RESEARCH ARTICLES

Resident nurses' knowledge of care for people with intestinal ostomy

Roberto Corrêa Maffia Farias^I; Norma Valéria Dantas de Oliveira Souza^II; Francisco Gleidson de Azevedo Gonçalves^III; Helena Maria Scherlowski Leal David^IV; Ariane da Silva Pires^V; Luanna Klaren de Azevedo Amorim^VI

^I Stomatherapy Specialist by the Nursing School of the University of Rio de Janeiro. Specialist in Surgery in the lines of Residence Nursing. Rio de Janeiro. Brazil. E-mail: betoenf@bol.com.br
^II Ph.D. in Nursing. Associate Professor of the Medical-Surgical Nursing Department. Professor of the Graduate Programo f the Nursing School at the University of Rio de Janeiro State. Brazil. E-mail: norval_souza@yahoo.com.br
^III Master in Nursing by the Graduate Programo f the Nursing School at the University of Rio de Janeiro State. Occupational Nursing Specialist. Rio de Janeiro. Brazil. E-mail: gleydy_fran@hotmail.com
^IV Ph.D. in Collective Health. Professor of the Graduate Programo f the Nursing School at the University of Rio de Janeiro State. Brazil. E-mail: helena.david@gmail.com
^V Ph.D. student in Nursing. Nursing Specialist in Stomatherapy. Assistant Professor of the Medical-Surgical Nursing Department at the University of Rio de Janeiro State. Brazil. E-mail: arianepires@oi.com.br
^VI Master in Nursing by the Graduate Programo f the Nursing School at the University of Rio de Janeiro State. Brazil. E-mail: luklaren@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.17966

ABSTRACT

This quantitative study aimed to examine the strengths and weaknesses in 35 resident nurses' knowledge of care for clients with ostomy was conducted at a university hospital in Rio de Janeiro city in 2012. Strengths (right answers) showed in the residents' surgical clinical knowledge, particularly of the location and main types of ostomy (90%), replacing the collector system and cleaning the ostomy (66%), detection of complications and preventive measures (76%), and family guidance (27%). Salient weaknesses in clinical medical residents' knowledge of working with these clients included difficulties regarding: selfcare guidance (87%), and detection of complications and preventive measures (87%). It was concluded that internal medicine residents displayed more weaknesses in knowledge of the subject than surgical clinical residents. Keywords: Ostomy; nursing; teaching; health education.

INTRODUCTION

The objective of this study is to analize the knowledge of resident nurses on the care process of people with ostomy. The interest of this topic was through the professional practice as a nurse and a nursing teacher in a surgical clinic of a university in the city of Rio de Janeiro. At that time, it was observed empirically that many nursing home residents had difficulties in caring for people with intestinal ostomy, especially in the management of stomas and the guidelines for self-care.

It was also realized that some nurses of the inpatient units had insecurity not only in performance but also they had a theoretical deficit in ostomy patients´ care. Such empirical observations strengthened the desire to investigate the previously pointed object, specifically among residents, being in formal learning process and then being more accustomed to professional development.

As a contribution, this study sought to broaden the discussion about assistance to patients with ostomy, being relevant because it can provide support for the preparation of proposals that favor the expansion of knowledge on the topic, helping in this way, the training of professionals.

From this brief contextualization about the topic, the following research problem were selected: Do the resident nurses in the surgical clinic and medical clinic units have theoretical knowledge to the care process of patients with intestinal stoma?

According to the research problem, a general objective was listed: to assess the knowledge of the resident nurse for the provision of care for patients with ostomy. In this perspective, it was selected as a specific objective: to analyze the strengths and weaknesses in the knowledge of residents nurses about the care of patients with ostomy.

LITERATURE REVIEW

"The term ostomy is of Greek origin and it means artificial opening of an internal organ on the body surface surgically created"^1:336. There are several types of ostomy, the most common in clinical practice are intestinal and urinary².

The stomas are named from the body sites in which they were made. Thus, the intestinal stomas may be referred to as colostomies (located in the colon), ileostomies (in the ileum) and jejunostomies (located in the jejunum)³.

An ostomy is an impressive situation in the life of a person. In this sense, there is the sense of mutilation, which results in the feeling of being different from other people. In addition, this surgical procedure generates anxiety and fears, since it is closely related to self-image and social life, as a person loses the containing capacity of feces and flatus, living dependent on a collector equipment, often uncomfortable and bulky. With these changes, there is the difficulty of insertion and maintenance in the workplace, due to the need to constantly go to the bathroom and labor restrictions when having a stoma^3,4.

The main diseases that lead to intestinal stomas construction are: colorectal cancer, diverticular disease, inflammatory bowel disease, anal incontinence, ischemic colitis, familial adenomatosis polyposis, trauma, megacolon, severe perineal infections, and others^5,6.

The nurse is one of the first members of the multidisciplinary team to relate to the patient with colostomy after surgery. In this regard, he must be able to answer the questions and concerns of these patients, and the care with security, preventing and detecting early complications that may adversely affect the process of social inclusion or compromise the biopsychosocial integrity of the individual with a stoma^7,8.

METHODOLOGY

It is a quantitative study of cross-sectional design, with variables obtained through a questionnaire pre-tested and validated by peers. The chosen field for the development of the research was a university hospital located in the municipality of Rio de Janeiro, where it provides assistance in the three levels of care (primary, secondary and tertiary). That institution, there are teaching activities developed, research and extension, serving as a practical field for undergraduate and graduate students in the health area.

The sectors that provided the data collection were four medical wards, along with two wards of general surgery, also including surgical intermediate unit. The choice of these sectors was based on the fact that there are pateints in pre and postoperative of ntestinal stoma.

The research population consisted of residents nurses of the Surgical Clinic and Medical Clinic Programs, from the first and second years of residence, with a total of 35 participants. Residents acted with patients with ostomy for less than three months were excluded, the minimum time for inclusion in the research. There were also excluded residents on vacation and sick leave at the time of data collection. The excluded were four participants, with a final population of 31 residents, being 19 medical clinic and 12 Surgical clinic.

Data collection started after the approval of the Ethics Committee on Human Beings Research, through the advice of number 024.3.2012, respecting thus the Resolution 466/2012 of the National Health Council (CNS). Before starting data collection with each participant, a free and informed consent was provided, explaining object, objectives and care about the confidentiality and anonymity of the participants. They signed the term into two ways, one was given to the participant and the other remained with the researchers.

The data collection instrument consisted of a questionnaire with closed questions, composed of a first part of socio-demographic characteristics of the participants, and another part with questions that explored the specific knowledge of patients´ care with ostomy.

The questionnaire was prepared by the researchers, with the validation reviewed by two experts: one from the research methodology area and the other from the stomatherapy area. In addition, there were pre-tests with the instrument by applying it to three resident nurses from other residency programs, different from those of medical and surgical, checking for clarity in reading and understanding of the issues. Data collection took place in July and August 2012.

The questionnaire content had four thematics focused to ensure a safe and quality care: i) location and main types of intestinal ostomy; II) care when changing the collecting system and cleaning the stoma; III) detection of complications and changes of preventive measures related to the stoma; and IV) patients/family orientation focused on self-care.

Each thematic contained three closed questions with four alternatives, with only one correct, for a total of 12 questions. The results were recorded in simple and percentage frequencies. The evaluation of participants' performance was analyzed according to each thmatic addressed in the research form.

The data were entered into the appropriate database, created from MS-Excel program, in its 2007 version for MS-Windows XP specifically for this purpose. After feeding this database and verification of information, descriptive analyzes only of simple frequencies for all the variables employed were held. The data were presented through graphs and analyzed based on the theoretical reference of stomatherapy.

RESULTS

Profile of study participants

The 31 participants in the sample were characterized according to sociodemographic characteristics, considering the following variables: gender, age and nationality. The results showed that most of the residents were women - 30 (96.7%). Regarding the age of the participants, there was a higher frequency between the age range of 22 to 27 years old, registering a maximum of 32 years old and the lowest of 22 years old.

There was a predominance of residents from Rio de Janeiro - 25 (80.6%). However there was a resident from each of the following states: Bahia (BA), Espírito Santo (ES), Goiás (GO), São Paulo (SP), Rio Grande do Sul (RS) and Rio Grande do Norte (RN); thus, 6 (19.4%) respondents were from outside of Rio de Janeiro.

Referring to the Residency Program where participants were entered, 19 (61.2%) belonged to the Clinical Program and 12 (38.8%) to the Surgical Program, observing a large number of residents of the first year of residence - 20 (64.6%). Most residents - 26 (83.8%) - had only a residence and labor activity.

As for the training college graduation, most participants, 17 (54.1%) were graduated in private educational institutions, however 14 (45.1%) were residents of public institutions. It should be noted that 7 (22.5%) residents already had other specializations in Nursing, such as stomatherapy, health management, occupational nursing and gerontology. Regarding the time since graduation, 26 (83.9%) residents had between six months to two years of completion of the degree course.

AS the adherence in the research for the Residence Program, the lowest rate of participants who completed the questionnaire were residents of the second year of Medical Clinic (78%). Regarding the other residents, there was 100% participation.

Strengths and weaknesses in the knowledge of residents

Regarding the knowledge about the care for the patient with ostomy, , the results at the surgical clinic and medical clinic of resident nurses were treated separately, because the theoretical content of these programs are different. Thus, the performance of each of these groups were analyzed distinctly.

Surgical clinic residents have a higher potential (hits) on the four thematics of the questionnaire - I) location and main types of intestinal ostomy; II) care when changing the collecting system and cleaning the stoma; III) detection of complications and changes of preventive measures related to the stoma; IV) patients/family orientation focused on self-care - as compared to medical clinic residents.

Thus, in the location and the main types of intestinal stoma, 28 (90.3%) of the surgical clinic residents responded correctly to this topic. About care of changing the collecting system and cleaning the stoma, the frequency of these hits reached 20 nurses (64.5%). As for the detection of complications and prevention measures related to changes in intestinal stoma, they revealed 23 (74.1%) correct answers; and related guidelines to patient/family, the number of hits were 7 (22.5%).

A distribuição de acertos dos residentes de clínica médica apontou os resultados 9 (32%), 17 (54%), 5 (18%) e 4 (13%) para as temáticas I, II, III, IV, respectivamente; assim, o quantitativo de acertos foi menor para esses residentes.

The distribution of hits in medical clinic residents showed 9 (32%), 17 (54%), 5 (18%) and 4 (13%) for the thematics I, II, III, IV, respectively. Thus, the amount of correct answers was lower for those residents. With regard to weaknesses, it can be seen, in the four investigated themes, that the medical residents showed a greater proportion of weakness, since the amount of errors was high in 21 (68%), 14 (45, 1%), 25 (80.6%) and 28 (90.3%) in each examined subject. It is evident that the surgical clinic residents had less wrong answers in the following proportions: 3 (9.6%), 10 (32.2%), 7 (22.5%) and 23 (74.2%) in each thematic addressed in the questionnaire.

DISCUSSION

The distribution of residents by gender showed that most participants were female, 97% women and 3% men. This result is in line with other studies on the subject showing the predominance of women in undergraduate nursing, or nursing as an essentially female occupation^9,10.

It is necessary to consider the influence of Florence Nightingale to institutionalize, in Victorian England (1862), a profession for women because they were naturally prepared from values that are considered feminine in that period¹¹. According to the National Institute of Educational Studies and Research (INEP), another reason for this outcome refers to increased mostly female participation, from 2001 to 2010, in higher education: in 2010, the total of 6,379,299 enrollments in education higher, 57% were women, and among graduates, women's participation reached 60.9%¹².

Regarding to age, 80% of residents surveyed were aged between 22 and 27 years old, followed by 20% of residents aged between 28 and 32 years old. This result is close to the Census of Higher Education (CES), conducted by INEP in 2009, according to which the Brazilian higher education is predominantly female, aged on average 21 years old in registration, 19 years old for entrance and 23 years old to complete the degree course¹³.

About nationality, 65% of residents were from the Rio de Janeiro and 35% originated in other states such as Bahia, Espírito Santo, Goiás, São Paulo, Rio Grande do Sul and Rio Grande do Norte. This diversification nurses from other states confirms the national recognition of professionals residence of the university hospital programs investigated, whose mission is to provide comprehensive, humane and excellent health care, and transforming agent of society through education, research and extension¹⁴.

Another aspect to consider is the fact that the residence in nursing of the present study have been linked, in 2011, to the University School of Nursing, which the hospital investigated is located. Thus, the residence was recognized as a specialization course, which is to ensure resident at the end of the program, the title of specialist in a particular area of knowledge¹⁴.

As for the origin of higher education institutions in which residents attended the graduation, there has been a prevalent quantitative coming from private universities (52%), compared to public institutions graduates (48%). This result is in line with the Higher Education Census 2010, according to which the private school system had a strong growth since 2001. Further confirmation came from the enrollment in these institutions, which increased 59% over the 17% of the public, during the same period.

Regarding the quantity of higher education institutions in 2010, there were 2,378 institutions, of which 88.3% were private, state 4.5%, 4.2% federal and 3.0% municipal. Thus, the number of vacancies is considerably lower among public institutions, a fact also verified for the nursing course¹².

According to INEP in 2010, 2,182,229 undergraduate students entering, which corresponds to an increase of 109.2% compared to 2001. During this period, the federal category showed proportionally the highest elevation in the number of entrances (140.5%), then the private category (115.4%). Therefore, in 2010, private institutions had 78.2% of undergraduate entrances; followed by federal, with 13.9%; state, 6.5%; and municipal, with 1.5%. In 2010 there was 973,830 graduates, representing the most significant result; compared to other years, the total is 145.8% higher than recorded in 2001. The highlight was the upward trend of private category of participation that in 2010, accounted for 80.4% of graduates¹³.

On higher education in Brazil in 2003, there was an increase of 70% of the courses in the private sector, and only 30% in the public sector. For the Undergraduate Program in Nursing, the offer from the private sector was 73.4%, while the vacancies came to be 88.7%. Most courses are located in the Southeast and South, with the highest GDP in the country, determining factor for the development of the region. The highest proportion of nurses is in the Southeast, which expresses a promising market as it improves access for admission in undergraduate courses in nursing¹⁵.

As for the time of training of resident nurses, it is noted that most of them were just graduated (83%) having an average of between 6 months and 2 years of graduation conclusion. This situation is explained by the initial search of the newly formed for training and professional qualification in the area of interest. In this sense, the choice of residence involves the search for knowledge and specialized practices for establishing technical, human and ethical care. Thus, nurses qualified to conduct health education activities, management of care, teaching, research, extension and supply of care in specific areas by providing them a specialization¹⁰.

With regard to residents who have other employment in this study, 16% carry out work activities together with the residence, and 84% of them developed just such specialty. This can be explained by the fact that residency programs having a workload of 60 hours per week, which for the most part, the nurse is impossible to reconcile the activities of the residence with other work activities¹⁰.

The residents with other labor activity declined in 2013, as the competition regulations for residence in nursing established that the registered candidate should be committed to the program in the form of exclusive dedication. This requirement complies with the standards of the National Commission on Multidisciplinary Residency in Health and the Unified Rules of Multidisciplinary Residency Programs and Healthcare Worker area of Rio de Janeiro State University.¹⁴

The medical clinic residents nurses showed greater weakness on the four topics addressed in the study compared to the surgical clinic resident nurses. This result can be explained by the lack of theoretical content of intestinal ostomy on specific theoretical programming of that Program. However, in the surgical clinic program, residents build this knowledge as there are lectures aimed at preparing the resident for the care process to patients in ostomy situation. It is worth noting that the medical wards are not specific fields for admission of patients with intestinal ostomies; however, due to the increasing involvement of people with health problems that lead to the construction of a stoma, there is then a growing number of people with ostomies hospitalized in medical wards¹⁶.

The weakness of most prevalent knowledge of surgical residents involved the theme IV guidance for self-care. This content is very important because one of the patients with ostomy service objectives is to enable them to self-care so they are independent in their actions to daily life. To learn to look after the colostomy can not only live with more quality of life but also identify early changes in their health-disease process, minimizing or preventing complications^7,17,18.

Regarding the higher prevalence of theoretical weakness of medical clinic residents, orientation for self-care (87%), followed by theme III diagnosing complications and preventive measures for change prevention (82%) were highlighted. It should be emphasized the importance of early detection of complications of ostomies, which are very diverse, such as: the peristoma dermatitis, prolapse and the retraction of the stoma, the parastomal and peristomal hernia, stenosis of the stoma, the mucocutaneous detachment. Thus, there are many complications described that slow down or kick the process of social inclusion of ostomy patients^17,19.

For this reason, the nurse needs to be able to early detect such complications as well as to prescribe, conduct and supervise preventive and curative measures that prevent or minimize the complications. In addition, it is important to note that installing a complication can lead to another, as the retraction of the stoma favor the occurrence of peristoma dermatitis. Thus, there is the risk of increasing the patients´ length of stay, increasing the bio-psychosocial suffering of the person and add greater financial burden for the person, family and society¹⁷.

It is worth mentioning the significant occurrence of their knowledge of the weakness in the theme II care when changing the collecting system and cleaning the stoma, for medical and surgical residents. For example, it is expected to decrease the exchange of the adhesive plate and prescribes cleaning up the collection bag and the stoma, which involves the use of technologies that help in patient´s welfare and at the same time, preventing complications. There are technologies that allow minimizing odors and, concomitantly, the elimination of flatus; prescribing collectors are specific equipment for each type of stoma, also considering the biopsychosocial characteristics of the patient. In this sense, there is a knowledge relevant the nurse must develop to take care with safety and quality of patients with stoma, guaranteeing their wellness¹⁷.

CONCLUSION

It is concluded that medical clinic residents showed greater weakness in knowledge on the subject than the surgical clinic residents. However, it should be emphasized that both residents groups showed weaknesses in knowledge related to care the person with stoma, being identified as important and necessary to ensure safe care to this patients.

Considering the weaknesses shown by residents, some considerations must be woven, among which that knowledge is dynamic, especially in health care, where the epidemiological picture of population changes. Also it should be understood that the technologies can be used in favor of better service to patients. Thus, emphasizing these two aspects, there has to be a continually assess and adapt curricula and programs of theoretical and practical of resident nurses to enable them to the reality around them.

One limitation of this study was the design of quantitative research, performed in a unique scenario, not allowing generalizations. It is recommended that the topic in the curricula of undergraduate, considering this a serious health problem that deserves attention in order to ensure a qualified training. It is suggested to carry out new studies in other settings and contexts, considering the growing number of ostomy, especially among young people.

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