About 188 500 people are currently living with a stoma in the UK and it is estimated that more than 28 000 new stomas are formed each year; and the number is increasing (Association of Stoma Care Nurses UK (ASCN UK), 2021). Stomas are formed during surgery to divert the passage of urine or faeces from its normal route (Bedford, 2022). Different types of stomas are formed for a variety of conditions and clinical indications; they can be permanent or temporary and formed electively or as part of emergency surgery.
The formation of a stoma significantly impacts patients' lives, necessitating comprehensive postoperative education for effective self-care and adaptation (Le Ber and Fronzo, 2022). Education enables self-care, prevents delays in discharge and reduces complication rates, and it is therefore cost-effective (Forsmo et al, 2016). Many people have little knowledge of stoma care, and it can be complex, thus there is an increased need for essential education and self-management skills (Liu et al, 2023). Despite the critical role of this education, the UK lacks a standardised approach, leading to varied outcomes and inefficiencies.
This review of the literature critically examines the current state of postoperative stoma care education, identifying gaps in practice and research, and advocates for the establishment of a national care pathway to enhance care quality and patient satisfaction.
Postoperative stoma care education guidelines
Stoma education was traditionally provided in the postoperative period and a large amount of professional effort has been put into patient education and training over the years. ASCN UK produced Stoma Care. Nursing standards and audit tool in 2021, which outline the structure, process and outcome of care in the postoperative period, which includes education. The standards describe best practice for the stoma care nurse (SCN), based on safe, effective, holistic care and provide templates to audit the effectiveness of these standards.
The nature of stoma education has changed with the development of the enhanced recovery after surgery (ERAS) approach, introduced by Henrik Kehlet in 2009 (Kehlet, 2022). ERAS is a multimodal approach to optimising the care of patients through all stages of the surgical process (National Institute for Health and Care Excellence (NICE), 2020). There is no national standard demonstrating how this evidence-based programme, which includes pre- and postoperative patient education, is implemented in practice (NICE, 2020).
ERAS principles of care have been shown to have benefits to stoma patients. They include earlier discharge, less stress and better outcomes (Marsden, 2020). ERAS focuses on patients' active participation in the recovery process, in keeping with the NHS value of ‘working together’ (Poland et al, 2017; NHS Professionals, 2024). ERAS studies that consider the benefits to stoma patients are difficult to compare directly, because they use varying methods and outcome measures; however, they all show that patients benefit from stoma education in the postoperative period (Marsden, 2020). SCNs and ward nurses have a clear role to play in postoperative education for the success of ERAS for stoma patients. However, if stoma patients' length of stay is reduced, there is a risk that there is not sufficient time for the SCN to provide the most effective postoperative education (Rolls et al, 2023). It is also hard to measure the impact of postoperative stoma education in isolation within these studies, because it is only one aspect of the ERAS pathway (Younis et al, 2012). An added problem is that, in the current climate, there is also a shortage of SCNs.
The development of ERAS principles has influenced the focus of research and guidelines for stoma care education. This is reflected in the wealth of recent research, review articles and opinion pieces that discuss the evidence and importance of pre-operative education, but with very little focus on aspects of postoperative education. This lack of emphasis on postoperative education research has been described by Rosenberg and McGee (2023) as the ‘orphan area of interest’. According to stoma patients, postoperative stoma care education is very important when recovering and adapting to a new way of life. It is crucial to get postoperative care correct, even though it is a small part of a patient's journey, because it will have a long-term impact on their outcomes when adjusting to life with a stoma (Le Ber and Fronzo, 2022).
The lack of focus on research on stoma education is discussed in a literature review by Faury et al (2017) where they identified 15 relevant studies regarding patient education in stoma care, compared to 118 studies in diabetes care. This suggested to Faury et al (2017) that discussing stomas is a taboo subject, which may also be a barrier to prioritising research in this area. Their review also reported that most educational interventions were in the postoperative period and there was a variation in teaching time and frequency.
Stoma patients' needs and wants
The importance of effective care is emphasised in articles in this review of the evidence of the ERAS principles, but care must also be holistic and adapted to the individual's needs by the SCN. The literature on stoma patients' needs and wants was included in this review, as having a stoma will impact on every aspect of a person's life, and effective postoperative care can potentially make a big difference to their journey and outcomes (Le Ber and Fronzo, 2022).
Using patients or members of the public to develop research into patients' needs is invaluable and can reveal findings that may not have been otherwise considered (Snowdon et al, 2023). However, there was no evidence of patients leading formal research into postoperative stoma education, nor was patient and public involvement in the development of research projects identified in the review.
The present review of the literature reveals common themes with regard to stoma patients' needs; for example, effective stoma care education must be holistic because learning requirements vary between people (Le Ber and Fronzo, 2022). Another theme discussed in the literature is that, for postoperative education to be effective, the conditions must be right. Patients who have undergone stoma surgery in hospital must be engaged by the health professional facilitating the education, and given the right amount of information at the right time to learn the practical skills so they can be discharged home safely (Williams, 2012).
Multimodal methods of education and information-giving have rapidly increased and developed over recent years to meet patients' varied needs, but there is no definitive guidance as to which methods achieve the most effective education. The ASCN UK (2021) standards outline the key elements to consider in teaching, drawing on these different methods. It is the SCN's role to assess learning requirements and choose which method of education best meets that person's need (Le Ber and Fronzo, 2022). The SCN also needs to help the patient navigate reliable sources of stoma-related information, to avoid confusion caused by seeing incorrect information. Education sources can include stoma charity information leaflets, websites and helplines, research support groups, peers, hospital information leaflets and mock stoma kits and social media. Education time directed by the individual (alongside standardised information-giving by a health professional) is also important, one author called this ‘free form’ time (Burton et al, 2011).
Mock stomas (consisting of a rubber model of a stoma that patients can attach to their abdomen) are an example of an effective new teaching tool used in stoma education. Vickers (2022) studied a small sample of 37 patients who had a mock stoma in their pre-operative information pack. Importantly, when looking at the effectiveness of postoperative education, this small study demonstrated how including a mock stoma in multimodal teaching could increase engagement and independence with stoma care and reduce length of hospital stay. Some participants also found the mock stoma to be a useful tool to train family members or carers at home about their care (Vickers, 2022). Further research is needed to evaluate the impact of the mock stoma as an effective education teaching tool, but it clearly has been found to have benefits (Vickers, 2022).
The ‘Ostomates' agenda’ was written by a group of stoma patients in East Kent and published in Colostomy UK's stoma patients' support magazine Tidings (Christian, 2023). It included information about what they expected to be included in their postoperative care and teaching. The nurses used this information to develop a framework for delivering a clearer, more structured pathway of care. The East Kent stoma group suggested that, if this structure was in place in more regions, then stoma patients' quality of life would see improvements nationally (Christian, 2023).
The suggestion that effective stoma education improves patients' quality of life is undisputed in multiple studies using a variety of research methods (Triyanto, 2021). In an article by Le Ber and Fronzo (2022), Sarah Smith, a social media blogger living with a stoma, discussed the importance of using education to engage patients to improve their outcomes. She highlighted that effective education should include family members and carers if the patient is unwell, unable to process the information, or will need assistance with their stoma care due to other factors.
The role of the ward stoma link nurse
A ward link nurse is defined by the Royal College of Nursing (RCN) as a nurse with an interest in and knowledge of a specialty. They work alongside specialist nurses to assist with the education of ward staff and patients and have successfully been implemented in other areas of care, such as infection prevention and control (RCN, 2021). The benefits to staff and patients are apparent with the implementation of a link nurse role in other specialties, but evidence for its effectiveness in stoma care education is limited (Perry-Woodford and Whayman, 2005). The link nurse role in supporting delivery of stoma care education is not outlined in the ASCN UK standards (2021). There is no standard for their use nationally on the wards; this risks the benefits and importance of the supporting role of the link nurse being overlooked (Newcombe, 2016).
The current challenges to delivering postoperative education include reduced length of stay; staffing issues; pressure on beds; and an ongoing need to reduce the cost of care and complication rates (Marsden, 2020). It is Marsden's (2020) view that to avoid delayed discharge, stoma link nurses can have a key role in intensive stoma education training to support the SCN to meet stoma patients' postoperative education seven days a week (Marsden, 2020).
The introduction of ward stoma link nurse can be an effective measure to overcome some of the challenges of postoperative education and barriers to learning. For example, when the SCN is unavailable, the link nurses can bridge the gap in care and may be able to deliver the right information at the right time (Le Ber and Fronzo, 2022). Newcombe (2016) suggests that this care by the ward or link nurse is as significant as more formal teaching sessions provided by the SCN. This opinion is supported by other authors who suggest that having more than one person involved in postoperative stoma education improves its effectiveness (Faury et al, 2017). This is in keeping with providing individualised care and meeting the individual needs of the patient, at a time that suits them. A person receiving individualised and holistic care may view this as an element of effective postoperative care.
There is a significant variation in stoma care services delivered across the country (Porrett et al, 2023) and the use of link nurses in this area of care is not widely documented in the literature examined. Perry-Woodford and Whayman (2005) outlined that, for the role to be successful, the link nurse needs his or her time, support and knowledge needs met by the SCN and the management team. The link nurse does not replace the SCN's experience and knowledge, but, if implemented successfully, the introduction of the role is an effective way to increase holistic care and improve standards of care. The role potentially offers a solution to bridge the gap between ward nurses, who may have limited knowledge of stomas, and the SCN, with their expert knowledge, in areas where there is a high turnover of staff or inexperienced staff on the ward (Perry-Woodford and Whayman, 2005).
Care pathways in stoma care
There is no national standard pathway for postoperative stoma care and education, and the implementation of pathways in different hospitals in practice varies (Faury et al, 2017; Porrett et al, 2023). Care pathways have been shown to improve patient outcomes and costs (Marinova and Marinova, 2023). Coloplast UK initiated a review of the evidence for a national integrated best practice pathway, working with an independent Project Advisory Board and Project Group (Porrett et al, 2023). The report produced highlights that there is a clear need for a defined pathway for all stages of the stoma patient's journey, which includes ‘pre-op, in hospital, returning home and life with a stoma’ (Porrett et al, 2023: 35). The authors suggest that an integrated pathway should build on best practices, be cohesive and use a holistic model of care. They outline essential criteria to include in a national pathway, which includes postoperative care. The report states that SCNs are the central figure to ensure the pathway is effective, holistic and cost-effective, and an important aspect of their role is postoperative information-giving, education and support (Porrett et al, 2023).
Patients value the use of pathways in providing a structure to care (Christian, 2023). A Google search revealed several local care pathways have been used and developed by experienced SCNs (Marinova and Marinova, 2023). Nizum and Jacob (2022) carried out a systematic review of ostomy care pathways and concluded that such pathways may contribute to patient satisfaction, reduce length of stay and readmission. They discuss that effectiveness of such pathways is hard to evaluate due to the quality of the literature available (Nizum and Jacob, 2022).
In keeping with ASCN UK standards (2021), the role of the SCN is clearly defined in these pathways. Liu et al (2023) identified that two to three sessions with the SCN are usually sufficient to teach stoma-care skills, but there is no similar analysis for the input of stoma link nurses. It is important to new stoma patients that they receive clear and accurate information about their stoma care; independence with stoma care is the beginning of acceptance of their new life with a stoma (van Loon et al, 2020).
Using a pathway for postoperative stoma care and education is a cost-effective method of improving patient outcomes (Marinova and Marinova, 2023). The pathway Marinova and Marinova (2023) implemented outlined the patient's journey, but they did not highlight the value of the role of stoma link nurses and ward nurses educating within the postoperative period. This finding is consistent with most postoperative stoma care pathways; this risks losing the identified benefit of having stoma link nurses working alongside SCNs.
The value of stoma care pathways as an effective framework for stoma education is not a new concept and was discussed by Davenport (2014), who implemented a cost-effective, RCN-accredited, stoma care pathway across five pilot sites. The pathway included only a small section on postoperative education, and the roles of people delivering the education on the pathway are not defined. Davenport's findings do support the view that a structured pathway, based on evidence and research, benefits most patients; 95% of patients reported that the pathway provided a valuable service – it promoted excellence and was cost-effective (Davenport, 2014).
In the literature search only one pathway was found that had a more structured focus on postoperative education, which included the ward nurse role as well as that of the SCN (van Loon et al, 2020). Unlike in other pathways, ward nurses were active in all stages, supporting the SCN at weekends and between formal teaching sessions. The pathway focus is on education, engagement and involving carers. Van Loon et al (2020) measured its effectiveness by assessing independence with practical aspects of stoma care at day 4 after surgery. Some 68% of patients were independent, compared to 8% in the control group (van Loon et al, 2020). There was no statistical difference between emergency and elective patients on the pathway. This reinforces the benefit of using a pathway for all patients, because it was successful for both groups despite the lack of pre-operative education for emergency patients.
Using knowledge gained from this critical review, existing pathways, and analysis of stoma patients' needs and wants, the author has developed a pathway for postoperative care and education for elective stoma surgery. A draft copy of the pathway is included in Table 1. The SCN, stoma link nurse and ward nurses are active in different stages of the pathway. It focuses on postoperative education, team working and actively engaging with patients, carers and family members to achieve the best outcome. It also includes other members of the multidisciplinary team, such as the consultant, pharmacist and physiotherapist. A dietitian is not routinely included, but the MUST nutrition score is calculated routinely on admission and during the inpatient stay (BAPEN, 2003). The SCN should provide general dietary advice and refer to a dietitian if required for additional input or follow-up. If further psychological support is required, the SCN should facilitate the referral and discuss support available to meet the individual patient's needs. It is a team approach to stoma education, to ensure that the most effective postoperative education is delivered efficiently and holistically.
| Admission | Ward nurse: during admission process clarify patient's knowledge of stoma care, check patient agrees with stoma site marking. Discuss needs with relatives/carers and arrange appointments for education on days 1, 2, 3 if required. Escalate any concerns to consultant/nurse in charge. Pharmacy to review medications. Dietitian to review and plan care if required |
| Day of surgery | Ward nurse to observe stoma and document on observation chart. Complete stoma care plan each shift. If unplanned stoma, inform stoma link nurse or stoma care nurse (SCN) |
| Day 1 | SCN or stoma link nurse to reassess patient's education needs and develop postoperative planAims of education: educate about importance of independent care and what this involves. Actively engage patient in care as able. Patient to empty pouch with supervision of ward nurse. Physiotherapist/occupational therapist to assess and provide care plan |
| Day 2 | SCN or stoma link nurse to support patient with a complete bag change. Practical teaching to include peristomal skin assessment, diet, output monitoring. Encourage patient to be involved with pouch change |
| Day 3 | Aim: patient to independently change stoma bag under the supervision of ward nurse, stoma link nurse or SCN |
| Day 4 and further days | Continue with daily bag changes and education. SCN or stoma link nurse to assess readiness for discharge and to see if further specialist input is required. If they are unavailable to assess the patient, the ward nurse should contact the SCN or stoma link nurse to ensure supplies of stoma products are available |
| Discharge day | Patient should be independent with stoma care needs. Discharge when consultant, SCN or stoma link nurse, and members of multidisciplinary team involved in care agree that discharge criteria have been met. Consultant to authorise discharge. Pharmacy to review medications.Further days – if further training required or discharge is delayed, ward nurses to encourage independence with stoma management and liaise with stoma link nurse and/or SCN on how to meet the patient's needs. Document the patient's progress daily. Note: if condition changes inform SCN and refer to dietitian if required |
The pathway has been designed to optimise patient outcomes, reduce complication rates, and provide cost-effective care within the RCN's Principles of Nursing Practice (2010) using the evidence discussed in this review. Before implementation, the pathway will be reviewed by all members of the multidisciplinary team and a sample of patients at the author's hospital. The effectiveness of the postoperative education and care will be audited after implementation using the ASCN UK standards audit. The audit will examine whether ASCN UK standards are being met and if patients are satisfied with the care they received in hospital and how this has affected them in their transition to life with a stoma. This is to ensure that, in measuring the effectiveness of the pathway, the stoma patients' views are prioritised.
The pathway is focused on learning the practical skills essential for living with a stoma and outlines the team members involved. It is very important that it is used as a guide and adapted to the individual's holistic needs, so that care is not task oriented. The practical focus of the pathway is also to give structure to the patient's recovery, following the strong evidence of ERAS principles and the ASCN UK standards (2021). This will also aid staff who are unfamiliar with stoma care and help the patient to see what a typical postoperative journey involves. This practical focus also helps to avoid delays to discharge, preventable complications, unnecessary product use and unplanned readmissions. The SCN is critical in implementing the pathway, using their specialist knowledge to adapt it to the patient's needs and co-ordinating this within the team.
The pathway includes a stoma link nurse because this role has been widely supported and developed in the author's hospital for other specialist areas. The link nurse role provides the opportunity for ward nurses to develop a specialist interest within their continuing professional development (CPD) time and can help to provide more wraparound support for the patient when the SCN is not on site. The pathway focuses on reducing length of stay through giving structure to the learning skills required for a successful discharge, which has benefits for the stoma patient and staff, and is a framework that can be adapted by SCNs to enable holistic and cost-effective care.
Conclusion and recommendations
This critical review of the literature has examined the effectiveness of postoperative stoma education for the elective surgical patient. The review has identified that stoma education has changed over time, with the implementation of ERAS, but most education is still delivered in the postoperative period. Pre-operative education aims to engage patients in their stoma care, this has proved to be effective in reducing the amount of postoperative training needed and has been shown to be accepted by patients (Burch, 2014). Stoma care education has benefits for patients; however, due to its complex nature, there is no consistency to the education provided in the UK (Liu et al, 2023). Patients benefit from a defined pathway of care and the quality of life of more stoma patients could be improved by a structured approach to education and care (Christian, 2023).
The review and consideration of the stoma patients' needs and wants shows that the most effective postoperative education is holistic, which is best facilitated through the specialist skills and knowledge of the SCN. Multimodal methods of education have been developed as useful tools to meet individual needs (Le Ber and Fronzo, 2022). The SCN has an important role in delivering effective postoperative education in all the studies examined. The benefits of stoma link nurses are a less considered element of stoma education but have been demonstrated to be an invaluable resource.
Stoma patients' views of postoperative care and education are reflected in the ASCN UK (2021) standards of best practice. The development of a national pathway for stoma education in the postoperative period would provide an essential tool for SCNs, stoma link nurses and other members of the multidisciplinary team to use to implement the standards in practice (Marinova and Marinova, 2023). It could ensure that more stoma patients benefit from the most effective education and should include the stoma patients' needs and wants (Christian, 2023). The pathway should be cost-effective and be based on research and evidence-based care (Davenport, 2014).
Link nurses are a valuable resource, but this is often overlooked in stoma education research (Newcombe, 2016). Using a pathway to outline the role of the ward link nurse and SCN would help to clarify how ward stoma link nurses can enhance the effectiveness of postoperative stoma education. An example of how this can be achieved is demonstrated in the work of van Loon et al (2020). SCNs should be the central person within a multidisciplinary pathway, because it is shown to be cost-effective and benefits stoma patients by meeting their individual needs (Porrett et al, 2023).
Rosenberg and McGee (2023) described postoperative stoma education as ‘the final exam before home’. To pass the ‘exam’, a clear pathway that includes best practice for postoperative education is required. This will optimise patients' learning to manage their stoma independently to pass their ‘exam’, by acquiring the practical skills for a safe discharge home.
The lack of formal research to determine best practice in postoperative stoma education, combined with the variation in practice and outcomes, means the effectiveness of stoma patients' education in the UK cannot be accurately measured. The recent review of evidence-based protocols calls for a best practice pathway for all aspects of patient care, to include a postoperative care pathway to standardise care and address the unmet needs of stoma patients (Porrett et al, 2023). If a national pathway of stoma postoperative care and education was developed, implemented, and audited then the true effectiveness of postoperative education could be established, to ensure stoma patients achieve the best outcomes.
The author has developed a pathway using the evidence from this critical review to improve care in her area for elective stoma patients in the independent sector. Its effectiveness is being reviewed against the ASCN UK standards. It is an example of how the key findings can be implemented in practice using the best available theory, evidence, and views of stoma patients' needs and wants. Effective postoperative stoma education can include a pathway of care, and this helps new stoma patients and their families to adjust, reduces time in hospital and involves a multidisciplinary approach to care and education (van Loon et al, 2020; Nizum and Jacob, 2022). This pathway needs to be used as a guide and audited against the ASCN UK standards to ensure care remains holistic, meets individuals' needs, and is not replaced by task-oriented care.
Finally, this literature review has found insufficient evidence to determine whether postoperative stoma care is effective for the elective surgical patient. However, this review has highlighted many important aspects that contribute to effective postoperative stoma education and information-giving for the individual undergoing elective surgery. Using the evidence from the literature review, the author has been able to develop a postoperative pathway with the aim of improving postoperative stoma care for the stoma patient. The author plans to measure the tool's effectiveness by audit of the service following implementation, using ASCN UK's standard audit tools (2021), patient outcome monitoring and satisfaction surveys.
KEY POINTS
- Postoperative stoma education is an essential component of care and builds on pre-operative education to enable self-care, prevent delays in discharge and complications, and it is cost-effective
- There is a lack of focus in the literature on stoma education compared to other specialties
- There is little formal research to determine best practice in postoperative stoma education, combined with variations in practice and outcomes, which means effectiveness cannot be accurately measured
- There is no current national postoperative stoma care pathway, although care pathways improve patient outcomes and are cost-effective
- Ward stoma link nurses are a valuable resource and can be an effective tool to overcome some challenges of postoperative education and barriers to learning
CPD reflective questions
- How is postoperative stoma care education adapted to meet individual needs in your workplace?
- What methods of education and information giving can you use to education patients in stoma care?
- What barriers to learning are there in your ward environment and how can these be overcome?
- How can the multidisciplinary team improve postoperative stoma care in your workplace?