ORIGINAL RESEARCH

Stomatherapy content and teaching strategies in the undergraduate nursing curriculum

Francisco Gleidson de Azevedo Gonçalves^I; Fabio Luiz Moreira Reis^II; Natalia André Barbosa Silva^III; Norma Valéria Dantas de Oliveira Souza^IV ; Thereza Christina Mó Y Mó Loureiro Varella^V; Ariane da Silva Pires^VI

^I Nurse. Master in Nursing. Specialist in Stomatherapy. College of Nursing, State University of Rio de Janeiro. Brazil. E-mail: gleydy_fran@hotmail.com
^II Nurse. Specialist in Stomatherapy. College of Nursing, State University of Rio de Janeiro. Brazil. E-mail: fabiomreis@hotmail.com
^III Nurse. Specialist in Stomatherapy. College of Nursing, State University of Rio de Janeiro. Brazil. E-mail: natalia_u3@hotmail.com
^IV Nurse. PhD Associate Professor, College of Nursing, State University of Rio de Janeiro. Brazil. E-mail: norval_souza@yahoo.com.br
^V Nurse. PhD Adjunct Professor, College of Nursing, State University of Rio de Janeiro. Brazil. E-mail: thereza1208@gmail.com
^VI Nurse. Master. PhD Student, Assistant Professor, College of Nursing, State University of Rio de Janeiro. Brazil. E-mail: arianepires@oi.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2018.28921

ABSTRACT

Objectives: to identify the theoretical and practical stomatherapy-related subjects in the undergraduate nursing program, analyzing their program content, strategies and outlines; and to discuss the approach to the content and the teaching strategies adopted by teachers for such content. Method: qualitative, documentary study, conducted at the nursing department of Rio de Janeiro State University. The documentary research used specifically the outlines and timetables from the 1st to 9th undergraduate terms. Data were collected in November 2016, and subjected to thematic content analysis. Results: the content addressed in the undergraduate course was found to refer predominantly to the themes of wounds and stomas, and no incontinence-related content was identified. Conclusion: there was considered to be a need to introduce content on anal and urinary incontinence, given the epidemiological relevance and psychophysical suffering of people with such problems.

Descriptors: Ostomy; nursing; teaching; wounds and injuries.

INTRODUCTION

The teaching of stomatherapy in the undergraduate course of nursing of the College of Nursing of the State University of Rio de Janeiro has been the proposal of this research that was carried out based on the analysis of the content of programs and menus of the course in question. The objective arose from the empirical observation made during our professional practice that nursing professionals and students have many doubts and difficulties in providing care to the patients with wounds, stomas and incontinences.

In this sense, it is considered that the content on stomatherapy care during training should be strengthened in Undergraduate Nursing Courses because with the increase in life expectancy and the change in the population profile, there has been a growth of elderly people and, consequently, an increase of chronic noncommunicable diseases, increasing the number of people with stomas, wounds and incontinences.

Nursing has as its object the work the provision of care for human beings who are in any kind of adversity, whether in the physical or psychic dimension. It is the responsibility and duty of nursing to promote and protect human life, as well as contribute to the recovery of health, making its care to become a form of art and a science¹.

It is inferred that nurses can improve care for persons with wounds, stomas and incontinences through the technical and scientific knowledge related to stomatherapy, corroborating the relevance of this study, which intends to investigate the content related to stomatherapy that are developed in the undergraduate nursing course.

The study is justified by the evidence of low scientific production on the subject, confirmed by a literature review. Literature was sought in the portal of the Virtual Health Library (VHL), and only four scientific publications dealing with stomatherapy, nursing and teaching were found.

In order to broaden the scientific production on the topic of stomatherapy in undergraduate courses, separate bibliographic abstractions in the VHL were made with the following descriptors: nursing, higher education and wounds and injuries. This resulted in four additional articles. The keywords wounds, stomas and incontinences were also used in the search, resulting in another four publications, however, two of these had already appeared in the previous searches. Thus, a total of 10 scientific texts related to the theme were found.

Considering this initial contextualization, the following guiding question was selected for the present study: What theoretical-practical content and what teaching strategies are used by the teachers to teach the content of stomatherapy in undergraduate nursing courses?

In order to answer this question, the following objectives were drawn: to identify the theoretical-practical contents related to stomatherapy in the Undergraduate Course of Nursing, analyzing its programmatic contents, strategies and menus; and discuss the approach to the content and the teaching strategies adopted by teachers to teach such contents.

LITERATURE REVIEW

Stomatherapy is a specialty in expansion and has grown in the national market for its role in several areas, not only in the health care activities but also in teaching, research, administrative, saling, advisory and consulting activities. Stoma therapists can work in public, private, outpatient units, clinics, medical offices, offices specialized in stomatherapy, and home care, and they have the possibility of having their own venture².

Nurses specialized in stomatherapy are those who have specific knowledge and skills to care for people with stomas, with acute and chronic wounds, fistulas, catheters, drains, and anal and urinary incontinence³.

It is noteworthy that this specialty is growing in Brazil and a great number of nurses seek qualification in the area. However, many institutions still do not have these specialized professionals in their staff. However, it is known that the majority of nurses in their clinical and/or surgical practice end up, at some point, dealing with patients who will need care in the stomatherapy area⁴.

Nursing specializations are fundamental to stimulate the improvement, competence and realization of research, opening new fields for nurses. The specialist nurse is someone who has mastery of theories, flexibility in their use, the ability to act accordingly to the client's real needs, and they use the client's intuition, reasoning and experience⁵.

Regarding the labor market, a study of 30 stoma therapist nurses graduated from the Stomatherapy Course at the University of Taubaté described that 28 (93.3%) worked in activities in their area of ​​specialization, and 10 (33.3% ) had up to 10 years of service. It is observed that the majority were inserted in the hospital environment, that is to say, 17 (55.3%) of the investigated nurses. The teaching and research areas were also mentioned⁶. However, another study mentions that the hospital and primary health care are no longer exclusive to the labor market, providing a range of possibilities for expansion⁷.

The labor market in contemporary society is marked by many demands, such as professionals with a high level of qualification, with autonomy for decision-making, competent to rapidly incorporate technologies, and responsible for responding to the problems of the most different processes of production. Thus, in order to adapt to the new market trends, the professionals have sought qualification through postgraduate courses as a strategy to meet the demands imposed in the world of work⁸.

Although the job market requires a profile of specialized nurses, the National Curricular Guidelines in the article 3 explain that the Undergraduate Nursing Course should present a profile that is generalist, humanistic, critical and reflexive⁹. This reinforces the need for postgraduate training strategies to meet such requirements.

It is perceived that this profile demands a great effort from the faculty and from students, because nursing is a profession focused on the well-being of human beings and requires special training and the production of knowledge that underlies professional action¹⁰. To do so, during undergraduate training, it is necessary to develop contents related to the nurses' various areas of action, in order to enable them to act safely in the face of the population's health demands. However, when there are highly complex health problems, there is a need for resolution by specialists, and when nurses are not experts in the field, they must have the knowledge to know how to refer the cases to specialists and, above all, to detect that the problem lacks specificity of performance.

METHODOLOGY

This is a documentary research with a qualitative approach carried out at the College of Nursing of the State University of Rio de Janeiro, in which the menus and the planning of subjects from the first to the ninth semester of graduation were analyzed.

Data collection took place in November 2016, in the morning and afternoon shifts, during which there were several approaches with the menus and schedules made available by the coordination of the undergraduate course of the institution. It should be noted that we obtained authorization from the nursing coordination and direction of the unit to carry out the research.

Data processing was performed using the thematic content analysis technique. This technique is defined as a set of communication analysis techniques, aiming to obtain, through systematic procedures and description objectives, the content of the messages^11,12.

Therefore, the operationalization of the process of analysis followed the three stages of the technique. In the first stage, called pre-analysis, an exhaustive reading of the data was made, followed by the organization of the material and the formulation of hypotheses. Subsequently, the material was explored, seeking to encode the raw data. In the third and last phase, the data were interpreted and delimited in thematic axes, according to the meanings assigned. Thus, after applying this technique, two categories emerged - Thematic contents: focus on wounds and stomas; and Strategies applied to the teaching of stomatherapy.

Results and Discussion

After applying the content analysis technique in the menus and teaching plans of the subjects of the Undergraduate Nursing Course, it was verified that contents related to stomatherapy were approached in seven of the nine semesters; however, there was no content on incontinence in the menus, nor in the planning. In this sense, the contents covered were wounds for the most part, and stomas in a lower proportion.

Thematic contents: focus on wounds and stomas

The contents on wounds and stomas that are approached in the undergraduate course were discussed In this category. These contents were detected in the menus and programmatic contents. They are addressed mainly in the 2^nd, 3^rd, 4^th, 5^th, 6 ^th, 8^th and 9^th periods.

It should be noted that a preponderance of content on wounds was found, as this is addressed in the 3^rd, 6^th, 8^th and 9^th semesters. Thus, there is a focus on the concept of wounds such as diabetic foot and pressure injury, classification of the lesions, physiology of the healing process, and main types of coverages used in the treatment and prevention of injuries.

Nurses take care of the client's wound by treating it with the best coverage or medicine on the market. However, their competence goes beyond curative care because nurses plan a comprehensive care according to the specifics of each individual, identifying his basic human needs to promote health, prevent injuries and help him recover. Thus, care for patients with skin lesions requires a multiplicity of knowledge that interferes with the healing process, such as the underlying disease, nutritional status, allergies, degree of hydration of the skin, associated diseases, among others¹³.

Care for wounded people is inherent in the professional practice of nurses, including cases when the injury is complex, where care must be exclusive duty of these professionals; it is not allowed to delegate it to any other member of the nursing team¹³. The concept of wound is understood as: "The interruption of the continuity of a body tissue, to a greater or lesser extent, caused by any type of trauma or triggered by a clinical condition, which starts the organic defense fronts o counterattack" ^14:9.

Wounds can be classified according to the characteristics of the causal agent of the opening of a lesion, such as: incised wounds (by sharp agents, causing a linear wound, as in the case of a surgical wound for example); blunt wounds (caused by objects that break the integrity of the skin); perforating wounds (thin, tapering instrument that tears the skin and adjacent tissues); penetrating wounds (agent that perforates tissues and can enter a cavity); and transfixing wounds (perforating or penetrating object that crosses the tissues of a given organ)¹³.

Regarding the care technologies for lesions, it was identified that the most approached during the semesters of the undergraduate course were coverages, classified as hard technology. Coverages are applied on the wound to promote rapid healing or to prevent that lesions develop in the skin of people¹³.

Hard technologies that permeate care to individuals with wounds involve devices, materials, and pharmacological coverages used in topical therapy. Regarding these technologies, there is concern about the availability of these resources to plan the care, as there is an insidious shortage of products in public health services that compromise the quantity and quality of medical and hospital supplies available for the work of nurses¹⁵.

Hard care technologies are represented by concrete materials, such as equipment, standards and organizational structures¹⁶. In the assistance to individuals with wounds, it is emphasized that nurses give importance to materials used in the direct care to the injured tissue.

Regarding the content on stomas in the menus and teaching plans, it is pointed out that they were approached in order to conceptualize and classify intestinal stomas, nursing care for people with stomas, equipment used, as well as the main nursing care for clients with digestive disorders: intestines (colon cancer, rectum cancer), esophagus (varicose veins and polyps), stomach (cancer and gallbladder), which are pathologies that may result in the creation of stomas as palliative or curative care.

Stomas are named based on the body locations on which they were made. Thus, intestinal stomas can be called colostomy, ileostomy and jejunostomy¹⁷.

The creation of a stoma is an impactful event on a person's life. In this condition, the feeling of mutilation arises, which results in the feeling of being different from other people. In addition, a surgical procedure generates anxiety and fear, because surgeries are closely associated with self-image and social interaction, since the person loses the capacity of continence of the stool and flatus and must live depending on the collection equipment, which is many times uncomfortable and bulky. Besides such transformations, there is a difficulty of insertion and maintenance in the world of work deriving from the need for constant use of the bathroom and occupational restrictions of people who have a stoma^18,19.

The main diseases that lead to the construction of an intestinal stoma are: colorectal cancer, diverticular disease, inflammatory bowel disease, anal incontinence, ischemic colitis, familial polyposis adenomatosis, trauma, megacolon and serious perineal infections^20,21.

Given this context, nurses are the first members of the multidisciplinary team to interact with clients who have a post-operative stoma, having the opportunity to respond to their doubts and concerns and provide them care with safety, preventing and detecting early complications that may jeopardize the process of social inclusion or compromise the biopsychosocial integrity of the person with stoma^4,22,23.

The contents of nursing care with catheters and drains, dermatological physical anamnesis and examination, and health care in the primary health care area, focusing on complications resulting from Diabetes mellitus, were verified to a lesser extent. It should be noted that there were also references in the menus and teaching plans to nursing care in aging, to the main characteristics of pathological aging and its health problems, to physical changes and repercussions on the skin of elderly people.

Regarding the content on urinary and fecal incontinence, there was no mention in any semester of the undergraduate course. There is, therefore, a knowledge gap in the training of undergraduates, and that gap possibly will reflect on the care given to this clientele, once that, when faced with the real work experience, many clients will present these health disorders.

Strategies applied to the teaching of stomatherapy

The strategies used by teachers to teach their theoretical and practical classes (in the teaching laboratory or health services), were discussed in this category. The main strategies used are: expository class with the use of datashow, class with demonstrative videos to elucidate and consolidate the content, use of the laboratory of skills and realistic simulations for demonstration and management of lesions and stomas in manikins, presentation of some coverages, and equipment used in stomatherapy clients.

The laboratory of skills and realistic simulations of the College of Nursing has been systematically used as teaching strategy; teachers make use of this environment in all the analyzed semesters. It is known that the application of simulations in health sciences education has become a fundamental and frequent tool for the training of students in undergraduate and postgraduate courses. However, there are potential correlations between the efficacy of the manikin as a simulator and other types of simulation, including virtual reality simulation²³.

Simulators bring benefits for the development of students in multiple scenarios. However, other simulation methods such as virtual simulation can add knowledge and be used in conjunction with high fidelity resources in order to expand the possibilities and experiences in scenarios whose access would sometimes be limited^24,25.

Teaching nursing students can be a challenge when only random learning opportunities are available and clinical experiences are usually linked to the type of client and the practice scenario. With the simulation strategy, there is an opportunity to practice skills in a safe environment that allows skills to be improved through repeated exposure over time ²⁴.

In the laboratory of skills and realistic simulations of the College of Nursing, teachers demonstrate to their students the care related to drains and the types of stomas, catheters and basic coverages, training nasoenteric and gastric catheterization and enemas, as well as catheterization and bladder control in mannequins. The use of the main devices, materials and specific equipment in customers is also addressed, including the collecting equipment and the adjuvants.

It is worth noting that the students perform laboratory practices on physical examination with focus on the integumentary apparatus, physical examination of elderly patients, with a view to identify the functional capacity and application of tests of daily life activities, training of cognitive and affective and psychomotor abilities in the verification of capillary glycemia and diabetic foot. Thus, the laboratory provides a safe environment where students have the opportunity to make an assessment and make a decision without endangering the existence of a human being. This teaching strategy is relevant, because nursing is a practical profession; active learning for the care of the client has always been the preferred method for the achievement of competencies^25,26.

Issues such as HIV and leprosy care with a focus on skin lesions are approached through seminars developed by invited experts. It should be emphasized that the primary care practice with supervised visits and conversation wheels, intensified in the last two semesters of the course in the modality of internship, are also frequent teaching strategies.

Knowledge about nasoenteric and gastric catheterization, enemas, drains, colostomies, and bladder catheter and also water control are superficially treated during the course, focusing on the topics related to bladder catheterization and passage of nasoenteric and nasogastric tubes. The use of interactive manikins, computer simulations and lectures make learning about enemas, drains and colostomies, which are rarely mentioned, even easier and more didactic. Scenarios such as those previously mentioned enable the unification and applicability of theoretical knowledge in the care practice, favoring actions in a safe and controlled clinical environment, without risk of compromising the care to the client ²⁶.

CONCLUSION

The analysis of the menus and teaching plans of the Undergraduate Nursing Course made it evident the need to intensify the development of some contents related to stomatherapy. It is known that the goal of undergraduate courses is to train generalist nurses, but it is important to offer a minimum content to allow the future professional to detect highly complex health problems, so as to refer the patient to specialists or act in a way that does not cause harm to the health of the person who needs specialized care.

It is considered that the contents related to the care of colostomy should be more discussed at the undergraduate level, addressing complications and also approaching other types of stomas. Another important point is the urgent need to introduce the content of incontinence in the course, as this is a frequent problem in the elderly population and in women, resulting in serious biopsychosocial damages for this population.

We also found that content on wound care was consistently addressed throughout the undergraduate course, deepening in complexity and at the same time diversifying the types of wounds and the care demanded.

It is inferred that this documentary analysis made it possible to identify the main teaching strategies used by teachers. Of particular note is the use of the laboratory of teaching and skills, the conversation wheels, the dialogic expository classes, and the study of cases. They are teaching strategies which contribute, creatively, to the apprehension of skills and competence for the development of nursing care in the context of stomatherapy. It is considered that this variety of teaching strategies is a strong point of the course in favor of learning about stomatherapy because it makes the process dynamic and realistic.

We believe that one limitation of this study was to use only a higher education institution of public nature, of the State, as field of research. Thus, the findings should not be generalized. Yet, they portray an institutional reality.

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