Ya-Xing Wang,Jun-Xiang Tian,Ke-Sen Zhang

1Department of medicine and health, Handan Vocational College of Science and Technology, Hebei, China; 2Tianjin Nursing Society,Tianjin,China.

Abstract Objective:To discuss the research status of self-care agency assessment and intervention of enterostomy patients at home and abroad,and to provide reference for medical staff to understand the defects and needs of self-care agency of enterostomy patients and implement effective intervention. Methods: By searching the literature comprehensively, the latest research progress of self-care agency assessment and intervention of enterostomy patients at home and abroad was summarized. Results: The self-care agency assessment tools for patients with enterostomy included Stoma Self-Care Scale(SSCS), Specific Self-Care for Ostomized Patients Questionnaire(CAESPO) and Self-Care Competence of the Person with an Intestinal Stoma: Nursing School of Porto(CAO-EI: ESEP).Interventions included extended care, educational intervention and multidisciplinary team nursing. Conclusion: The concept of renewal should be used to evaluate the self-care agency of enterostomy patients from various aspects.In the future, we should actively carry out standardized research on the content and time of extended nursing and educational intervention, promote the extensive and standardized implementation of multidisciplinary team nursing, and promote the comprehensive improvement of self-care agency of enterostomy patients.

Keywords:Enterostomy;Self-care agency;Evaluation;Intervention

Introduction

Newly enterostomy patients in China are increasing year by year.Existence of enterostomy causes a negative impact on patients'body, emotion, cognition,social functions and quality of life [1], while self-care agency develops a decisive role on promoting patients to adapt to enterostomy and their health mind.It is a leading factor affecting patients'quality of life and it is also the focus concerned by the chronic disease research field at home and abroad.Focusing on self-care agency intervention in early stage (within 3 months) can continuously improve patients' self-care agency and quality of life.Preoperative intervention also develops a positive effect on improving stoma management ability after discharge [2].The findings show that [3] majorities of enterostomy patients give priority to self-care at home after discharge, so their self-care agency is not high.Particularly,in prevention of common complications at the stoma and surroundings and daily life, patients' self-care agency obviously is not enough.Moreover, the cultivation speed of stoma therapists (ET) in China can't satisfy clinical nursing and patients' needs, obstructing the entire recovery of stoma patients after discharge [4].As a result, it is extremely important to improve self-care agency of enterostomy patients.

Self-care agency assessment tools of enterostomy patients

Stoma Self-care Scale,SSCS-early stage version[5]

This scale was modified according to stoma self-care scale of Piwonka [6] and content contained by measurable skills of Johnson's stoma care by combining with features and portable requirements of early-stage China's perpetual colostomy patients after operation.The early-stage version focuses on testing patients' skills to replace ostomy bags independently,so as to measure patients' self-care agency of enterostomy in early stage (within 3 months) after operation, including 10 items of selecting suitable ostomy bags, preparing for articles required by replacing ostomy bags, and removing old ostomy bags from skins.As using telephone evaluation, “yes” or“no” were respectively assigned with 1 or 0.The total score range from 0 to 10.When patients filled in a form for assessment by themselves, Likert 5-level scoring method was adopted.The total score of the scale ranged from 10 to 50.In these two scoring methods, the higher score, the higher self-care agency.The content validity of the scale was 0.94.Cronbach's α coefficient was 0.9548.In 2013, Zhang JE,et al.combined with features and simple requirements of common perpetual colostomy patients to form SSCS-common edition [8].This scale is focused on measuring enterostomy patients' skills of nursing stoma in daily life.4 items in the early-stage edition have been changed,but the scoring method hasn't been changed.The content validity of the scale was 0.93.Cronbach's α coefficient was 0.936, showing that this scale has been widely used in domestic.

Specific Self-care for Ostomized Patients Questionnaire[9]

This scale was edited by a Spanish scholar Collado E in his dissertation-Self-care and Quality of Life[10]by integrating Mariscal's specific self-care model and Orem's self-care defect theory as the theoretical framework, helping medical workers to evaluate different aspects of patients' self-care, including personal development, social interaction and specific self-care issues.Specific Self-care for Ostomized Patients Questionnaire includes 3 parts, including patients' social demographic investigation, relevant clinical data investigation and self-care agency evaluation.Self-care agency assessment includes 58 items, including assessment on general self-care agency (22 items), personal development and social interaction of self-care agency(18 items),and self-care agency of enterostomy(18 items).According to 3 fields of Orem's self-care, 3 scales of evaluating self-care agency can be subdivided into knowledge, attitude and behavior dimensions.Each item got 1-4 scores.The accumulated total score of the scale ranged from 58 to 232.The higher score, the higher self-care agency.Among which,Cronbach's α coefficient was 0.889 and test-retest reliability was 0.987 [11].At present, this scale only has Spanish and English version, while Chinese version still should be translated and modified.

Self-Care Competence of the Person with an Intestinal Stoma:Nursing School of Porto(CAO-EI:ESEP)

The scale was prepared by Nursing School of Porto[12] according to the stoma care and stoma self-care outcome indexes in nursing outcome classification by combining with literature and clinical experience.Self-care agency of enterostomy contains 6 dimensions,including 45 items, such as knowledge (9 items),self-monitoring (7 items), explanation (4 items),decision-making (4 items), execution (17 items), as well as selection and utilization of sanitary resources(4 items), etc.As discharge, Cronbach's α coefficient of this scale was 0.93.When it was used in the community environment, Cronbach's α was 0.91,indicating good internal consistency.This scale adopted Likert level 3 scoring method.The higher score, the poor self-care agency.Rodrigues et al adopted this score and found that evaluating patients'self-care agency before operation had the important significance for nurses to greatly identify patients'needs and formulate satisfactory nursing interventions[13].Continuous assessment after operation enabled nurses to identify patients' actual and potential difficulties when enterostomy patients got new knowledge, skills and attitude.To sum up, it is a favorable tool for nursing diagnosis.This measurement tool now has no Chinese version, which requires translation and intercultural adjustment.

Interventions of improving self-care agency of enterostomy patients

Extended nursing

The key for enterostomy patients to reduce therapy and nursing time at hospital and promote rehabilitation depends on long-term good continuous nursing after discharge.It can give patients a chance to become familiar with professionals during the hospitalization period.It can continuously provide stoma nursing technique guidance for patients, improve self-care agency, and overcome early-stage adaptation difficulties after discharge.

Extended nursing with the single form.The extended nursing forms of enterostomy patients include telephone follow-up, network exchange platform,family follow-up, community nursing, stoma outpatient, and stoma fellowship.Telephone follow-up is the widely used intervention and follow-up mode in current days, showing the advantages of economy and high efficiency [3].However, non-visualization and language barriers affect the effect of telephone follow-up.On the contrary,network exchange platform in WeChat and QQ greatly solve the non-visible problem and it can give a feedback and guidance by voices, texts, pictures and videos.In this way,patients'self-care agency is significantly improved [14].Family follow-up is more convenient for face-to-face guidance with stoma patients and their family, so as to find out and correct patients'self-care in real time and reinforce nursing compliance.Nevertheless, due to insufficient nurses, it is difficult to be popularized in China within a short time.In a sense, it can be compensated by developing community nursing.Also, it is necessary to set up the general clinical clinic of stoma nursing.Special stoma nurses trained should be responsible for clinical reception of patients in consultation and solve the self-care problem [15].However, due to the late development of stoma outpatient in China, it still has a limitation in current days.However, with the cultivation of ETs, stoma outpatient will be gradually increased.Stoma fellowship-the continuous nursing form—can promote patents'mental social adaption by organizing regular lectures and communicating with partners,thus it is good for patients to actively go back to the society[16].

Extended nursing with the synthetic form.Continuous nursing with the synthetic form is integrated with advantages of the single form, while compensating for the former's disadvantages.Therefore, it becomes a common continuous nursing form at home and abroad in recent years.Zhang JE, et al.adopted the synthetic continuous nursing: guidance manual before discharge, early-stage telephone intervention after discharge, WeChat communication after discharge or other language, text and image information transfer,so as to improve self-care agency of enterostomy patients [17].In this way, patients can stably adapt to the daily life with stoma in the critical period of transfer.Wang F, et al.carried out the synthetic community intervention and improved self-care agency of enterostomy patients through pairing with community nurses, regular family guidance of community nurses, regular telephone follow-up of nurses in general surgery department, and communication with respondents [18].Chen, et al.conducted continuous nursing for perpetual enterostomy patients through special nursing teams with telephone follow-up, family interview, special stoma outpatient and stoma fellowship with the subjects of stoma ETs, thus patients could consolidate enterostomy knowledge and skills and enhance self-care agency [19].Furthermore, with the dominance of case managers [20] and advanced practice nurses (APN) [21], the continuous nursing formulated by patients also can satisfy needs of enterostomy patients' self-care and improve health outcomes of patients.

Educational intervention

Education can help patients to integrate enterostomy into life.Enterostomy patients need continuous education to improve their self-care agency during the process of adapting to stoma.

Educational intervention contents.Educational contents should be adjusted according to enterostomy patients' occupation, age, education and religion.At present, lots of educational contents are targeted at self-care knowledge and skills, but they are relatively rough in enterostomy patients' social, mental and sexual damage problem.Due to changes in excretion mode and existence of stoma, enterostomy patients will generate the negative impacts on unacceptance,self-abasement, anxiety and depression, so as to affect their social life.As a result, health education should contain contents that alleviating patients' negative emotion and improving their social adjustment.Huang MX, et al.adopted 3S education mode and improved social mental adaptation and self-care agency of enterostomy patients through family support education,stoma self-care knowledge, skill education and cultivation of self-confidence [22].Zhang J, et al.implemented health education path intervention,mastered patients'mental state through communication before operation, and conducted the individuality education on patients' concern and anxiety, so as to effectively improve patients' self-care agency and health behavior[23].

The development form of educational intervention.Education on enterostomy patients can be the personal educational guidance of nurses or can use propaganda manual, video guidance and partner education.Partner education and video guidance are relatively new educational forms in recent years.The study of Liu[24]found that the effect of partner education was superior to the conventional health education (P＜0.01) and it could greatly improve self-care agency of enterostomy patients and improve their anxiety state.Dalmolin A,et al.integrated audio-visual technology into the educational intervention,thus teaching nursing practice could be changed and reconsideredv [25].Patients'interest in studying self-care knowledge and skills would be motivated.Crawford D, et al.found that self-care skills and knowledge of enterostomy had no statistical difference by making a comparison between face-to-face nurse guidance for three times and face-to-face nurse guidance for twice with video guidance for once [26].It is worth studying video guidance as the multi-form educational intervention of nurses'health education assistance.

Development time of educational intervention.The best time study of Joshua G, et al.indicated that preoperative enterostomy education was superior to the single postoperative education.Before operation,patients often have no idea about enterostomy and daily life changes after operation[27].Nurses establish trust and respect with patients and family in the preoperative stage and inform patients' self-care enterostomy items and progressive muscle relaxation training to reduce patients' anxiety, promote postoperative recovery, and prevent from complications.However, domestic and overseas studies have no uniform conclusion about duration time and frequency of educational intervention.

Precondition of educational intervention.Effective development of educational intervention should fully communicate with sanitary professionals and enterostomy patients or family, and evaluate patients'self-care needs and potentials.This conforms to the nursing philosophy with the dominance of nurses and orientation of patients [28].Adding patients in the health education team not only will make patients become active health management from the passive health maintenance, but also will perfect the educational scheme.Rodrigueset al.evaluated patients'enterostomy in the preoperative stage, finding out the lower cognitive level in enterostomy features,complications, nursing devices, and available community resources, so as to formulate the more effective preoperative and postoperative education plan to meet patients' requirements and improve self-care agency of patients[13].

Multidisciplinary team

Multidisciplinary team (MDT) is a new-type mode for diagnosis and treatment path, and clinical guidance formed by a large-scale medical center in recent ten years with the guidance of evidence-based medicine and foundation of multi-center stochastic clinical study[29].At the beginning, the team mainly attended the diagnosis and treatment activity.In 1995, it was the first time to be introduced to the nursing field.MDT is one of applications.Through the organic combination of multiple relative departments or professional experts,it can fully develop the multidisciplinary collective coordination.Nurses and family will monitor patients'lifestyles in the whole process, pay attention to cultivating patients' self-management capacity, and collaborate completion of patients' nursing.MDT can reduce negative impacts caused by personal subjective judgment or the one-sided decision-making of a single subject and improve reasonability and feasibility of the nursing scheme.It is often used for recovery nursing of chronic disease and tumor.The domestic MDT of enterostomy is composed of doctors in proctology department, stoma ET or supervisor nurses, dieticians and psychological consultation teachers.Multiple studies prove that MDT can effectively improve enterostomy patients' self-care agency and quality of life [30, 31].However, relative to overseas MDT,China's MDT has the imperfect working mode, so the regularized MDT working mode should be further explored.

Summary and prospect

Enterostomy means multiple significant changes,which should be overcome by developing self-care agency of patients.Nurses confirm enterostomy patients' self-care defects and needs through assessment, adopt the specific nursing intervention,and promote improvement on enterostomy patients'self-care agency.Meanwhile, they can measure the effectiveness of nursing intervention in accordance with score changes before and after intervention.The continuous nursing with the synthetic form has the better practical effect.Nurses should positively carry out combination of continuous nursing with different forms.Educational intervention of enterostomy patients should standardize the intervention contents,duration, and frequency, so as to confirm the best educational intervention.Implementation of MDT enables patients to gain more professional and multi-level nursing services, and comprehensively improve enterostomy patients'self-care agency.

However, relative to the overseas, there are some problems: assessment depth and width of enterostomy patients' self-care agency are not enough.There are fewer assessment items and they are partial to assessment of skills and knowledge, but ignore measurement on enterostomy patients'self-care agency from the social level, such as self-care agency of enterostomy patients with social resources, social contact, communication and personal development capacity in the self-care process.Intervention is mainly concentrated on improving self-care knowledge and skills, but intervention is seldom focused on social mental issues of enterostomy patients'self-care.Hence,future research can start from these aspects, so as to comprehensively improve enterostomy patients'self-care agency.