J Wound Ostomy Continence Nurs. 2014;41(6):560-565. Published by Lippincott Williams & Wilkins
OSTOMY CARE
Staff Nurse Confidence in Their Skills and Knowledge and Barriers to Caring for Patients With Ostomies Heidi Huddleston Cross ■ Cheryl A. Roe ■ Dongliang Wang
■ ABSTRACT
KEY WORDS: barriers, nurse confidence, ostomy, patient
satisfaction
PURPOSE: Patients with ostomies often state that staff
nurses display a lack of confidence in knowledge and skills related to ostomy care. This study examined the confidence and perceptions of barriers among hospital staff nurses when caring for ostomy patients. DESIGN: Descriptive, cross-sectional study. SUBJECTS AND SETTING: A convenience sample of 576 staff nurses, including 510 registered, 61 licensed practical, and 5 unspecified nurses, participated in the study. The study sample practiced at 3 sites: an academic medical center, a Veteran’s Administration Center, and a not-forprofit hospital in the state of New York. METHODS: Links to a 17-question electronic survey were distributed by e-mail. The survey included items that queried demographics, availability of an ostomy nurse, ostomy training in school, and frequency of care of ostomy patients. Participants also responded to 22 statements using a 6-point Likert Scale (1 = Strongly Disagree, 6 = Strongly Agree). These statements queried confidence in providing ostomy care and perceived barriers. RESULTS: Higher confidence in ostomy care knowledge (k) and skills (s) was associated with being an LPN (P < .0001 [k], P = .003 [s]), years of nursing experience (P = .009 [k], P = .01 [s]), having ostomy training (P = .002 [k], P = .02 [s]), frequency of providing ostomy care (P < .0001 for each), and knowing how to obtain and use ostomy supplies (P < .0001 for each). The highest reported confidence was associated with emptying a pouch (mean ± SD, 5.32 ± 0.91), and the lowest was knowledge of nutrition for persons with ostomies (3.96 ± 1.21). Almost 1 in 5 respondents (18.6%) was unaware that a certified ostomy nurse practiced at their institution. CONCLUSION: Confidence of staff nurses in delivering ostomy care was higher with training and experience. Opportunities for continuing education may increase staff nurse confidence in providing ostomy care. The greatest barrier was lack of knowledge about the presence of an ostomy nurse as a resource in caring for patients.
560 J WOCN ■ November/December 2014
■ Introduction Ostomy surgeries are performed for many reasons such as cancer, diverticulitis, or trauma. The number of people living with an ostomy in the United States is approximately 650,000 to 730,000.1 A report from the United Ostomy Associations of America estimated that 128,000 new ostomy surgeries were performed in 2007.1 Patients admitted to hospitals for ostomy surgery often experience anxiety, fear, depression, body image impairment, anger, and denial.2 Previous studies have shown the numerous advantages of involving a WOC nurse in preoperative as well as postoperative care and teaching.3-7 Even established ostomy patients experience anxiety when hospitalized, concerned that their ostomy needs may not be met in terms of routine care and supplies. The nursing care of persons with ostomies requires specific knowledge, skills, and appropriate supplies. While WOC nurses strive to provide education and care to all ostomy patients, they must rely on staff nurses to deliver routine care to these patients. Having a staff nurse who is confident and knowledgeable in providing this care is hypothesized to play a significant role in patients’ satisfaction with overall care received.5 This study addressed
Heidi Huddleston Cross, RN, MSN, FNP-BC, CWOCN, Upstate University Hospital, Syracuse, New York. Cheryl A. Roe, MS, Instructor, Upstate Medical University, Syracuse, New York. Dongliang Wang, PhD, Assistant Professor, Department of Public Health and Preventive Medicine, Upstate Medical University, Syracuse, New York. The authors declare no conflict of interest. Correspondence: Heidi Huddleston Cross, RN, MSN, FNP-BC, CWOCN, Upstate University Hospital, 750 East Adams St, Syracuse, NY 13210 ([email protected].). DOI: 10.1097/WON.0000000000000065
Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 560
31/10/14 5:06 PM
J WOCN
■ Volume 41/Number 6
2 questions related to staff nurse confidence when delivering care to persons with an ostomy: (1) What is the selfperceived confidence level of staff nurses related to care of ostomy patients in terms of knowledge, skills, and supplies and (2) what are the potential barriers (related to attitudes, beliefs, and work conditions) staff nurses face when caring for ostomy patients? We operationally defined confidence as belief or selfassurance in one’s ability to succeed.8 Ostomy care was operationally defined as the routine care of patients with ostomies such as emptying, changing, stoma and skin care, and procuring supplies. For the purposes of this study, barriers are defined as factors that impede the nurse’s ability to deliver ostomy care and education to patients.
■ Methods An electronic survey was developed and distributed to RNs and licensed practical nurses (LPNs) at 3 acute care facilities, including a 409-bed academic medical center, a 466-bed acute care facility, and a 103-bed Veteran’s Administration Medical Center. Study procedures were reviewed by the institutional review boards of the 3 respective facilities, and all granted exemption from review. The survey was distributed by e-mail using Survey Monkey (http://www.surveymonkey.com), using each institution’s “All nurses list.” The target population was any currently practicing RN or LPN caring for adult or pediatric patients with an ostomy. An explanatory letter was included, with completion of the survey indicating consent to participate. As an incentive, each participant was offered participation in a raffle for a $100 gift certificate, with a total of 7 certificates awarded. At the primary investigator’s institution, coffee coupons were offered to any nurse completing the survey; this additional incentive was offered because participants at this research site had participated in the content validation process, placing an additional burden on their time.
■ Instrument The questionnaire we used was developed for purposes of this study. The survey included items regarding demographic data, availability of and referral to an ostomy nurse, training in school, frequency of care, and 2 tables with agree-disagree items on a 6-point Likert Scale (1 = Strongly Disagree, 6 = Strongly Agree). Items queried factors related to nursing confidence, and others queried potential barriers. Confidence level-type questions were grouped according to knowledge, skills, and supplies. A single question was included that queried the use of supplies, which was insufficient for statistical analysis. Responses to that item were grouped with other knowledge questions. Confidence level in terms of knowledge was measured by 7 questions, while the confidence level for skills was measured by 6 items. Survey questions about barriers were grouped according to 3 areas: attitudes,
Cross et al
561
beliefs, and work conditions. A single item focused on attitudes, and it was grouped with belief questions. Therefore, belief was measured by 5 items, and work conditions by 4 items. The questionnaire used in our study underwent content validation. Content is the extent to which the method of measurement includes all the major elements relevant to the construct being measured.9 To achieve content validity, the questionnaire was presented to skin care resource and research nurses in our facility, who were asked to review the questionnaire for readability and comprehension. In addition, a panel of WOC nurses reviewed the questionnaire and evaluated the extent to which it queried all aspects of the primary construct of the study. The questionnaire was revised based on these groups’ recommendations, with repetition of this process until all were in full agreement that the objectives had been met.
■ Data Analysis For descriptive purpose, responses to each item included in the survey were tallied and displayed in a tabular format. Numeric variables were summarized using descriptive statistics such as mean and standard deviation. Frequencies and relative frequencies were computed for all categorical variables, and box plots were used to display the data when appropriate. Confidence levels were measured via scores calculated by summing responses over a group of related question items. The reliability of these question groupings was investigated using factor analysis, and by computing the Cronbach alpha for each group. Subjects having a missing value for any question within a group were excluded from the analysis. For 6 questions, the scale on the disagree-agree continuum was reversed to more accurately align positive versus negative responses. For example, “Ostomy care is unpleasant, making me at times reluctant to do it,” where an answer of “strongly agree” would indicate a negative response. The effects of other factors on the levels of confidence and perception of barriers were assessed by either 2-sample t tests or analysis of variance (ANOVA). Alternative statistical methods assuming unequal variances were applied if the assumption of equality of variances between groups did not hold. Linear regressions were applied for factors with ordinal scales, including the number of years of nursing, frequency of care, and understanding how to obtain supplies and how to use them. A P level ≤ .05 was used to determine statistical significance. Data analyses were performed using SAS version 9.2 statistical software (SAS Institute, Cary, North Carolina).
■ Results Six hundred fifty surveys were returned; however, 74 surveys were provided by nurses who indicated that they did not provide direct care to inpatients. These respondents
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 561
31/10/14 5:06 PM
562
J WOCN
Cross et al
were eliminated from data analysis, leaving 576 evaluable surveys. We were unable to calculate a precise response rate; we were not informed of how many nurses were on the lists, and some addresses had not been updated, resulting in returned e-mails. Approximately 2600 e-mails were sent (minus returned e-mails), resulting in an approximate 25% response rate. Demographic and clinical practice characteristics are summarized in Table 1. Ninety percent of respondents were women; 82% primarily cared for adults, 12% pediatrics, and the rest indicated both. Eighty-eight percent were RNs, and 11% were LPNs. Fifty-one percent had been a nurse for 10 years or less, 22% indicated 11 to 20 years’ experience, 15% had practiced for 21 to 30 years, and 12% for more than 30 years. Those on surgical units comprised the largest group (21%), followed by critical care nurses (18%) and nurses on medical units (16%). Survey respondents were asked if there was a certified ostomy nurse at their facility. All 3 facilities have an active wound and ostomy program, yet 4% of respondents indicated “No” and 14.6% indicated “I don’t know.” In response to the item “I consult the ostomy nurse when I have a patient with a new ostomy,” 22.5% responded “No” and 5.6% indicated absence of an ostomy nurse at their facility. Similar results were found for the statement, “I consult the ostomy nurse in my facility/practice when I have a patient with difficulty such as leakage and skin breakdown,” with 12.8% indicating “no” and 5.6% indicating no knowledge of one. Table 2 summarizes responses to items that queried confidence delivering ostomy care. The highest mean was associated with emptying an ostomy appliance (mean ± SD, 5.32 ± 0.919), and the lowest was in knowledge of nutrition (3.96 ± 1.217). The Cronbach alpha was 0.91 for the knowledge group and 0.94 for the skills group, indicating adequate internal reliability. The mean knowledge score for the group, based on 526 completed responses to this section of the survey, was 30.96 ± 6.65, and the mean score for skill level in providing ostomy care, based on 535 evaluable responses, was 28.32 ± 6.12. The mean score for knowledge items was slightly above an “Agree” response, while the mean for skills fell between “Slightly Agree” and “Agree.” Licensed practical nurses reported higher confidence levels for knowledge (34.3 ± 5.5 vs 30.6 ± 6.7, P < .0001) than RNs. They also reported higher confidence levels for skills when compared to RNs (30.1 ± 6.1 vs 28.1 ± 6.1, P = .003). Years of nursing experience was significantly related to self-perceived confidence level of knowledge (P = .009) and to the confidence level of skills (P = .01), as was having received training in school (P = .002 for knowledge; .04 for skills). With 1 more year of experience, the mean self-perceived confidence level of knowledge was 0.32 higher and the mean confidence level of skill was 0.27 higher. The mean difference in confidence levels between nurses with and without training was 2.2 in terms
■ November/December 2014
TABLE 1.
Respondent Demographics Demographic Characteristics
% (n)
Primary area of practice Adult
81.9% (472)
Pediatric
12.3% (71)
Both
5.4% (31)
Are you an RN
88.5% (510)
LPN
10.6% (61)
Unspecified
0.9% (5)
Gender Male Female
8.9% (51) 89.9% (518)
Age, y 20-30
24.7% (142)
31-40
24.0% (138)
41-50
27.1% (156)
51-60
22.2% (128)
61+
2.1% (12)
How many years have you been a nurse? 1-10
50.9% (292)
11-20
21.9% (126)
21-30
14.6% (84)
>30
12.5% (72)
Primary area of focus Surgical
21.0% (121)
Critical care
18.1% (104)
Medical
15.8% (91)
Oncology
9.5% (55)
Cardiology
5.6% (32)
Rehabilitation
5.0% (29)
Emergency department
4.9% (28)
Perioperative
4.9% (28)
Neurology
4.2% (24)
Psychiatry
2.6% (15)
Float pool
2.4% (14)
Long-term care
1.9% (11)
Neonatal
1.2% (7)
Obstetrics
0.7% (4)
Gynecology
0.5% (3)
Home care
0.7% (4)
Other
0.9% (5)
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 562
31/10/14 5:06 PM
J WOCN
■ Volume 41/Number 6
563
Cross et al 40
TABLE 2.
Knowledge and Skills Statements
Mean
b
Standard Deviationb
Knowledge statements: I feel confident:
30
20
Knowing the difference between colostomy, ileostomy, urostomy
4.89
1.094
Preventing skin problems
4.63
1.031
Dealing with odor
4.52
1.199
Knowing when to attach to a larger drainage bag
4.37
1.284
Ordering correct supplies
4.34
1.220
FIGURE 2. Frequency of ostomy care vs confidence level in
Dealing with skin problems
4.19
1.186
Teaching nutrition to ostomy patients
3.96
1.217
skills. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
Emptying an ostomy appliance
5.32
0.919
Changing an ostomy appliance
4.77
1.187
Cutting wafer to appropriate size
4.69
1.178
Measuring a stoma
4.66
1.162
Applying paste
4.63
1.2
Attaching to a larger bag
4.26
1.302
10
0 Never
Rarely
Sometimes
Frequently
Always
Frequency of ostomy care
Skills statements: I feel confident:
Scores: 1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = slightly agree, 5 = agree, 6 = strongly agree. bMean and standard deviation for the entire sample (N = 526).
a
them (Figures 5 and 6) were found to be significantly more confident in both skills and knowledge (P < .0001 for each question). Table 3 summarizes responses to belief and work environment items. As previously described, items related to beliefs or attitudes and items related to work conditions were grouped into these 2 factors. The Cronbach alpha was 0.47 for the belief group and 0.58 for the work conditions group. These Cronbach alphas do not indicate internal reliability, and therefore no further analyses were conducted using these factors.
■ Discussion The aim of this study was to examine confidence and knowledge levels of staff nurses, and the barriers they face. Persson and colleagues10 evaluated ostomy patients’ satisfaction while being cared for in hospitals and found that
Level of confidence in knowledge
of knowledge and 1.0 in terms of skill. Both of these groups were more confident than nurses who did not remember learning about ostomy management during their nursing educational program. The frequency that nurses reported caring for persons with ostomies was significantly related to confidence in knowledge and skills for both RNs and LPNs (P < .0001; Figures 1 and 2). Nurses who stated that they understood how to obtain supplies (Figures 3 and 4) and how to use 50
Level of confidence in knowledge
Level of confidence in skills
a
40
30
20
50 40 30 20 10 0
10
1
2
3
4
5
6
Understanding how to obtain ostomy supplies
0 Never
Rarely
Sometimes
Frequently
Always
Frequency of ostomy care
FIGURE 1. Frequency of ostomy care vs confidence level in
knowledge. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
FIGURE 3. Understanding how to obtain ostomy supplies vs
confidence level in knowledge. Scale: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree; 6 = strongly agree. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 563
31/10/14 5:06 PM
564
J WOCN
Cross et al 40
Level of confidence in skills
Level of confidence in skills
40
■ November/December 2014
30
20
10
0
30
20
10
0
1
2
3
4
5
6
1
2
3
4
5
6
Understanding how to use ostomy supplies
Understanding how to obtain ostomy supplies
FIGURE 6. Understanding how to use ostomy supplies vs confi-
confidence level in skills. Scale: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree; 6 = strongly agree. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
dence level in skills. Scale: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree; 6 = strongly agree. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
participants were not entirely satisfied with the quality of care they received while hospitalized. Our clinical experiences also suggest that patients with ostomies find that some needs are not met when receiving care in acute care facilities, and that nurses readily admit to a lack of confidence and knowledge in caring for patients with ostomies. Higher confidence in ostomy care knowledge and skills was associated with more training, the number of years of nursing experience, higher frequency of providing ostomy care, and knowing how to obtain and use supplies. These findings may explain why LPNs demonstrated greater confidence than RNs, with RNs perhaps assuming a greater supervisory role in practice, and LPNs more of a practical, bedside role within the 3 facilities where data were collected. We attempted to assess potential barriers related to work conditions with questions about ostomy supplies
and teaching materials availability, as well as the influence of lack of time. Lack of time did not emerge as a strong factor. The statement “Ostomy supplies are easy to order” generated responses indicating “slight agreement.” This finding suggests that ostomy nurses need to take steps to increase staff nurse knowledge about supplies available in
Level of confidence in knowledge
FIGURE 4. Understanding how to obtain ostomy supplies vs
TABLE 3.
Belief Statements and Work Conditions Means
Standard Deviation
I am concerned I may harm my patient’s stoma
4.56a
1.167
Patients refuse ostomy care, wanting to care for their ostomy themselves
3.88a
1.239
50
Patients should care for their own ostomy
4.85b
.946
40
I am concerned I may do something incorrectly
3.89a
1.357
Ostomy care is unpleasant, making me reluctant
4.28a
1.235
Ostomy supplies are easy to order
3.95b
1.213
Lack of time is a factor in delivering care promptly
3.75a
1.296
Lack of time is a factor in delivering care properly
3.96a
1.280
Ostomy patient teaching materials are available
4.49b
1.136
30
Belief statements
Work conditions
20 10 0 1
2
3
4
5
6
Understanding how to use ostomy supplies
FIGURE 5. Understanding how to use ostomy supplies vs confidence level in knowledge. Scale: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree; 6 = strongly agree. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
aReversed scale: 1 = strongly agree, 2 = agree, 3 = slightly agree, 4 = slightly disagree, 5 = disagree, 6 = strongly disagree. b1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = slightly agree, 5 = agree, 6 = strongly agree.
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 564
31/10/14 5:06 PM
J WOCN
■ Volume 41/Number 6
their institution and to simplify the ordering process. In addition to staff nurse training, we recommend additional education of distribution or central supply staff in an effort to streamline procurement of supplies. Almost 1 in 5 nurses (18.6%) indicated either that there was no ostomy nurse or that they were unaware of one in their facility, despite active ostomy departments at all 3 data collection sites. We believe that this finding represents the most clinically relevant barrier to caring for ostomy patients. It is possible that part of the reason for these responses may be that the question was being answered by off-shift nurses, when indeed an ostomy nurse may not be on the premises right at that time. Nevertheless, one would expect that referral to an ostomy nurse would be initiated, particularly with new ostomies or with issues such as leakage. Based on this finding, we advocate efforts to ensure that staff are informed about the presence of an ostomy nurse in their facility, if one is available, along with instruction about the process for consultation.
Limitations The sample population may have included responses from nurses who were not predominantly bedside nurses. Future surveys should exclude respondents who do not provide direct bedside care to inpatients in acute care facilities. Ultimately we were not able to satisfactorily answer the belief and attitude research question, owing to poor internal reliability within the belief and attitude construct items. Development of a valid and reliable tool for measuring these constructs is needed to more fully explore this clinically relevant question.
■ Conclusions Bedside nursing care of ostomy patients may be accompanied by anxiety and frustration for both patients and nurses, often due to a lack of confidence and knowledge
Cross et al
565
and skills among staff nurses who care for these patients. Findings from this study suggest that confidence of staff nurses is higher with training in ostomy care and experience with caring for patients with stomas. Opportunities for continuing education may increase staff nurse confidence in providing ostomy care. Ostomy nurses must make their presence known so that proper referral can be initiated for optimum patient care and satisfaction.
■ ACKNOWLEDGMENT This study was supported by a research grant from the Center for Clinical Investigation of the Wound, Ostomy, and Continence Nurses Society.
■ References 1. Cooke C. American ostomy census. The Phoenix. 2009;5(1):2829, 64-67. 2. Raynaud SN, Meeker BO. Coping styles of older adults with ostomies. J Gerontol Nurs. 2003;28(5):30-36. 3. Haugen V, Bliss D, Savik K. Perioperative factors that affect long-term adjustment to an incontinent ostomy. J Wound Ostomy Continence Nurs. 2006;33(5):525-535. 4. Quintana-Jimenez P, Pastor-Juan C, Prados-Herrero I, et al. A prospective, longitudinal, multicenter, cohort quality-of-life evaluation of an intensive follow-up program for patients with a stoma. Ostomy Wound Manag. 2010;56(5):44-52. 5. Marquis P, Marrel A, Jambon B. Quality of life in patients with stomas: the Montreux study. Ostomy Wound Manag. 2003;49(2):48-55. 6. Brand M, Dujovny N. Preoperative considerations and creation of normal ostomies. Clin Colon Rectal Surg. 2008;21:5-15. 7. Brown H, Randle J. Living with a stoma: a review of the literature. J Clin Nurs. 2005;14(1):74-81. 8. Soukhanov A, Rooney K, editors. Encarta World Dictionary. 1st ed. New York: St. Martin’s Press; 1999. 9. Burns N, Grove S. The Practice of Nursing Research. Philadelphia: WB Saunders; 2001:400. 10. Persson E, Gustavsson B, Hellstrom A, Lappas G, Hulten L. Ostomy patients’ perceptions of quality of care. J Adv Nurs. 2005;49(1):51-58.
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 565
31/10/14 5:06 PM
OSTOMY CARE
Staff Nurse Confidence in Their Skills and Knowledge and Barriers to Caring for Patients With Ostomies Heidi Huddleston Cross ■ Cheryl A. Roe ■ Dongliang Wang
■ ABSTRACT
KEY WORDS: barriers, nurse confidence, ostomy, patient
satisfaction
PURPOSE: Patients with ostomies often state that staff
nurses display a lack of confidence in knowledge and skills related to ostomy care. This study examined the confidence and perceptions of barriers among hospital staff nurses when caring for ostomy patients. DESIGN: Descriptive, cross-sectional study. SUBJECTS AND SETTING: A convenience sample of 576 staff nurses, including 510 registered, 61 licensed practical, and 5 unspecified nurses, participated in the study. The study sample practiced at 3 sites: an academic medical center, a Veteran’s Administration Center, and a not-forprofit hospital in the state of New York. METHODS: Links to a 17-question electronic survey were distributed by e-mail. The survey included items that queried demographics, availability of an ostomy nurse, ostomy training in school, and frequency of care of ostomy patients. Participants also responded to 22 statements using a 6-point Likert Scale (1 = Strongly Disagree, 6 = Strongly Agree). These statements queried confidence in providing ostomy care and perceived barriers. RESULTS: Higher confidence in ostomy care knowledge (k) and skills (s) was associated with being an LPN (P < .0001 [k], P = .003 [s]), years of nursing experience (P = .009 [k], P = .01 [s]), having ostomy training (P = .002 [k], P = .02 [s]), frequency of providing ostomy care (P < .0001 for each), and knowing how to obtain and use ostomy supplies (P < .0001 for each). The highest reported confidence was associated with emptying a pouch (mean ± SD, 5.32 ± 0.91), and the lowest was knowledge of nutrition for persons with ostomies (3.96 ± 1.21). Almost 1 in 5 respondents (18.6%) was unaware that a certified ostomy nurse practiced at their institution. CONCLUSION: Confidence of staff nurses in delivering ostomy care was higher with training and experience. Opportunities for continuing education may increase staff nurse confidence in providing ostomy care. The greatest barrier was lack of knowledge about the presence of an ostomy nurse as a resource in caring for patients.
560 J WOCN ■ November/December 2014
■ Introduction Ostomy surgeries are performed for many reasons such as cancer, diverticulitis, or trauma. The number of people living with an ostomy in the United States is approximately 650,000 to 730,000.1 A report from the United Ostomy Associations of America estimated that 128,000 new ostomy surgeries were performed in 2007.1 Patients admitted to hospitals for ostomy surgery often experience anxiety, fear, depression, body image impairment, anger, and denial.2 Previous studies have shown the numerous advantages of involving a WOC nurse in preoperative as well as postoperative care and teaching.3-7 Even established ostomy patients experience anxiety when hospitalized, concerned that their ostomy needs may not be met in terms of routine care and supplies. The nursing care of persons with ostomies requires specific knowledge, skills, and appropriate supplies. While WOC nurses strive to provide education and care to all ostomy patients, they must rely on staff nurses to deliver routine care to these patients. Having a staff nurse who is confident and knowledgeable in providing this care is hypothesized to play a significant role in patients’ satisfaction with overall care received.5 This study addressed
Heidi Huddleston Cross, RN, MSN, FNP-BC, CWOCN, Upstate University Hospital, Syracuse, New York. Cheryl A. Roe, MS, Instructor, Upstate Medical University, Syracuse, New York. Dongliang Wang, PhD, Assistant Professor, Department of Public Health and Preventive Medicine, Upstate Medical University, Syracuse, New York. The authors declare no conflict of interest. Correspondence: Heidi Huddleston Cross, RN, MSN, FNP-BC, CWOCN, Upstate University Hospital, 750 East Adams St, Syracuse, NY 13210 ([email protected].). DOI: 10.1097/WON.0000000000000065
Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 560
31/10/14 5:06 PM
J WOCN
■ Volume 41/Number 6
2 questions related to staff nurse confidence when delivering care to persons with an ostomy: (1) What is the selfperceived confidence level of staff nurses related to care of ostomy patients in terms of knowledge, skills, and supplies and (2) what are the potential barriers (related to attitudes, beliefs, and work conditions) staff nurses face when caring for ostomy patients? We operationally defined confidence as belief or selfassurance in one’s ability to succeed.8 Ostomy care was operationally defined as the routine care of patients with ostomies such as emptying, changing, stoma and skin care, and procuring supplies. For the purposes of this study, barriers are defined as factors that impede the nurse’s ability to deliver ostomy care and education to patients.
■ Methods An electronic survey was developed and distributed to RNs and licensed practical nurses (LPNs) at 3 acute care facilities, including a 409-bed academic medical center, a 466-bed acute care facility, and a 103-bed Veteran’s Administration Medical Center. Study procedures were reviewed by the institutional review boards of the 3 respective facilities, and all granted exemption from review. The survey was distributed by e-mail using Survey Monkey (http://www.surveymonkey.com), using each institution’s “All nurses list.” The target population was any currently practicing RN or LPN caring for adult or pediatric patients with an ostomy. An explanatory letter was included, with completion of the survey indicating consent to participate. As an incentive, each participant was offered participation in a raffle for a $100 gift certificate, with a total of 7 certificates awarded. At the primary investigator’s institution, coffee coupons were offered to any nurse completing the survey; this additional incentive was offered because participants at this research site had participated in the content validation process, placing an additional burden on their time.
■ Instrument The questionnaire we used was developed for purposes of this study. The survey included items regarding demographic data, availability of and referral to an ostomy nurse, training in school, frequency of care, and 2 tables with agree-disagree items on a 6-point Likert Scale (1 = Strongly Disagree, 6 = Strongly Agree). Items queried factors related to nursing confidence, and others queried potential barriers. Confidence level-type questions were grouped according to knowledge, skills, and supplies. A single question was included that queried the use of supplies, which was insufficient for statistical analysis. Responses to that item were grouped with other knowledge questions. Confidence level in terms of knowledge was measured by 7 questions, while the confidence level for skills was measured by 6 items. Survey questions about barriers were grouped according to 3 areas: attitudes,
Cross et al
561
beliefs, and work conditions. A single item focused on attitudes, and it was grouped with belief questions. Therefore, belief was measured by 5 items, and work conditions by 4 items. The questionnaire used in our study underwent content validation. Content is the extent to which the method of measurement includes all the major elements relevant to the construct being measured.9 To achieve content validity, the questionnaire was presented to skin care resource and research nurses in our facility, who were asked to review the questionnaire for readability and comprehension. In addition, a panel of WOC nurses reviewed the questionnaire and evaluated the extent to which it queried all aspects of the primary construct of the study. The questionnaire was revised based on these groups’ recommendations, with repetition of this process until all were in full agreement that the objectives had been met.
■ Data Analysis For descriptive purpose, responses to each item included in the survey were tallied and displayed in a tabular format. Numeric variables were summarized using descriptive statistics such as mean and standard deviation. Frequencies and relative frequencies were computed for all categorical variables, and box plots were used to display the data when appropriate. Confidence levels were measured via scores calculated by summing responses over a group of related question items. The reliability of these question groupings was investigated using factor analysis, and by computing the Cronbach alpha for each group. Subjects having a missing value for any question within a group were excluded from the analysis. For 6 questions, the scale on the disagree-agree continuum was reversed to more accurately align positive versus negative responses. For example, “Ostomy care is unpleasant, making me at times reluctant to do it,” where an answer of “strongly agree” would indicate a negative response. The effects of other factors on the levels of confidence and perception of barriers were assessed by either 2-sample t tests or analysis of variance (ANOVA). Alternative statistical methods assuming unequal variances were applied if the assumption of equality of variances between groups did not hold. Linear regressions were applied for factors with ordinal scales, including the number of years of nursing, frequency of care, and understanding how to obtain supplies and how to use them. A P level ≤ .05 was used to determine statistical significance. Data analyses were performed using SAS version 9.2 statistical software (SAS Institute, Cary, North Carolina).
■ Results Six hundred fifty surveys were returned; however, 74 surveys were provided by nurses who indicated that they did not provide direct care to inpatients. These respondents
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 561
31/10/14 5:06 PM
562
J WOCN
Cross et al
were eliminated from data analysis, leaving 576 evaluable surveys. We were unable to calculate a precise response rate; we were not informed of how many nurses were on the lists, and some addresses had not been updated, resulting in returned e-mails. Approximately 2600 e-mails were sent (minus returned e-mails), resulting in an approximate 25% response rate. Demographic and clinical practice characteristics are summarized in Table 1. Ninety percent of respondents were women; 82% primarily cared for adults, 12% pediatrics, and the rest indicated both. Eighty-eight percent were RNs, and 11% were LPNs. Fifty-one percent had been a nurse for 10 years or less, 22% indicated 11 to 20 years’ experience, 15% had practiced for 21 to 30 years, and 12% for more than 30 years. Those on surgical units comprised the largest group (21%), followed by critical care nurses (18%) and nurses on medical units (16%). Survey respondents were asked if there was a certified ostomy nurse at their facility. All 3 facilities have an active wound and ostomy program, yet 4% of respondents indicated “No” and 14.6% indicated “I don’t know.” In response to the item “I consult the ostomy nurse when I have a patient with a new ostomy,” 22.5% responded “No” and 5.6% indicated absence of an ostomy nurse at their facility. Similar results were found for the statement, “I consult the ostomy nurse in my facility/practice when I have a patient with difficulty such as leakage and skin breakdown,” with 12.8% indicating “no” and 5.6% indicating no knowledge of one. Table 2 summarizes responses to items that queried confidence delivering ostomy care. The highest mean was associated with emptying an ostomy appliance (mean ± SD, 5.32 ± 0.919), and the lowest was in knowledge of nutrition (3.96 ± 1.217). The Cronbach alpha was 0.91 for the knowledge group and 0.94 for the skills group, indicating adequate internal reliability. The mean knowledge score for the group, based on 526 completed responses to this section of the survey, was 30.96 ± 6.65, and the mean score for skill level in providing ostomy care, based on 535 evaluable responses, was 28.32 ± 6.12. The mean score for knowledge items was slightly above an “Agree” response, while the mean for skills fell between “Slightly Agree” and “Agree.” Licensed practical nurses reported higher confidence levels for knowledge (34.3 ± 5.5 vs 30.6 ± 6.7, P < .0001) than RNs. They also reported higher confidence levels for skills when compared to RNs (30.1 ± 6.1 vs 28.1 ± 6.1, P = .003). Years of nursing experience was significantly related to self-perceived confidence level of knowledge (P = .009) and to the confidence level of skills (P = .01), as was having received training in school (P = .002 for knowledge; .04 for skills). With 1 more year of experience, the mean self-perceived confidence level of knowledge was 0.32 higher and the mean confidence level of skill was 0.27 higher. The mean difference in confidence levels between nurses with and without training was 2.2 in terms
■ November/December 2014
TABLE 1.
Respondent Demographics Demographic Characteristics
% (n)
Primary area of practice Adult
81.9% (472)
Pediatric
12.3% (71)
Both
5.4% (31)
Are you an RN
88.5% (510)
LPN
10.6% (61)
Unspecified
0.9% (5)
Gender Male Female
8.9% (51) 89.9% (518)
Age, y 20-30
24.7% (142)
31-40
24.0% (138)
41-50
27.1% (156)
51-60
22.2% (128)
61+
2.1% (12)
How many years have you been a nurse? 1-10
50.9% (292)
11-20
21.9% (126)
21-30
14.6% (84)
>30
12.5% (72)
Primary area of focus Surgical
21.0% (121)
Critical care
18.1% (104)
Medical
15.8% (91)
Oncology
9.5% (55)
Cardiology
5.6% (32)
Rehabilitation
5.0% (29)
Emergency department
4.9% (28)
Perioperative
4.9% (28)
Neurology
4.2% (24)
Psychiatry
2.6% (15)
Float pool
2.4% (14)
Long-term care
1.9% (11)
Neonatal
1.2% (7)
Obstetrics
0.7% (4)
Gynecology
0.5% (3)
Home care
0.7% (4)
Other
0.9% (5)
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 562
31/10/14 5:06 PM
J WOCN
■ Volume 41/Number 6
563
Cross et al 40
TABLE 2.
Knowledge and Skills Statements
Mean
b
Standard Deviationb
Knowledge statements: I feel confident:
30
20
Knowing the difference between colostomy, ileostomy, urostomy
4.89
1.094
Preventing skin problems
4.63
1.031
Dealing with odor
4.52
1.199
Knowing when to attach to a larger drainage bag
4.37
1.284
Ordering correct supplies
4.34
1.220
FIGURE 2. Frequency of ostomy care vs confidence level in
Dealing with skin problems
4.19
1.186
Teaching nutrition to ostomy patients
3.96
1.217
skills. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
Emptying an ostomy appliance
5.32
0.919
Changing an ostomy appliance
4.77
1.187
Cutting wafer to appropriate size
4.69
1.178
Measuring a stoma
4.66
1.162
Applying paste
4.63
1.2
Attaching to a larger bag
4.26
1.302
10
0 Never
Rarely
Sometimes
Frequently
Always
Frequency of ostomy care
Skills statements: I feel confident:
Scores: 1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = slightly agree, 5 = agree, 6 = strongly agree. bMean and standard deviation for the entire sample (N = 526).
a
them (Figures 5 and 6) were found to be significantly more confident in both skills and knowledge (P < .0001 for each question). Table 3 summarizes responses to belief and work environment items. As previously described, items related to beliefs or attitudes and items related to work conditions were grouped into these 2 factors. The Cronbach alpha was 0.47 for the belief group and 0.58 for the work conditions group. These Cronbach alphas do not indicate internal reliability, and therefore no further analyses were conducted using these factors.
■ Discussion The aim of this study was to examine confidence and knowledge levels of staff nurses, and the barriers they face. Persson and colleagues10 evaluated ostomy patients’ satisfaction while being cared for in hospitals and found that
Level of confidence in knowledge
of knowledge and 1.0 in terms of skill. Both of these groups were more confident than nurses who did not remember learning about ostomy management during their nursing educational program. The frequency that nurses reported caring for persons with ostomies was significantly related to confidence in knowledge and skills for both RNs and LPNs (P < .0001; Figures 1 and 2). Nurses who stated that they understood how to obtain supplies (Figures 3 and 4) and how to use 50
Level of confidence in knowledge
Level of confidence in skills
a
40
30
20
50 40 30 20 10 0
10
1
2
3
4
5
6
Understanding how to obtain ostomy supplies
0 Never
Rarely
Sometimes
Frequently
Always
Frequency of ostomy care
FIGURE 1. Frequency of ostomy care vs confidence level in
knowledge. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
FIGURE 3. Understanding how to obtain ostomy supplies vs
confidence level in knowledge. Scale: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree; 6 = strongly agree. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 563
31/10/14 5:06 PM
564
J WOCN
Cross et al 40
Level of confidence in skills
Level of confidence in skills
40
■ November/December 2014
30
20
10
0
30
20
10
0
1
2
3
4
5
6
1
2
3
4
5
6
Understanding how to use ostomy supplies
Understanding how to obtain ostomy supplies
FIGURE 6. Understanding how to use ostomy supplies vs confi-
confidence level in skills. Scale: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree; 6 = strongly agree. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
dence level in skills. Scale: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree; 6 = strongly agree. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
participants were not entirely satisfied with the quality of care they received while hospitalized. Our clinical experiences also suggest that patients with ostomies find that some needs are not met when receiving care in acute care facilities, and that nurses readily admit to a lack of confidence and knowledge in caring for patients with ostomies. Higher confidence in ostomy care knowledge and skills was associated with more training, the number of years of nursing experience, higher frequency of providing ostomy care, and knowing how to obtain and use supplies. These findings may explain why LPNs demonstrated greater confidence than RNs, with RNs perhaps assuming a greater supervisory role in practice, and LPNs more of a practical, bedside role within the 3 facilities where data were collected. We attempted to assess potential barriers related to work conditions with questions about ostomy supplies
and teaching materials availability, as well as the influence of lack of time. Lack of time did not emerge as a strong factor. The statement “Ostomy supplies are easy to order” generated responses indicating “slight agreement.” This finding suggests that ostomy nurses need to take steps to increase staff nurse knowledge about supplies available in
Level of confidence in knowledge
FIGURE 4. Understanding how to obtain ostomy supplies vs
TABLE 3.
Belief Statements and Work Conditions Means
Standard Deviation
I am concerned I may harm my patient’s stoma
4.56a
1.167
Patients refuse ostomy care, wanting to care for their ostomy themselves
3.88a
1.239
50
Patients should care for their own ostomy
4.85b
.946
40
I am concerned I may do something incorrectly
3.89a
1.357
Ostomy care is unpleasant, making me reluctant
4.28a
1.235
Ostomy supplies are easy to order
3.95b
1.213
Lack of time is a factor in delivering care promptly
3.75a
1.296
Lack of time is a factor in delivering care properly
3.96a
1.280
Ostomy patient teaching materials are available
4.49b
1.136
30
Belief statements
Work conditions
20 10 0 1
2
3
4
5
6
Understanding how to use ostomy supplies
FIGURE 5. Understanding how to use ostomy supplies vs confidence level in knowledge. Scale: 1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree; 5 = agree; 6 = strongly agree. Whisker plots illustrate, for each response group, the minimum and maximum responses, the lower, median, and upper quartiles, and mean response (+).
aReversed scale: 1 = strongly agree, 2 = agree, 3 = slightly agree, 4 = slightly disagree, 5 = disagree, 6 = strongly disagree. b1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = slightly agree, 5 = agree, 6 = strongly agree.
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 564
31/10/14 5:06 PM
J WOCN
■ Volume 41/Number 6
their institution and to simplify the ordering process. In addition to staff nurse training, we recommend additional education of distribution or central supply staff in an effort to streamline procurement of supplies. Almost 1 in 5 nurses (18.6%) indicated either that there was no ostomy nurse or that they were unaware of one in their facility, despite active ostomy departments at all 3 data collection sites. We believe that this finding represents the most clinically relevant barrier to caring for ostomy patients. It is possible that part of the reason for these responses may be that the question was being answered by off-shift nurses, when indeed an ostomy nurse may not be on the premises right at that time. Nevertheless, one would expect that referral to an ostomy nurse would be initiated, particularly with new ostomies or with issues such as leakage. Based on this finding, we advocate efforts to ensure that staff are informed about the presence of an ostomy nurse in their facility, if one is available, along with instruction about the process for consultation.
Limitations The sample population may have included responses from nurses who were not predominantly bedside nurses. Future surveys should exclude respondents who do not provide direct bedside care to inpatients in acute care facilities. Ultimately we were not able to satisfactorily answer the belief and attitude research question, owing to poor internal reliability within the belief and attitude construct items. Development of a valid and reliable tool for measuring these constructs is needed to more fully explore this clinically relevant question.
■ Conclusions Bedside nursing care of ostomy patients may be accompanied by anxiety and frustration for both patients and nurses, often due to a lack of confidence and knowledge
Cross et al
565
and skills among staff nurses who care for these patients. Findings from this study suggest that confidence of staff nurses is higher with training in ostomy care and experience with caring for patients with stomas. Opportunities for continuing education may increase staff nurse confidence in providing ostomy care. Ostomy nurses must make their presence known so that proper referral can be initiated for optimum patient care and satisfaction.
■ ACKNOWLEDGMENT This study was supported by a research grant from the Center for Clinical Investigation of the Wound, Ostomy, and Continence Nurses Society.
■ References 1. Cooke C. American ostomy census. The Phoenix. 2009;5(1):2829, 64-67. 2. Raynaud SN, Meeker BO. Coping styles of older adults with ostomies. J Gerontol Nurs. 2003;28(5):30-36. 3. Haugen V, Bliss D, Savik K. Perioperative factors that affect long-term adjustment to an incontinent ostomy. J Wound Ostomy Continence Nurs. 2006;33(5):525-535. 4. Quintana-Jimenez P, Pastor-Juan C, Prados-Herrero I, et al. A prospective, longitudinal, multicenter, cohort quality-of-life evaluation of an intensive follow-up program for patients with a stoma. Ostomy Wound Manag. 2010;56(5):44-52. 5. Marquis P, Marrel A, Jambon B. Quality of life in patients with stomas: the Montreux study. Ostomy Wound Manag. 2003;49(2):48-55. 6. Brand M, Dujovny N. Preoperative considerations and creation of normal ostomies. Clin Colon Rectal Surg. 2008;21:5-15. 7. Brown H, Randle J. Living with a stoma: a review of the literature. J Clin Nurs. 2005;14(1):74-81. 8. Soukhanov A, Rooney K, editors. Encarta World Dictionary. 1st ed. New York: St. Martin’s Press; 1999. 9. Burns N, Grove S. The Practice of Nursing Research. Philadelphia: WB Saunders; 2001:400. 10. Persson E, Gustavsson B, Hellstrom A, Lappas G, Hulten L. Ostomy patients’ perceptions of quality of care. J Adv Nurs. 2005;49(1):51-58.
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-12-00038_LR 565
31/10/14 5:06 PM
