergone colostomy.
CONCLUSIONS
The present study explored the effectiveness of multimedia patient education materials for improving the self-care performance of patients with colorectal cancer colostomy. Significant differences were observed in postoperative self-care knowledge and skills between patients with colorectal cancer colostomy who received video-based (multimedia) patient education and those who received patient instruction through conventional means. The experimental and control groups exhibited no significant differences in terms of demographics and self-care knowledge and behavior before surgery. After the implementation of the intervention, the experimental group improved considerably in stoma self-care knowledge and ability before hospital discharge. The results suggest that multimedia patient education was an effective method to improve self-care skills among patients with colorectal cancer who received a colostomy. The authors hypothesize that the multimedia instruction enabled patients to repeatedly practice self-care, thereby improving their self-care knowledge and skills. This finding supported the authors’ research hypothesis.
Implications for Clinical Practice
Nurses may apply research results (ie, the efficacy of multimedia patient education) in nursing assessments to satisfy the needs of patients with colorectal cancer who have undergone colostomy and provide suitable nursing services. Medical institutions may develop online platforms for administration of patient education. Researchers may compare internet-based methods with DVD-based methods, and results may serve as a reference for effective nursing instruction regarding postoperative stoma care to patients with colorectal cancer.
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