SHAPE was implemented as a quality improvement project to improve nursing practice and promote better patient outcomes in stoma patients with a parastomal hernia. The name SHAPE came about when visualising the goals and outcomes of combining education with support group sessions. Originally, the project was called Stoma Hernia and Preventive Exercises but, following the first group session, it was soon realised these sessions offered more of a focus on stoma health so SHAPE was renamed Stoma Health and Preventive Exercises.
Parastomal hernias
A parastomal hernia is defined as a protrusion through the abdominal wall defect created during stoma-forming surgery. They range in size from a small asymptomatic bulge to a large complicated mass with life-threatening symptoms (Cowin and Redmond, 2012). According to North (2014), a parastomal hernia is the most common complication post surgery and stoma patients have a lifelong risk of developing a hernia because of the surgical defect created within the abdominal wall. Earlier research identified that more than 50% of patients presented with a parastomal hernia in the first year post surgery (Thompson and Trainer, 2007). Further surgery may be needed to repair the hernia but that comes with a high incidence of reoccurrence and associated risks.
In many NHS services, patients can wait a long time to be seen by a colorectal consultant and to be triaged for surgical intervention unless they immediately present with a strangulated hernia, which is life threatening (Lambrecht, 2021). Antoniou et al (2018) recommended that diagnostic data are essential to inform policy development to categorise parastomal hernias as a clinical priority, but there is a lag in policy reform in practice. Stoma nurse specialists are ideally placed to influence practice and policy reform.
Parastomal hernias pose many clinical challenges for the stoma nurse, such as finding suitable appliances, treating compromised peristomal skin and the management of bowel interruption/dysfunction. Such patients are usually frequent clinic attendees who need additional support and may require repeated hospital admissions. Managing complications is costly because of increased product usage and staff resources but it was ultimately the challenge faced by patients presenting with a parastomal hernia that influenced a change to practice. Parastomal hernias complicate recovery and impact on the patient's adjustment to life with a stoma.
Staff training
Community stoma nurse specialists from Western Health and Social Care Trust (WHSCT) in Northern Ireland attended a training event by clinical exercise specialist Sarah Russell, sponsored by Convatec, on ‘Rehabilitation and Movement following Stoma Surgery’ to obtain the knowledge and skills needed to teach patients safe and effective post-stoma abdominal exercises. The training highlighted evolving evidence on the benefits of physical activity and abdominal strengthening exercises to help patients reduce the risk of developing a parastomal hernia.
Following on from the training a Stoma Health and Wellbeing Event was organised with Sarah Russell invited as a special guest; it was a great success, with more than 100 patients in attendance all practising safe abdominal exercises. Feedback indicated that patients would benefit from more knowledge on physical activity after stoma surgery and wanted more opportunities to meet up with other ostomates.
Exercises for stoma patients
The relationship between physical activity and good health is well recognised, with national and local agendas addressing measures to educate the population to be more active and prevent long-term health conditions (Department of Health, 2011; WHSCT, 2023). SHAPE is a platform that can be used to implement principles set out in such frameworks. SHAPE also addresses the unique needs of stoma patients and, as a component of a stoma-specific recovery pathway, will help alleviate fears about taking part in physical activities following life-changing surgery. Cancer support charities provide the necessary information and support to promote positive lifestyle changes and although SHAPE echoes the ethos of the ‘Move More’ campaign (Macmillan Cancer Support, 2017), many stoma patients do not have a cancer diagnosis and SHAPE allows for diversity of diagnosis and age.
Research on cardiac recovery programmes has found that they promote positive patient outcomes (British Heart Foundation, 2017). Stoma patients face similar challenges to cardiac patients: recovery from major surgery, physical de-conditioning, comorbidities, lack of confidence, body image issues and lifestyle adjustments. SHAPE aims to positively impact stoma patients' recovery after surgery.
Clinical guidelines from the Association of Stoma Care Nurses (ASCN) (2016) stated that it is the responsibility of stoma nurses to advise and educate stoma patients on physical activity but research by Russell (2017) reported that patients are not receiving adequate advice on the importance and benefits of physical activity after surgery. In response to service user feedback, and following reflection on current practice, educating patients on the benefits of physical activity and teaching safe and effective abdominal exercises became a priority. In addition, there was now an opportunity to advocate for a support group within a clinical priority framework.
Audit
Reaching out to the Quality Improvement Department within our Trust proved a good starting point to support and develop SHAPE as a quality improvement initiative. It was suggested that the PDSA model (Plan, Do, Study, Act) provided an ideal audit cycle framework to capture the impact of integrating SHAPE into practice (NHS England/NHS Improvement, 2021). The four aims of SHAPE were to:
- Encourage patients to return to physical activities
- Teach appropriate abdominal exercises to retrain abdominal muscle strength
- Reduce the risks and incidence of parastomal hernia
- Reform policy and the referral pathway.
Data collection methods were devised to capture outcomes against the four aims. The timeframe for the project was 2 years. Administrative support was funded by the Martha McMenamin Foundation. Group sessions were planned in a local health centre, with tea and coffee facilities provided.
The ‘doing phase’ (implementation) consisted of one-to-one nurse teaching of three abdominal exercises in a lying, sitting and standing position, starting for stoma patients at week 1 and 2 post surgery. This would be a component at each clinical consultation. Data were recorded on risk of hernia, whether abdominal exercises were being practised, and activity level starting at weeks 1 to 2.
Attending a SHAPE group session, wearing of a support garment and if a hernia was evident were assessed at weeks 10 to 12, weeks 26 to 28 and weeks 50 to 52 post surgery. Measurement of abdominal girth was recorded at each interval and support garments were fitted at week 10 to 12. Questionnaires were distributed at week 20 and again at week 50 post surgery to measure the value of SHAPE education.
The project ran for 2 years and included six group sessions with around 20 to 25 patients in attendance at each session. On 27 April 2019 the Ileostomy Association sponsored a river walk and open day with support from stoma product manufacturers, who endorsed SHAPE as a positive initiative.
Results
A study of initial results revealed that 90% of patients reported an increase in physical activity levels, and a 30% reduction in the number of patients presenting with a parastomal hernia. A decrease in patients' abdominal girth was also observed.
This clinical data captured evidence to reform the referral process and was presented to surgical colleagues. Since the initiative the referral process has been streamlined and nurses are more able to raise concerns. Nurse referral letters to colorectal colleagues, highlighting the degree of a patient's parastomal hernia symptoms, now allow for more timely patient reviews. The stoma nurses continue to work to highlight parastomal hernia as a clinical priority.
All four aims of SHAPE were achieved, with a secondary finding being that 100% of patients benefitted from peer support at the sessions. Acting on the results took commitment and resilience as plans to disseminate SHAPE were stalled because of the COVID-19 pandemic, although face-to-face teaching continued.
Present and future plans
SHAPE is now an established component of our recovery pathway. All new patients are provided with one-to-one nurse teaching on safe abdominal exercises, documentation is adapted to record abdominal girth, activity level, parastomal hernia risk and details of support garments. Weekly group SHAPE sessions are now led by a personal trainer who herself has a stoma and provides inspiration to patients. Classes are funded in collaboration with social workers as part of a programme to promote physical and mental wellbeing. Patients are encouraged to attend SHAPE sessions for at least 6 weeks to gain knowledge and confidence with physical activity and abdominal exercises. Representatives from stoma product manufacturers provide refreshments with informal product/service updates. Stoma nurses participate in and facilitate a question-and-answer session at each class. In partnership with patients, stakeholders and with multi-professional support, SHAPE is having a positive impact on nursing practice and patient outcomes.
Plans to promote SHAPE this year have included a river walk and an open day sponsored by stoma product manufacturers and endorsed by patient support associations in June to promote the benefits of physical activity to live well with a stoma.
Ambitious plans for SHAPE include pursuing a Quality Standard endorsed by the National Institute for Health and Care Excellence (NICE). NICE (2023) uses the best available evidence to develop recommendations that guide decisions in health and social care services. Highlighting SHAPE as a quality improvement priority would secure a stoma-specific quality standard to guide best practice.
Information on SHAPE was shared at the ASCN conference 2022 in Harrogate and won our service the Gold Award at the BJN Awards in March 2023 for Stoma Nurse of the Year!
I believe that the following quote from Socrates sums up our philosophy when improving patient care: ‘The secret of change is to focus all of your energy, not on fighting the old, but on building the new.’