As the end of 2020 approaches, it is timely to look back and reflect on what such an unprecedented year this has been for us as clinical nurse specialists and service providers, alongside all the changes that the NHS and social care staff have had to make to ensure that their clinical services are maintained.
With restrictions on face-to-face contact has come the requirement to reduce the number of outpatient clinics and home visits, leading many stoma nurse specialists to employ innovative ways of maintaining their service to patients during the COVID-19 pandemic. With some staff shielding, sick or redeployed to support frontline care, it has been essential to triage and prioritise patients to help keep everyone safe and maintain vital services.
NHS England (2020) has encouraged a transition to new ways of delivering care to prevent the transmission of SARS-COV-2: this has meant reducing patient footfall and having fewer staff in hospitals and finding the means for both clinicians and patients to have clinical interactions in their home environments.
Historically, the role of the stoma nurse has been very ‘hands on’ and many may be sceptical about whether this year's enforced changes in providing ongoing care and support for patients in the community can continue to deliver a meaningful and clinically effective service. Although many healthcare services are starting to reopen with face-to-face contact, we need to continue triaging all patients and challenging ourselves on the feasibility of meeting our patients’ individual needs in alternative ways.
The COVID-19 pandemic has given us all the opportunity to rapidly develop our services in ways unimaginable just a few months ago. With the continued impact of COVID-19, we need to sustain the use of these new processes and changes to the way we work, balancing the importance of providing face-to-face support for all those patients who have a clinical need, while remaining conscious of the need to protect our patients' health and wellbeing.
Yet, as we move into 2021, it is timely for us to pause and reflect on the question, ‘Is the way we are delivering our stoma care during this “new normal” delivering a meaningful and effective service?’ And can it be argued that these recent changes in practice have helped us embrace the NHS self-care agenda (NHS UK, 2019)?
Embracing technology
We all acknowledge how vital the role of discharge planning is for a safe transition into the community for a new ostomist (Prinz et al, 2015), yet due to the risk of exposure to SARS-COV-2 in hospital our patients are continuing to be discharged as soon as is feasible after surgery. With continued restrictions on visitors to wards, and on relatives and carers accompanying patients to clinic appointments, the use of video calls has enabled us to find ways to involve extended family and care agencies in planning their stoma care.
It has been essential to have the right technology available to us to be able to provide virtual consultations, and maintain email and SMS contact as alternatives. Both the NHS and commercial stoma care providers have been working together to facilitate this for all, but we can empathise with the IT challenges that this may have caused for some departments.
When we make any change to service delivery, feedback from all service users is paramount to evaluate care provision. We feel confident that we have continued to deliver timely, robust and individualised care. It has not always been easy. At times, patients have needed support with using the technology, but they have also largely welcomed this innovation.
Patients have provided us with feedback about how they have felt about embracing new technology to maintain contact with us, with comments such as:
‘I had quick and timely access to my stoma nurse.’
‘I was able to email my stoma nurse a picture of my stoma for her to review before my consultation. It was an effective way to have my stoma reviewed.’
‘I felt happy that I did not need to attend a hospital clinic but could still be seen.’
Virtual alternatives
So what can we now expect in 2021? It seems that a vaccine is in sight, our world will be opened up once again, and the option for stoma nurse specialists to resume a normal physical face-to-face service could be restored. However, do we want to revert to our old ways of working or should we be aiming to retain some or all of the changes we have worked so hard to implement during the pandemic?
The experiences we have had this year should be used as a catalyst for change, to help us shape the future of our stoma care services and offer patients greater choice in the way they choose to receive their stoma care.
For example, at University College London Hospitals (UCLH) we are a tertiary referral centre. Prior to the COVID-19 pandemic, it was customary for many patients to travel a considerable distance to see the stoma nurse specialists or their colorectal surgical team for follow-up appointments. Many patients currently feel wary of travelling through London to see us—they have health concerns, mobility issues or are shielding. Yet, even when the risks imposed by COVID-19 have abated, will all our patients' needs be best served by a full resumption of a face-to-face service, with the time, expense and inconvenience of travel, when many of them have complex health issues? Are home visits by stoma nurses always the most efficient use of our resources?
At UCLH, we have been scheduling our patients' annual follow-ups well into next year—when we can be reasonably confident that COVID-19 restrictions will have eased—and we have found that many patients are actively choosing to maintain future contact with us via video or telephone appointments.
So has the opportunity now arisen for stoma nurse specialists to embrace a move to a digital future? Are all our patients ready for this? Many already access the internet or social media for information or peer support. Digital and telephone support for stoma care have the advantage of being timely, convenient and cost-effective both for the patient and the stoma nurse specialist.
In our experience, often simply receiving an email with a photo of the stoma site, then carrying out a structured telephone or video assessment, clarifies the issue and enables us to suggest a solution or organise samples to be sent to trial, without the need for a home visit or a journey to clinic. Some stoma-related issues such as lifestyle or dietary concerns lend themselves to discussion just as effectively by phone or video consultation.
Could we make use of digital technology in preoperative counselling for elective patients? Could stoma care delivered via a digital platform succeed in reaching out to those ostomates who do not know their local stoma nurse?
Conclusion
The time is ripe to innovate, audit and evaluate these new and different ways of delivering our services. We can learn from both our own experiences and from that of those who have gone before us in delivering telehealth care in remote areas such as the Australian Outback or the Scottish Highlands (McCall et al, 2008; Theodoulou et al, 2019).
Inevitably, some patients are less able to access technology and we need to ensure that our services provide equity of access, remaining flexible to the needs of everyone. For future service planning, we need to consider whether we can offer a wide range of strategies to get closer to our patient group.
If we allow ourselves to simply fall back into our old ways, the advances we have seen over the past few months will be lost. Benjamin Franklin famously said: ‘Out of adversity comes opportunity.’ Stoma specialist nursing has moved forward in the past few months more than we could ever have imagined 1 year ago. It is up to us to continue this journey.