Essay: Integrated literature review – psychosocial impact of stoma on QoL

1.0. Assignment summary and review (about 240-300 words)
This integrated literature review has examined the psychosocial impact of stoma on QoL. A literature search generated relevant studies within the last 10 years. The search involved the use of CINAHL, Cochrane Library resources, PubMed and ScienceDirect. 3 emergent themes were produced from this review; ‘Altered Body Image after Stoma Formation’; ‘Psycho-sexual Impact of Stoma Formation’; and ‘Quality of Life after Ostomy’. The studies identified improved QoL with HCPs’ contact however, there were insufficient input from HCPs, adverse effect of ostomy on psychosocial aspects and lack of interest for some of the ostomates to contact HCPs. All the selected studies were critically evaluated systematically, following the stages of research process. The clinical implication includes a need for further training and education for HCPs to improve psychosocial support system, facilitate better communication for better follow to improve QoL. The future study advancement includes strategies to improve outcomes of the identified needs for future areas of research, more quantitative research studies should be developed to evaluate QoL and increase knowledge in this area.
The literature review has systematically evaluated 5 primary research studies. The review has outlined the author, study design/approach and study aim/objective as presented in a tabular form with rationale for study selections. Furthermore, the emergent themes of the literatures have been outlined and evaluated. Also, evaluation of key findings has been highlighted and critically analysed. This considered methodological strengths and drawbacks of the study. In conclusion, discussion and analysis of key findings of the studies has been reviewed, gaps in research knowledge and clinical practice, identified and recommendations for further research provided.
2.0. Introduction and Background (including a rationale).
According to Vonk-Klaassen et al, (2015), many people find it difficult to access healthcare services. Therefore, it is unimaginable how these individuals deal with problems related to their ostomies and how these impact on their QoL. Therefore, this integrated literature review aims to explore the evidence and literatures on the psychosocial impact of ostomy on QoL of Ostomates. Studies have shown that some individuals experience loss of control, loss of confidence and reduced self-esteem and these impacts incredibly on their QoL (ref). Danielson, Burchart and Rosenberg (2013), highlighted these impact on their inability to maintain an intimate relationship. Brown, (2017). emphasized that psychological impact is an intricate topic and provides opportunity for other themes such as body image, sexuality and QoL to be discussed.
In view of the disruption of normal functioning of the excretory system, Brown adds that the role of the nurse specialist therefore, is to apply the nursing process holistically to care for the physical as well as the psychological/emotional needs to improve QoL. Therefore, further investigations will focus on answering the following research questions; How does altered body image disturbance impact on QoL? To what extent can health care professionals’ intervention improve QoL of ostomates? And what systems are put in place to reduce sexual difficulties faced by ostomates and their partners?
The literature review will use a systematic approach of search strategy process to evaluate the selected studies. 5 primary research studies will be selected for review and evaluation. The outline of these studies will consist of the author, study design/approach and study aim/objective. These will be presented in a tabular form, giving rationale for study selections. Furthermore, the emergent themes emanated from the key findings of the literatures will be systematically evaluated and discussed discretely. In addition, evaluation of key findings will be highlighted, presenting a critical analysis of methodological strengths and limitations. Finally, the conclusion will be preceded by a discussion and analysis of key findings of the studies reviewed, followed by identification of gaps in research knowledge and clinical practice while providing recommendations for further research.
The reconstruction of bowel and/or bladder could arise in the process of treatment of certain conditions such as inflammatory bowel diseases, rectal or bowel cancer and trauma (ref). This poses a huge challenge and disrupts the normal excretory function of the body system (Ref). The excreta leave the body via an opening on the abdominal wall and collects in a bag attached externally on the abdominal wall. This is referred to as stoma (ref). Data show that an estimate of 100,000 people in the United Kingdom are living with stoma and there are about 21,000 new cases each year (Notter and Chalmers, 2012). Approximately 50% of these cases end up with permanent stoma (Coloplast, 2010). The physical challenges impact incredibly on the psychosocial aspects of life (ref), Nonetheless, psychosocial support is mostly disregarded because focus is more on the physical impact hence the rationale to evaluate psychosocial impact of ostomy on QoL (Brown, 2017).
3.0. Search Strategy Process.
The research process involved an extensive literature search from evidence-based resources such as National Institute for Health and Care Excellence (NICE), CINAHL, Cochrane Library resources, PubMed and ScienceDirect. CINAL access and yielded more publications and journal articles in this subject area. 6 relevant studies were generated and 3 studies from PubMed. out of these 5 were selected for the review. The search key terms used included ‘Ostomies’, ‘Stoma’ or ‘Adult’ and / or ‘quality of life’ and/or ‘psychosocial’, or ‘Psychosocial impacts’, and ‘Psychosocial issues’. These words were used separately and in combination as a guidance for the search. Inclusion criteria were young and older adults > 18 years, male and female, patients living with stomas, articles and research papers published within 2010-2018. The studies were limited to 10 years to ensure all information obtained were valid, relevant and up to date. International studies were included as there were ‘dearth’ of literatures in the UK, however international studies were selected in view of different/level of the healthcare systems internationally compared to the UK. These included studies from United States of America, Denmark, India, Netherlands and the UK. Exclusion criteria included, children, the elderly, non-evidence-based resources from social media, Wikipedia and newspapers, Studies outside 2010-2018 and people living without ostomy.
UK Stoma Care Clinical guidelines and NICE,
4.0. Main body: Evaluation and Integration of evidence:
Five studies were selected for analysis in this review, with 5 being qualitative. However, I paper (systematic review) reviewed 3 qualitative and 3 quantitative studies. For an overview of the research studies, study design/approaches and aims of each study (Refer to Table 1).
4.1 Table 1. Studies Selected for Review
Investigators Study Design/Approach Study Aim/Purpose
Thorpe, McArthur and Richardson (2013) existential phenomenological study ‘pre-reflective lived experiences’ of individuals living with a new stoma and the impact of HCP contact
Notter and Chalmers (2012) Pilot Study
Explored problems impacting the QoL of individuals with stoma.
Ramirez et al. (2009). Hermeneutical Phenomenological Study Explored the perceptions and lived experiences of sexuality in females with permanent stoma.
Danielsen, Burcharth and Rosenberg (2013).
Systematic Review Explored and evaluated evidence across 6 studies investigating the impact of an ostomy on partners of individuals with stomas.
Anaraki et al. (2012) cross-sectional study Evaluating the perceptions of lived experience of QoL of individuals living with stoma.
4.2 . Altered Body Image after Stoma Formation: Thorpe, Arthur and McArthur (2016); Ramirez et al., (2009).
Thorpe, McArthur and Richardson (2013) conducted a UK existential phenomenological study which examined the ‘pre-reflective lived experiences’ of individuals living with a new stoma and the impact of contact with the healthcare professional at a Regional General NHS Teaching Hospital, UK. A purposive method of sampling comprised (n-22). All from the same large regional hospital; 12 individuals with new ostomy in place, 3 nurses specialised in stoma care, 3 ward-based nurses and 4 proctologists. A triangulation method of data collection which consisted open one-to-one interviews, using 5-way analytical framework. Data was collected at 3,9 and 15 months after-surgery. Participants’ recovery and fitness were assessed via reflection on their experience post-surgery at 3-months. At 9 months, social reintegration was evaluated and the evaluation at 15 months provided opportunity for improved knowledge. The interviews took place in the participants home environment and the HCPs were interviewed at work their place or home environment for convenience. 3 themes were identified from the key findings of this study; ‘relationship with HCPs’; ‘Being prepared’ and ‘regaining autonomy’.
The key findings of this study established that interaction between the HCPs and the patients facilitated self-determination, adaptation and acceptance of self in terms of building new sense of body image and increased social confidence. This in turn facilitated ‘physical capacity, mastering stoma function, purposeful care acceptance, and support of others’. The methodological strength of this study lies in the use of unstructured interview approach facilitated exploration and permitted individual expression. Moreover, applying five-stages framework informed by Merleau-Ponty’s (1945, translated 2002) philosophy on body and self, facilitated iterative data analysis. The use of triangulation method of sampling increased reliability and production of enriched data via cross verifications from different participants (data from HCPs and patients). Contrarily, the methodological setback of this study; the use of longitudinal approach is time consuming, exhaustive and expensive (Parahoo, 2014). Also, the researcher is known by the HCPs, therefore, HCPs may feel obliged, and so influence decision to participate and could impact on full disclosure of issues due to bias.
4.3. Psycho-sexual Impact of Stoma Formation: Danielsen, Burcharth & Rosenburg (2013); Nichols and Reimer (2011); Notter and Chalmers (2012). Ramirez et al., (2009).
Notter and Chalmers (2012) conducted a pilot study which explored problems that impact on coping with stoma and QoL. A non-probability method of purposive sampling consisted (n-369); males (n=166) and females (n=203) living with colostomy, age > 50 years, 90% married, a few divorced, mostly widowed in higher age group. The main method of data collection comprised self-completed questionnaires processed as postal surveys, included mainly closed-end questions and a few open-ended questions for clarification purposes, originally invented for study to evaluate QoL and coping in older people with stoma (Notters et al., 2003). Individuals with stoma took part in a single interview at their home environment, exploring their transformations over time. At 3 months, they were considered to have recovered and to be physically fit to reflect on their experience, their social integration at 9 months, and their lived research expertise at 15 months. Themes that emerged indicated that ostomy construction caused problems with financial issues, social activities, emptying/disposal, skin damage, adjustment, sexual intimacy, body image and self-confidence.
The key findings highlighted how the physicals problems have impacted on mental and emotional problems due to an ostomy. As high as 30% men and 27% women reported an adverse effect of an ostomy on their capability to enjoy sexual intimacy. 45% of men and 25% of women experienced difficulties in physical sexual performance resulting from deep pelvic surgery. Furthermore, reduced level of confidence and anxieties arising from physical impacts such as smell, leaks impacted on the ability of the individual/partner to cope with or the individual to form a new relationship. The methodological strength of this study; It is economical, this method provided an opportunity to reach a wider population within a comparatively short space of time (Coughlan and Cronin, 2017). It also produced highly reliable results and eliminates investigators bias. It is deductive, and the research questions allowed responses to be converted to a quantitative data sets to yield results for generalisation purposes (Polit and TatanoBeck, 2010.) The methodological limitation of this study rests on the use of surveys which produced superficial data and lack of detailed information (Proctor, 2008). This method of data collection and analysis are time consuming, difficult and subjective. The use of open-ended questions mostly requires articulative, eloquent respondents, so, demands of skills to write at a reasonably higher level and ability to express one’s feelings (Roberts, et al. 2014)). This creates bias in the selection process which potentially, would impact on results obtained (Heiervang and Goodman, 2011).
In contrary, Ramirez et al. (2009), conducted a hermeneutical phenomenological study of the perceptions and lived experiences of intimate relationship in female colorectal cancer survivors with stoma >/=5 years, mean age 70 years, post-surgery in USA. A non-probability method of purposeful sampling consisted (n-30) heterosexual women with ostomies. White Non-Hispanic (n=22), Asian (N=3), Pacific Islander (N=2), African American (N=2) and Hispanic (N=1). 20 married, 2 partnered and 8 single. The method of data collection comprised of semi-structured, open-ended interview, and audio-recording transcribed verbatim, which inquired on challenges of body image, gender and sexuality in female with ostomies. They were either interviewed in their homes, local medical facility, or convenient location, however, most chose their homes. 8 themes emerged from the findings of this study; ‘body image, ‘comorbidities’, ‘ostomy care’, ‘complications’, ‘sexuality’, ‘the nature of relationship with spouse’ and ‘sense of self femininity’. This is contradictory to the findings of Notter and Chalmers with the study ho argued that that
The key findings of the study identified that altered body image had no long-term major problem to most of the participants. These were grouped into categories; group 1 (N=11) did not experience long -term problems in their sexual relationship. The reason being that their spouses were supportive and accepted their configured bodies. Group 2 (N-7) identified having long-term sexual difficulties during intercourse triggered by vaginal discharges consequential to cancer treatments. Group 3 experienced lasting, age-related sexual changes(N-3), although married, they did not consider sexual intercourse as a main determinant of their relationships. Nevertheless, one woman identified lack of interest sexual relationship but was still sexually active. Group 4 (N=9) indicated that they had no sexual experience following surgery, owing to their belief regarding stoma and intimacy. These women felt undesirable to a prospective partner although they wished for an intimate relationship. The methodological strength of this study was the use of audio recordings which facilitated easy transcription, provided an opportunity for a various perspective and review of any unnoticed information for improved analysis and validity of findings (Hek and Moule (2011). (Heck & Moule, 2011). However, Transcription of audio recorded information is time consuming, laborious and expensive. More so, sexuality is extremely sensitive and a personal subject, some participants may feel uncomfortable being honest and candid in some answers, thus affect the results (Parahoo, 2014).
This is corroborated by Danielsen, Burcharth and Rosenberg (2013) who carried out a systematic review exploring how the impact of stoma formation impacted on the spouse of ostomates, Data from 3 quantitative studies were examined ; including, 1 descriptive, prospective non-comparative study; 1 observational descriptive and comparable prospective study; and 1 cross-sectional study with correlational design that evaluated the impact of an ostomy on partners of individuals with stomas. The 3 qualitative studies examined included 2 individual interviews and 1 focus-group interview. The review consists a composite sample of (n-418) participants. Data was collected across the studies using validated and non-validated questionnaires; the psychological measures of influence, such as State-Trait Anxiety Inventory analysed anxiety (Spielberger et al., 1983), the Beck Depression Inventory, assessed the severity of depression (Beck et al., 1961) and Burden Assessment Scale measured the impact on their partners (Reinhard and Horwitz, 1995). The key finding produced 4 emergent themes; ‘Lack of information and participation’, ‘sexual life’, ‘social function’ and ‘support when adapting to stoma’. This supports the study of Ramirez et al., who claimed that having a supportive partner improves QoL in this regard.
The key findings of the review identified significant impacts of stoma on the sexual/social life of the spouses. It was identified that the spouses wanted to be involved in stoma education whilst emphasis should be placed on the psychological characteristic of stoma surgery as anxiety and depression were identified as key concerns. The methodological strengths of the review; it is explicit uses strategies to reduce bias and errors (Schmidt and Hunter, 2015). The limitation of this study is based the retrieval of fewer number of studies, despite all broad search strategies undertaken. however, some of these focused mainly on cancer, creating a sub-group of spouses suggesting that studies used did not equally contribute to the findings. Again, the studies were not of very high methodological value. However, these were still used. Also, It Was not possible to carry out a formal meta-analysis since the quantitative studies yielded dissimilar outcomes.
4.4. Quality Of Life after Ostomy: Anaraki et al., (2012); Notter and Chalmers (2012); Danielsen, Burcharth & Rosenberg (2013).
Anaraki et al. (2012), conducted a cross-sectional study, evaluating QoL of individuals who are reasonably fit physically and mentally, not having any other condition impacting on their QoL, >18 years, living with a stoma >/=3 months, and involved with the Iranian Ostomy Association in Iran. A purposive non-probability random sample comprised (n=102); male(N=58) and female (N=44). Data was collected using a disease specific self-administered City of Hope-quality of life-Ostomy questionnaire (Anaraki et al. 2014). The questionnaires comprised of two categories; section one involved ostomy specifics, treatment, disease and other individual characteristics question such as work, diet and activity. Section two comprised questions regarding psychosocial, psychological, physical and spiritual status. Predictors of QoL were identified using ‘univariate and multiple regression analysis’ (Anaraki et al). The findings of this study produced 4 emergent themes; ‘Daily stoma care and diet’; ‘problem with the location of stoma’; and ‘body image’.
These revealed that …… This supports the study of
The key findings of the study found out that living with an ostomy impacts on QoL as most of patients reported having experienced problems to restart sexual intimacy. This finding confirms the study of Gemmil et al, (2010), in another study, who reported that 55% of patients resumed sexual activity out of 70% involved in sexual activity pre-surgery. There were issues identified with change in diet, depression, stoma location and body appearance. It suggested that psychosocial and physical problems decreased self-confidence, social relationship and may lead to some degree of social isolation. The results from the ‘regression analysis’ in the current study, presents depression and problem with stoma location to be statistically significant, predicting QoL of patients (P<0.05). However, the results of the univariate analysis identified that depression, problem with location, the underlying problem of ostomy, style of clothing, type of ostomy, statistically significant affects overall QoL and its subscale (P<0.05). The methodological strength of this study, lies in the validity of investigated relationship between correlations at preestablished time. Conversely, the cross-sectional design hindered casual inferences (Iacus, King and Porro, 2012). Again, the participants were all patients of the Ostomy Association in Iran. Therefore, it challenges generalisability of the findings (Kukull and Ganguli, 2011). Also, there is limited interpretation of result due to inadequate information regarding other factors influencing QoL.
5.0. Commentary Key Findings of the Studies Reviewed:
Overall, the selected primary studies identified similar findings, however, some of these differ, considering long-term or short-term effects of ostomy on QoL. According to Larrain (2013), women are more anxious with their appearance and consider it as significant part of their ‘personality and identity’ compared to men. This confirms the findings of Ramirez et al. which revealed pain during intercourse due to structural vaginal changes from radiation treatments, lack of confidence, anxiety, rejection and body image disturbance in women, whilst men were more worried about noise leakages and adjustment. However due to cultural reconfiguration some of these participants identified coping strategies to overcome long-term effects on their QoL. In support of the above study, Danielsen, Burcharth and Rosenberg identified significant impact on sexual and restricted social life of the spouses. Overall, spouses desired more support from HCPs/family/friends. Similarly, Notter and Chalmers, recommends ongoing HCP counselling and advise to support with problems of acceptance, adjustment and adaptation to body image, intimacy, sexuality, although most participants identified no preference in the nurse specialist advice.
In addition, Anaraki et al., agrees that living with an ostomy affects all aspects of QoL, thus, recommends education on sexual and psychological consultation for patients and families. The study of Ramirez et al. (2009), Corroborates with the study of Anaraki et al. in terms of dissatisfaction in sexual activities. Thorpe, McArthur and Richardson focused primarily on effect of contact with HCPs, its findings corroborate with other study findings in terms of improved support. However, unlike other studies, it does not consider body image/impact or intimate relationship and its consequences.
6.0. Conclusion & Research Recommendations:
Ramirez et and Thorpe et al, confirmed the findings of Popek et al, (2010), which discovered that acceptance and ability to cope was greater in ostomates who had a supportive spouse revealing the importance of supportive spouse/family in adjustment to resume a social life. Moreover, Karaburu et al (2014), Tao et al, (2013) and Danielsen, Burcharth and Rosenberg, established the significant improve psychosocial impact after HCPs intervention.
Nurses are expected to understand the patients’ expectations to be able to contribute to and improve nursing care practice. It requires the concept of intersubjectivity to establish a rapport and support relationship to deliver a comprehensive care (Umpiérrez, 2013). The nurses’ role has been emphasised on the selected studies used in this review as educator, advocate, adviser, coordinator in delivering a holistic therapeutic care (ref). Individuals with colostomy undergo life-changing experience to cope with altered body image, sexuality and other psychosocial associated with ostomy (Dabirian A, et al. 2011). To many individuals, the impact of physical challenges on/and psychosocial wellbeing affects all aspects of their life. Thus, to cope with this transformation, the individual may need support, education and empowerment in the process of ‘acceptance, adjustment and adaptation’ to regain independence (Zamanzadeh, etal., 2015). Therefore, after discharge, individual holistic care assessment/delivery are expected to be planned, coordinated and integrated for proper care continuity (NHS England, 2013). In this regard, stoma education and support become vital. Consequently, nurses should support and educate patients through an established nurse-patient relationship for improved QoL.
It is obvious that there is a wealth of research about why and how stoma is formed and cared for, however, there is still a gap in research knowledge on psychosocial challenges, education and support for ostomates. During post-surgery after discharge, individual holistic care assessment/delivery should be planned, coordinated and integrated for proper care continuity. In this regard, stoma education and support become vital.
Nursing care incorporates physical as well as psychosocial/sexual, spiritual needs of ostomates. The findings in this review indicates that advise and support from a stoma nurse improved self-confidence, put individuals in control of their own care, and facilitated social adjustments. However, it was highlighted that many individuals were not free in discussing the sexual difficulties they faced, therefore, the healthcare service providers should provide adequate training for HCPs to improve their skills and have a better approach that will facilitate openness and free discussion for counselling to identify and support their sexual and psychological needs for improve QoL.