| BACKGROUUDMiles surgery is the main treatment of colorectal cancer recently, with the improvement of postoperative survival rate, there is an upward trend in the number of colostomy .More and more people enter into the chronic long-term care field, after completing the basic stoma therapy at the hospital. Colostomy seriously affects the patient’s physiological, psychological and the social function’s adaptation, the patients need to long face with a series of problems brought by the colostomy. However, the health education outside the hospital of colostomy people is currently the relatively weak link in colostomy nursing work. The current situation in our country is :①the most treatment and care of colostomy people are still confined to hospitalization, the nursing of colostomy people outside hospital lags behind;②The patients need long-term home life with stoma,the colostomy nurse can’t often provide relevant nursing service guidance;③The professional guidance of colostomy patients is currently less in community care.There are many studies at home and abroad about the Self-management Program research on colostomy patients, but its pertinence, continuity, operability, self-assessment and promote strength is not strong. The handbooks currently widely used to facilitate the colostomy people to self-manage stoma in the clinical are more some of the company’s own production. There are more product introduction plates,and mostly brief basics stoma、stoma care complications identification process, and so on,which are theoretical knowledge,the setting has yet to see, in view of the colostomy continuity of the Self-management Program, and the handbooks rarely involves the setting of the colostomy people’s self-involvement plates content. We will construct a handbook of self-management, which is suitable for patients with permanent colostomy use in our country,reference to relevant materials at home and abroad,with studying and discussing the self-management problems of permanent colostomy people,and combined with the actual situation of clinical nursing in China. The handbook of self-management for patients with permanent colostomy provides a practical and effective tool for the patients with permanent colostomy to manage themselves,so as to provides a guidance and supervision role on self-management,such as stoma management,emotion management and role management, furthermore, provide references for the clinical and community nursing of the patients with permanent colostomy.OBJECTIVEThis study aims to investigate the self-efficacy of permanent colostomy patients at different stages, and explore its impact factors; And structure a scientific、feasible and easy-to-read handbook of self-management for patients with permanent colostomy in view the case of self-management, which is suitable for the patients with permanent colostomy use in our country, so as to provides a practical and effective tool for the patients with permanent colostomy to manage themselves, furthermore, provide references for the clinical and community nursing of the patients with permanent colostomy.OBJECTS AND METHODS1. Qualitative research on the early self-management status and the needs of permanent colostomy patientsA qualitative study of the phenomenological method is used in this study, and performing purposive sampling to select 24 cases of permanent colostomy. The requirements are patients of a hospital in Guangzhou, who are on the postoperative hospitalization or the postoperative chemotherapy. Each interviewee makes the patients know the detailed content of guidelines and detailed implementation plan of the research.There are two interviewers, one person is responsible for recording and records, to ask when necessary, one person reference interview outline in-depth interviews with patients. The interview takes about 30 min and the sample size is based on the data "saturation" principle.2. Cross-sectional survey on the self-efficacy of permanent colostomy patients at different stages and analysis of its impact factorsA total of 267 cases of permanent colostomy patients at different stages(postoperative hospitalization, postoperative chemotherapy and home rehabilitation),coming from 14 domestic top three hospitals, were investigated using the general information questionnaire、C-COH、the Stoma Self-Efficacy Scale、and Perceived Social Support Scale(PSSS), by the cross-sectional survey method.After the approval of the patients, trained investigators explain to them with a unified guidance language,recycling questionnaire on the spot,a total of 280 questionnaires were distributed,267 valid questionnaires were returned, and the recycling effective rate was 95.36%.3. Constructing the handbook of self-management for patients with permanent colostomyBy the early qualitative interviews and cross-sectional survey, the expert coordination group research and discuss the current self-management problems of the permanent colostomy people, then, we determine the basic framework of the handbook of self-management for patients with permanent colostomy, referring to Omaha question classification system, aiming at self-management tasks, which is on the basis of the literature review and interviews with experts,and combined with the actual situation of clinical nursing in China. With Delphi method,23 experts in the area of colostomy nursing were investigated two times. Based on the opinions of the experts, the handbook of self-management for patients with permanent colostomy was constructed. The experts come from 8 Provinces and 20 domestic top three hospitals. Age range is from 33 to 51, and the average age is (42.48±4.65);The experts’ working years range from 10 to 31,its mean is(22.70±5.15); Education background:a master’s degree three (13.04%), undergraduate degree 18 (78.26%), college degree 2 (8.70%); all the experts are above intermediate professional title.10 of them(43.48%) have high technical title and 10 of them (43.48%) have vice-senior title,3 of them (13.04%) have intermediate title. In addition, we understand the use effect evaluation to the handbook of the colostomy patients as the role of the audience, by the in-depth interviews on 8 cases permanent colostomy patients of a hospital in Guangzhou, then revising and improving the handbook, to further improve the practical application value of the handbook.RESULTS1. The early self-management status and the needs of permanent colostomy patientsAfter reading and listening all the records, four themes are generalized:(1)Colostomy management ability is on the low side:①Colostomy cognitive errors; ②Colostomy self-care willingness and ability are on the low side, there are many problems in the colostomy nursing, and the economic burden of colostomy supplies is heavy;(2)Emotional experiences are diversification, and wanting to have a plurality of emotional support:①Emotional response is complex, and diversification; ②Poor psychological adjustment, and wanting to have a plurality of emotional support;(3)Role maladjustment: ①Family role maladjustment:Role behavior conflict, role behavior reinforcement, role behavior abnormalities;②Difficult to adapt to the previous job roles; ③Social phobia;(4)Wanting to have a plurality of information support:①More information demandcontent; ②The diversity of education.2. The self-efficacy of permanent colostomy patients at different stages, and its impact factors.2.1 Each index of descriptive statistics of permanent colostomy people at different stagesThe total score of self-efficacy of colostomy patients was (75.97±23.92),ranked in the middle level, and it showed a rising trend at postoperative hospitalization, postoperative chemotherapy and home rehabilitation(P<0.01). The total score of living quality of colostomy patients was (5.21±1.43),ranked in the middle level, and it showed a rising trend at postoperative hospitalization, postoperative chemotherapy and home rehabilitation(P<0.01). But there were no statistically significant difference between self-efficacy and living quality of the patients during the postoperative hospitalization and chemotherapy period(P>0.05).The total score of social support of colostomy patients was (5.05±1.10),ranked in the middle level, there were not statistically significance among the total score of social support at different stages(P>0.05).2.2The impact factors analysis of the self-efficacy of permanent colostomy patients at different stagesAfter univariate analysis, correlation analysis and multiple linear regression analysis, we drawled:The influencing factors of self-efficacy of the patients included psychological well-being, the proportion of medical insurance, social support, age, postoperative time, spiritual well-being, and Body Mass Index(BMI)(P<0.05);The influencing factors of self-efficacy of the patients at postoperative hospitalization included psychological well-being, BMI and age(P<0.05);the influencing factors of self-efficacy of the patients at postoperative chemotherapy included the proportion of medical insurance, psychological well-being, age and living state (P<0.01);the influencing factors of self-efficacy of the patients at home rehabilitation included spiritual well-being, social support, self-care degree, gender and the monthly cost of ostomy supplies(P<0.05).3. Had constructed the handbook of self-management for patients with permanent colostomy3.1 The reliability and consistency of the expert consultationIn this study, when selecting experts, we give full consideration to the regional representation of experts, the subject representative and different age levels. The experts come from 8 Provinces and 20 domestic top three hospitals; there are both the clinical practice of experienced senior experts, and the thinking, active, relatively easy to accept new things young experts. The reliability of consultation results can be measured by the experts’ representativeness, positivity and authority, and coordination index of expertindicators. Experts positive index is reflected by the questionnaire’ response rate, the response rates of two rounds investigation are 91.3% and 100%; There were 17 (87%) and 10(47.6%) experts put forward constructive suggestions in the first and second rounds respectively; Authoritative coefficient of experts is 0.864 and 0.879 in the first and second rounds respectively, while generally reliability coefficient (Cr>0.70) is acceptable.Therefore, experts’ forecast is based on practical and theoretical basis. After two round of the expert consultation, the coordination index (Kendall’s W) are 0.387(x2=243.960, P=0.000) and 0.307(x2=180.388, P=0.000) respectively, which shows that the experts opinions’ coordination is significant and the survey results are acceptable.3.2 The necessity, rationality, and feasibility of the handbookThe experts’ opinion of the necessity is described using Likert 5-scale method, rationality and feasibility of the items, after the second round of the expert consultation, all experts have given the specific evaluation and practical suggestions for the handbook (draft).(1) About the necessary questions, the mean of each question are more than 4 points (out of 5 points, the same below) in two rounds of consultation,which boundary between the essential and necessary.The standard deviation of necessity scores range from 0.402～0.837 and 0.301～0.740.(2) About the reasonable questions, the mean scores of each question range from 3.29～4.43 in the first round of consultation.Of which,the scores were low about the cause analysis and treatment measures of the common stoma complications, individualized prescriptions and behavioral self-assessment and reflection parts, and the expertsare controversial,and the average of the rest are at least 4 points.We integrated and revise the part of the contents of the handbook,after comprehensive the constructive comments made by the experts,of which, the colostomy complications part emphasizes the identification and prevention of colostomy complications,the two plates of individualized prescriptions and behavioral self-assessment and reflection are fused as a plate of the individual self-management program.And deleting the self-reflection part,increasing the perioperative management content of colostomy nursing,which make the mean scores of each question range from 3.67～4.76 in the second round of consultation.(3)About the feasible questions,the mean of four questions are less than 4 points in the first round of consultation, the following four questions were:①"after a simple mission (30 min mission), the colostomy patients at postoperative hospitalization can understand the content of this’handbook’, what do you think its workable?";②"The language style, graphic design of this ’handbook’ are convenient for patients in reading comprehension, what do you think its workable?";③"Is the setting of the individual prescription workable?";④"Is the setting of the behavior of self-evaluation and reflection workable?". The mean of six questions are more than 4 points in the second round of consultation after revising, and the mean scores of each question range from 4.14～4.71.Most of experts have given the specific evaluation and practical suggestions for the handbook (draft), so that the second round of expert opinions tends to basic convergence.3.3 The audience evaluation of the handbookThe majority of colostomy patients give a high degree of recognition to the handbook after about two weeks of trial, and consider the handbook strong practicality and readable:① The patients grasp the relevant knowledge and skills of the stoma by reading and learning the handbook;② The handbook is designed beautifully, comprehensive, and easy to understand. And it is consistent with the clinical practice, which is ease of use. But there are also a part of colostomy patients puts forward some opinions and suggestions of the handbook:①The design:The fonts and pictures are small, individual images selection can be gentle;② The content:The stoma self-management notes section is too cumbersome, and the patients’ compliance is poor.CONCLUSION1. There are many problems in the early stage self-management status of permanent colostomy patients, and they want to have a plurality of social support.There are many problems in the early stage self-management status of permanent colostomy patients, including stoma management, emotion management and role management. And they want to have a plurality of social support. The detail of the case were that permanent colostomy patients had poor even mistake, knowledge about permanent colostomy, and had less ability and willingness to make self-nursing, and feel heavily shame, poor psychological adjustment,low adaption to environment, social activity anxious, and more information demand. Medical staffs should give the patients individualized self-management education and psychological care based on the self-management status of early postoperative of permanent colostomy patients, pay more attention to the adaptation level of colostomy patients, strengthen social support systems and improve continuity of medical care, so as to improve the ability of stoma management, emotion management and role management comprehensively, and thereby to improve their quality of life.2. The self-efficacy of permanent colostomy patients showed a rising trend at postoperative hospitalization, postoperativechemotherapy and home rehabilitation, ranked in the middle level.. But the medical staff should pay more attention to the self-efficacy of the patients at postoperative hospitalization and postoperativechemotherapy.And the influencing factors of self-efficacy of permanent colostomy patients at different stages was different, the medical staff should carry out the special interventions of self-efficacy.The self-efficacy, quality of life and social support of permanent colostomy patients at different stages are all at middle levels.Colostomy patients’ self-care efficacy and social-efficacy level are low than the common people, and the confidence and satisfactory of sex life are the lowest.The patient’s self-efficacy and quality of life level are rose along with the time,but there were no statistically significant difference between self-efficacy and quality of life of the patients during the postoperative hospitalization and chemotherapy period.Social support of patients at different stages is still at low level, and there were no significant difference in statistic. This has remind us that the importance to improve the permanent colostomy people’s self-efficacy, life quality and social support level, especially in the early stage after colostomy. The influencing factors of self-efficacy of permanent colostomy patients at different stages was different,the medical staff should assessand screen the high-risk factors of self-efficacy positively, according to the individual circumstance and stage, to formulate the individualized intervention measures, so as to enhance the patients’ self-confidence to deal with and manage the disease, thereby increasing the level of self-efficacy.3. The main contents of the handbook has be setThat the mean is beyond 3.5 and the coefficient of variance is less than 0.2 are used to the screen indexes. We constructed the handbook of self-management for patients with permanent colostomy by combining with the advice of experts and the discussion results of subject group. We revise and improve the handbook according to the audience evaluation of the handbook.The handbook strives to achieve easy-to-read language, which is in the form of illustrations, and itsscientific, systematic and operability are strong. The handbook includes colostomy self-management, self-management of everyday life,and individual self-management solution, which stressed self-participation in patients, medical staff supervision is complementary.The handbook of self-management for patients with permanent colostomy provides a practical and effective tool for the patients with permanent colostomy to manage themselves,so as to provides a guidance and supervision role on self-management,such as stoma management,emotion management and role management, furthermore, provide references for the clinical and community nursing of the patients with permanent colostomy.4. The scientific, effectiveness, practicability and readability of the handbook is strong.The analysis of the coefficient of experts’ enthusiasm, the extent of authority, the concentration of experts’ opinions show that the handbook is reliable, and the results indicate that the necessity and scientificity of the most content of the handbook are confirmed by the invited experts.In addition, the majority of colostomy patients give a high degree of recognition to the handbook after about two weeks of trial, and consider the handbook strong practicality and readable5. Significance of constructing the handbook of self-management for patients with permanent colostomyThe construct of "the handbook of self-management for patients with permanent colostomy" has make up for the continuity Self-management Program and self-participation in the current manual that clinically Colostomy Company widely used, the manual has provided a useful instrument for colostomy patients, which make disease management, role management and emotion management instruction. The application of the manual can be used to improve the nursing staffs’ awareness of colostomy patients’ self-management ability, and help patient change from passivity management to initiative management, help patient participant social.The application of the manual has also provided reference for clinical and community of permanent colostomy people’s nursing. |
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