The (hidden) role of the nurse and the stoma therapist Measuring stoma self-care skills by using the Urostomy Education Scale (UES)
learning refers to their attitudes and feelings toward the stoma. Affective learning begins with willingness to view the urostomy, leading to participation in stoma care and the recognition of the advantages of independence linked in self-care. Psychomotor learning refers to the ability to perform the practical skills necessary to change the appliance and obtain a mental image of how the skills are performed. Everyday life and hidden aspects The creation of a urostomy impacts multiple aspects of daily life. These changes influence urine elimination, body image, personal care, sexual and psycho-social health and health- related quality of life. Several studies have demonstrated that new stoma patients have many physical and psychological needs that remain unmet at the time of discharge from their initial hospitalisation [11]. Concerns regarding body image and sexual function, pain/rashes around the stoma and challenges regarding the appliance are prevalent [12-14]. These factors can lead to additional clinic visits or phone service requirements, stoma-related complications and impaired health-related quality of life [15-17]. The stoma nurse or therapist may be available in small class sessions or one-on-one consultations before and after surgery. In these sessions, other perspectives of living beyond stoma surgery are often put forward by the patient or family members. The aspects discussed here describe the hidden role of the stoma nurse and involve individual needs, mostly about the fear of recurrence, loneliness, lack of self-esteem due to sexual aspects, lack of confidence with the stoma and a change in their social position. Both women and men report a significant amount of unmet needs [18]. Women especially request information regarding sexual aspects, and the preferred staff member to approach is the clinical nurse specialist [16]. However, surprisingly few ask for counselling or resources outside the hospital service despite indicating an unmet need [19]. Pre-operative psychological support Special attention should be paid to patients with a history of mental illness or other cognitive impairments, as they are at higher risk of psychological problems or delirium post-operatively [20]. Pre-operative psychological support can allow patients to express and work through any emotional concerns, feelings and anxiety about their surgery and the urostomy [21]. After surgery, counselling can provide information to help the patient understand and gain control of the new lifestyle situation. Thus, it is important to create an environment in which the patient and their relatives feel free to express themselves and ask any questions on their own terms. This helps to reduce stress and anxiety and increases trust and cooperation between the patient, the stoma nurse and other staff members [6].
A new emerging multi-modal, multi-disciplinary, and goal-oriented (instead of the traditional disease- oriented) approach is ideal when deciding whether to surgically intervene in elderly patients with multiple comorbidities and impairments. Thus, it is pivotal to establish patients’ goals and priorities as well as a shared decision-making process involving the prehabilitation team (e.g. stoma nurse, dietician, physiotherapist, anaesthesiologist and surgeon). Here, the nurse supports the patient and their family in discussing the benefits and risks of the proposed stoma surgery, as well as potential alternative definitive treatments. Identification of the patient’s goals, hopes and their surgical expectations ensure adequate informed consent and a tailored and appropriate treatment [22]. After the shared clinical decision process, patients should be informed about and motivated to take on the important role they have in maximising their early post-operative recovery and regaining physical function and confidence in stoma care. Giving patients information both before and after surgery will help them to gain control of their situation and cope better physically and mentally. Stoma care education It is well known that coping strategies following urostomy surgery are improved when patients receive relevant information and education on stoma care and a care plan based on a shared decision process [23-25]. Patients report that education should be provided by a nurse with expertise in ostomy care or a stoma therapist, and stoma supportive care ( pre- and post-operatively) is highly requested [21]. Unfortunately, there is little published evidence on the value of pre- and post-operative educational sessions, although exiting evidence indicates that the positive effect of pre-operative stoma education on post-operative stoma self-care is sustainable up to one year [26]. The literature demonstrates a discussion as to whether stoma care should be managed by well-informed and experienced ward nurses or specialised stoma care nurses in practice. Across Europe, there are different approaches depending on the local pathway and the investigated aspect of stoma care [27]. To decide the best path to assure quality of care, standardised supportive care plans should be available to guide the process and allow for key areas where further interventions can be identified, and the Urostomy Education Scale (UES) can facilitate this process [17]. However, the use of standardised care plans is not intended to offer a ‘one size fits all’ approach to care and patients' individual needs must be considered and used to individualise care plans to the patient’s capacity [6]. So far, there are no available evidence-based standard care plans, although international societies in the field of stoma care have provided practice guidelines and recommendations that could encourage their construction. However, there
is an urgent need for international consensus on uro-stoma education plans to support patients and spouses, and the UES can facilitate and guide the development of evidence-based care plans. The Urostomy Education Scale The UES is a highly validated and reliable scale developed with support from the EAUN. It is cross- culturally validated and translated to several languages (Figure 1). The scale is based on internationally recognized minimum standards in stoma care categorised into seven skills considered necessary for changing a uro-stoma appliance [17, 27, 28]. This tool documents the progress of a patient's level of stoma self-care during the teaching process and has the ability to involve the patient already in the prehabilitation setting by introducing the scale as an instrument to communicate with the patient and guide the practical teaching process based on the patients physical and mental capacity. Moreover, the scale can help identify specific skills which need increased awareness in a day-to-day care plan. The seven skills are reaction to the stoma, removing the stoma appliance, measuring the stoma diameter, adjusting the size of the urostomy diameter in a new stoma appliance, skin care, fitting a new stoma appliance and the procedure for emptying stoma collection devices. Each skill is rated on a four-point scale ranging from 0 to 3 points depending on the patient's need for support. The total score ranges from 0 to 21 points, with higher scores indicating a higher level of independence to perform stoma self-care (Figure 1). Detailed information of the UES has been published previously [17, 27, 28]. To improve stoma self-care skills, continuously daily education and adjustment is recommended by the stoma therapist societies. This often puts stoma therapists under tremendous pressure, as hands on teaching and practical training is time consuming and there is no quick fix. Therefore, practical (hands-on) training with a stoma appliance and testing different appliances in the prehab setting is of high importance for familiarising a patient with the upcoming change of bodily functions, at least on a contractual level. It may be an abstract situation for both the patient, family or nurse to begin with, but those motivated will become quite competent with self-care skills [26]. Tips and tricks To improve the level of self-efficacy, it is important to consider: • Goal-setting in a shared decision process with relevant clinicians • Focus on interventions to enhance the specific stoma self-care skills needed to change a stoma appliance • Provide continuous individualised goal-directed stoma education pre- and post-operatively • Continuous access to supportive care pre- and post-operatively as well as in the rehab setting is needed by the patients and spouses, who rate it as highest importance for ultimately performing an independent change of a stoma appliance Conclusion The role of the nurse and the stoma therapist has significantly changed over the past decade, perhaps due to the ”hidden role during hospitalization”, to becoming a key player in preparation for surgery! Measuring stoma self-care skills is possible and the UES can promote a common language between patients, ward nurses, stoma-nurses in both the primary care setting and rehab setting, and secure adequate support and follow-up. Moreover, the UES can initiate early involvement of the patient, inform practice and improve targeted and tailored stoma care. Stoma prehabilitation is effective and can sustainably improve stoma care self-efficacy. Thus, the Stoma Therapist has become a key player and a highly recognised contributor in the pre-operative setting, and pivotal to the patient’s health-related quality of life. References can be requested from the corresponding author.
Dr. Bente Thoft Jensen Asst professor -FAAN Dept. of Urology, Aarhus University Hospital & Aarhus University (DK) Chairman of the EAUN Bladder Cancer Group
Uro-oncology nurses are at the forefront in every Enhanced Recovery after Surgery (ERAS) programme and are vital in screening, preparing and educating patients ahead of surgery to adjust for common risk factors, current impairments and limitations that can compromise functional recovery after surgery [1]. The role of stoma care in the ERAS pathway Stoma care is an integrated component of the multi-professional cancer care continuum in radical cystectomy pathways [2] and affects both the pre- and postoperative setting. ERAS has successfully reduced length of hospital stay (LOS) across surgical specialties and significantly changed the surgical paradigm of care in major cancer surgery now in both the pre- and post- operative setting [3]. Historically, stoma care was provided in the post-operative setting, but due to changes in the patient pathway and the reduced time to teach and adapt to the stoma postoperatively, stoma care should now be introduced already in prehabilitation setting. This change will maximise the individual’s ability to obtain stoma competencies and manage the stoma independently, thus regaining self-care as soon as possible. Key Skills for stoma care Stoma care includes skill-building and counselling about living with an ostomy, stomal and peristomal skin care, and the skills needed to change an ostomy pouch [4]. The ability to manage an ostomy
appliance independently is the single most important factor for predicting a positive
psychological adjustment to life with a stoma after cancer surgery [5-7]. Practicing the skills related to a full change of an ostomy pouch is a first step towards independence and acceptance following stoma surgery [4, 5, 8]. Key skills include; emptying the pouch, removing the pouching system, cleaning and observing the stoma and the peristomal skin, and preparing and applying the new appliance [8]. The patient’s ability to collectively perform these skills is defined as stoma self-care [9]. Stoma self-care education requires cognitive, affective, and psychomotor learning [10]. Cognitive learning refers to the individual’s ability to understand the information conveyed, and affective
Skill
0 points
1 points
2 points
3 points
Score
1. Reaction to the stoma
The patient copes with the stoma and is pre- paring for the future
The patient has seen and touched the stoma on his/her own initiative
The patient has seen and touched the stoma on the initiative of the nurse The patient needs assistance to remove the stoma appliance The patient needs assistance to measure the stoma diameter correctly The patient needs assistance to cut the size of the urostomy diameter The patient needs assistance to clean and dry the skin The patient needs assistance to fit a new stoma appliance The patient needs assistance to perform the emptying procedure
The patient shows no interest in/has difficulty coping with the stoma.
2. Removing the stoma appliance
The patient can remove the stoma appliance independently The patient can meas- ure the stoma diameter correctly independently The patient can cut the size of the urostomy diameter inde- pendently The patient can clean and dry the skin independently The patient can fit a new stoma appliance independently The patient can perform the emptying pro- cedure independently
The patient needs verbal guidance to remove the stoma appliance
The nurse removes the stoma appliance
3. Measuring the stoma diameter
The patient needs verbal guidance to measure the stoma diameter correctly
The nurse measures the stoma diameter
4. Adjusting the size of the urostomy diameter in a new stoma appliance
The patient needs verbal guidance to cut the size of the urostomy diameter The patient needs verbal guidance to clean and dry the skin The patient needs verbal guidance to fit a new stoma appliance The patient needs verbal guidance to perform the emptying procedure
The nurse cuts the size of the urostomy diameter
5. Skin care
The nurse cleans and dries the skin
6. Fitting a new stoma appliance
The nurse fits a new stoma appliance
7. Emptying procedure (Emptying bag and attaching/detaching night bag)
The nurse performs the emptying procedure
Saturday, 11 March 09:25 - 09:35 Plenary Session: Locally advanced BCa: Misconception of informed consent eURO Auditorium 1, Yellow Area
Total points Figure 1. The Urostomy Education Scale
European Urology Today
February/March 2023
45
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