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Validation of the urostomy education scale: the European experience.

Bladder cancer is the fourth most common cancer among European males. Once diagnosed with muscle invasive bladder cancer, a radical cystectomy is the first line treatment, which results in a urostomy. The placement of a urostomy and the care required impacts the patient's life. Previous research validated the Urostomy Education Scale as the first standardized tool capable of documenting the patients' level of stoma self-care skills and useful to guide patient education interventions. A Danish-Dutch Fellowship was established to support and provide further evidence of applicability of the Urostomy Education Scale.

Key Words: Urinary diversion, cystectomy, patient education, self-care, instrument validation.

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Objectives:

1. Explain the effects a urinary stoma can have on the lives of patients undergoing this treatment for bladder cancer.

2. Discuss the Urostomy Education Scale as the first standardized tool capable of documenting the patients' level of stoma self-care skills.

Bladder cancer accounts for about 7% of the total cancers in Europe (Ferlay et al., 2010). The annual incidence rate is 30/100,000 in Denmark (DK) and 20/100,000 in The Netherlands (NL). In both countries the male-female ratio has been stable--around 3:1 during the last decade, with a minor annual variation (Danish Bladder Cancer Registry, 2009; Integral Cancer Centre Netherlands, 2012). Radical cystectomy remains the first line of treatment for patients diagnosed with invasive and high-risk, non-invasive bladder cancer. This treatment includes completely removing the bladder and the creation of a urinary diversion. According to previous research, the most common abdominal rerouting is a urostomy ad modum Bricker (Johansen et al., 2008; Stenzl et al., 2012).

Living with a urinary stoma has been shown to considerably affect patients' daily life (Bekkers, van Knippenberg, van den Borne, & van Berge-Henegouwen, 1996; Tal et al., 2012). One important factor for predicting positive psychological adjustment to life with a urinary stoma is the ability to change a stoma appliance independently (Geng et al., 2009; Metcalf, 1999; O'Connor, 2005; Piwonka & Merino, 1999). Therefore, stoma care education is a highly prioritized postoperative intervention (Geng et al., 2009). Results from recent research suggest patients benefit from early preoperative education (Bryan & Dukes, 2010; Burch & Slater, 2012; Younis et al., 2012). The research literature also documents that coping strategies are enhanced when patients receive relevant information and education on stoma care, specifically from nurses (Bekkers et al., 1996; Metcalf, 1999; Slater, 2010; Tal et al., 2012). Stoma education includes the topics of adjusting psychologically to living with a stoma, peristomal skin care, and change of a stoma appliance (Bryant, 1993; Slater, 2010). Therefore, stoma self-care education includes three learning aspects: cognitive, affective, and psychomotor aspects (O'Shea, 2001). It is paramount to include all learning aspects to ensure sufficient and high-quality stoma self-care education (Kristensen, Laustsen, Kiesbye, & Jensen, in press).

Background

The introduction of fast track pathways in clinical practice challenges traditional stoma care education (Kehlet, 2011). The time available in-hospital to educate patients in stoma care is significantly decreased (Johansen et al., 2008). Therefore, it is highly recommended to follow a standardized education plan when teaching stoma care (Geng et al., 2009; Metcalf, 1999; O'Connor, 2005; Olsen et al., 2002; O'Shea, 2001). A validated and evidence-based education plan provides standardized education, reducing the possibility for staff to alter the content. This can improve quality of stoma care and reduce random clinical practice among staff (Abramson & Abamson, 1999; Grimshaw et al., 2006; Grol & Grimshaw, 2003). A literature review revealed a stoma education plan (Konya, Sanada, & Tsuru, 2006) and a stoma adjustment scale (Simmons, Smith, Bobb, & Liles, 2007). However, no tool to measure the level of stoma self-care was found.

Thus, the Urostomy Education Scale was developed, validated, and pilot-tested. The Urostomy Education Scale allows nurses to report their perceived level of the patient's ability to perform stoma care. Development of the Urostomy Education Scale was based on current literature in stoma care (Bryant, 1993; Burch, 2005; Geng et al., 2009; Metcalf, 1999; O'Connor, 2005; Ostomy Guidelines Task Force et al., 2010; Rust, 2007; Simmons et al., 2007; Vujnovich, 2008) and in cooperation with representatives from the European Association of Urology Nurses (EAUN). Areas recognized as standard procedure in stoma care were categorized into seven skills necessary for changing a stoma appliance. Each skill is rated on a four-point scale ranging from 0 to 3 points (0 = the patient is totally dependent on the nurse, 1 = the patient requires assistance, 2 = the need for verbal guidance, and 3 = the ability to provide care independently) (see Table 1). Summing the responses provides a total score, which can range from 0 to 21 (Kristensen et al., in press), with higher scores indicative of a better ability to perform stoma self-care.

Face and content validity were evaluated in a panel of experts by using Delphi research methods during the fall of 2010. This expert panel concluded the scale demonstrated good face and content validity. Inter-rater reliability, and construct and criterion validity were determined using the responses of 12 men and women who underwent the placement of a urinary stoma for treatment of high-risk, non-invasive and muscle-invasive bladder cancer in a Danish university hospital (Kristensen et al., in press). One-way analysis of variance showed the Urostomy Education Scale significantly distinguished urostomy self-care skills between beginners and advanced patients (p = 0.01). No difference was found testing criterion validity. The Urostomy Education Scale demonstrated satisfactory inter-rater reliability with Limits of Agreements (LOA) ranging from -3.6 to 3.0, and 86% of scores differed by 2 points.

Because the tool demonstrated robustness expressed by high validity and inter-rater reliability in the Danish single study, a European joint venhlre project was established through the EAUN to further validate the Urostomy Education Scale. Two internationally recognized bladder cancer centers participated: the Department of Urology at Aarhus University Hospital, Denmark (DK), and The Netherlands Cancer Institute Antoni van Leeuwenhoek Ziekenhuis (NL). These two centers perform 105 and 35 cystectomies annually, respectively.

The Study

Aim

The aim of this study was to further psychometrically test and determine the generalizability of the Urostomy Education Scale. Data from this study will identify treatment trends throughout these two countries.

Design/Methodology

This study was a validation study using the method based on the Danish validation study (Kristensen et al., in press).

The Urostomy Education Scale. The Urostomy Education Scale was translated into Dutch in accordance with principles outlined by the World Health Organization (WHO) (2012) and performed by an external translation company (Medical Knowledge Group, SoHo Square, London, UK). Once translated, Dutch and Danish clinical experts reviewed the Urostomy Education Scale.

Preparation. All study protocols and implementation materials were translated to ensure the correct introduction of methods used in the Danish single study (Kristensen et al., in press). This process allowed the Dutch study group to prepare appropriately and to ensure leadership involvement and commitment (Grol & Grimshaw, 2003; Kehlet & Wilmore, 2008). The Danish expert group performed the introduction (Kristensen et al., in press). The Ethical Review Committee at the study sites approved all study activities.

Sample/Participants

The study population consisted of 25 volunteered, consented patients who underwent an elective radical cystectomy, followed by an uncomplicated recovery. There were 12 participants from Denmark and 13 from The Netherlands, respectively. The study population reflected the common gender distribution with a ratio of 3:1 (Danish Bladder Cancer Registry, 2009; Integral Cancer Centre Netherlands, 2012). At each study site, an enterostomal therapist, who routinely provides stoma care, provided the stoma education. Based on years of experience and using Patricia Benner's Novice to Expert Model (Benner, 2000), three nurses were placed within one of three study-developed categories: 1) competent, defined as two years of experience or less; 2) proficient, defined as more than two years of experience; or 3) expert, certified as an enterostomal therapist.

Data Collection

Obtaining data for testing construct validity. Determining the ability of the scale to discriminate between the study groups (presumably differing in postoperative stoma self-care skills), construct validity was investigated (Abramson & Abamson, 1999). Participants were placed into one of three groups: beginners, intermediates, and advanced. Beginners were defined as patients at postoperative day one or two, and were expected to be fairly inexperienced in changing their stoma appliance. Intermediates were patients at postoperative day three or four, and were expected to have a slightly higher level of stoma self-care skills. Advanced were patients at postoperative day six or seven, close to discharge, and were expected to be capable of independently changing their stoma appliance.

All 25 participants were educated in changing their stoma appliance according to European standards (Geng et al., 2009). During hospitalization, each participant had one daily training session. One session was a validation session, where the three selected nurses independently observed and scored the patient's stoma self-care skills on the Urostomy Education Scale. A complete change of appliance was performed in each session to provide the observing nurses the opportunity to score all seven skills on the Urostomy Education Scale. Problems related to pain or nausea were addressed prior to the sessions in accordance with standard care. Data on pain and nausea were collected using a Numeric Rating Scale (NRS) (Cell, Ameen, & Mead, 2004; Saxby, Ackroyd, Callin, Mayland, & Kite, 2007; Williamson & Hoggart, 2005).

Obtaining data for testing reliability. Reliability refers to the reproducibility, stability, or consistency of information (Abramson & Abamson, 1999). To evaluate whether the nurses' level of experience influenced reliability, the selected nurses had different levels of experience in teaching patients stoma care. The three nurses independently scored the patients' skills during the training session. The scores were determined and calculated anonymously and independently, and kept in the medical records.

Data Analyses

All statistical analyses were performed with STATA version 11, and p-values less than 0.05 were considered statistically significant. Construct validity was analyzed with one-way analysis of variance (ANOVA) as the difference in scores between the three groups of patients. A sensitivity analysis was performed, adjusting for equal learning abilities. Different level of experience in stoma care was analyzed with a paired t-test of difference in scores between the competent, the proficient, and the expert nurse. Assumptions for using t-test were carried out. Reliability was analyzed by pairing the nurses' scores on the Urostomy Education Scale and plotting data using Bland-Altman Plots with LOA. To investigate a possible common trend in stoma care, study data were analyzed by study site and with pooled data.

Results

Demographically, the gender distribution in the two study populations was equal (see Table 2). There was no site-specific difference between groups of patients with respect to age, pain, and nausea. The mean pain rating was 1.8 (DK) and 2.4 (NL), respectively; the nausea rating was 0.8 (DK) and 0.7 (NL), respectively. Most patients had a tolerable level of pain and nausea, with a numeric rating scale (NRS) score of 3 or lower.

The Danish and Dutch nurses' scores are displayed in Figure 1. The scores progressed according to patient group and outlined agreement among nurses scoring the patients' stoma self-care skills.

Construct Validity

A review of the 95% confidence interval (CI) in the Danish and Dutch data determines there was no significant difference in mean scores between the two study sites. When combining the study data, we found stronger estimates, with 95% CI being more narrow (see Table 3).

Testing construct validity within the combined data set, a statistically significant difference was identified between beginners and advanced patients (p = 0.01) (see Table 4). Performing sensitivity analysis, it was now possible to show a statistically significant difference between all three groups of patients (p = 0.02, p < 0.001, and p = 0.04, respectively).

Reliability

When testing reliability, the main assumption was no significant difference between nurses regarding their scores (Bland & Altman, 1999). The mean scores for nurses were consistent in both study sites and when combining these data (see Table 5).

There were no statistically significant differences in scores between nurses based on levels of experience (see Table 6). Because our results demonstrate no strong evidence of significant difference between nurses' scoring, it was possible to continue analyzing reliability. In the Danish setting, LOA ranged from -3.6 to 3.0 compared to the Dutch setting, where LOA ranged from -4.2 to 3.7 points (see Figure 2).

After combining these data, a slightly narrower LOA was found ranging from -3.7 to 3.2 (see Figure 3). Fifty-one out of 75 scores equal to 68% (95% CI: 56; 78) were within a difference of either 0 or 1 point. Sixty-four out of 75 scores differed with 2 points or less, equal to 85% (95% CI: 75; 92).

Discussion

The level of research evidence for stoma care is generally low because publications tend to be descriptive or case studies (Geng et al., 2009). Recent studies have documented segments on optimizing patient pathways for the relevance of preoperative stoma education and stoma site marking education (Bryan & Dukes, 2010; Burch, 2005; Burch & Slater, 2012; Younis et al., 2012). However, a review of the literature failed to locate a standardized tool capable of documenting patients' level of stoma self-care skills.

The Urostomy Education Scale focuses only on the skills required to change a stoma appliance. Irrespectively of stoma care includes other constructs (living with a stoma, taking care of the peristomal skin, changing a stoma appliance), and consideration of including other instruments may provide a wider perspective related to stoma care. Jemec and associates (2011) have developed a tool that evaluates skin problems, excluding the necessity of including skin problems in the Urostomy Education Scale. Psychological challenges tend to occur during the rehabilitation process; thus, assessing them, while important, should be done after discharge and not be incorporated in the Urostomy Education Scale.

Analyzing construct validity in the Dutch study population identified no difference between the three groups of patients (see Table 4). This can be explained by inadequacy of explicit exclusion, criteria (such as previous experience in stoma care), and reduced hand motor skills. In a validation study, such factors can skew outcomes because the learning abilities are not equal when entering the study (Abramson & Abamson, 1999). To avoid misclassification, it was necessary to perform a sensitivity analysis, adjusting for previous stoma care experience, and a clear difference between beginners and advanced patients was yet found corresponding to the Danish study (Kristensen et al., in press).

Pooling data from the Dutch and Danish study revealed a significant difference in scores between all three groups of patients (see Table 4), suggesting high construct validity. Whether it is fair to compare and pool data from the two centers can be discussed. From a demographic point of view, it seems fair to compare these populations because the two are similar concerning life expectancy and prevalence of public disease and chronic illness (EurOhex, 2012a, b). The years of life spent in positive health in both countries are slightly higher for women than men. However, in both countries, women spend a larger proportion of their life in ill health (EurOhex, 2012a, b). Further, standardized death rates due to cancer are similar as well as estimates for old-age support ratio (Eurostat, 2012; Organisation for Economic Co-operation and Development [OECD], 2012). From a health care point of view, the health care structure and the incidence rate of bladder cancer are strikingly similar (Ferlay et al., 2010). On the basis of this epidemiological and demographical information, we found it reasonable and safe to combine data. Summarizing the results concerning construct validity, increased data improved the overall validity, making it possible for the Urostomy Education Scale to distinguish between all three groups of patients.

For analyzing reliability, which refers to reproducibility of results, steps should be taken not to attain complete reliability but to reduce variation to some reasonable limits (Abramson & Abamson, 1999). To reduce the learning curve and variation of the original Danish research protocol, standard procedures and the Urostomy Education Scale were translated into Dutch in an appropriate scientific manner (WHO, 2012). As another precautious step, the Danish study group was present in The Netherlands when introducing the scale, making sure the standardized procedure was not overlooked by staff. Further, the Dutch study group had a training session using the scale. In summary, we strongly believe we have taken any possible precautions when analyzing reliability (Abramson & Abamson, 1999).

Analyzing reliability LOA ranged from -4.2 to 3.7 points in the Dutch study (see Figure 2) and was found to be slightly broader compared to the Danish study (Kristensen et al., in press). This suggested an increased variation among the Dutch nurses and may be explained by a prolonged learning curve among the Dutch nurses due to the difference in annual surgical flow. A higher number of scores may improve the learning curve and thereby reduce variation leading to similar LOA.

Pooling data revealed a slightly narrower LOA and provided direction for future areas of interest in the validation process.

The Urostomy Education Scale was previously found to be reliable and valid (Kristensen et al., in press). Acknowledging the above-mentioned limitations the combined information in this study provides important information and has strengthened the knowledge. The Urostomy Education Scale continues to demonstrate robustness with satisfied reliability and improved construct validity distinguishing between all three groups of patients (see Table 4).

Clinical guidelines and standardized care can improve efficacy and quality of treatment and care (Dijkstra et al., 2006; Mainz, 2003). Therefore, our results warrant clinical attention and implementation in clinical practice. It is estimated that up to 40% of all research is not implemented in clinical practice, and major difficulties arise when introducing evidence and clinical guidelines into routine daily practice (Grol & Grimshaw, 2003). Being aware of the importance of standardized care, both study groups experienced an unmet need for a standardized tool when validating the Urostomy Education Scale. Sharing experiences, these Dutch nurses expressed a big difference among the nursing staff in approaching patients postoperatively. This could reflect the more specialized approach toward stoma care specialist services in The Netherlands compared to Denmark. Interestingly, reliability was higher in the Danish setting, justifying the use of general nurses with a high level of stoma care skills. However, the role of clinical nurse specialists and enterostomal therapists (ETs) remains a subject for future discussion.

Being the only validated tool available for measuring stoma self-care skills, these results should be introduced and tested internationally to make an international standard for documenting, comparing, and developing stoma self-care.

Conclusion

This study confirmed the Urostomy Education Scale is a robust tool in stoma therapy, with high reliability and validity. Moreover, the tool is useful across Europe with comparable health care and demographics.

With a robust and valid scoring tool, it is possible for nurses to secure continuous, standardized, and evidence-based care by documenting and passing on exact information on the level of stoma self-care skills on a day-today basis. Further, it helps ensure optimal quality of patient education and assists in securing a transition between hospital and primary care. Using the Urostorey Education Scale in daily clinical practice will provide important information for further validation of the tool.

Research Summary

Purpose

Previous research has demonstrated high validity and inter-rater reliability for the Urostomy Education Scale. A European joint venture project was established through the European Association of Urology Nurses (EAUN) to further psychometrically test and determine the generalizability of the Urostomy Education Scale. Data were collected from two internationally recognized bladder cancer centers: the Department of Urology at Aarhus University Hospital, Denmark (DK), and the Netherlands Cancer Institute Antoni van Leeuwenhoek Ziekenhuis (NL). Analyses of these data identified treatment trends throughout these countries.

Material and Method

The study population included 25 volunteered, consented patients who underwent an elective radical cystectomy, followed by an uncomplicated recovery. There were 12 participants from Denmark and 13 from The Netherlands.

Postoperatively, these participants were placed into beginner, intermediate, and advanced categories, based on time since surgery. The difference in scores between each postoperative category was measured.

Stoma education was provided at each study site by an enterostomal therapist, who routinely provides stoma care. Based on years of experience, three nurses were classified as 1) competent, defined as two years of experience or less; 2) proficient, defined as more than two years of experience; or 3) expert, certified as an enterostomal therapist.

Reliability was determined by pairing the nurses' scores and plotting data using Bland-Altman Plots with Limits of Agreements (LOA). To investigate a possible common European trend in stoma care, data from both study sites were combined.

Results and Discussion

A statistically significant difference was identified between all three groups of patients (p = 0.02; p < 0.001; and p = 0.04, respectively) when adjusting for earlier stoma experience aiming capability to discriminate significantly.

LOA was found ranging from -3.7 to 3.2. A total of 68% (95% CI: 56; 78) of the scores were within a difference of either 0 or 1 point, and 85% (95% CI: 75; 92) differed with 2 points or less.

Conclusion

The results of this study confirmed that the Urostomy Education Scale is a robust tool for use in guiding patient education and assessing knowledge regarding stoma care. Moreover, the tool appears to be generalizable across Europe with comparable health care and demographics.

The use of a robust and valid instrument allows nurses to ensure optimal quality of the patient education and minimize the transition confusion often apparent between the hospital and primary care settings.

Level of Evidence-II (Polit & Beck, 2012)

Acknowledgments: The authors would like to thank NKI-AVL and all participating staff at Department of Urology, NKI-AVL, especially Rob Kuin, RN, oncology nurse; Mieke Vreem, RN, oncology nurse, ostomy care nurse; Alice van der Scheer, Aakster, RN, oncology nurse; and Marjette Beije, RN, oncology nurses, ostomy care nurse. Moreover, we thank the EAUN fellowship programme and the Foundation of Inge Eriksen for financial support.

doi:10.7257/1053-816X.2013.33.5.219

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Jensen, B.T., de Blok, W., Kiesbye, B., & Kristensen, S.A. (2013). Validation of the Urostomy Education Scale: The European experience. Urologic Nursing, 33(5), 219-229. doi:10.7257/1053-816X.2013.33.5.219

Bente Thoft Jensen, PhD-Student, RN, MPH, is a Research Nurse, Urology Department, Aarhus University Hospital, Denmark.

W. de Blok, MANR is a Clinical Nurse Specialist/Nurse Practitioner, Uro-oncology, Netherlands Cancer Institute, Amsterdam.

Befit Kiesbye, is employed at Aarhus University Hospital, Denmark.

Susanne A. Kristensen, MHSc, RN, is a Urology Nurse, Aarhus University Hospital, Denmark.

Table 1.
The Urostomy Education Scale

     Skill           0 Points           1 Point

1. Reaction to    The patient       The patient
the stoma         shows no          has seen and
                  interest in/has   touched the
                  difficulty        stoma on the
                  coping with       initiative of
                  the stoma.        the nurse

2. Removing the   The nurse         The patient
stoma appliance   removes the       needs
                  stoma appliance   assistance to
                                    remove the
                                    stoma appliance

3. Measuring the  The nurse         The patient
stoma diameter    measures the      needs
                  stoma diameter    assistance to
                                    measure the
                                    stoma diameter
                                    correctly

4. Adjusting      The nurse cuts    The patient
the size of       the size of the   needs
the urostomy      urostomy          assistance to
diameter in a     diameter          cut the size
new stoma                           of the urostomy
appliance                           diameter

5. Skin care      The nurse         The patient
                  cleans and        needs
                  dries the skin    assistance to
                                    clean and dry
                                    the skin

6. Fitting a      The nurse fits    The patient
new stoma         a new stoma       needs
appliance         appliance         assistance to
                                    fit a new
                                    stoma appliance

7. Emptying       The nurse         The patient
procedure         performs the      needs
(emptying bag     emptying          assistance to
and attaching/    procedure         perform the
detaching night                     emptying
bag)                                procedure

Total Points

     Skill           2 Points          3 Points       Score

1. Reaction to    The patient has   The patient
the stoma         seen and          copes with the
                  touched the       stoma and is
                  stoma on his/     preparing for
                  her own           the future
                  initiative

2. Removing the   The patient       The patient
stoma appliance   needs verbal      can remove the
                  guidance to       stoma appliance
                  remove the        independently
                  stoma appliance

3. Measuring the  The patient       The patient can
stoma diameter    needs verbal      measure the
                  guidance to       stoma diameter
                  measure the       correctly
                  stoma diameter    independently
                  correctly

4. Adjusting      The patient       The patient can
the size of       needs verbal      cut the size
the urostomy      guidance to cut   of the urostomy
diameter in a     the size of       diameter
new stoma         the urostomy      independently
appliance         diameter

5. Skin care      The patient       The patient can
                  needs verbal      clean and dry
                  guidance to       the skin
                  clean and dry     independently
                  the skin

6. Fitting a      The patient       The patient can
new stoma         needs verbal      fit a new stoma
appliance         guidance to fit   appliance
                  a new stoma       independently
                  appliance

7. Emptying       The patient       The patient
procedure         needs verbal      can perform
(emptying bag     guidance to       the emptying
and attaching/    perform the       procedure
detaching night   emptying          independently
bag)              procedure

Total Points

Source: Developed in 2010 by S. Kristensen, B. Kiesbye,
and B.T. Jensen at Aarhus University Hospital, Denmark.

Table 2.
Distribution of gender, age, and postoperative pain and nausea in
25 patients undergoing cystectomy ad modum Bricker in 2011 at
Aarhus University Hospital, Denmark ([n.sub.1] = 12) and The
Netherlands Cancer Institute Antoni van Leeuwenhoek Ziekenhuis,
The Netherlands ([n.sub.2] = 13). Patients were divided into
three groups according to their level of self-care skills for
changing a stoma appliance.

                             Total        Beginner
Danish Results              (N = 12)       (n = 4)

Gender, N (%)
  Men                     10.0 (83.3)    3.0 (75.0)
  Women                    2.0 (16.7)    1.0 (25.0)
Age in years, mean (SD)    69.6 (4,9)    73.5 (0.6)
Pain (NRS), mean (SD)      1.8 (2.0)      1.0 (2.0)
Nausea (NRS), mean (SD)    0.8 (1.9)      0.0 (0.0)

                             Total        Beginner
Dutch Results                (N=13)        (n = 4)

Gender, N (%)
  Men                     11.0 (84.6)    4.0 (100.0)
  Women                    2.0 (15.4)     0.0 (0.0)
Age in years, mean (SD)    67.5 (7.3)    75.0 (6.3)
Pain (NRS), mean (SD)      2.4 (2.4)      3.0 (3.6)
Nausea (NRS), mean (SD)    0.7 (1.7)      0.0 (0.0)

                          Intermediate    Advanced
Danish Results              (n = 4)        (n = 4)

Gender, N (%)
  Men                     4.0 (100.0)    3.0 (75.0)
  Women                    0.0 (0.0)     1.0 (25.0)
Age in years, mean (SD)    69.3 (4.9)    66.0 (5.3)
Pain (NRS), mean (SD)      2.5 (1.7)      1.8 (2.4)
Nausea (NRS), mean (SD)    1.3 (2.9)      0.0 (0.0)

                          Intermediate    Advanced
Dutch Results               (n = 5)        (n = 4)

Gender, N (%)
  Men                      3.0 (60.0)    4.0 (100.0)
  Women                    2.0 (40.0)     0.0 (0.0)
Age in years, mean (SD)   63.4 (6.-1)    75.3 (3.2)
Pain (NRS), mean (SD)      2.8 (1.9)      1.3 (1.5)
Nausea (NRS), mean (SD)    1.8 (2.5)      0.0 (0.0)

Notes: N= numbers, SD = standard deviation,
NRS = numeric rating scale.

Table 3.
Stoma self-care scores for each group of patients based on 25
patients undergoing cystectomy ad modum Bricker in 2011 at Aarhus
University Hospital, Denmark ([n.sub.1] =12) and The Netherlands
Cancer Institute Antoni van Leeuwenhoek Ziekenhuis, The
Netherlands ([n.sub.2] = 13). A sensitivity analysis adjusted
for previous stoma care experience.

                          Pooled Data *         Danish Data
                              N = 25           [n.sub.1] = 12
                          Mean (95% CI)        Mean (95% CI)

Original-Analysis

Beginner                  8.4 (3.8; 12.9)      6.4 (1.1; 11.8)
Intermediate             11.1 (6.9; 15.3)     13.8 (0.9; 26.8)
Advanced                15.7 (11.1; 20.2)     16.8 (3.3; 29.7)

Sensitivity Analysis

Beginner                 5.8 (-0.3; 12.0)       6.4 (3.2; 9.7)
Intermediate             11.8 (6.8; 16.7)     16.5 (8.3; 24.7)
Advanced                16.5 (11.1; 21.9)    19.1 (10.9; 27.3)

                            Dutch Data
                          [n.sub.2] = 13
                          Mean (95% CI)

Original-Analysis

Beginner                10.3 (-1.1; 21.8)
Intermediate              8.9 (4.5; 13.3)
Advanced                 14.6 (8.5-120.6)

Sensitivity Analysis

Beginner                4.7 (-41.7; 51.0)
Intermediate              8.9 (4.5; 13.2)
Advanced                 14.6 (8.5; 20.6)

* Pooled data (N = [n.sub.1] + [n.sub.2]).

Note: CI = confidence interval.

Table 4.
Mean differences in stoma self-care scores with 95% confidence
intervals. Scores are based on 25 patients undergoing cystectomy ad
modum Bricker in 2011 at Aarhus University Hospital, Denmark
([n.sub.1] = 12) and The Netherlands Cancer Institute Antoni van
Leeuwenhoek Ziekenhuis, The Netherlands ([n.sub.2] = 13). A
sensitivity analysis adjusted for previous stoma care experience.

                                  Pooled Results
                                      N = 25

                           Mean Difference
                              (95% CI)         p-value
Original Analysis

Intermediate--Beginner     2.7 (-2.3; 7.8)    0.27
Advanced--Beginner         7.3 (2.1; 12.4)    0.01 *
Advanced--Intermediate     4.5 (-0.5; 9.6)    0.07

Sensitivity Analysis

Intermediate--Beginner     5.9 (1.1; 10.7)    0.02 *
Advanced--Beginner        10.7 (5.7; 15.6)    <0.001 *
Advanced--Intermediate      4.8 (0.2; 9.3)    0.04 *

                                  Danish Results
                                  [n.sub.1] = 12

                           Mean Difference
                              (95% CI)        p-value
Original Analysis

Intermediate--Beginner    7.4 (-0.1; 15.0)    0.05
Advanced--Beginner        10.3 (2.8; 17.9)    0.01 *
Advanced--Intermediate    2.9 (-4.7; 10.5)    0.41

Sensitivity Analysis

Intermediate--Beginner    10.0 (5.1; 15.0)    0.002 *
Advanced--Beginner        12.7 (7.7; 17.6)    0.001 *
Advanced--Intermediate     2.6 (-2.7; 7.9)    0.28

                                 Dutch Results
                                 [n.sub.2] = 13

                          Mean Difference
                              (95% CI)       p-value
Original Analysis

Intermediate--Beginner    -1.4 (-8.9; 6.1)   0.68
Advanced--Beginner        4.2 (-3.6; 12.1)   0.26
Advanced--Intermediate    5.6 (-1.8; 13.1)   0.12

Sensitivity Analysis

Intermediate--Beginner    4.3 (-3.2; 11.8)   0.23
Advanced--Beginner        9.9 (2.1; 17.7)    0.02 *
Advanced--Intermediate    5.6 (-0.4; 11.6)   0.06

* Significant.

Note: CI = confidence interval.

Table 5.
Mean score in stoma self-care scores with 95% confidence intervals.
Estimates are based on three nurses with different experience in
teaching patients stoma care scoring stoma self-care skills in 25
patients undergoing cystectomy ad modum Bricker in 2011 at Aarhus
University Hospital, Denmark ([n.sub.1] = 12) and The Netherlands
Cancer Institute Antoni van Leeuwenhoek Ziekenhuis, The Netherlands
([n.sub.2] =13).

                      Pooled Results

                    N      Mean (95% CI)

Expert nurse       25    11.6 (9.3; 13.9)
Proficient nurse   25    11.6 (9.2; 14.0)
Competent nurse    25    11.9 (9.5; 14.3)

                         Danish Results

                   [n.sub.1]      Mean (95% CI)

Expert nurse           12       12.3 (8.4; 16.1)
Proficient nurse       12       12.2 (8.2; 16.1)
Competent nurse        12       12.6 (8.4; 16.8)

                          Dutch Results

                   [n.sub.2]     Mean (95% CI)

Expert nurse           13        11.0 (7.9;4.1)
Proficient nurse       13       11.1 (7:7;14.5)
Competent nurse        13       11.2 (8.1;14.4)

Note: CI = confidence interval.

Table 6.
Mean differences in stoma self-care scores with 95% confidence
interval. Estimates are based on three nurses with different
experience in teaching patients stoma care scoring stoma self-care
skills in 25 patients undergoing cystectomy ad modum Bricker in
2011 at Aarhus University Hospital, Denmark ([n.sub.1] = 12) and
The Netherlands Cancer Institute Antoni van Leeuwenhoek Ziekenhuis,
The Netherlands ([n.sub.2] = 13).

                                         Pooled Results

                                  Difference
                                   (95% CI)      SD    p-Value

Expert nurse--Proficient nurse         0        1.6      1.00
                                  (-0.7; 0.7)
Expert nurse--Confident nurse        -0.3       1.8      0.44
                                  (-1.0; 0.4)
Proficient--Confident nurse          -0.3       1.8      0.44
                                  (-1.0; 0.4)

                                          Danish Results

                                   Difference
                                    (95% CI)      SD    p-Value

Expert nurse--Proficient nurse        0.1        1.5      0.48
                                  (-0.9; 1.0)
Expert nurse--Confident nurse         -0.3       1.6      0.47
                                  (-1.3; 0.7)
Proficient--Confident nurse           -0.4       1.6      0.39
                                   (-1.5; 0.6)

                                           Dutch Results

                                   Difference
                                    (95% CI)      SD    Value

Expert nurse--Proficient nurse        0.1        1.7     0.87
                                  (-1.1; 0.7)
Expert nurse--Confident nurse         -0.2       2.0     0.69

Proficient--Confident nurse           -0.2       1.9     0.78
                                  (-1.3; 1.0)

Notes: CI = confidence interval, SD = standard deviation.
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Article Details
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Title Annotation:CNE: SERIES/RESEARCH
Author:Jensen, Bente Thoft; de Blok, W.; Kiesbye, Befit; Kristensen, Susanne A.
Publication:Urologic Nursing
Article Type:Report
Geographic Code:4EUDE
Date:Sep 1, 2013
Words:6437
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