Effect of Educational Program on Nurses Performance about Colostomy Care

Introduction

Colorectal cancer (CRC) has a major international health concern because of its high incidence and mortality rates (Favoriti, et al., 2016). The CRC, which comprises approximately 1 million and 400 new cases and about 700 deaths, is the third most prevalent type of malignancy in the United Nations Association and the 4th largest global cause of cancer mortality worldwide (Arnold, et al., 2016).

Over the past few years, the prevalence of CRC has increased enormously; in particular, the number of newly diagnosed CRC cases has increased from 700 to 83000 in 1990 to 1 million and 31 1000 in 2012 (Ferlay, et al., 2015 &Rafiemanesh, et al., 2016). The colostomy is a stoma that is formed after removing the large bowel or colon and is an opening in the abdominal wall that's made during surgery (Laughlin & Rullier, 2018).      

The most secure type of treatment can include acute diverticulitis, rectal cancer, trauma, or bowel-inflammatory conditions (Huang, et al., 2020). Physical and psychological issues including anxiety, shame, depression, and a negative physical image affect patients with a stoma
(Betty Lebona, et al., 2016).         

Nurses can play a major part in the understanding and have an important role in adjustment to the colostomy patients and their families. This position is only effective if the nurses have expertise and skills help (Chindaprasirt, et al., 2017).

Initial evaluation and education help for patients in the colostomy surgery, before and after surgery, however, Patient care and education quality are influenced by the expertise and capacity of nurses. Since patient care is one of the tasks of nurses, they need enough expertise to care for patients (Duruk & Uçar, 2018). 

Therefore, the understanding of nursing skills and expertise influences patient education and healthcare satisfaction. Nurses should be qualified before hospital discharge to determine the physical, psychological, and cultural needs of the patient (Nazike Duruk, 2017).

Significance of the Study

United Ostomy Association (UOA) 2015 stated that over 750,000 Americans currently have an ostomy. However, about 36 % of the surgeries performed are colostomies.  While, in Hong Kong (2017), there are approximately 15,000 patients with a stoma. Furthermore, in the Netherlands in 2017, there are about 32,000persons with a permanent stoma. Other report estimates that 650,000 people in Egypt currently have a stoma and about 3000 new surgeries are performed each year with a colostomy (Sheikh et al., 2013).

Evidence-based practice (EBP) has demonstrated that preoperative ostomy education is more effective than postoperative. Instituting a coordinated EBP approach preoperatively to ostomy care resulted in 75% of participants achieving ostomy independence in 5 days or less (Bryan & Dukes, 2017). Preoperative ostomy nurse education programs are associated with a greater probability for improvement in the ostomy patient outcomes (Subih & Neil, 2016).

Aim of the Study

The current study aimed to assess the effect of educational program on nurse's performance about colostomy care.

Research hypothesis:

(1)            There will be a significant difference between the pre-test and post-test of knowledge level regarding colostomy care among study sample nurses.

(2)            There will be a significant difference between the pre-test and post-test of practice level regarding colostomy care among study sample nurses.

(3)            There will be a positive relationship between selected socio-demographic variables and nurses performance.

Research Design

A Quazi- experimental research design was utilized to fulfill the aim of this study.

Setting

The current study was carried out at two settings: 1^st setting oncology center (Surgical department, inpatient chemotherapy department), 2^ndsetting Minia University Hospital (General surgical department).

Sample

The sample was selected by randomization method (40) of all nurses who were working in the selected settings that mentioned before and were participate in the study would be included.

Inclusion Criteriafor the nurses:-

All nurses are on duties.

Exclusion Criteria for the nurses:

Nurses who aren’t will to participate in this study.

Study Duration:

The total data collection was collected over a period of six months starting from July 2019 to December 2019.

Data Collection Tools:

Tools of data collection were developed by the researcher after extensive review of literature and similar studies conducted elsewhere. After that the developed questionnaires are revised by 5 panels of medical surgical nursing staff, a structured knowledge questionnaire was developed.

Data collection: The data was collected by using two tools:

The First Tool:

Part I: Socio demographic data sheet for nurses including (age - gender - working department – educational status-occupation-years of experiences, etc.

Part II : Structured knowledge questionnaire  to assess nurses knowledge about colostomy care ,  it was  modified by the researcher after extensive literature review and  it   includes   20 questions about colostomy care such as meaning of colostomy, indication, types, normal appearance of the stoma, types of pouches ……etc.

Scoring System:

• Each correct answer was given a score of one and incorrect answer a score of zero, it was assigned for each answer representation (correct, incorrect) respectively.
• Total score for knowledge questionnaire about colostomy care classified as (low knowledge <60% (< 12 score), moderate knowledge 60% - 75% (12-15 score), high knowledge ≤75% (15- score or above) (Nabeel, et al., 2013).

Second Tool: “Observational Checklist Sheet about Colostomy Care”:

• This sheet was filled by the researcher, it was adopted from (Potter ,et al., 2016),it consists of 4^th domains for evaluating nursing practice about  colostomy care :
  • 1^st domain assessment of the   stoma and peristomal skin including (7) steps.
  •  2^nd domain Applying new ostomy appliance including (25) step.
  •  3^rd domain irrigation of the stoma including (27) step.
  • 4^th domain emptying the pouchincluding (8) steps.

Scoring System:

The score for each domain rank from (0-1-2), not done was given a score (0), done in-correctly was given a score (1), done correctly given a score (2) the score for each item were summed to create a total score 134 items.

Total observational checklist about colostomy care (≤ 60%) was considered satisfactory, (< 60%) was considered unsatisfactory.

Total scores were classified as (weak performance < 60%, acceptance performance 60 % - 75%, good performance knowledge ≤75%.                               

Tools validity

The study tools were developed after reviewing the related literature .To determine content and face validity, these tools were tested by a Jure committee that consists of five medical-surgical nursing experts. Recommendations were followed, the questions that were not appropriate were taken out and some questions needed clarification and modifications were done.

Tools reliability

Tools were tested for content reliability using Alpha Cronbach’stest.it was (0.96) for the first tool, (0.86) for the second tool. 

Pilot study

A pilot study was conducted on (4 nurses) 10% of the total sample to test feasibility, objectivity, and applicability of the data collection tool .To estimate the needed time to fill the data collection. Based on the results of the pilot study, no refinement/modifications were done for data collection instruments; nurses who shared in the pilot study were included in the actual study sample.

Ethical Consideration        

 An official permission to carry out the study was obtained from the ethical committee of the faculty of nursing, dean of nursing faculty, Oncology Center director and Minia University Hospitaldirector.

Subject's participation in this study was voluntary, they were informed about the importance, aim, nature, and purpose of the study, and they had the right to withdraw from the study at any time without any rationale. Oral and written consents were obtained from subjects; they were informed that the obtained data will not be included at any further researches without a second consent. Confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data.

Procedure

 The current study was achieved through three phases, Assessment phase (pre- test), implementation phase (conducting education program) post-test immediately, and follow up phase.

 1-Assessment phase :-(pre-test)

Once official permission were granted ,the assessment phase  (pre-test) collected through(six weeks) to test studied sample actual level of knowledge and practice regarding colostomy care.

The researcher collected the sample through three days per week (In morning &evening shift). The study was carried out in the period from july2019through December.

• During assessment phase the researcher held the first meeting with nurses to introduce herself and giving an explanation about the nature and purpose of the study .they were informed that about participation in this study is voluntary and they had the right to withdraw at any time, oral approval of nurses to share in the study was achieved.
• After obtaining the acceptance from nurses to participate in the current study,  the researcher provided an over view and clarification about the assessment  questionnaire then the self- administered questionnaire  was distributed to each nurse to assess data related to socio-demographic status(Appendix A) ,the questionnaire took about 15 minute to be completed.
• The total sample (40) was divided in to small group (4 group) each group consists of (10) nurses, each group received (3) session.
•  The time of each session was taken (35 to 45) minutes.
• First session of assessment phase (pre-test) the researcher assesses knowledge of nurses about colostomy care by using 1^st tool (Appendix A).
• Second &Third session of assessment phase (pre-test) the researcher assess practice of nurses about colostomy care by using 2^nd tool (Appendix B).

2- Implementation phase:( post-test immediately)

• During implementation of education program, the nurse in the study sample received the knowledge about colostomy care and the researcher applies the following procedures to the patient in front of nurses: how to assess stoma and peristomal skin, changing the ostomy appliance, colostomy irrigation and pouch emptying.
• Then allow nurses to asking questions, discussion and reach high level of understanding.
• This phase also was taken three sessions for each group (10 nurses), each session took about (30-45 minutes).
• During first session the researcher explained knowledge and demonstrated steps of   colostomy care that mention before, applied the procedure of pouch emptying, assessment of  stoma and  peristomal skin care  ,according to checklist in front of study sample group. 
• Second session: the researcher applied the procedure of changing an ostomy appliance and colostomy   irrigation, according to checklist in front of study sample group.
• Third session: post-test immediately was done for each group by using 1^st tool&2^nd tool (Appendix A& Appendix B).

3-Evaluation phase (follow up)

Three time of evaluation were done for each nurse:

(1)            First time of evaluation (pretest) done before implementation of the knowledge questionnaire and observational checklist about colostomy care.

(2)            Second time of evaluation (immediate posttest ) done immediately after explanation of knowledge questionnaire about colostomy care & application of procedures to patient in front of nurses about (assessment of stoma and peristomal skin care, changing an ostomy appliance, colostomy irrigation and emptying the pouch).

(3)            Third time of evaluation(posttest) done after 3 months of  assessing nurses about  knowledge & practice related to colostomy care of patient.

• The entire study sample received brochure as a guide (Appendix E) (in Arabic) it was developed by the researcher and revised by 5 panels of medical surgical nursing staff, it was included (knowledge& practice related to colostomy care.

Statistical analysis of data

The collected data were organized, tabulated, categorized analyzed, and data entry was performed using the statistical package of social science (SPSS) version (20). Descriptive   statistics were applied (e. g mean, standard deviation, frequency and percentage). Pearson's correlation coefficient was applied between quantitative variables.  A significant level value was considered when p<0.05.The smaller the p-value obtained, the more significant is the result (*), less than0.001was considered highly significant (**).The P- value is the probability of error of the conclusion.

Results:

Table (1): Distribution of Study Subjects Regarding their Socio demographic Characteristics (n=40).

Table (1) Reveals that; more than one third of study sample (age was between 30-< 35years and their mean age ± SD was 32.95 ± 3.65, their educational level was Diploma in nursing(45%) and working in Oncology Surgical department). The highest percentage of study sample (80%) was females. Also, as regard to their occupation results shows that more than two thirds working as a bed side nurse. Finally, more than half of them)   55%) had > 10 years of experience.

.

Figure (1): Distribution of Study Subjects Regarding to their Age, Gender & Years of Experience (n=40)

Figure (1): Reflected that highest percentage (45%) were belongs to 30-<35year of age& least percentage   (7.5%) were in 20-<26years and their mean age ± SD was 32.95 ± 3.65. Regarding to gender the highest percentage from them constituted (80%) were females. Regarding to Years of experience, most of studied sample experiences was more than ten years constituted (55%), on opposite side the least percentage of them was less than five years constituted (20%).

Table (2): Distribution of Nurses knowledge Level regarding colostomy care educational program (n = 40)

* Statistical significant (P ≤ 0.05)                   ** highly Statistical significant (P ≤ 0.01)

Table (2) Shows that, the majority of study group had low level of knowledge preimplementing colostomy care educational program, and more than two thirds of study group constituting  had moderate knowledge level post-test, however the most of study group after education program had high knowledge  with  highly statistically significant differences (p= 0.001**).

Figure (2): Nurses Practice Mean Score regarding colostomy care educational program (n = 40).

Fig (3): Reflected that Mean ± SD in pre-test was (26.8 ± 11.5)&in posttest was (91.3 ± 13.7 )and after 3 months was (107.7 ± 8.09 ) and there was a highly statistical significant respectively .

Table (3): Distribution of Nurses Practice Level Regarding Colostomy care Educational Program (n = 40)

* Statistical significant (P ≤ 0.05)                   ** highly Statistical significant (P ≤ 0.01)

Table (3): Shows that, all of studied sample in pretest had weak performance level regarding colostomy care, while in post-test more than half of them had accepted performance, and after 3 months the majority had a good performance. There were statistical significant among pre, post, and after 3months of implementing colostomy care educational program with p-value (0.000**).

Table (4): Correlation between Nurse’s Total Knowledge Scores and Total Practice Scores Regarding Colostomy Care educational program (n = 40).

* Statistical significant (P ≤ 0.05)         

Table (4): shows that, there were a positive correlation between total knowledge and total practice scores regarding colostomy care educational program (n=40) where in posttest (r value=0.364 & p= 0.021) more than(r value) in pre-test and after 3 months this reflected that there was a statistical significant in posttest and after 3 months.

Table (5): Correlation between selected Socio-demographic Characteristics (Age, Educational status and Years of experience) and Nurses Level of Practice of Implementing colostomy care educational program (n=40)

Table (5) Shows that, there were no statistically significant correlation between the selected Socio-demographic Characteristics (Age & Educational status& Years of experience) of studied sample  and their level of practice Pre& post Immediately &After 3 months  colostomy care educational program, except with educational status, there was a significant correlation with the level of practice pre- educational program with p-value (0.038).

Table (6): Correlation between selected Socio-demographic Characteristics (Age, Educational status and Years of experience) and Nurses Level of Knowledge of Implementing colostomy care educational program (n=40)

Table (6) Shows that, there were no statistically significant correlation between the selected Socio-demographic Characteristics (Age & Educational status& Years of experience) of studied sample  and their level of knowledge  Pre& post Immediately &After 3 months  colostomy care educational program.