Ostomy Educational Program for Nurses in Jordan
Having an ostomy does not mean having a lifelong disability. Living well with an ostomy can be achieved through patient preparation, education, and planning. Nurses who are knowledgeable in ostomy care can help a patient adjust to an ostomy. The purpose of this paper is to discuss the need for ostomy education for nurses in Jordan. Although performed to improve patient health, ostomy surgery can be a life-changing event with both physical and psychological consequences. Persons with ostomies can experience poor quality of life (QOL), along with feelings of stigmatization, degradation, and isolation.1 The ostomy itself can present a constant reminder of the disease, or it can be viewed as a potential cure for the disease. Nurses and other healthcare providers can play a key role in this perception and have a significant impact on how patients and their families adjust to the ostomy.2 However, this role is successful only when nurses are supported by the required knowledge and skills. Therefore, structuring an educational program becomes necessary to improve ostomates’ QOL, decrease postoperative complications, and enhance ostomates’ adjustment to the ostomy. Ostomy frequency is increasing worldwide. There are approximately 750,000 ostomates in the United States. The number of ostomates in the United Kingdom exceeds 100,000. Approximately 45% of ostomies are temporary, lasting from three to six months. Ostomy patients’ ages range from newborn to 90 years of age (United Ostomy Association of America, 2011). However, not all countries maintain statistical data on ostomates. No overall ostomy statistics exist for the population of Jordan. Additionally, no studies have been published in Jordan addressing ostomy care or ostomy educational programs. Nurses certified in ostomy and wound care, known as either an enterostomal therapist (ET) or a wound ostomy continence nurse (WOCN), deliver specialized evidence-based care to ostomates. Because there are no ETs or WOCNs in Jordan, ostomy care becomes the responsibility of the bedside nurse, both pre- and postoperatively. Ostomy care that utilizes current evidence-based practice (EBP) standards as a foundation for nursing care has been shown to improve patient outcomes.3-6 Successful outcomes of ostomy care include teaching self-care and instilling confidence in patients so they can effectively manage their own care once discharged and home. Educating patients is an essential nursing role in all types of care settings and cultures. Nurses must be skilled in assessing the patient’s physical, psychological, and cultural needs to provide appropriate care prior to hospital discharge. Ostomy education for nurses should be a systematic, client-centered process, and provided in academic and workplace settings. Ideally, basic ostomy care education should be taught in the undergraduate nursing curriculum.7 Incorporating ostomy evidence-based care in the curriculum may improve patient outcomes, increase nurses’ professional knowledge, and develop better educators in ostomy knowledge and self-care.3 Ostomates who received specialized ostomy care experience less ostomy complications. Ostomy-specific nursing care can reduce ostomy-related complications, thus providing subsequent financial savings and improving the quality of care.8,9 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.10 Preoperative ostomy nurse education programs have been found to be associated with a greater probability for improvement in the Ostomy Quality of Life Index.11 Nursing education and practice have an interdependent relationship: each stimulates and reflects the other’s progress, and each is affected by changes in the other, as well as by changes in the larger healthcare world.12 Recommendations to increase ostomy knowledge can be applied in undergraduate preparation as well as in the workplace. Within the academic environment, education and practice about ostomy care can be done through in-class discussion using case studies and incorporating clinical experiences with ostomates. Although persons knowledgeable in ostomy care may have acquired ostomy-specific education outside of Jordan, many nurses in Jordan providing ostomy care rely only on practices learned from experienced nurses or through trial and error. There is value in learning from experienced nurses, but these practices may not represent the most current ostomy EBP developments. Currently, specific ostomy education is not included in undergraduate curricula in Jordan. Because of this, it is imperative to have ostomy education in the workplace. One method to develop and increase ostomy knowledge among nurses is through computer-based programs in the workplace. Nurses reported a statistically significant increase in knowledge of ostomy care and increased confidence in their ability to provide care after completing a computer-based educational program.13 Providing nurses with patient educational materials can help them become more familiar with ostomy care, such as a video that can be reviewed as needed.14 Another method for ostomy education is the use of a small, A-J pocket card as an alphabet mnemonics review of WOC core curriculum. The suggested ten common concepts that could be alphabetized are: Activity, Bathing, Clothing, Diet, Exercise, Follow-up, Gas, Home care, Intimacy, and Just Ask Questions.15 Cultural and religious beliefs must also be learned, as they can influence ostomy management. Educational strategies for culturally competent care can incorporate cultural implications into ostomy care.11,15 Providing ostomy care within the Arab region, where the predominant religion is Islam, has unique cultural and contextual considerations. Caring for ostomates in Jordan and other Arab countries is challenging for nurses; they need to be aware and knowledgeable regarding ostomy care within this culture. As an example, the majority of people in Jordan are Muslim. For those who pray five times a day, preparation for prayer includes ritual cleansing, which makes it is necessary for ostomates to have a clean pouch in situ while performing their prayers. Evidence in Quran states (Al-Maeda verse six), “O ye who believe! When ye rise up for prayer, wash your faces, and your hands up to the elbows, and lightly rub your heads and (wash) your feet up to the ankles. And if ye are unclean, purify yourselves. And if ye are sick or on a journey, or one of you cometh from the closet … that ye may give thanks.” The Prophet Muhammad said, “The boundary line between Islam and disbelief is ‘Salah.’” The first of the conditions for Salah is “Cleanliness,” or Taharah. Being without Taharah occurs after passing fecal matter or after breaking wind. For ostomates, this means they had to complete Taharah each time for prayer. As Prophet Muhammad said and cited in Sahih Muslim, Taharah book chapter two, 225, “The prayer of none amongst you would be accepted in a state of impurity till he performs ablution.” Jordanian hospitals should be encouraged to hire ETs or WOCNs to formulate and implement ostomy care policies and guidelines. In addition, these specialized nurses can develop additional educational programs for the bedside nurse to become more experienced in ostomy care. Membership can be encouraged in professional organizations dedicated to promoting high standards of ostomy care. These organizations can provide educational programs to help nurses become more competent in ostomy care such as the Wound, Ostomy, and Continence Nursing Organization (WOCN). Jordanian nurses need professional organization memberships to be able to access these benefits. Finally, research studies are needed in Jordan to determine the effects of nursing-specific ostomy knowledge and care on QOL and cost. Ostomy care is a complex skill that takes time and practice to achieve its mastery. The EBP approach to ostomy care takes into account the patients’ need to be self-sufficient and their desire for personal control. Central to that care is educating nurses in the appropriate ostomy care, which also takes into account the emotional, physical, and spiritual aspects to enhance ostomates’ coping and self care.17 This clinical knowledge is needed by nurses caring for this population in Jordan.
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Dr. O’Neill is a Professor, Our Lady of Holy Cross College, New Orleans, LA, USA. Please contact Maha Subih at University of Jordan-Nursing Faculty, Queen Rania Street- Amman- Jordan, PO Box 1194.