Prospective measurement of the trajectory of adjustment outcomes among new stoma patients

The OAI-23, a validated 23 item measure of adjustment which reduces to four domains of interest: Acceptance, Preoccupation, Social Engagement and Anger;

and including

An inventory of clinical and personal demographics.

Time series analyses was conducted to explore the adjustment trajectory over a nine month post stoma formation period. Cross sectional analyses (utilising clinical and personal demographics against adjustment trajectories) was also conducted to explore the relative influence of key patient descriptors.

This is a collaborative study conducted by 10 centres lead by Prince of Wales Hospital Sydney. It has lead to 7 clinical papers looking at different aspects of the data collected thus far. The other centres taking part in this study are: The Wollongong Hospital, Shoalhaven, The Sutherland Hospital, Royal Hospital for Women, St Vincent’s Hospital, Concord hospital, Royal Prince Alfred Hospital, Hunter/ New England, John Hunter Hospital and Newcastle Private.

Potential benefits

The study will contribute an important descriptive and cross-sectional analysis which is largely missing from the literature. This has service planning ramifications in relation to the psychological supports which this group of patients contemporarily need. Study participants will be afforded the opportunity to reflect on and relate how they are feeling, following their stoma surgery, and may be better positioned to access more help should they require it.

Reference: Simmons K, Smith J, Maekawa A (2009) Development and Psychometric Evaluation of the Ostomy Adjustment Inventory‐23 Journal of Wound Ostomy & Continence Nursing 36(1): 69-76.


ABSTRACTS & BIOGRAPHIES

Prospective measurement of the trajectory of adjustment outcomes among new stoma patients

Ms Carol Stott1, Mrs Lisa Graaf1, Mrs Julia Kittscha2, Mr Greg Fairbrother3

1Prince Of Wales Hospital, Randwick, Australia, 2The wollongong Hospital, Wollongong, Australia, 3Sydney Research, Sydney LHD, Sydney, Australia

Background:

Psychological distress among patients requiring both temporary and permanent stomas is increasingly common. Little prospectively collected data exists that describes a trajectory of ostomy adjustment over time.

Aim:

This proposed project seeks to utilise the Ostomy Adjustment Inventory [OAI-23] (Simmons et al, 2009) as a primary adjustment outcome tracking instrument in a prospective descriptive study of the adjustment trajectory among new stoma patients.

Method:

Design: Prospective descriptive study with cross-sectional elements.

Sample: Consecutively enrolled new stoma patients (both temporary and permanent) from eleven metropolitan and regional NSW Local Health Districts

Protocol: A questionnaire instrument was offered to study participants at five points of measurement: i) pre-discharge, ii) two weeks post-discharge, iii) three months post-discharge, iv) six months post-discharge, v) nine months post-discharge.

Measurement: The instrument comprises:

  1. i) the OAI-23, a validated 23 item measure of adjustment which reduces to four domains of interest: Acceptance, Preoccupation, Social Engagement and Anger;
  2. ii) An inventory of clinical and personal demographics.

Analysis: Repeated measures analyses were conducted to explore adjustment trajectories over a nine month post stoma formation period.

Results

Adjustment trajectories for the four OAI-23 domains from the first 2 years of data collection for the agglomerated multisite sample will be described and discussed.

Reference: Simmons K, Smith J, Maekawa A (2009) Development and Psychometric Evaluation of the Ostomy Adjustment Inventory‐23 Journal of Wound Ostomy & Continence Nursing 36(1): 69-76.

Biography:

Carol has worked as a CNC in Stomal Therapy & Wound Management for over 30 years. She has presented at many national and international conferences and has published papers on many aspects of stomal Therapy & Wound Management. She has been an active member of AASTN & WCET and has held several positions over the years including journal editor of the Journal of Stomal Therapy Australia. She is currently a member of the WCET education committee


Adjustment to stoma: Comparing metropolitan and regional/rural experiences

Mrs Brenda Christinasen1

1Illawarra Shoalhaven Local Health District, Nowra, Australia

It could be perceived that patients living in a metropolitan area would adjust better to stoma surgery than their counterparts living in regional/rural areas, based on access to services. The accessibility of stomal therapy nurses and outpatient clinics in metropolitan areas can seem to be better than regional and rural areas. It is unclear if the stomal therapy nurse to patient ratio is different between the areas or whether the distance patients have to travel to see a stomal therapy nurse in regional/rural areas is greater, and thus a barrier to access.

A literature review was conducted and revealed scant information relating to this topic. This identifies a significant gap in evidence related to adjustment to stoma between metropolitan and regional/rural areas.

Using the data collected from the Stoma Adjustment Study (SAS) this paper will evaluate adjustment to stoma in patients living in metropolitan versus regional & rural areas. The early data from the study shows adjustment (in terms of stoma acceptance) among patients at 6 months after discharge to be greater in regional areas compared to that of those living in metropolitan areas. Such findings have service planning ramifications in relation to the psychological supports which this group of patients contemporarily need.

This paper will report further on similarities and differences using demographic and adjustment scores using the OAI-23 validated 23 item measure of adjustment, thus seeking to bring evidence to the fore regarding the metropolitan/regional & rural divide in stomal therapy service.

Biography:

Brenda Christiansen is employed as a Stomal Therapy CNC based in the community of a regional centre in the IIlawarra Shoalhaven Local Health District. The service covers 3 sites including acute, rehabilitation and  paliative care. This service sees the client from the preoperative phase, through the acute hospital stay and follow-up after discharge.


Outcomes following stoma surgery for bowel management for faecal incontinence

Mrs Lisa Graaf1, Ms Carol Stott1, Mr Greg Fairbrother2

1Prince Of Wales Hospital, Randwick, Australia, 2Sydney LHD, Sydney, Australia

Colostomy formation is increasingly used for bowel management for patients with faecal incontinence to improve their Quality of life (QOL).  There are several reasons why people have faecal incontinence and they include spinal cord Injury (SCI) and anterior resection syndrome. Also, temporary or permanent stomas are also used when a person has a pressure injury to divert the faecal stream so as to aid and enhance wound healing.

Literature suggests that QOL can be improved for this group after stoma formation, though the subgroup of patients with SCIs is complex and presents stomal therapy nursing with some unique challenges.

Patients enrolled in the Stoma Adjustment Study (SAS), a prospective multi-site follow up of patients following stoma creation were coded for whether the stoma had been formed for bowel management purposes. The Ostomy Adjustment Inventory (OAI-23) was offered to study participants at six points of measurement:  pre-operatively, pre-discharge, two weeks post-discharge, three months post-discharge, six months post-discharge and nine months post-discharge.

: Repeated measures analyses which were conducted to explore adjustment trajectories over the follow up period were assessed against the ‘stoma created for bowel management’ code. It was noted that the ‘Anxious preoccupation’ and ‘Anger’ domains of the OAI-23 were consistently higher for bowel management patients. This was not the case for the ‘Acceptance’ and ‘Social Engagement’ domains of the instrument. Also of note was that bowel management patients were highly represented among the group of patients who refused involvement in the study.

Biography:

Lisa has worked as a Stomal Therapy & Wound CNC for over 20 years. She has presented papers at many national conferences and is the authors of papers published in national and international journals


Qualitative feedback at six months and nine months post discharge from the patients participating in the Stoma Adjustment Study (SAS)

Mrs Katherine Wykes1

1Prince Of Wales Hospital, Randwick, Australia

Background:

Patients coping with formation of a new stoma face many challenges post discharge. Current literature confirms that quality of life in relation to usual daily activities and relationships can significantly contribute to adjustment to life with a stoma. We sought to gather qualitative data about barriers to recovery from our multi-centre prospective study.

Method:

The multi-centre trial utilises a questionnaire instrument [based on the Ostomy Adjustment Inventory [OAI-23]) as a primary adjustment outcome tracking measure. Open-ended questions were also included in order to gain textual data describing participants’ subjective experience of adjustment from study participants. We reviewed and thematically analysed the qualitative responses collected so far at six and nine months with a focus on adjustment to employment, social activities, hobbies, sleeping, intimacy, communication within relationships and barriers to recovery generally.

Findings:

Qualitative data collected from a sample of participants that have reached six and nine month follow up suggests that barriers to recovery include the ongoing frequent task of stoma maintenance and considerations around social activities, hobbies and exercise.

Conclusion:

Returning to usual or modified daily activities within the participant’s anticipated timeframe maximises adjustment to life with a new stoma. Regaining intimacy in relationships and communicating with family members and/or support person aids acceptance, can relieve anxiety and contributes to improved adjustment outcomes. The qualitative responses received so far from participants in the Stoma Adjustment Study support many of the OAI-23 sourced quantitative findings about adjusting to life with an ostomy.

Biography:

Katherine Wykes is a Clinical Nurse Consultant in Stomal Therapy and Wound Care for both adults and neonates across a teaching hospital campus in Sydney, Australia She has also gained recent experience working within a specialised Anorectal Physiology nursing department in Sydney. Katherine has studied in both the UK and Australia and holds a Masters in Clinical Nursing, Graduate Certificate in Stomal Therapy Nursing and a Diploma in Higher Education in Nursing. She has previously spent a year as a Colorectal Cancer Specialist Nurse at a London teaching hospital before returning to her passion in Stomal Therapy nursing within Australia. Katherine continues to develop her skills, knowledge and experience by working alongside a team of experts and fantastic role models within these fields. This has given her opportunity to preceptor students, partake in research projects and professionally develop by presenting at national conferences.

 


Two stomas and the trajectory of ostomy adjustment among this uniquely challenging group of patients

Ms Colleen Mendes1

1Royal Prince Alfred Hospital, Camperdown, Australia

Pelvic exenteration surgery is highly invasive, offering the only treatment option for locally advanced pelvic cancer. These patients may have two stomas formed. There is a lack of prospectively collected data that describes the trajectory of ostomy adjustment over time, particularly among this very complex cohort of patients.

This presentation aims to describe an adjustment trajectory for patients who have two stomas, both patients with one and two new stoma creations. A description of subjective feedback provided by these patients about the adjustment-related challenges they have faced will also be presented.

This is a multicentre prospective descriptive study, which is enrolling patients undergoing formation of a new stoma. A questionnaire instrument (the OAI-23, a validated 23 item measure of adjustment which reduces to four domains: Acceptance, Preoccupation, Social Engagement and Anger)is offered to study participants at six points of measurement: pre-surgery, pre-discharge, two weeks post-discharge, three months post-discharge, six months post-discharge and nine months post-discharge.

Findings among this uniquely challenging group of patients with two stomas will be compared with the wider group of new stoma patients in the sample. Differences and challenges will be discussed.

Biography:

Colleen Mendes is a Clinical Nurse Consultant in Stomal therapy at Royal Prince Alfred Hospital, Sydney, She has a 25 year nursing career, with 10 years specialising in this field. Colleen has extensive experience in stoma, wound, continence, antigrade colonic irrigation, sacral nerve neuromodulation programming and anorectal physiology.


How important are demographics, stoma permanence and stomal therapy nurse follow up as stoma adjustment-related factors?

Mr Ian Whiteley1

1Concord Repatriation General Hospital , Concord , Australia

Studies of adjustment and quality of life (QOL) following stoma creation are relatively scant. Those that have been conducted have used differing tools and have focused on different independent predictors over differing follow up periods. In most cases they demonstrate low QOL post-surgery with variable QOL recovery over time.  Findings regarding predictors of long term QOL or adjustment recovery are not yet conclusive.

This paper reports preliminary findings of an ongoing multicentre study being conducted across 10 health care facilities in NSW. The study investigates how people adjust to having a stoma over time and utilises the Ostomy Adjustment Inventory (OAI-23). Clinical and personal demographics are also collected. The aim of this presentation is to describe differences in adjustment in relation to whether the stoma is temporary or permanent. The role of key personal demographics such as partnered status will also be described. As well, intensity of follow up by stomal therapy nursing is a potentially important associate of adjustment and results from the study regarding this will be presented.

To date we have found evidence in favour of the OAI-23’s ‘acceptance’ domain being better for those with permanent stomas, at least up until the 3 month follow up point. Those who were partnered were found to have better adjustment scores than un-partnered participants across multiple OAI-23 domains. The character of STN follow up has so far also found to be important.

Biography:

Ian Whiteley is currently employed as the Stomal Therapy & Wound Care Nurse Practitioner at Concord Repatriation General Hospital in Sydney. He began his nursing career in 1998 and has worked in Stomal Therapy & Wound Care since August 2005.

Ian has a sustained record of research productivity using diverse methodologies. He has 24 publications in national and international peer-reviewed journals and six published case studies that demonstrate his commitment to clinically focussed research dissemination.  Ian is first author on 83% of these publications.


Pre-operative stoma site marking and adjustment to stoma: Connecting the gaps

Mrs Julia Kittscha1

1Illawarra Shoalhaven Local Health District, Wollongong, Australia

Pre-operative stoma education and stoma site marking by a trained professional is deemed best practice. In Australia this is commonly performed by the Stomal Therapy Nurse but may also be conducted by trained Registered Nurses or surgeons. Appropriate stoma location is reliant on appropriate stoma site marking pre-operatively, however this is not always achievable in an emergency situation.

Evidence supports a reduction in postoperative stoma complications in the presence of pre-operative stoma site marking and pre-operative education/counselling by a Stomal Therapy Nurse. This has also been shown to increase health related quality of life (HRQOL) in the postoperative period. However, this evidence base is small and many studies lack prospective study designs.

Stoma site marking was recorded as part of the data collection for the Stoma Adjustment Study (SAS) using the OAI-23, a validated 23 item measure of adjustment, to establish whether it was a factor in adjustment to stoma surgery over time.  The main findings relating to the association between siting and adjustment were noted to have occurred in the ‘anxious preoccupation’ (AP) domain of the OAI-23, where those who were sited were significantly lower on AP scores at all-time points. ‘Social engagement’ scores were also better for those who were sited, but the relationship was not as strong. This trend was not the case for ‘anger’ nor ‘acceptance’.

Although too early to draw conclusions, the study results so far support stoma site marking as a positive factor in adjustment following stoma surgery.

Biography:

Julia Kittscha has been a Clinical Nurse Consultant in Stomal Therapy for 20 years. Her current role at Wollongong Hospital in NSW Australia encompasses the acute setting, nurse led clinic, periphery hospitals and community. She is passionate about Stomal Therapy Nursing and relishes sharing her skills to empower others.