ENTEROSTOMAL THERAPY NURSING INTERVENTIONS AND SOCIAL

ADJUSTMENT OF PATIENTS FOLLOWING OSTOMY SURGERY

A THESIS

SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF MASTER OF SCIENCE

IN THE GRADUATE SCHOOL OF THE

TEXAS WOMAN'S UNIVERSITY

COLLEGE OF NURSING

BY

KAREN K. MARTIN, BSN, RN, CETN

DENTON, TEXAS

DECEMBER 1994

TEXAS ✓WOMAN'S UNIVERSITY DENTON, TEXAS

Oct . 2 5 , 19 9 4 Date

To the Associate Vice-President for Research and Dean of the Graduate School:

I am submitting herewith a thesis written by

Karen K Martin

titled Enterostama l Therapy Nursing Tntenrenti ans and

Socjal Adjustment of Patients Following ostomy Surgery

I have examined the final copy of this thesis for form and content and recommend that it be accepted in partial fulfillment of the requirements for the degree of Master of Science, with a major in Nursing.

We have read this thesis and

Ma�o�o{h, Jb�

Accepted:

�/1 Associate Vice� for Research and Dean of the Graduate School

DEDICATION

I would like to dedicate this thesis to my brother,

Scott Martin, who would have been proud of me for

accomplishing this goal. I love you!

iii

ACKNOWLEDGMENTS

Many individuals have been helpful along the road to

the completion of this study. I would like to especially

recognize my committee members whose continual support and

belief in me played a major role in the completion of this

journey. To Dr. Lois Hough, my initial chairperson, for

her efforts to assist me in fulfilling the requirements

for graduate school; Dr. Oneida Hughes, who assumed the

responsibility of my chairperson, after Dr. Hough's

retirement; Dr. Rose Nieswiadomy, who graciously agreed to

join my.committee and committed her precious time and

expertise in preparing this study report; and Dr. Shirley

Ziegler, for whom I hold such high admiration for her

dedication to education and the nursing profession. Dr.

Ziegler's ongoing encouragement and voluntary assistance

in performing the statistical analysis of my data

facilitated the completion of this study. I would also

like to thank my typist, Marion Smalley, whose wisdom and

patience played a major role in the completion of this

thesis. Thank you all for helping make one of my dreams

come true.

iv

I also want to acknowledge my parents, Ed and Barbara

Martin, who have always encouraged me to go after my

dreams. Rowdy Yates, my golden retriever, always kept me

company during the long hours spent at the computer. And,

a special thank you to my boyfriend, Kenneth DeFrance, who

has weathered the storms over the past years of graduate

school with me. He served as errand runner, message

deliverer, and counselor throughout it all. Thank you for

being there and believing in me.

To my friend, colleague, and role model, Peggy

Miller, who has nurtured me through my nursing career and

inspired me to return to graduate school. There are no

words to express my appreciation to her for all she has

done to assist me in reaching this point.

V

ENTEROSTOMAL THERAPY NURSING INTERVENTIONS AND SOCIAL ADJUSTMENT OF PATIENTS FOLLOWING OSTOMY SURGERY

ABSTRACT

KAREN K. MARTIN, BSN, RN, CETN

TEXAS WOMAN'S UNIVERSITY COLLEGE OF NURSING

DECEMBER 1994

The purpose of this study was to determine whether

Enterostomal Therapy (ET) nursing interventions during the

postoperative period positively affected social adjustment

in individuals who had undergone ostomy surgery. The

convenience sample consisted of 20 subjects (12 in the

experimental group and 8 in the comparison group), who

were 36 to 84 years of age, and had undergone first-time

ostomy surgery.

Social adjustment was measured using Maklebust's

(1985) Ostomy Adjustment Scale which was mailed to

subjects 6 to 8 weeks postoperatively. Each subject's

ostomy adjustment score was the sum of 18 items on the

scale. Analysis of data did not support the hypothesis,

and no conclusions could be made regarding the effects of

ET nursing interventions on new ostomy patients' social

adjustment scores. There was evidence that family members

vi

played major roles as support persons in the

rehabilitation of new ostomy patients.

vii

TABLE OF CONTENTS

DEDICATION

ACKNOWLEDGMENTS . .

ABSTRACT

Chapter

I. INTRODUCTION

II.

Problem Statement . . . . Justification of the Problem Theoretical Framework . . . . Assumptions . . . . Hypothesis . . . . . . . . Definition of Terms . . . . . Limitations . . . . . . . . . Summary

REVIEW OF THE LITERATURE

Body Image . . . . . . Alteration in Body Image . . . . Variables Affecting Adjustment

Following Ostomy Surgery . . . . . Crisis Theory . . . . . . . . Summary . . . . . . . . . . . . . .

III. PROCEDURE FOR COLLECTION ANDTREATMENT OF DATA .

Setting . . . .Population and Sample . . . . Protection of Human Subjects . . . . Instrument

Page

iii

. . . iv

. . vi

1

2

2

3

7

7

7

9

9

11

· . . . 11

. . . 13

. 16

23

28

. . . 29

30

31

32

. . . 33

35 Data Collection Treatment of Data • • • • . • 3 6

viii

IV. ANALYSIS OF DATA

Response to the Study Description of the Sample Findings . . . . . . . . . . . . . . Additional Findings Summary of Findings

V. SUMMARY OF THE STUDY

Summary . . . . . . . . . . . Discussion of Findings . . . . Conclusions and Implications . . . . Recommendations for Further Study

REFERENCES

APPENDICES

Page

. 37

. 37

38

40 . . 41

. 42

43

. . 43

. 45 . . 47

. 49

. . 51

A. Maklebust's Ostomy Adjustment Scale . . 55

B. Enterostomal Therapy Nursing Interventions . 57

C. Graduate School Approval Letter

D. Agency Permission Forms . . . . .

E. Graduate School Approval Letter . . . .

F. Cover Letter . . . . . . . . . . . . .

ix

59

. . 61

. 65

. . 67

CHAPTER I

INTRODUCTION

It is estimated that more than 100,000 people undergo

ostomy surgery each year for treatment of various

malignant, congenital, inflammatory, or traumatic

conditions. The surgical creation of an ostomy produces

dramatic changes in the normal body structure, as well as

its functions. The construction of an abdominal stoma

influences the basic needs for love, acceptance, and self­

actualization and often negatively affects the person's

body image (Hedrick, 1987). Consequently, the person's

self-concept may decrease, generating feelings of

depression, anger, fear of rejection, helplessness, and/or

loss of control.

The creation of an ostomy potentiates a crisis and

the individual is faced with the need to revise his or her

body image. For successful rehabilitation, the nurse must

assist the individual in utilizing resources needed to

cope with body image changes. Proficiency in stoma care,

sound coping skills, and positive reactions by others

facilitate this adjustment. The goal of intervention is

1

restoration of equilibrium and a return of the individual

to the precrisis level of function.

Problem Statement

The problem of this study was to determine:

2

Is there a difference in the level of social

adjustment between new ostomy patients who receive

enterostomal therapy nursing interventions during

hospitalization and new ostomy patients who do not receive

enterostomal therapy nursing interventions during

hospitalization?

Justification of the Problem

The purpose of this study was to determine whether

Enterostomal Therapy (ET) nursing interventions during the

postoperative period of hospitalization would positively

affect social adjustment in individuals who have undergone

ostomy surgery. Any situation, illness, or injury that

causes a change in one's body image is a crisis, and the

person will progress through the phases of crisis in an

attempt to reintegrate the body image (Aguilera, 1990).

The few studies carried out on the effect of nursing

interventions on the rehabilitation of the ostomy patient

have reported findings on counseling, consistency of care,

approach to ostomy patient teaching, and family support

3

as important in facilitating adaptation and restoration of

equilibrium of the ostomy patient. Although the

literature generally supports the crisis intervention

modality for unanticipated traumatic events of a

situational nature, including the loss of a body part and

its function, there have been limited research studies

conducted with ostomy patients. Further research is

needed to identify the conditions under which crisis

intervention is effective in the rehabilitation of the

ostomy patient.

The problem of this study is relevant to nursing

because nurses in a multitude of work situations encounter

persons who are experiencing a crisis following ostomy

surgery. Specifically, ET nurses may assist in the

prevention of a crisis at all phases of the ostomy

patient's experience--beginning before surgery and

continuing through the adjustment process.

Theoretical Framework

Aguilera's (1990) problem-solving model of crisis

intervention is the framework that was used in this study.

According to Aguilera, a crisis occurs when a stressor or

emotional hazard overwhelms a person's coping mechanisms

and he or she experiences a temporary loss in ability to

maintain equilibrium. The crisis is characteristically

self-limiting and lasts from 4 to 6 weeks. Aguilera

indicated, within the problem-solving model of crisis,

that three interrelated balancing factors contribute to

the production of a crisis as well as influence the

outcome of the crisis. The factors are (a) realistic

perception of the event, (b) adequate situational

supports, and (c) coping mechanisms. The presence or

absence of these factors can affect the patient's ability

to regain equilibrium. The individual may work out new

and effective problem-solving techniques that add to his

or her capacity to deal with future difficulties in a

healthy way or develop maladaptive coping mechanisms that

leave the individual vulnerable to future crises.

4

The component of Aguilera's (1990) model significant

to this study is the balancing factor of situational

supports. Situational supports refer to persons who are

available in the environment and who can be depended on to

help the individual solve problems. The situational

supports become the individual's significant others, and

it is from them that the client learns to seek advice and

support in solving daily problems in living. Any

perceived failure to obtain adequate situational support

to meet needs may compound a stressful situation.

Negative support could be equally detrimental to the

5

individual's self-esteem. When one's self-esteem is

lowered by a threatening situation, such as a change in

body image, the individual seeks out situational supports.

If faced with a stressful situation when there is lack of

situational supports, the individual may experience a

state of disequilibrium and possible crisis (Aguilera,

1990).

Aguilera described individual crisis intervention as

a form of brief psychotherapy that concentrates on the

demands of situations for novel adaptation reactions. It

emphasizes assessment of the psychosocial processes of the

person in crisis. All intervention is designed to solve

the unique problems that initiated the crisis at hand.

The therapist looks for the etiology of the disequilibrium

and identifies the actions necessary to regain the

previous level of function. Success of crisis

intervention depends on accurately assessing the nature of

the crisis for the individual, being aware of the time

limitations, remembering the necessity of remaining goal

oriented, and remembering the necessity of directive

therapy, at times (Aguilera, 1990).

The steps of crisis intervention as described by

Aguilera are:

1. Assessment of the nature of the problem and the

strengths, weaknesses, and resources of the client.

2. Planning of interventions based on knowledge of

the client's past coping mechanisms that have been

successful in similar circumstances and that can be

reinforced for use in this crisis situation.

3. Interventions designed to get the person to

cognitively understand the situation, fully explore the

current feelings being experienced, examine possible

coping behaviors, and encourage contact with family or

significant other(s).

4. Reinforcement of successful coping behavior and

planning of how to use new coping skills in the future.

6

The creation of an ostomy and accompanying change in

body image has the characteristics of a crisis in that it

is a stressful situation of such magnitude and severity as

to be out of the individual's abilities to cope

effectively using his or her usual problem-solving

methods. Because the creation of an ostomy is associated

with a physical change in body structure and function,

crisis intervention can be useful in identifying

situational supports to assist the ostomy patient in

adjusting to his or her new self-concept.

Assumptions

The assumptions for this study were:

1. Crisis situations occur periodically in the

normal life span.

2. A crisis is time limited, lasting 4 to 6 weeks.

3. The impact of a crisis disturbs equilibrium and

places the individual in a vulnerable state.·

4. The experience of ostomy surgery is

psychologically threatening.

5. Adaptation of the ostomy patient can be detected

and measured.

Hypothesis

The hypothesis of this study was:

New ostomy patients who receive enterostomal therapy

nursing interventions while hospitalized have a higher

score on level of social adjustment, as measured by the

Maklebust's Ostomy Adjustment Scale, 6 to 8 weeks

postoperatively than new ostomy patients who do not

receive enterostomal ther�py nursing interventions during

hospitalization.

Definition of Terms

For this study, the following terms were used

according to these definitions.

7

8

1. Level of social adjustment--a level of adaptation

to an ostomy as measured by a score on the Ostomy

Adjustment Scale (Appendix A).

2. Enterostomal therapy nursing interventions--a

structured teaching and counseling program, with slight

variation in content to cover areas specific to the type

of ostomy, for the new ostomy patient to promote positive

adaptation (Appendix B).

3. New ostomy patient--any patient 18 years and

older who has undergone ostomy (colostomy, ileostomy, or

ileal conduit) surgery for the first time; has had no

previous experience with an ostomy; and is able to speak,

understand, and read English.

4. Ostomy--surgical opening into an area of the

gastrointestinal or genitourinary tract.

a. Colostomy--surgical opening into the colon

for the purpose of bowel diversion.

b. Ileostomy--surgical opening into the ileum

for the purpose of bowel disease.

c. Ileal Conduit--a supravesicular urinary

diversion created by the transplantation of the

ureters into a prepared and isolated segment of the

ileum that is tunneled to an opening in the abdomen.

Limitations

The limitations of this study were:

1. A convenience sample was used; therefore, the

findings may not be generalized to all new ostomy

patients.

9

2. Some of the subjects' ostomies were permanent and

others were temporary, which may have influenced

adaptation.

3. The age range of subjects varied.

4. The nature of the disease or illness leading to

the ostomy surgery and other concurrent treatments and/or

illnesses may have affected the course of a subject's

recovery.

5. The degree of support available from family,

friends, and other sources may have influenced patients'

adaptation.

6. Those in the control group received interventions

that varied in content and amount of information.

7. There were no data on which to judge the initial

equivalence of the two ostomy groups.

Summary

Ostomy surgery potentiates a crisis in that it is a

stressful situation out of the realm of an individual's

usual problem-solving methods of coping. Because the

10

creation of an ostomy is associated with a change in body

structure and function, crisis intervention can be useful

in assisting the ostomy patient in adjusting to his or her

new body image.

CHAPTER II

REVIEW OF THE LITERATURE

This chapter begins with a discussion of body image,

which is altered when a person undergoes ostomy surgery.

The review of the literature continues with a discussion

of other subtopics, including alterations in body image,

variables affecting adjustment following ostomy surgery,

and crisis theory. Variables that affect adjustment

following ostomy surgery include attitudes and ability of

nursing staff, teaching/counseling, and social support.

Crisis theory is discussed in regard to the facilitation

of adaptation and restoration of equilibrium in the ostomy

patient.

Body Image

Body image theory is helpful in understanding the

psychosocial responses of people to ostomy surgery.

Norris (1970) described body image as the ever-changing

total of conscious and unconscious information,

perceptions, and feelings about one's body in space as

different and apart from all others. Body image is the

11

mental picture (or emotional view) of one's self as seen

in the mind's eye (Gillies, 1984).

12

The dimensions of body image concept include self­

concept, body-concept, self-esteem, body scheme, self­

connection, and body image boundary. Self-concept is the

cognitive aspects of self-perception that reflects an

objective summary of what one thinks about oneself. Body­

concept is the cognitive aspects of self-knowledge that

reflects what one knows about one's body structure and

functions. Self-esteem is the evaluation of one's self­

worth. Body-scheme is the concept of one's physical being

as an object in space. Self-connection refers to

estimating the probable effect of a specific disorder on

an individual's self-esteem. Body image boundary is the

individual's perception of the outermost limit of his

physical being, or the point of interface between his body

and the environment (Gillies, 1984).

The formation of one's body image begins at birth and

evolves slowly through the process of growth and

development. It includes not only appearance but also

perception of bodily functions, sensations, and mobility.

The body and the image of the body are the objects of

strong emotions because of the psychic investments we have

in them. Body image acts as a time of reference that

13

influences one's ability to perform (Norris, 1970).

Adjustment to any change in perceived self may be

difficult to make. Gradual changes in the body provide

time for one's mental image to adjust to one's mirror

image in order for a person to maintain an accurate self­

perception. A great and sudden change to the body is more

threatening than numerous small changes evolving over a

period of time (Norris, 1970).

In the American culture, achievement, beauty,

intactness, health, and strength are valued highly and

play an important role in the development and maintenance

of self-concept and body image (Norris, 1970). Surgical

procedures causing a disturbance in the relationship of

body parts can drastically alter a person's perception of

his or her body.

Alteration in Body Image

Each person carries a mental image of his or her own

appearance and this image may or may not be congruent with

the actual body structure. Disturbances in body image

occur when a disparity develops between the way the

individual has always pictured his or her body and the way

he or she currently perceives it (Norris, 1970). Body

image disturbances commonly occur with ostomy patients

because some part of the body is surgically removed.

1,

Surgery has an impact on the wholeness of the body and

therefore on the body image.

14

Common among all patients requiring ostomy surgery is

the need to adjust to a sudden change in body structure

and function (Hedrick, 1987; Mccloskey, 1976; Murray,

1972; Norris, 1970). A person with an ostomy can no

longer ignore what may have been considered as the dirty

or unpleasant part of his or her bodily existence;

elimination of body waste takes place right under his eyes

and nose (Norris, 1970). Mutilative surgery threatens an

individual's wholeness as the person is faced with an

alteration in the body's physical structure. No longer is

he or she capable of coming close to society's ideal--the

perfect body. The individual's physical appearance has

been robbed of its integrity. A disturbance or crisis

arises when the person fails to accept the change in his

or her body and tries to cling to the old body image.

In a survey of 409 ostomy association members from 23

states and 5 Canadian provinces, Dlin, Perlman, and

Ringold (1969) determined that every subject's self-image

was altered somewhat by ostomy surgery. Corresponding to

body image theory, many respondents indicated a direct

relationship between lowered self-esteem and their altered

body.

15

Orbach and Tallent (1965) interviewed 48 patients

with colostomies 5 to 10 years after surgery to assess the

impact of the colostomy on body sensation and beliefs

about the body. All 48 subjects believed that their body

form had been altered in a destructive way. They reported

feeling debased and demeaned because their excretion came

from the front of their bodies and that they must now face

people with their substitute anus. Thirty-one of these

subjects were administered projective psychologic tests.

The results of these tests indicated that these subjects

no longer had confidence in their bodies, due to their

feelings of internal weakness, fragility, and fear of

being subjected to further study. Many of the subjects

were confused about how their body could maintain adequate

functioning in view of the extensive changes that ostomy

surgery had introduced. The common concern of the

subjects was the physical change in body image and

feelings of self-distortion resulting in anxiety and

mourning for the lost part.

In a study conducted by Sutherland, Orbach, Dyk, and

Bard (1952), consisting of 29 male colostomates and 28

female colostomates, the researchers found that nine of

the male subjects continued working at their previous

level of function. Of the remaining 20 male subjects, 17

16

were employed with restriction in activity, which led to a

decrease in status and earnings capacity. Three of the

male subjects were unemployed. Of the 20 female subjects

who did housekeeping prior to their colostomies, nearly

all of them continued doing housework; however, they had

reduced the heavy aspects of it. The study demonstrated

that both men and women referred to their continuing

weakness and lowered work efficiencies. Their self­

imposed work restrictions were, in the majority of the

cases, beyond their physical limitations, thus implying

psychological disturbance related to altered body

structure.

Variables Affecting Adjustment Following Ostomy Surgery

The literature indicates that a number of variables

are, in some manner, related to an adult's response to

ostomy surgery. The few studies on the impact of nursing

interventions on the adaptation of the ostomy patients

reported findings on attitudes and abilities of nursing

staff, information giving, teaching/counseling, and social

supports. All of these factors have been identified as

important in the patient's social adjustment.

17

Attitudes and Abilities of Nursing Staff

In her work with over 400 colostomy patients, Katona

(1967) acknowledged that the patient's personal adjustment

is dependent upon many factors. She observed that after

ostomy surgery, patients' attitudes toward the ostomy were

greatly influenced by the attitudes and the abilities of

the medical and nursing staff who cared for them. The

initial actions and reactions of the nurse, family

members, and other special people in their lives

influenced how they accepted and adjusted to the ostomy.

Katona stated that the patient will note every expression

on the nurse's face and incorporate any evidence of

disgust into his or her own self-image. Jackson (1976)

reported similar findings from her observation of the

nurse-patient relationship for eight new colostomy

patients during morning care. She observed the nurse­

patient interactions and responses in terms of goal

setting, information-seeking, and reactions and behaviors

expressing perceptions of well-being. She concluded that

the treatment and attitude of staff toward the patient

during the initial postoperative period significantly

influenced the patient's adjustments either positively or

negatively.

18

In a descriptive study of nurses' preparation of the

patient with an ostomy for self-care, Ewing (1989)

observed a total of 68 nurse-patient interactions with 16

patients during ostomy appliance changes. In most of the

appliance changes observed, the nurse provided most of the

care for the patient. She noted there was lack of

continuity of care; patients developed some self-care

skills, only to revert to nonparticipation in a subsequent

appliance change with a different nurse. The 12 patients

who were observed were discharged from the hospital at a

low level of self-care preparation. Ewing recommended a

more coordinated approach to nursing care, so that the

short period available for self-care preparation could be

maximized for the patient's benefit.

Deeney and McCrea (1991) explored the satisfaction

during hospitalization of six surgery patients undergoing

ileostomy or colostomy surgery. Patients reported that

they did not sleep well or did not find the food

appetizing, but felt that not much more could have been

done to assist them. A common concern was that they

needed more information about the operation, including the

information that their rectums would be removed. Only one

subject received an instructional booklet while in the

hospital, and the nurse did not follow up on this book

19

with the patient. The patients felt that the nurses were

effective in meeting their physical needs, but also

reported that the nurses never sat and listened or asked

them how they felt. They did say that the nurses had been

of assistance in helping them overcome embarrassment

related to stoma care.

Information Giving

The factor of information-giving and psychosocial

adjustment of the ostomy patient was studied by Druss,

O'Connor, Prudden, and Stern (1968). Patients were found

generally to want to learn, even though they may not ask

questions or seek information. The patients reported that

staff nurses were unable and/or unwilling to instruct them

in management of their ostomies and impart knowledge that

would facilitate return to independence. A number of

studies have reported that the education and counseling

received by ostomy patients is haphazard or non-existent

(Achterberg, Lawlis, Carlton, & Smith, 1979; Dlin, 1978;

Hedrick, 1987).

A survey of 250 people (Tacker, Tacker, & Breiman,

1967) from seven ostomy clubs reported that 12-14% of the

respondents did not know preoperatively that their surgery

would put bowels on the outside. Three times as many

ileostomates as colostomates believed that nursing care in

20

the hospital was inadequate and that they were discharged

from the hospital without adequate knowledge of self-care.

Many of the colostomates replied that they had to revamp

ideas taught them in the hospital. Local ostomy clubs

were identified as an important source of psychological

encouragement to the ostomates surveyed. Studies by Druss

et al. (1968) and Grubb and Blake (1976) reported similar

findings.

Teaching/Counseling

Watson (1983) studied 31 patients who had undergone

corrective ostomy surgery for treatment of colorectal or

bladder cancer, in an effort to determine whether short­

term counseling instituted during the postoperative period

would positively alter self-concepts, particularly the

component of self-esteem. Results indicated that patients

who received counseling intervention demonstrated positive

alteration in self-concept and self-esteem as compared

with the control group. The most frequently reported

feelings were sadness, anger, fear, confusion, revulsion,

shame, and worthlessness. The major focus of adaptation

was on the ostomy, as opposed to the diagnosis of cancer.

The study identified that the creation of an ostomy

produces negative self-esteem and post-operative

21

counseling is helpful in assisting the individual to adapt

to the ostomy experience.

Hedrick (1987) studied 40 ostomy patients in an

effort to determine the impact of education and counseling

during the first days of their crisis period on level of

social adjustment at a later time. Twenty ostomy patients

received education and counseling by an ET nurse while

hospitalized and were compared to 20 ostomy patients who

had not received ET interventions during hospitalization.

Social adjustment 2 to 3 months postoperatively was

measured by the score on Maklebust's Ostomy Adjustment

Scale. Matched patient scores on the test score reflected

a higher level of adjustment for patients who received

interventions by the ET nurse. According to patient

response, the ET nurse played a primary role in assisting

the patient toward adjustment.

Social Supports

The literature consistently reports that the response

of close family members is a key factor to an ostomy

patient's psychosocial adjustment (Dyk & Sutherland, 1956;

Hedrick, 1987; Lipson, 1985; Kelman & Milner, 1989;

Mikolon, 1982). Family acceptance of the patient and his

or her ostomy surgery facilitates the patient's self­

acceptance of the change in his or her body's structure

22

and function. Dyk and Sutherland (1956), in a study of

colostomy patients, found that the acceptance and support

of the spouse is crucial to a patient's success or failure

in adaptation to an ostomy. These investigators did

extensive research about the family relationships of

persons with colostomies. The existing family relations

were found to play a definite role in the adjustment

process. A positive relationship of mutual affection

appears to provide an important support for resolution of

crisis and restoration of equilibrium.

Watson (1983) and Hedrick (1987) reported that

patients identified the ET nurse as the person most

helpful to them during hospitalization when compared to

staff nurses, physicians, or counselors. The ET nurse was

the one perceived as giving the most needed information

and instruction on learning self-care skills and in

providing emotional support for psychosocial adaptation of

the new ostomy patient.

The relationship between perceived level of

adjustment and type of ostomy, as well as the impact of a

postoperative visit by a United Ostomy Association (UOA)

visitor, were investigated in a study by Maklebust (1985).

Results indicated that patients who were visited by a UOA

visitor perceived a higher level of adjustment following

23

ostomy surgery than those who did not receive a visit.

There was no significant difference in ostomy patients'

adjustment among the three types of ostomies. A related

study by Krainski (1994) looked at social support, coping

strategies, and long-term adaptation of ostomy patients

among self-help group members (UOA). High quality of life

scores indicated that the people in this study adapted

fairly well to their ostomies. The results of these

studies suggested that the support of a visitor from a

self-help group may be important to the adjustment of an

ostomy.

Crisis Theory

A crisis is a human response to a stressful situation

that one's usual patterns of responses, behaviors, and

coping mechanisms are inadequate to handle the present

feelings resulting from this event (Murray, 1972). A

crisis results from interaction between an external

stressor and a vulnerability within the individual.

crisis state is a period of transition and is

The

characteristically time limited, lasting from a few days

to 6 or 8 weeks (Aguilera, 1990). Crisis, according to

Caplan (1964) and Aguilera (1990), occurs when a stressor

or emotional hazard overwhelms a person's coping

24

mechanisms and they experience a temporary loss in ability

to maintain equilibrium.

Crisis theory is based on the work of Lindemann

(1944) who outlined the grieving process of survivors of

Boston's Coconut hotel fire and Caplan (1964) who

advocated the role of crisis resolution in prevention of

mental illness. Caplan began with the premise that a

crisis presents the individual with both an opportunity

for personal growth and the danger of increased

vulnerability in the future. The individual may work out

new and effective problem-solving techniques that add to

his or her capacity to deal with future difficulties in a

healthy way or maladaptive coping mechanisms that leave

the individual vulnerable to future crisis.

Crisis intervention is the systematic application of

problem-solving techniques, based on crisis theory,

designed to help the client move through the stages of

crisis as quickly and pain free as possible. It is a

short-term helping process that focuses on resolution of

the immediate problem through use of personal, social, and

environmental resources (Aguilera, 1990). The minimum

therapeutic goal of crisis intervention is psychological

resolution of the immediate crisis and restoration to at

least the level of functioning that existed prior to the

crisis period (Aguilera, 1990).

25

Crisis theorists distinguish between situational and

developmental crisis. Situation crisis occurs as a result

of some unanticipated traumatic event that is usually out

of one's control. Examples include death of a family

member, divorce, loss of a job, natural disaster,

diagnosis of a chronic or fatal disease, or unanticipated

surgery. In contrast, maturational or developmental

crises are normal transition states that people experience

throughout their lives. They usually can be anticipated

and involve life span periods of development and major

social role changes. Examples include puberty, marriage,

birth of a first child, and retirement.

Sultenfuss (1982) utilized the four stages of

grieving or adaptation to guide assessment and

intervention. According to this framework, the individual

experiencing a real or threatened change or loss may

predictably go through the following behavioral responses

or stages, each of which are normal and therapeutic in

nature. The behavior responses defend the individual from

a situation that is perceived as threatening to his or her

physical or psychosocial survival.

According to Sultenfuss, the adaptation phases one

goes through in response to an alteration in body image

are: (a) shock and panic, (b) defensive retreat, (c)

26

acknowledgement, and (d) adaptation or resolution. In

shock and panic, the person feels the impact of the loss

but is unable to assimilate it. This results in

immobilization. Stage two involves recognition of the

change. Denial is the usual response because the

individual is still unable to incorporate its whole

meaning and implication. Acknowledgement in the third

stage occurs when the individual realizes that the stoma

is real and begins to explore its meaning. This may be

the most painful stage because the response may be one of

resistance and refusal. In adaptation, assimilation of

the event along with its significance allows the

individual to return to the pre-crisis level of

functioning (Sultenfuss, 1982).

For the ostomy patient, intervention within the

hospital environment preoperatively and postoperatively

follows crisis management theory, which emphasizes early

intervention in the crisis situation to promote adaptive

response. Lipson (1985) acknowledged that crisis

intervention can be performed by anyone who possesses the

skills but contended that there are two types of

specialists--ET nurses and UOA visitors--who accomplish

more than anyone else to help ostomy patients adaptively

resolve crises and adjust to their ostomies.

27

In a quantitative study of 35 people with ostomies,

Burrows and Droes (1978) reported common themes from

patients that the ET nurse was their "savior" and that

hospitals should not perform ostomies unless there is an

ET nurse on staff. A technical emphasis in the hospital

was also apparent in their study. Many of those

interviewed were more thankful for the technical expertise

than for their psychosocial skills. When asked how the ET

nurse helped, they commonly reported that the ET nurse

knew what to do and made them feel good, she was able to

make their sore skin heal, and she changed the pouch the

same way every time so they could learn. Brogna (1985)

asserted that ET nursing interventions established

consistency of care and promoted feelings of adequacy in

the new ostomy patient. Interpersonal interventions

directed toward helping patients to develop new patterns

of functioning and coping behaviors will aid in restoring

balance. In this manner individualized, consistent care

should have a positive effect on the self-concept of new

ostorny patients.

28

Summary

Alterations in body structure may have a negative

influence on patients' self-concepts. Feelings of

confusion, inconsistency, and inadequacy predominate in

such instances. Interpersonal interventions directed

toward helping patients to develop new patterns of

functioning and coping will aid in restoring balance. In

this manner, individual specialized care should have a

positive influence on the self-concepts of those patients

who experience ostomy surgery.

CHAPTER III

PROCEDURE FOR COLLECTION AND

TREATMENT OF DATA

The research design for this study was a non­

equivalent control group, posttest only approach. This

approach is defined by Polit and Hungler (1991) as a

quasi-experimental design in which the independent

variable is manipulated by the researcher and there is a

control group, but no random assignment of subjects.

independent variable in this study was enterostomal

The

therapy nursing interventions. The dependent variable was

social adjustment as measured by the patient's score on

Maklebust's Ostomy Adjustment Scale.

Polit and Bungler (1991) pointed out that the most

important distinction between this type of research and

experimental research is the difficulty of inferring

·causal relationships. Other limitations include

convenience sampling, a small sample size, and the

comparison group being exposed to unknown variables prior

to teaching. The positive aspect in this design is that

it is strong in realism; therefore, it is more likely to

be generalizable to other realistic settings. This design

29

30

is useful in examining relationships among variables in

one group in order to make predictions about the behavior

of another similar group.

Setting

The setting for this study was located in a large

urban area in the southwestern United States. It included

two acute care hospitals for the experimental group and

the homes of the individual subjects for the comparison

group. The acute care hospitals consisted of a 385-bed

Level I trauma center and a 150-bed general hospital.

Both hospitals are non-profit organizations that serve the

middle and lower class population. The two home health

agencies, from which subjects of the comparison group were

identified, serve clients in the urban and surrounding

rural areas from all classes of society. The agencies had

a large caseload of Medicare patients and have services

for the indigent population. Each of the home health

agencies also had a certified ET nurse on staff that

agreed to be a resource for identifying new ostomy

patients who had been discharged without structured

teaching from an ET nurse in the hospital.

The ET nursing interventions took place in the

patient's room in the hospital. All the rooms were

private and well lighted to provide a quiet environment

31

conducive to teaching. The comparison group was

identified through ET nurses working for home health care

agencies who received a referral to see new ostomy

patients at home from hospitals who did not have ET

nursing services available.

Population and Sample

The target population of this study was all new

ostomy patients in the United States that met the

delimitations of the study. The delimitations consisted

of those clients who were 18 years and older, had

undergone ostomy surgery for the first time, had no prior

ostomy experience, and were able to understand and read

English. The accessible population included any new

ostomy patients admitted at one of two acute care

hospitals who had received ET nursing interventions or had

been referred to one of two home health care agencies in a

large urban area in the southwestern United States.

The sampling technique was nonprobability convenience

sampling. The convenience sample was obtained from the

accessible population as described above. The sample

consisted of 20 subjects, 12 subjects in the experimental

group and 8 subjects in the control group. The subjects

in the experimental group were obtained in the hospitals

by notification of the ET nurse from the physician,

32

operating room nurse, and/or staff nurse of patients that

had undergone ostomy surgery. The comparison group

consisted of individuals identified by ET nurses working

for the two home health care agencies who received a

referral at the time of the patient's discharge from a

hospital that did not have ET nursing services available.

Protection of Human Subjects

Prior to collecting data, permission was obtained

from the Human Subjects Research Committee at Texas

Woman's University for a Category I study (Appendix C).

Permission was also obtained from the agencies from which

the subjects were obtained (Appendix D). Finally,

permission was obtained from the Graduate School at Texas

Woman's University (Appendix E).

All subjects were assured in writing that their

identity would remain anonymous. They were specifically

instructed not to write their names on the questionnaires.

No pressure was exerted on the subjects to participate in

the study. The general nature of the study, the content

of the questionnaire, and the estimated amount of time

required to complete the questionnaire were explained in a

cover letter mailed with the questionnaire to prospective

participants (Appendix F). The letter also conveyed that

RETURN OF THE QUESTIONNAIRE SIGNIFIED CONSENT OF THE

SUBJECTS TO PARTICIPATE IN THE STUDY.

Instrument

33

Maklebust's (1985) Ostomy Adjustment Scale (Appendix

A) was used as the measurement instrument and permission

for its use was given (Maklebust, personal communication,

February 1992). Section I of the instrument consisted of

demographic data and questions related to ostomy history.

Variables in this section included age, gender, religion,

race, marital status, education level, and employment

status. In addition, subjects were asked with whom they

lived, the type of ostomy they had, the reason for the

ostomy, if an ET nurse was involved in their care and

teaching, and who helped the patient most in adjusting to

the ostomy.

Section II of the Ostomy Adjustment Scale (Maklebust,

1985) was used to measure psychological adjustment of an

ostomy patient. This section consists of 18 questions

concerned with adjustment. The Ostomy Adjustment Scale

uses a 7-point Likert-type scale ranging from (1) strongly

agree to (7) strongly disagree (Maklebust, 1985).

34

Validity

Maklebust (1985) obtained content validity by

constructing the instrument based on a review of the

literature and by asking five specialists in the field of

ET nursing to review and analyze the instrument. The

group of ET nurses all agreed that it represented the

variables being measured and had content validity

(Maklebust, 1985).

Reliability

Reliability testing was achieved by Maklebust using a

test/retest method with a group of 23 volunteer ostomy

patients at a 4-week interval. She computed the

correlation between the two sets of scores to determine

the reliability estimate. A Pearson product-moment

correlation coefficient was obtained(� = .94) and the

instrument was considered to have an acceptable measure of

reliability (Maklebust, 1985). No further efforts

relating to validity and reliability have been reported.

In scoring this instrument, Maklebust split the

questions. For questions 1, 4, 5, 6, 7, 8, 11, 12, and

17, the higher the score, the better the adjustment. For

questions 2, 3, 9, 10, 13, 14, 15, 16, and 18, the lower

the score, the better the adjustment (Maklebust, 1985).

The total adjustment score was the sum of the 18 item

35

scores. Possible scores ranged from 18 to 126. A higher

score represents good adjustment and a lower score

represents poor adjustment. The ostomy adjustment scale

represents an ordinal level of measurement (Maklebust,

1985)

Data Collection

The data for this study were collected over a 15-

month period. Patients who were admitted to the two acute

care hospitals for ostomy surgery, who met the designated

criteria, and who received the standardized ET nursing

interventions (Appendix B) were potential subjects for the

experimental group. Names and addresses for the subjects

in the control group were obtained from the ET nurses

working for the two home health care agencies.

The data collection questionnaire (Appendix A), the

questionnaire cover letter (Appendix F), and a stamped,

pre-addressed return envelope was mailed to 41 subjects

no less than 7 weeks and no more than 8 weeks

postoperatively. A stamped, pre-addressed post card was

included in the packet with instructions to return it

separately from the questionnaire if the subject wanted a

copy of the study results. A time limit of 2 weeks was

given for the return. This allowed for the resolution of

the crisis period and re-establishment of equilibrium as

described by Aguilera (1990).

To decrease the chance of bias, the ET nursing

interventions were performed by three different nurses.

36

It was also anticipated that three nurses would increase

rgw chance of obtaining the desired sample size. A

patient teaching guide and checklist (Appendix B) based on

the International Association for Enterostomal Therapy

(1989) Standards of Care were used by the nurses to guide

the ET nursing interventions. The researcher had oriented

the other two nurses to the teaching guide and checklist

to guide standardized interventions for all ostomy

patients in the experimental group. The two ET nurses at

the home health care agencies had been oriented to the

requirements for identifying subjects for the comparison

group.

Treatment of Data

Each subject's scores were totaled and after

variables were matched, scores were compared between the

two groups by means of a t-test for independent samples.

A£ value of < .05 was used to test for significant

differences between the two groups. A one-tailed test of

significance was appropriate for the directional research

hypothesis stated in this study.

CHAPTER IV

ANALYSIS OF DATA

A non-equivalent control group, posttest only, quasi­

experimental study was conducted for the purpose of

determining if a significant difference existed in the

level of social adjustment between new ostomy patients who

had received ET nursing interventions in the hospital and

those who had not. Maklebust's Ostomy Adjustment Scale

was utilized to collect the data. This chapter presents

the quantitative description of the sample and the results

of the study.

Response to the Study

Of the 41 mailed questionnaires, 22 (54%) were

returned and of these 20 (48%) contained useable data.

The response rate for the experimental group, 12 out of 25

(48%), was essentially equal to the comparison group, 8

out of 16 (50%). Four questionnaires were returned and

not useable, 3 could not be delivered due to incorrect

address, and 1 was returned with less than 50% of the

questions answered.

37

38

Description of the Sample

The sample consisted of 20 new ostomy patients in the

southwestern United States. The sample was composed of 12

new ostomy patients who had received ET nursing

interventions during hospitalization and 8 new ostomy

patients who had not received ET nursing interventions

during hospitalization. The subjects ranged in age from

36 to 84 years. The mean age for the control group was

56.9 years, and the mean age for the comparison group was

62.1 years. The 12 subjects in the control group

consisted of 7 (58%) women and 5 (42%) men, while the

experimental group consisted of 4 (50%) women and 4 (50%)

men. There were 2 Hispanics and 18 whites in the sample;

both Hispanics were in the experimental group.

The types of stoma represented in the control group

included 6 (50%) colostomy, 1 (17%) ileostomy, and 4 (33%)

ileal conduit patients. The reason for the ostomy in 8

(68%) subjects was cancer, 1 (9%) subject had ulcerative

colitis, 1 (9%) subject had diverticulitis, and 2 (16%)

subjects has other reasons for the surgery (1 had a blood

clot to the colon following hip surgery and 1 had a

perforated bowel). Eight (66%) of the subjects said their

ostomy was permanent. The comparison group was made up of

5 (62%) colostomy and 3 (48%) ileal conduit subjects. The

reason for the ostomy was cited by 2 (25%) subjects as

cancer, 2 (25%) subjects had diverticulitis, 2 (25%)

subjects had ulcerative colitis, and 2 (25%) subjects

listed other reasons for surgery (1 had a dead colon

following abdominal surgery and 1 had a perforated colon

with peritonitis). The ostomy was permanent for 5 (50%)

of the subjects.

39

In the control group, 8 (66%) preferred the

Protestant religion, 2 (16%) preferred the Catholic

religion, 1 (9%) specified no religion, and 1 (9%) marked

"other," but did not specify the type. Religious

preference of the comparison group subjects included 6

(75%) Protestant and 2 (25%) Catholic. Six (50%) of the

experimental group listed a post-high school education and

6 (50%) listed a high school education. Educational

levels listed by the subjects in the comparison group were

as follows: 3 (37%) beyond high school, 4 (50%) high

school, and 1 (13%) grade school. In the experimental

group, 9 (75%) subjects were married, 1 (16%) was widowed,

and 1 (9%) was divorced. In the comparison group, 7 (87%)

were married and 1 (13%) was widowed. Seven (58%) in the

experimental group and 3 (37%) in the comparison group

were currently employed.

40

Findings

The level of adjustment to an ostomy was determined

by computing the means and standard deviations for

responses given to the ostomy adjustment scale items.

Possible scores for ostomy adjustment range from 18 to

126. The mean social adjustment score for the control

group (n = 12) was 78.58 with a range of 29 to 113 and a

standard deviation of 26.03. The comparison group (n = 8)

had a mean score of 82.42, with a range of 70-93 and a

standard deviation of 10.8.

The hypothesis of this study stated that new ostomy

patients who received enterostomal therapy nursing

interventions during hospitalization have a higher score

on level of social adjustment, as measured by Maklebust's

Ostomy Adjustment Scale, 6 to 8 weeks postoperatively than

new ostomy patients who have not received enterostomal

therapy nursing interventions while hospitalized. The

hypothesis was tested by means of ah-test for independent

samples. The results of the one-tailed test of

significance wash (17) = -.37, £ = .35; thus the

hypothesis was not supported. There was no statistically

significant difference in the level of social adjustment

of new ostomy patients who had and who had not received

enterostomal therapy nursing interventions while hospitalized.

-

41

Additional Findings

All (100%) of the subjects in the experimental group

and 6 of 8 (75%) subjects in the comparison group replied

that their surgery had been explained to them so that they

understood it. Both of the subjects who had not had

surgery explained to them commented that they had

undergone emergency surgery.

All of the subjects (n = 20) in both groups indicated

that their families were sources of support to them after

ostomy surgery. They were also asked to identify and rank

order those individuals who helped them in adjusting to an

ostomy. The family was listed the most often by subjects

in both groups as being the most helpful. The second most

frequently listed person was an enterostomal therapy

nurse, and the third person listed was a nurse. When

asked if an ET nurse participated in their care, 10 (83%)

subjects in the experimental group said yes and 2 (17%)

subjects said no. Seven (87%) subjects in the comparison

group reported having an ET nurse participate in their

care and 1 (13%) did not. Thus, an assumption of the

study was not met. The question did not differentiate

between those patients having an ET nurse in the hospital

and those patients who did not have an ET nurse until they

were home.

42

Summary of Findings

The hypothesis that new ostomy patients who received

ET nursing interventions while hospitalized would score a

higher level of social adjustment on the Maklebust's

Ostomy Adjustment Scale, 6 to 8 weeks postoperatively than

new ostomy patients who did not receive ET nursing

interventions during hospitalization was not supported.

Additionally, there was no significant relationship found

between social adjustment scores and any of the

demographic variables of new ostomy patients.

CHAPTER V

SUMMARY OF THE STUDY

The problem of this study was to determine if a

difference existed in the level of social adjustment

between new ostomy patients who received enterostomal

therapy nursing interventions during hospitalization and

new ostomy patients who had not received enterostomal

therapy nursing interventions during hospitalization.

This chapter presents a summary of the study, discussion

of the findings, conclusions and implications of the

study, and recommendations for further study.

Summary

This research study was a non-equivalent control

group (posttest only), quasi-experimental study to

determine if a significant difference existed in the level

of social adjustment between new ostomy patients who

received ET nursing interventions during hospitalization

and those who did not receive ET nursing interventions

during hospitalization. The hypothesis for this study was

that new ostomy patients who receive enterostomal therapy

nursing interventions while hospitalized score a higher

43

44

level of social adjustment on the Maklebust Ostomy

Adjustment Scale than new ostomy patients who do not

receive enterostomal therapy nursing interventions during

hospitalization. The conceptual framework for this study

was Aguilera's (1990) problem-solving model of crisis

intervention. The goal of nursing, as described by

Aguilera, is to assist the client in restoration of

equilibrium and a return to the precrisis level of

function.

The data were collected over a 15-month period using

a convenience sample. The sample consisted of 12 subjects

in the experimental group and 8 subjects in the control

group. The experimental group of new ostomy patients

received ET nursing interventions while in the hospital.

All subjects received an Ostomy Adjustment Questionnaire

packet in the mail 6 to 8 weeks postoperatively.

Maklebust's Ostomy Adjustment Scale was used to collect

data to determine the level of social adjustment of both

groups. Analysis of data showed� (17) = -.37, 2 = .35;

thus the hypothesis was not supported. Protocols for

implementation of ET nursing interventions and for the

collection of data based on Aguilera's (1990) problem­

solving model were developed.

Discussion of Findings

The findings of this study are not consistent with

studies done by Hedrick (1987) or Watson (1983). These

researchers found that patients who received ET nursing

teaching/counseling interventions during hospitalization

were better adjusted than those patients who did not

receive ET nursing interventions.

45

The mean social adjustment score for the control

group was 78.58, with a range of 29-113, and a standard

deviation of 26.03. The comparison group had a mean score

of 82.42, with a range of 70-93 and a standard deviation

of 10.8. The large standard deviation of 26.03 in the

control group indicates considerable variability in ostomy

adjustment scores. After reviewing the raw data for each

subject, the investigator noted several extremely low

scores on the ostomy adjustment scale for subjects in the

control group. These outliers accounted for the large

standard deviation and also negatively skewed distribution

of the data. These findings were also reported in

Maklebust's (1985) study when developing the ostomy

adjustment scale. It is possible that the ostomy

adjustment scale may not be sensitive to the variables

being tested. Given the small sample size, the risk of a

type II error is great. According to Cohen (1987), for a

46

one-tailed t-test with an expected moderate effect size

(.5), probability level of .OS, and desired power of 0.80,

100 subjects would be required, SO in each group.

In regard to who was most helpful to the subjects

following ostomy surgery, a family member was listed most

frequently, an ET nurse the second most frequently, and a

nurse the third most frequently. Because an ET is a nurse

and some ostomy nurses are not ETs, the choice of helpful

persons may have been confusing. Whether or not

respondents realized that enterostomal therapy is a

nursing specialty is unknown. The question regarding if

an ET nurse participated in their care did not

differentiate between care in the hospital and care at

home. Since all patients were to have an ET nurse

participating in their care at home, patients may not have

been clear what an ET nurse was.

According to crisis theory (Aguilera, 1991) if

patients did receive interventions within the 6-8 week

interval, successful resolution can occur. Thus, ET

nursing interventions at anytime during this interval may

facilitate ostomy adjustment. Therefore, the important

aspect for ostomy patients may be that they receive

constant and consistent care within the 6-8 week period

following ostomy surgery.

47

Conclusions and Implications

Based on the findings of this study, no conclusions

can be made about the effects of ET nursing on new ostomy

patients' social adjustment scores. It was evident that

family members played a major role as a support system in

the adaptation and rehabilitation of the new ostomy

patient.

Based on the results of this study one can propose a

number of implications for professional nurses who provide

care to ostomy patients. It is imperative that nurses

determine whether or not ostomy patients have family

support systems available from which they can derive

assistance and emotional support. The area of family

support is of particular importance because this study

provides evidence that a family member was the most

helpful person in aiding adjustment to the person who has

had ostomy surgery. This is consistent with multiple

literature reports that the response of close family

members is a key factor to an ostomy patient's adaptation

(Dyk & Sutherland, 1956; Hedrick, 1987; Lipson, 1985;

Kelman & Milner, 1990; Maklebust, 1985; Mikolon, 1982).

Assessment should be made about the different ways that

family members are supportive to the ostomy patient. This

assessment will help the nurse design a plan of supportive

48

care during the entire surgical experience, from admission

to discharge. The patient's supportive family members can

be included at the onset and throughout the duration of

care. These family members can choose to be included in

the surgical explanation, ostomy self-care teaching

sessions, and the United Ostomy Association visit. Nurses

should take advantage of the time when family members

visit to give them explanations and to enlist their aid in

helping with the patient's adjustment process.

It seems evident that nurses need to become more

aware of the importance of assessing the psychosocial

impact of ostomy surgery on patients and their significant

others. Nurses may want to examine their own attitudes

toward an ostomy because this attitude may be conveyed to

the patient and hence influence patient adjustment.

Nurses should endeavor to foster open communication

regarding the person's body image, sexuality, values, and

attitudes in order to do a thorough psychosexual

assessment.

This study identifies ET nurses as the healthcare

professionals most helpful in facilitating adaptation of

the new ostomy patient. Nurses can coordinate the ostomy

patient's care so that ET services are available to all

ostomates. Enterostomal therapy nurses specialize in

49

supportive nursing care with specific technical management

and psychological insight. Nurses may also advise ostomy

patients that ETs may be available for consultation and

follow-up care on an outpatient basis.

Helping patients cope more effectively with an ostomy

is a challenge for nursing. Based on the findings of this

study the professional nurse should: (a) assess the

family's ability to support the ostomy patient, (b) assess

other support systems available to the patient, (c) plan

for possible inclusion of a family member or significant

other in the explanation of ostomy surgery and self-care

teaching, (d) plan for possible ET nurse consultation for

the patient and family if the hospital does not provide

one, and (e) plan for possible United Ostomy Association

visitor for the patient and family.

Recommendations for Further Study

Based on the findings of the study, the following

recommendations are made:

1. That the present study be replicated using a

larger sample size.

2. That a longitudinal study be conducted to assess

the ostomy adjustment variable objectively and at periodic

intervals to determine whether time significantly impacts

the social adjustment level of new ostomy patients.

3. That a study be undertaken to identify the

50

primary factors within the ET nurse/patient relationship

that are most helpful in promoting successful adaptation.

4. That a study be undertaken to further refine and

test the ostomy adjustment scale.

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Mikolon, S. (1982). Psychosocial issues in ostomy management. In D. Broadwell & B. Jackson (Eds.), Principles of ostomy care (pp. 438-442). St. Louis: C. V. Mosby.

Murray, R. (1972). Principles of nursing intervention for the adult patient with body image changes. Nursing Clinics of North America, 2, 697-707.

Norris, C. (1970). The professional nurse and body image. In C. Carlson (Ed.), Behavioral concepts and nursing intervention (pp. 39-65). Philadelphia: J. B. Lippincott.

Orbach, C., & Tallent, N. (1965). Modification of perceived body and body concepts. Archives General Psychiatry, 12, 126-135.

Polit, D., & Hunger, B. (1991). Nursing research: Principles and methods (4th ed.). Philadelphia: J. B. Lippincott.

Prudden, J. (1971). Psychological problems following ileostomy and colostomy. Cancer, 2..§.., 236-237.

Rheaume, N., & Gooding, B. (1991). Social support, coping strategies, and long-term adaptation to ostomy among self-help group members. Journal of Enterostomal Therapy Nursing, 18, 11-15.

Rolstad, B. (1987). Facilitating psychosocial adaptation. Journal of Enterostomal Therapy Nursing, 14, 28-34.

54

Sultenfuss, S. (1982). Psychosocial issues and therapeutic intervention. In D. Broadwell & B. Jackson (Eds.), Principles of ostomy care (pp. 443-449). St. Louis: c. V. Mosby.

Sutherland, A., Orbach, C., Dyk, R., & Bard, M. (1952). The psychologic impact of cancer and cancer surgery: Adaptarion to a dry colostomy. Cancer, 2, 857-872.

Tacker, A., Tacker, L., & Breiman, H. (1967). Colostomy problems. Journal of Kansas City Medical Society, .§Ji,

2-4.

Wassner, A. (1982). The impact of mutilating surgery or trauma on body-image. International Nursing Review, 29, 86-90.

Watson, P. (1983). Postoperative counseling for cancer/ostomy patients. Journal of Enterostomal Therapy Nursing, 10, 84-91.

APPENDIX A

Maklebust's Ostomy Adjustment Scale

Information regarding this copyrighted instrument may be obtained from:

Jo Ann Maklebust, MSN, RN, CS Harper-Grace Hospital 3990 John R. Street Detroit, Michigan 48201 Phone: (313) 464-8107

56

APPENDIX B

Enterostomal Therapy Nursing Interventions

58

Information regarding standards of care and nursing interventions for the ostomy patient may be obtained from:

Wound, Ostomy, and Continence Nurses (WOCN) Society 2755 Bristol St., Suite 110 Costa Mesa, CA 92626 Phone: 714/476-0268

APPENDIX C

Human Subjects Review Committee Exemption Form

TEXAS WOMAN'S UNIVERSITY DENTON DALI.AS HOUSTON

DALLAS CENTER

PROSPECTUS FOR THE THESIS

This prospectus proposed by: ____ K ___ a...;;r...,;;e..;.;n;.....;.;K'-.__:.;.H'-a r�t ;;;.;in;.;.__ ____________ _

Social Security Number: ___ 3 ..... J .... 5.._-_.7'""2...;;--1.Z,.l,,(Q-'-Z_,_3 _______________ _

Titled: ___ E_n _t_e _r _o_s_t_o_m_a_l_T_h_ e_r_ a-=p-=y'--N_u_r_s_i_n..;:;g_a_n d_S_ o_c_1_· a_l_R_e _a _d..;;..j_u_s_t_me_ n_t __ _

Followin g Ostomy Su rge ry

Has been read and approved by the members of his/her research comminee. This research (check one):

_ _,_x..__,_ Is Exempt from Human Subjects Review Committee review because

Category I Study - An onymous Que stion n aire

____ Requires Full Human Subjects Review Committee review because:

____ Requires Expedited Human Subjects Review Committee review because:

Research Committee: Type name

_L_o_i_s_H_o _u�g_h _______ (Chair)

r Snirley M. Ziegler

Oneida M Hqgbes

Dean, College of Nursing

·,ti�:!�&4 //:,1,i;w,� 1e/;.t/r._,

Sign3ture O Date

60

, I

.'J ~'

APPENDIX D

Agency Permission Forms

.!!XAS WO�AN1

! u,IVERS!TY

COLLEGE O� NUR�ING

A.GENCY PER�!SSMN FOR CONDUC"!'!NG STUDY*

T f. E Harre Hea J tb Senri ces cf Pa J J as

GR.U.:Ts TO t\.r!.re.'1. K. Martin

a scudent ent"olled in a program of nu:sing leading t? a Masce:'s D�g:eQ &t Te��s Woman's University, :h� privil�ee of it5 facili:ies in order to study th� followin� problem.

! 11 >t :1.;. t: � S O f � C. ::1 r; !. '/ � ..:; r ,t C: Iii i n,: S ,: :' ;; :' i V � ;, ,: \' ::l O 11 :':-! �,� th� �s���,� (oay not) b� idencifi�d in ch�f�::;:..! re:pon.

a LLLl. � b, ;; ; ? " .J. c 2., i � .:: ll h d .i r, :: ::- i i' ,: r. � d : C t" i � i n a l : � : � d II r. t , ! s t ,: c p ;1 : ,!,. :; -t :i I! :,, :! n d c o p y : T ',,,'?! <: o j, l 'l � I:! o f Nu t· :. .: n:;:

62

SOCI.:\L !<EAO.,"'t;ST!-!El-;'T Fou..:,wn:G OSTOM'l SC.,7.GER'!

.,

TEXAS WO�AN 1 £ UNIVERSITY

COLLEG� OF NURSING

AGENCY PERM!SSTON POR CCN'DUCTTN<; S7U'DP

THE __________________________________ _

GRANTS TO Kare..'l K. Ma...,·tin

a student enrolled i� a program of nu:slng leaciing to a Mascer's Degree ac Texas Wom�n•s Unive�sicy, :h� priv�lege oi ics facilici�s in order co scu�y che fol!owinq problem.

SCC!.AL RE.,:i.tJU� FOL!.CWDIG OSTCMY S-uRG�

l. T�P. a��n,;;: {-ff',-;:-:,') (ma;: uoi:) be· :dP.nr:itl';!,i i:i thefinal :-1?�0:-:.

:h� ��=as ot co�s�!�a�i�� �r �ciminis:;�:iv� ?���ccn�!i. � ;: he a � � n c y ( �) ( :n.1 y no c ) be i ci en c i f i �,: i r. c;: �f:.nal t'C:p1)rc:.

Th u a g � n c ;, ( w a n c s ) ( e .,e ., R o ,. · · 1• , .... ) a c o n t e :- e n c e . ..., ;_ c h ch� student when the report is complac�d.

Di1: e

,/tuu,.>,fif)2z� l&riJ 3ig�acu�c �t ScuJ�nc

; i t i.. � � s £ :r � ;_ C '.:) 'J i. � ,; � :-: � d i s :-; :- :. ·: �.! '.. ·? ,: •

O :- i g !. n a l : � � '..l C ft r. r: •. l l c .-; c ? :1 : .!. :� � :1 ·.: :,-·

'.!nd co9y: 7t,·t; <:�1:•?�':! v� :•:l!:-s!,,;;

63

E:'l'!'E:ROSTC!-1?-L T:~.F: N"JRSDJG ~-ND

----O:he r:

TEXAS WOMAN'S UNIVERSITY COLLEGE Of NURSING

AGENCY PERMTSSIO� 1.Q.B. CONDUCTING STUDY�

THE Visiting Nurse Association of Texas

GRANTS TO Karen K. Martin

a student enrolled in a program of nursing leading to a Masce;•s Degree at Tex�� Woman's Universic�. :he privilege of its facilici�s in order co study che followin� problem.

ENrEROSTOHAL THERAPY NURSING AND

SOCIAL REAOOUS'IMENT FOLLOWING osrOHY SURGERY

The cQndi�ions mutually agr�ed upon are as follows:

.. .

(7

* £i..U .Q.YJ;_ � � J. coo i e s ll h /.: d i � :: ::- i h :: r. e ,j : v r i � i n a l : $ t: u d it n t • l s t c o p y : A 1; � n c :,•:? n d CO pr : n:u <: 0 11 i:? � I! 0 .f Nu C's i n;;;

Personnel

Ac.iv i !: or

64

APPENDIX E

Graduate School Approval Letter

Ms. Karen Martin 11384 Fernald Ave. Dallas, TX 75218

Dear Ms. Martin:

TEXAS WOMAN'S UNIVERSITY

DENTON OALW HOUSTON

TiiECRADUATESCHOOL

P.O. Box !2479, Dl!nlon, Tex.11 i62().;..0.l79 817 /898-)-100

November 10, 1992

I have received and approved the Prospectus for your research project. Best wishes to you in the research and writing of your project.

dl

cc Dr. Lois Hough Dr. Carolyn Gunning

Sincerely yours,

Leslie M. Thompson Associate Vice President for Research and Dean of the Graduate School

�" £quo/ Opv,irt11nity/�!finna1itv t\cllon £1nvlo�tr

66

APPENDIX F

Cover Letter

68

Dear Participant,

I am a graduate student at Texas Woman's University

College of Nursing in Dallas. As part of the process of

completing a research requirement, I am conducting a study

to gather information about the teaching and counseling

that persons having ostomy surgery receive while they are

in the hospital. I hope that the information gathered in

this study will help improve teaching and counseling for

ostomy patients in the future. As a participant, I am

requesting you complete the enclosed anonymous

questionnaire, which asks for some personal information

and some of your reactions to having an ostomy. I need to

get information from you about what helped you the most

and what helped you the least in adjusting to your ostomy.

The questionnaire will take about 20 minutes of your

time to complete. Your response will be completely

anonymous. DO NOT write your name or address on the form

or the envelope. A stamped, self-addressed envelope has

been provided for your convenience in returning the

completed questionnaire. A response by ________ _

will be greatly appreciated.

Participation in this study is voluntary and if you

do respond, you do not have to answer every question. The

findings of this study will be reported by groups, not by

69

individuals. If you wish to receive a summary of the

study results, return the stamped, pre-addressed postcard

separately from the questionnaire.

My personal thinks to you for your consideration and

cooperation in helping me to complete my research project.

Sincerely,

Karen Martin, R.N. Enterostomal Therapy Nurse