ORIGINAL RESEARCH

From training to practice: nurse supervisors' perceptions of ostomy care

Juliano Teixeira Moraes^I; Carolina Fernandes Santos^II; Eline Lima Borges^III

^I Enterostomal Therapy Nurse. Doctor of Applied Science to Adult Health. Assistant Professor. Nursing Course of the Federal University of São João del-Rei. Divinópolis, Minas Gerais, Brazil. E-mail: julianotmoraes@ufsj.edu.br
^II Nursing Course Student of the Federal University of São João del Rei. Institutional Program for Scientific Initiation. Divinópolis, Minas Gerais, Brazil. E-mail: carolfernandesx@gmail.com
^III Enterostomal Therapy Nurses. Ph.D. in Nursing. Associate Professor. Nursing School of the Federal University of Minas Gerais. Belo Horizonte, Minas Gerais, Brazil. E-mail: eborges@ufmg.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.14733

ABSTRACT

Introduction: hospital nursing care for people with stoma is directed to actions that favor health promotion and recovery. Objective: to describe nurse supervisors' input on care for ostomy patients in the hospital. Method: this qualitative, descriptive study was conducted with 12 nurses at a general hospital in the Midwest of Minas Gerais, Brazil, from March to May 2014. Data were collected by semi-structured interview and grouped into the areas: Area 1 – Knowledge and experience in caring for people with an ostomy; Area 2 – Nurses' care for ostomies; and Area 3 – nurse supervisors' guidance. Results: although the study revealed that there is basic care for ostomy patients in the hospital, the nurses displayed limitations as regards the guidelines and specific care. Conclusion: the lacunae displayed by nurses regarding care for people with ostomies in hospitals occur to the detriment of training for generalist nursing professionals and of specific training on the subject.

Keywords: Ostomy; nursing care; hospital activities; continuing education.

INTRODUCTION

Nursing care focused on health care for the person with a stoma aims to promote effective care focused on promoting quality of life after surgery. Therefore, nursing care must be structured for the development of self-care from the oriented guidelines for the patient and his family¹.

At the hospital, the nursing care to the person with a stoma involves the perioperative period. This stage should consider that both the patient and the family are eager and receptive for information to give them subsidies to work their anxiety and fear of the unknown and activate the mechanisms of coping^2,3.

The hospital environment is configured then as space, territory or place in which the health team meets the many needs of the patients, individually or collectively, that require services and actions in the levels of promotion and restoration of health and prevention of problems⁴. It is through education that the nursing professional practice can propose strategies that can improve the individual´s ability to self-care and adapt to new life conditions^3,5.

In this context, this study aimed to describe the assistance of nurse supervisors related to the care of a patient with a stoma in the hospital. The study may help to develop strategies to encourage health promotion actions during the hospitalization period to rehabilitation, as well as to promote a reflection on the formation of the professional nurse in demand for care for a person with a stoma.

LITERATURE REVIEW

The person with a stoma is had an artificial opening of an internal organ on the body surface (ostomy). This opening is surgically created, and its name depends on the organ that is exteriorized⁶.

The word ostomy is Greek origin from the etymon "stoma" which sets out the idea of a "mouth"¹. Currently, considering the Brazilian spelling and consensus among experts, it adopts the terminology stoma/ostomy and patients with a stoma, but the term stoma/ostomy is still used when referring to names linked to governmental publications⁷.

There are several factors that can lead people to be subjected to surgery for the construction of a stoma, such as a colon and rectum cancer, ulcerative colitis, Crohn's disease and punctures caused by firearms and cold weapons⁸.

Having a stoma may represent a limitation to the life projects for many people. One of the greatest difficulties encountered is the physiological change in the removal of fecal waste and the mandatory use of collectors and adjuvant devices^2,8.

A variable supply collectors and adjuvant devices are available to promote self-care of people with a stoma. Such devices have a wide range of skin guards, plates, and collection bags among others, to improve the adaptation of stoma patients to their condition and needs⁹.

In this sense, the professional nursing plays a key role in the monitoring and development of skills for handling manifolds and adjuvant collectors to occur changes in attitudes and reinsertion of this person in the family and social environment through the provision of care¹⁰.

METHODOLOGY

This is a descriptive with a qualitative approach carried out in a hospital of Midwest Minas Gerais. This hospital is large and has a medical staff of about 200 physicians and more than 1,500 employees. More than 70% of its activities are related to the Unified Health System (SUS) and referenced by 57 cities in the Midwest region of Minas Gerais.

Nurse supervisors of nursing services that were already provided assistance to the patient with a stoma, working in clinical-surgical hospital sectors were included in the study. The interview took place with 12 of the 20 professional nurses who work in these services. The determination of the sample was by the saturation criterion information. Namely, that is the collection was stopped when the data became repetitive¹¹.

Data were collected from March to May 2014. Semi-structured interviews with five guiding questions aimed at capturing how professional nurses perceive the care given to the patients with a stoma in pre and postoperative. The interview was recorded individually and in private place and lasted on average 30 minutes. To ensure the privacy of each participant to the interview was coded E1 to E12, which is E1 to the first interview and so on until the twelfth interview (E12).

Data were collected after consideration of the Ethics Committees of the Federal University of São João del Rei and the hospital, and it was approved by the CAAE protocol: 23055513.0.0000.5545, and after signing the Informed Consent Form by the research participant as determined CONEP Resolution nº 466/2012.

The interviews were transcribed and recorded after grouped by standard responses and described in the analysis of areas: Domain 1- Knowledge and experience in meeting the people with stoma; Domain 2- The ostomy care by nurses; Domain 3- guidelines of nursing supervisors.

Then, it proceeded to the analysis of thematic content type, which can incorporate the question of meaning and intentionality as inherent to acts. After reading the responses, the researcher can turn their intuitions on assumptions that have been validated "a posteriori"¹¹. The content was then classified according to their emerging elements and described in groups according to the pattern of responses.

RESULTS AND DISCUSSION

The results pointed to a population of nurses aged 20 to 35 years OLD, with an average of five years of training. Of the 12 nurses interviewed, six had Post-graduation.

Domain 1 – Knowledge and experience in meeting the people with stoma

It was noted in the interviews that there was no uniformity in the response pattern for the training of ostomy care during their professional career. It is reported that when the issue was addressed in nursing schools, most of the time, the training was given by exhibition lectures without contextualizing the practice of care.

According to the National Curriculum Guidelines for Undergraduate courses training of the professional nurse, it is recommended to meet the social health needs, with an emphasis on SUS, ensuring comprehensive care, the quality, and humanization of the assistance, offering a generalist, humanist, critical and reflexive training¹².

It is also known that during their training these professionals articulate theoretical and practical activities from the beginning of the course, permeating all their training. Therefore, the nurse must be prepared to act ensuring quality and comprehensive care, performing and preventive and curative, individual and collective actions, required for each case, at all levels of care¹³.

However, regarding the care of the person with a stoma this formation has been associated only with specialization. Although it is known that the professional nurse stoma therapeutic (specialist Stomatherapy) is more technically prepared to act in this area, it is recognized that there are no nurse experts enough to meet the demand of health services⁸.

It is also considered that to meet the Ordinances MOH/SAS Nº 400 of November 19, 2009, and MOH/GM Nº 793 of April 24, 2012; it is expected that nurses with general education have basic skills to care for an ostomy. These ordinances are binding on the care of the person with a stoma in the Care Network of People with Disabilities. In this network, the patient is assisted at all levels of care, and the door entry is the primary care^14,15. In this respect, the generalist nurse linked to any point on the network must carry out actions aimed at the person with a stoma.

The research also revealed that there is a gap between theory and practice in teaching for the care of a person with a stoma, which may jeopardize the development of care standards. Autonomy and self-determination of the nurse happen when he has mastered the knowledge of his area, his practice, and when he links theoretical knowledge to health care¹³. Situations segregating theory and practice can generate conflictive situations given the linkage of nurses in the institution¹⁶.

However, knowing that there is a deficient training for the ostomy care in the nursing graduation, it is expected that the training programs and training in service fill this gap. Thus, upon entering the service, nurses should receive training to know the routine of that environment, and to assimilate concepts previously little investigated. These training and capacity building are educational processes where people acquire new knowledge and skills to achieve the objectives of the institution. It is noted that the quality and effectiveness of training reflects the nurses´ competence level in their functions¹⁷.

This group showed that the training activities and in-service training still failed to meet the care improvement of demand in ostomy or the subject has not been the subject of discussion even in the institution.

In the context of the nursing work, the learning obtained in training brings benefits such as: adapting to change, improving decisions, increased efficiency in the performance of functions, decreased organizational errors and potential expansion of behavior change. The training can also improve absenteeism and rotation of professionals, reducing costs of materials, increasing the quality of service and the degree of patients´ satisfaction¹⁸.

This continuing education process is essential for the care of the person with a stoma in a hospital or not, because although the hospitalization units guidance of people with a stoma, they are not always accurate or sufficient. A team trained in health services can solve with security problems arising after an ostomy⁶.

Domain 2 – The ostomy care by nurses

Although they have not had a full training and specific training, it was found that the nurses of this institution can describe the basic care such as cleaning process, hygiene, and replacement of the collection bag, which are common procedures in the hospital.

For care, it is important to review and strengthen the specific self-care actions developed during the hospital stay for the identification of stoma normal characteristics, effluent, and skin; the handling and exchange of collecting systems; the hygiene of the stoma and peristoma skin as well as the degree of involvement in activities of daily living. The ostomy should also be remembered to perform self-examination of the stoma, seeking early detection of the emergence of possible complications¹⁹.

The nurse should also consider the level of education of ostomy patients and the family because the development of self-care is directly proportional to the level of understanding of information received²⁰.

The training of the patient is important because of the process of support for education results in better care and consequently a better quality of life after surgery. Health education aims to inform the person with a stoma who is still in the hospital, on the changes in lifestyle, and provides guidance on how to act on them to receive the discharge²¹.

However, the deficit in ostomy care is justified by the nurses in this study through the limiting factors of care. Among these factors, there is the level of education of the person with a stoma, the lack of suitable materials, and the complications that can occur with the stoma.

The materials offered as collection bags and materials safe, comfortable and discrete aids play an important role in the rehabilitation process, so it is essential that nurses know how to evaluate and choose the right equipment for each individual^5,21.

Knowledge of the education of the person with a stoma by nurses allows information to be appropriate to the ability to understand the patient. The patient with a stoma is only able to store what was informed when getting adequate guidelines¹⁸. In this context, it was noted that the level of education in person with a stoma is of great importance for the development of skills aimed at rehabilitation.

In this context, it is expected that the person with a stoma receives hospital discharge along with all the guidance on the types and how to act in the face of complications from the ostomy. However, the study participants demonstrated gaps in the information about the complications that may arise after the stoma. Thus, it was realized that skills are needed to nurses focused on complications and actions that can prevent them, aiming lower impact on quality of life of the person with a stoma^1,19.

When nurses were asked about the risk factors, they highlighted the fact that there are readmissions of people with a stoma already guided for specialized services and the presence of a nurse specialist to care for ostomy (stoma) in the institution.

In the case of readmissions, although it is a facilitating factor for care, the guided patient connoted the insecurity of these professionals to meet in ostomy, which refers to assistance said by the person with a stoma. It is again the evident lack of training for care in an ostomy.

The nurse has the responsibility to serve and guide the patient with a stoma, even if it is readmitted for several reasons. However, when the patient with a stoma establishes a care plan made by himself and not by the nurse, there is the possibility of impact on the quality of care and consequently on rehabilitation of the stoma²⁰.

The study identified the participation of a specialist reference nurse to care for the ostomy in the hospital. Specific training for ostomy care is of great importance to an institution. The stoma therapeutic is the specialist nurse with knowledge, training, and skills to provide care for a patient with a stoma. Thus, the specialized service within the institution favors the patients learning even if it is guided by the generalist nurse ²². Although there is a professional expert, the institution does not have the stomatherapy service, which means that the assistance is not continuous, systematized and properly referenced or counter- referenced for specialized care.

Regarding the nursing consultation to the patient with a stoma, it was identified that the nurses of this hospital do not usually perform it, and when held, this is wrongly done and called "bed race."

By the COFEN Resolution 358/2009, the nursing process corresponds to the nursing consultation and should be performed in all institutions providing outpatient services, households, schools, community associations, among others. In this context, the nursing consultation should be carried out deliberately and systematically in all environments, public or private; that is the Nursing professional care²³.

It is up to the hospital nurses to develop an appropriate care plan for the patient living with a stoma, from the nursing consultation with the survey of diagnosis and then evaluate the results of interventions. The nursing consultation to ostomy aimed at professional/patient interaction to solve problems and questions that may impair the quality of life of this patient⁵.

Domain 3 – Guidelines of nursing supervisors

Concerning the guidelines given by the nurses in this study, it was noted that they emphasized only care about hygiene and emptying the collection bag.

The hygiene of the stoma is of great importance and aims to prevent probable complications, usually common in periostoma skin. It is essential that the patient knows the time when the collector needs to be emptied and do it properly. The focus on cleaning the stoma should begin in the immediate postoperative period, to achieve effective results about rehabilitation⁸.

Besides to the proper hygiene, emptying and changing the collector device, it is important that the patient understands the changes of emotional, nutritional and social order. It is understood that the ostomy may present difficulties in dealing with the changes arising from the ostomy, and consequently facing barriers when there are possible complications related to the stoma, with the risk even to distance themselves from the social environment due to the low self-esteem^4,24.

In this sense, the hospital nurse must provide this emotional disability and be prepared to guide and encourage the patient, watching him in full and not just as an individual with a stoma⁸.

At the hospital, it is expected that the ostomy patients receive appropriate guidance on their stoma and its complications. In the immediate postoperative period, the person with a stoma usually is willing to learn, since, after discharge, he will come across situations not experienced before surgery. The nurse should instruct the patient to establish self-care, and provide all necessary information about the ostomy, collector equipment, and complications. Care is needed when presenting a large amount of guidance to ostomy, for at this moment he is in anxiety stage and rarely understand everything is informed^3,5.

Also, Ordinance MOH/SAS nº 400 guides the patient with a stoma to receive referral after hospital discharge for care in specialized services in intermediate care. The hospital nurse is responsible for establishing flows and referral mechanisms and counter reference for assistance to people with stoma at all levels of care¹⁴.

In specialized services, patients with a stoma have individual service with multidisciplinary team (nursing, medicine, social work, psychology, and nutrition); care in group arranged in operative groups and educational activities in health; activities aimed at the inclusion of people with a stoma in the family, and the purchase and delivery of collectors and adjuvant equipment^14,22.

CONCLUSION

It was noticed that the hospital nurses have knowledge and practice deficit in the care to patients with a stoma. This issue can be justified by identifying gaps in the training of general professional nurses.

Nurses do not perform the nursing consultation to ostomy patients in this environment. As a result, the study showed that nurses could describe what to do about hygiene and exchange of collection bag, but they do not highlight guidelines on self-care and possible complications of stoma besides not referring to a specialized service.

It is believed that hospital nurses have abilities to develop an efficient in ostomy care. Recognizing the deficiency in nursing education, it is up to the professionals and the institution, the development of studies and training to improve service in the care of ostomy.

As study limitation, there was not an observation of care provided by the hospital nursing staff. New studies can evaluate the quality of nursing care for hospitalized ostomy patients.

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