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The Impact of Specialty Practice Nursing Care on Health-Related Quality of Life in Persons With Ostomies

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J Wound Ostomy Continence Nurs. 2015;42(3): Pulished y Lippincott Willims & Wilkins OSTOMY CARE The Impct of Specilty Prctice Nursing Cre on Helth-Relted Qulity of Life in Persons With Ostomies
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J Wound Ostomy Continence Nurs. 2015;42(3): Pulished y Lippincott Willims & Wilkins OSTOMY CARE The Impct of Specilty Prctice Nursing Cre on Helth-Relted Qulity of Life in Persons With Ostomies Cristin Coc Igncio Fernández de Lrrino Rquel Serrno Helen Grcí-Lln ABSTRACT PURPOSE: Ostomy ptients suffer significnt physiologicl chllenges tht cn ffect psychologicl vriles nd helth-relted qulity of life (HRQOL). The purpose of this study ws to compre HRQOL in group of ptients cred for in hospitls tht employed nurses specilizing in ostomy cre versus ptients who were cred for t hospitls tht did not employ nurses specilizing in ostomy cre. DESIGN: Multicenter, qusi-experimentl, prospective, longitudinl study. SUBJECTS AND SETTING: This is ntionl study set in Spin. We collected dt from 402 ostomy ptients in helth centers mong 16 Spnish regions from Mrch 2012 to June The verge ge of the ptients ws 61.3 ± yers (men ± SD). METHODS: Questionnires were dministered y the investigtors prior to nd 3 months fter the ostomy surgery. Two groups of ptients were compred: ptients in group 1 were treted y nurses specilizing in ostomies; ptients in group 2 were not treted y n ostomy nurse specilist. Two vlidted scles were used to determine HRQOL: EQ-5 D (Spnish version) nd the Montreux questionnire. RESULTS: Ptients in group 1 dpted etter to their ostomies thn group 2. They exhiited less concern with ppernce; incresed comfort with clening, chnging, nd throwing wy ostomy gs; nd decresed pin nd pin frequency. They reported less ferfulness; improvements in sleep, weight concerns, nd strength; nd etter overll helth, leding to greter percentge of ptients le to led norml life ( P .05). Sexul ctivity ws the only vrile tht worsened in oth groups, ut it ws more stisfctory t postopertion stge in group 1 ( P =.015). CONCLUSIONS: Ptients who received specilized ostomy cre experienced significnt improvements in HRQOL compred to ptients who were not cred for y specilist nurses. Our findings strongly suggest tht ptients undergoing ostomy surgery should e provided ccess to nurse specilist in ostomy cre since our results highlight the potentil enefit promoting the HRQOL of ptients. KEY WORDS: continence nursing, helth-relted qulity of life, ostomy, ostomy, specilty prctice nursing, well-eing, wound Introduction The cretion of n ostomy impcts ody imge, sexul function, mood, dily functioning, nd socil ctivities; its presence ffects the person nd those round them. 1-4 Persons living with n ostomy require eduction nd trining to mnge their stom nd to identify nd prevent stoml or peristoml complictions. 5, 6 While cretion of n ostomy is ssocited with n incresed lifespn, it exerts vrile effects on helth-relted qulity of life (HRQOL) The clinicl relevnce of HRQOL is incresingly recognized in recent decdes, prtilly due to n increse in the numer of persons living with 1 or more chronic conditions. 12, 13 Since HRQOL is sed on sujective ssessment, vlid nd relile instruments re essentil for its ssessment in oth clinicl nd reserch settings. 14 Persons living with n ostomy require comprehensive nd personlized cre. 15, 16 The first trining progrm devoted to enterostoml therpy ws creted in the United Sttes over 50 yers go. 17 The professionlism, competence, nd ility of stom therpists hve received widespred recognition Nevertheless, Spnish hospitls mnge ptient cre in ptients with ostomies in very different wys. Some Cristin Coc, PhD, Instituto Ante, Mdrid, Spin. Igncio Fernández de Lrrino, MPsy, Instituto Ante, Mdrid, Spin. Rquel Serrno, MPsy, Instituto Ante, Mdrid, Spin. Helen Grcí-Lln, PhD, IdiPAZ, Hospitl Universitrio L Pz, Mdrid, Spin. The uthors declre no conflict of interest. Correspondence: Igncio Fernández de Lrrino, Instituto Ante, C /Mrí de Guzmán 9, 4º A , Mdrid, Spin ( ). DOI: /WON Copyright 2015 y the Wound, Ostomy nd Continence Nurses Society J WOCN My/June 258 Coc et l J WOCN My/June 2015 centers employ nursing professionls tht specilize in ostomies, while others do not. The purpose of this study ws to compre HRQOL in 2 groups of persons with ostomies; sujects in group 1 were cred for y hospitls tht employed nurses specilizing in ostomy cre nd group 2 prticipnts were cred for t hospitls tht did not employ nurses specilizing in ostomy cre. We hypothesized tht stom cre delivered y specilty prctice ostomy nurses will result in etter outcomes for persons with stoms. Specific outcomes we evluted were moility difficulties, difficulties in personl cre nd usul ctivities, pin/discomfort, nxiety/depression, nd self-reported helth sttus. Methods The trget popultion comprised ptients scheduled to undergo ostomy surgery during 15-month period (Mrch 2012 to My 2013). Inclusion criteri were (1) cretion of new ostomy (colostomy, ileostomy, or urostomy); (2) 18 yers of ge, nd (3) sufficiently literte to complete study forms nd provide informed consent for prticiption. Exclusion criteri were inility to cre for their stom, inility to complete the questionnire, nd voluntry study withdrwl. Reserch procedures were reviewed nd pproved y 20 ethics committees enling us to smple ptients from 160 hospitls in Spin. Our informed consent protocol ssured confidentility, the voluntry nture of prticiption, nd nonymity; it conformed to Orgnic Lw 15/1999 for the Protection of Informtion. Instruments Study mterils included presurgicl intervention dt such s demogrphic informtion, clinicl dt relted to surgicl intervention, nd stom type. Prticipnts lso completed 2 instruments designed to mesure HRQOL. The EuroQol EQ 5D is generic HRQOL instrument previously vlidted for Spnish popultion. 23, 24 It consists of questionnire nd visul nlogue scle (EQ-VAS). The EQ-VAS mesures self-rted helth sttus using visul nlog scle. The EQ-VAS records the sujects perceptions of their own current overll helth nd cn e used to monitor chnges with time. The self-ssessment questionnire queries the suject s current helth in 5 dimensions: moility, self-cre, usul ctivities, pin/discomfort, nd nxiety/depression. Respondents re sked to grde their level of function in ech dimension sed on 3-point Likert scle (severe, moderte, or no disility). The Montreux instrument is disese-specific HRQOL instrument previously vlidted for Spnish popultion y Brero Juárez nd collegues. 7, 25 This 40-item questionnire ws sed on Likert scle of 6 vlues (0-5) nd collects informtion from different dimensions relted to the HRQOL nd then orgnized into 3 sections: Section 1 queries self-mngement relted to the hygienic cre of the stom; section 2 queries HRQOL in the following domins physicl well-eing, psychologicl well-eing, ody imge, pin, sexul ctivity, nutrition, socil concerns, nd mngement of devices; nd Section 3 queries generl issues in reltion to the cceptnce of the stom nd fmily reltionships. Scores rnge from 0 to 100. Higher scores indicte greter HRQOL. Both questionnires cn e completed in pproximtely 15 minutes. Study Procedures Two hundred ninety-seven investigtors from 160 hospitls collected dt from Mrch 2012 through June Prticipnts completed the instruments prior to nd 3 months fter ostomy surgery. Questionnires were dministered y the on-site investigtor upon dmission to hospitl nd during follow-up clinic visit. Ptients were informed of the purpose of the study nd provided written nd orl consent. Ptients under cre from nurse specilizing in ostomy cre received miniml suite of services during the preopertive nd postopertive phses. During the postopertive phse, the minimum suite of services included (1) comprehensive nursing ssessment nd (2) ssessment of HRQOL including ody imge nd sexul ctivity. In the protocol, we did not include stom site mrking since dt collectors ssessed oth urgent nd scheduled opertions nd were not consistently le to provide this service. The minimum suite of services offered during the postopertive phse (1) eduction regrding evlution, cre, nd hygiene of the stom nd peristoml skin; (2) eduction nd skill trining focusing on pouching system cre nd chnges; (3) dietry nd nutritionl dvice; (4) instruction on how to prevent nd recognize complictions; nd (5) dischrge with support (y telephone or ppointment), including emotionl support, support to promote dherence to phrmcologicl tretment, nd evlution nd monitoring. Dt Anlysis Dt were collected nd nlyzed using the Sttisticl Pckge for the Socil Sciences softwre, version 15 (SPSS, Chicgo, Illinois). We used the Student t test to evlute etweengroup differences for mens of quntittive vriles with norml distriution. When the requirements re not met for using prmetric tests, we chose the chi-squre test ( χ 2 ) to nlyze frequencies within ctegoricl vriles nd the Fisher exct test for dichotomous nlysis of frequency tles. The Mnn-Whitney U nd Kolmogorov-Smirnov (K-S) tests for 2 independent smples were lso used to compre group differences. Finlly, the Wilcoxon rnk test nd the Signs test for 2 relted smples were used to test questions in the sme group t 2 different time points (efore nd fter 3 months of the opertion). P vlues .05 were deemed sttisticlly significnt. Results Two thousnd two hundred questionnires were sent to prticipnts. Nine hundred were returned, ut 506 were J WOCN Volume 42/Numer 3 Coc et l 259 eliminted ecuse they were incomplete, the individul did not require ostomy surgery, or the person died. Four hundred two responses were deemed suitle for nlysis (313 in group 1 nd 89 in group 2), reflecting response rte of 18.3%. Two hundred eighty-nine (72%) prticipnts were mle. Respondents men ge ws 61.3 ± 13.7 yers (men ± SD). More thn three qurters of prticipnts (78%) were mrried, nd slightly more thn hlf (50.8%) were retired. Tle 1 summrizes sociodemogrphic chrcteristics of the study smple. Ostomy Chrcteristics The most common disese leding to ostomy cretion ws cncer, occurring in 80.3% of prticipnts. Colostomy ws the most prevlent form of stom, occurring in 51.6% of prticipnts, followed y ileostomies in 28.7% nd urostomies in 16.5%. Surgicl procedures requiring cretion of 2 to 3 types of ostomies occurred in 3.0% of respondents. More thn hlf of prticipnts hd permnent ostomy: 47.2% of group 1 prticipnts nd 52.8% of group 2 prticipnts. Temporry ostomies were performed in 41.8% of opertions, including 61.7% of opertions in group 1 nd 38.3% in group 2. More thn three qurters (81.1%) of the surgicl procedures leding to ostomy cretion were scheduled, ut 18.9% of prticipnts hd emergency opertions. Scheduled interventions were more common in group 1; nerly two-thirds of emergency procedures were performed on group 2 prticipnts ( P =.004). Ptients in group 1 were more likely to undergo preopertive stom site mrking thn were group 2 prticipnts (80.4% vs TABLE 1. Sociodemogrphic Chrcteristics y Group nd Totl Smple Group 1 (With SOC) Group 2 (Without SOC) P Totl Men ge (S.T.) 62.7 yers old (S. T = 13.1) 59.3 yers old (S.T = 14.2) yers old (13.7) Mritl sttus.88 Mrried 80.8% 74.5% 77.9% Single 10.3% 13.8% 11.9% Widow 6.1% 4.3% 5.2% Other 2.8% 7.4% 5.0% Living sitution.88 Prtner nd children 48.8% 48.4% 48.6% Prtner without children 33.0% 31.4% 32.3% Alone 8.8% 7.4% 8.2% With prents 6.0% 3.7% 5.0% With friends 0.6% 2.7% 1.5% Other 2.8% 6.4% 4.5% Eduction level.88 Elementry 48.6% 58.3% 52.8% High school 29.0% 23.9% 26.8% University level studies 12.9% 16.6% 14.5% Other 9.5% 1.2% 5.9% Work sitution.88 Pensioner 54.5% 47.0% 50.8% Employed 27.6% 38.7% 33.1% Unemployed 6.5% 3.9% 5.3% Retired (disled) 3.3% 2.8% 3.0% Student 0.9% 2.2% 1.5% Other 7.0% 5.5% 6.3% Arevition: SOC, specilized ostomy cre. Student t test. Chi-squre test. 260 Coc et l J WOCN My/June 2015 TABLE 2. Descriptions of Perceived HRQOL, VAS EQ-5D in Accordnce to Group nd Evlution Time, Before nd After (3 Months) the Ostomy Group 1 (With SOC) Group 2 (Without SOC) Descriptions Preopertive Ostomy Surgery P Preopertive Ostomy Surgery P Medin (typicl devition) 70.0 (21.6) 80.0 (14.8) (24.4) 60.0 (21.1).100 Arevitions: HRQOL, helth-relted qulity of life; SOC, specilized ostomy cre; VAS, visul nlogue scle. Sttisticlly significnt difference Wilcoxon nd Signs tests in preopertive nd fter 3-month ostomy VAS EQ-5D. No sttisticlly significnt difference Wilcoxon nd Signs tests in group %; P .001). We compred sociodemogrphic chrcteristics of the 2 groups, using the Mnn-Whitney nd Kolmogorov-Smirnov tests ( P vlues hve een provided in Tle 1 ). We found no sttisticlly significnt difference etween groups 1 nd 2, sed on these vriles. HRQOL in Ptients With nd Without Cre From n Ostomy Nurse Specilist Men HRQOL improved in oth groups, ut these differences were sttisticlly significnt only in group 1 ( P .001 for the Wilcoxon nd Sign Test). Descriptions of Perceived HRQOL ssessed using visul nlogue scle (VAS) EQ-5D in ccordnce to group nd evlution time, prior to nd following ostomy surgery, re summrized in Tle 2. Glol score from index EQ-5D (5 dimensions) is descried in Tle 3 (the digits for 5 dimensions cn e comined in 5-digit numer descriing the respondent s helth stte glol score). Tle 4 summrizes HRQOL Montreux index scores in ccordnce with group nd study time. We found significnt differences in terms of physicl well-eing t 3-month follow-up following ostomy surgery (group 1: ± vs group 2: ± 18.01; K-S = 1.458, P =.029; Mnn-Whitney U = 18,261.5, P =.003). After 3 months, ll ptients reported less discomfort/pin, ut the mgnitude of improvement ws significntly greter in group 1 ( χ 2 = 18,825; P .001) ( Figure 1 ). Group 1 prticipnts reported more strength 3 months fter the opertion (87.5%, group 1; 77.5%, group 2; K-S = 1.458, P =.029; Mnn-Whitney U = 18,409.5, P =.002). Approximtely one-third of prticipnts (31.8%) reported tht they were esily tired t 3 months fter ostomy surgery, 25.3% reported getting little tired, 32.0% got very little tired, nd 10.9% stted tht they felt no tiredness. Prticipnts in group 2 reported eing more tired t 3 months thn did ptients in group 1 (K-S = 1.867, P =.002; Mnn-Whitney U : 16,089.5, P .001). When queried prior to stom surgery, 76.4% of prticipnts felt tht despite the ostomy, they would e le to led norml life. Three months following surgery, the percentge of prticipnts who felt they could crry on norml life incresed to 83.5%; significntly more sujects in group 1 reported tht they would e le to led norml life thn prticipnts in group 2 (87.9% vs 78.5%; K-S = , P .001; Mnn-Whitney U = 17,942, P .001). Ptients from group 1 were lso more likely to report enjoying leisure time nd socil life (K-S = , P .001; Mnn-Whitney U : 17,942, P .001). Sexul ctivity decresed in oth groups following ostomy cretion. Before surgery, 66.9% of prticipnts reported tht their sexul ctivity ws completely sufficient for their needs (71.5% group 1, 61.7% group 2). However, sujects in group 1 were more likely to report TABLE 3. Descriptions of HRQOL EQ-5D Index, in Accordnce With Group nd Study Time Group 1 (With SOC) Group 2 (Without SOC) Descriptions Preopertive Ostomy Surgery P Preopertive Ostomy Surgery P Medin (typicl devition) (0.2307) (0.2178) (0.2749) (0.2221).625 Arevitions: HRQOL, helth-relted qulity of life; SOC, specilized ostomy cre. Sttisticlly significnt difference Wilcoxon nd Signs tests in preopertive nd fter 3-month ostomy EQ-5D index. No sttisticlly significnt difference Wilcoxon nd Signs tests in group 2. J WOCN Volume 42/Numer 3 Coc et l 261 TABLE 4. Descriptions of HRQOL Montreux Index in Accordnce With Group nd Study Time Group 1 (With SOC) Group 2 (Without SOC) Descriptions Preopertive Ostomy Surgery P Preopertive Ostomy Surgery P Medin (typicl devition) 68.7 (14.2) 74.8 (12.8) (15.1) 69.6 (14.8).383 Arevitions: HRQOL, helth-relted qulity of life; SOC, specilized ostomy cre. Sttisticlly significnt difference Wilcoxon nd Signs tests in preopertive nd fter 3-month ostomy EQ-5D index. No sttisticlly significnt difference Wilcoxon nd Signs test in group 2. sexul ctivity rted s sufficient thn were sujects in group 2 (K-S = 1.420, P =.035; Mnn-Whitney U = 19,926, P =.015). Concerns out the effect of the stom on ody imge were lso more likely to decrese in group 1 ptients (K-S = 1.996, P .001; Mnn-Whitney U = 16,728, P .001). Psychologicl well-eing in groups 1 nd 2 differed 3 months postostomy. Group 1 reported higher levels of FIGURE 1. Percentge of persons with ostomies with pin/ discomfort (A) pre- nd (B) 3 months postsurgery, strtified ccording to whether prticipnts received specilized ostomy cre (SOC) (P =.027) (χ 2 = 18,825; 2 l.g; P .001). hppiness (K-S = 1.527, P =.019; nd K-S = 1.543, P =.017), while group 2 experienced decline in hppiness nd stisfction with life (Mnn-Whitney U : 18,159, P .001; Mnn-Whitney U = 18,862, P =.008). More thn hlf of prticipnts (56.3%) reported fer of odors or lekge from the stom preopertively; only 32.6% retined tht fer 3 months postopertion. The highest levels of fer of odor nd lekge were reported in group 2 (K-S = 1.441, P =.031; Mnn-Whitney U : 36,604.5, P .001). Thirty-four percent of ptients reported nxiety relted to looking t their ostomy prior to surgery; no significnt differences were found when groups were compred. By month 3 following surgery, the proportion of ptents who experienced difficulty looking t their ostomy decresed to 15.9%. Ptients in group 1 were less likely to report difficulty looking t their stoms (K-S = 1.420, P =.035; Mnn-Whitney U : 19,926, P =.015). Self-mngement of the ostomy lso differed sed on vilility of n ostomy nurse specilist. Prticipnts in group 1 reported feeling more secure in clensing their stom thn those in group 2 (92.1% vs 75.0%; K-S = 1.834, P =.002; Mnn-Whitney U = 21,457.5, P =.005). They lso reported feeling more chnging the ostomy (94.8% in group 1 vs 80.0% in group 2; K-S = 2.644, P .001; Mnn- Whitney U : 20,987, P .001). Group 1 sujects reported greter security in their ility to otin ostomy supplies thn group 2 ptients (94.8% vs 80%; K-S = 2.677, P .001; Mnn-Whitney U : 19,071, P .001). Group 1 sujects lso reported greter confidence in ccess to someone who could provide expert dvice out prolems with their ostomies thn group 2 prticipnts (97.2% vs 77.3%; K-S = 3.571, P .001; Mnn-Whitney U : 17,435.5, P .001). When queried out dpttion to their ostomy, 56.7% of prticipnts felt tht they would sometimes, often, or lwys e le to completely forget out their stom. More ptients in group 2 reported optimism prior to surgery when compred to group 1 sujects (63.1% vs 50.7%). These proportions chnged following surgery; group 1 sujects experienced rise in the proportion who reported the ility to forget out their stom t times (50.7% vs 65.5%), while group 2 prticipnts experienced slight decline in this component of dpttion to their 262 Coc et l J WOCN My/June 2015 ostomy (63.1% vs 52.8%); differences in dpttion to the stom t 3 months ws sttisticlly significnt (K-S = 1.856, P =.002; Mnn-Whitney U : 19,776.5, P =.011). When queried out negtive dpttion to n ostomy efore surgery, 45.9% of prticipnts greed, very much greed, or completely greed with the sttement it would e impossile to ccept hving n ostomy (52.0% group 1, 39.2% group 2). This proportion declined to 35.8% following surgery, nd sujects in group 1 were less likely to report difficulty ccepting hving n ostomy thn were sujects in group 2 (32.2% vs 41.8%; K-S = 2.185, P .001; Mnn-Whitney U : 36,387, P =.008). Discussion Prticipnts who received specilized ostomy cre experienced higher HRQOL thn those who did not receive cre from n ostomy specilist ( P .05), s mesured y the EQ-50 nd Montreux questionnires. Our findings re similr to those reported in other studies of specilized cre Our results were lso consistent with those of Shrpe nd collegues, 30 who reported sttisticlly significnt improvements in the HRQOL when ptients received cre from n ostomy nurse specilist 3 months fter stom surgery. Our findings re lso consistent with other studies tht reported more positive dpttion to stom fter hospitl dischrge when ptients receive cre from n ostomy nurse speci
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