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An audit to examine patient views on CNS-led stoma-care services

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Vanessa Coleman, RN, DipN.

Clinical Nurse Specialist, Coloproctology/Stoma Care, Addenbrooke's NHS Trust, Cambridge

In July 1998 the Government issued the White Paper A First Class Service: Quality in the new NHS (DoH, 1998), and introduced the concept of clinical governance for the first time. The aim was to end a situation in which there were significant differences in the quality of care between hospital trusts. Clinical governance was therefore introduced to make NHS organisations accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical care would flourish (Scally and Donaldson, 1998).

In July 1998 the Government issued the White Paper A First Class Service: Quality in the new NHS (DoH, 1998), and introduced the concept of clinical governance for the first time. The aim was to end a situation in which there were significant differences in the quality of care between hospital trusts. Clinical governance was therefore introduced to make NHS organisations accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical care would flourish (Scally and Donaldson, 1998).

Audit of patient satisfaction
Two clinical nurse specialists (CNSs) in stoma care at Addenbrooke's NHS Trust in Cambridge decided to ascertain patient satisfaction with the stoma-care service since they took over the care of patients. The aim of the questionnaire was to gain information relating to the service each patient received from the stoma-care department, before, during and after an operation.

The questionnaire was completed using tick boxes and also included space for comments. Each questionnaire was anonymous, but allowed the patient to include details of sex, age, type of stoma and whether the operation had been planned or was an emergency.

The trust's audit department helped formulate the questions, and gave advice on appropriate wording and the length of the finished questionnaire.

In total, 100 patients were sent a questionnaire eight weeks after discharge to ensure that they had received two home visits by a CNS and had attended their postoperative outpatient appointment. Pre-paid envelopes were provided to encourage the respondents to return the questionnaires promptly. A letter was also included, explaining the purpose of the audit and why their comments would be appreciated. Seventy-seven questionnaires were returned.

The stoma-care department hoped that the information gained from the questionnaires would indicate whether patients were happy with the service they received or whether improvements were necessary.

Issues considered for the survey
Ethical issues were considered during the process and ethical dilemmas were investigated in conjunction with the UKCC's Code of Professional Conduct (UKCC, 1992). The trust's ethics committee confirmed that, as questionnaires are considered part of the audit process, committee approval was not necessary.

The right to obtain information via a questionnaire without first obtaining the respondents' permission or informed consent cannot be assumed (Burnard and Morrison, 1994). However, the staff in the stoma-care department decided that, by returning the questionnaire, each patient was giving implied consent for any information they provided to be used. When people are used as subjects in nursing research, human rights must always be protected. As Polit and Hungler noted, 'The requirement of ethical conduct may strike the reader as so self-evident as to require no further comment but the fact is that ethical considerations have not always been given adequate attention' (Polit and Hungler, 1993).

According to Coleman and Waller (2000), each patient undergoing surgery that will result in a stoma is entitled to the highest-quality, comprehensive, specialist nursing services that can be provided with the resources available. They also believe that patients' physical, psychological, social and spiritual needs should be acknowledged and appropriate information, advice and support provided to them and their families or carers, in order to enable patients to achieve an optimal rehabilitation. For the purpose of this audit it was considered inappropriate to send questionnaires to the following patients, despite the fact that they all received the service:

- Those that lived in areas other than Cambridgeshire, as any home follow-up would be undertaken by a stoma-care nurse from another trust

- Patients requiring palliative care, such as those with cancer who were in a hospice or undergoing continuing care.

The overall response rate to the questionnaire was 77%, with a male-to-female ratio of approximately 50:50. The findings of the questionnaire in relation to the structure of the service provided are now discussed.

Pre-operative care
The CNSs work with two designated colorectal surgeons who carry out all planned colorectal surgery. Both surgeons ensure that prompt referrals are made at diagnosis. Subsequent care delivery would be adversely affected in the event of a late referral to the service, as patient teaching opportunities could be missed. Overall, 24.6% of respondents were first seen at the clinic before their operation. This is not always an appropriate time to give information relating to stoma formation and hence pre-operative home visits are offered at a convenient time. Home visits were made to 15.5% of patients pre-operatively.

In the provision of clinical care during this pre-operative phase, the nurse specialist contributes advanced knowledge and expertise. The patient and family gain practical information and advice specific to their needs, thus enhancing the quality of care (Humphris, 1994). The nurse specialist also influences the delivery of care by acting as a role model for staff (Chuk, 1997). Role modelling increases the visibility and accessibility of specialist nurses, and they become a recognisable resource for staff and patients (Bousefield, 1997).

Research into the value of nurse specialists found that they were able to increase patient and family knowledge, thus reducing readmission rates and speeding up patient discharge in areas where their service was available, making it an extremely cost-effective resource (Miller, 1995).

Working as part of a multidisciplinary team requires skill in communication and maintaining effective interpersonal relationships. The nurse specialist must interact with other caregivers and organisational units to achieve patient-care goals. Robb (2001) cites 18 key tasks and responsibilities of the CNS, including the development and maintenance of an effective and appropriate communication network with other professionals.

The colorectal cancer nurse specialist is always present when patients are given their diagnosis. If the consultant discusses stoma surgery, she will provide a contact number for the stoma-care specialist nurse. Before the operation, it is up to the patient to telephone to gain further information. Table 1 provides a breakdown of times and places in which patients first met the stoma nurse.

In total, 84% of respondents stated that the nurse specialist had provided a sufficient explanation of the procedure, and that the given information was understood. This verbal information is backed up with written information.

Postoperative care
The department is in the process of writing and implementing an integrated care programme for colorectal patients. Integrated care promotes quality, allowing the effective delivery of appropriate health care, efficiency of service provision and consideration of the patient/family experience, which in turn contributes to quality assurance. Integrated care pathways are compiled to outline anticipated clinical practice for a group of patients undergoing a specific procedure or with a particular diagnosis or set of symptoms, using an evidence base (Bayliss et al, 2000). In essence, the pathway provides a multidisciplinary template or blueprint of the plan of care, and by following this template, unnecessary variations of treatment and outcome can be reduced. The pathway leads each patient towards a desired objective and ensures that specified interventions are delivered at the right time by the right professional, in the right way.

The implementation of a colorectal care pathway could help to alleviate the problem of bed availability. Wigfield and Boon (1996) suggested that pathways make it possible to identify reasons for delayed discharge. It is important that individual members of the multidisciplinary team do not compromise their clinical judgement while using a care pathway. Any member of the care team can deviate from the pathway provided there is a valid clinical reason for doing so. Johnson (2000) argued that using the tool effectively can facilitate adherence to best practice guidelines, while providing the local multidisciplinary team with a wealth of information that can be used to ensure best practice is maintained and monitored. In this way, the tool can play a major role in delivering clinical governance.

A stoma-care CNS visits the ward three times a week, and spends the other two days covering the community. Overall, 94% of patients saw the nurse between one and six days after surgery.

Care in the ward
The nurse specialist relies on the ward staff to support patients while they are taught how to manage their stoma. Despite the fact that ward nurses have a demanding job and often limited staff resources, 86% of respondents felt that they were well supported by ward staff. Only 7% did not feel well supported, making comments such as: 'The ward staff were good, but I felt they had to rush to be able to get all the other jobs done.' Six patients did not respond to the question.

The majority of stoma-care needs are met by ward staff to provide continuity of care. Marshall and Luffingham (1998) identified the fact that the deskilling of ward nurses may occur if specialist nurses take over patient care, and that collaboration is therefore crucial. They also suggest that the presence of specialist nurses should enhance the role of general nurses, encouraging them to extend the boundaries of their practice.

When discussing the role of the specialist nurse, it is difficult to divorce education, practice management and research from one another, as they are integrated activities. A nurse is a specialist only if involved in all of these areas. Expectations of CNSs differ between organisations and they fulfil a diversity of roles. This can be directly linked to evolution of the role to fulfil the appropriate needs of the service. However, if you examine all the individual roles, core elements do emerge. These can be divided into four main areas:

- Expert clinician

- Educator

- Consultant

- Researcher.

Leadership skills are necessary in all four areas.

The role of the specialist nurse has developed due to the reduction of junior doctors' working hours. The evolution of physicians' assistants and the general shortage of medical staff have also had an impact on this development (Castledine, 2000). Specialist nurses are expanding their roles to accommodate patients' needs for more specific and detailed research-based information and specialist nursing care. Many departments also run nurse-led clinics.

Castledine (2000) notes: 'Specialisation and sub-specialisation are inevitable these days because of the rapid expansion and developments in medical knowledge. It is impossible for one person to be an expert in all aspects of health care. A specialist is someone who is educated and has experience in, and develops the competencies and skills of, a particular field or endeavour.'

Arrangements for discharge
The colorectal surgeon consults the nurse specialist to determine an appropriate time of discharge. One of the service standards requires that the patient must have completed at least two independent unsupervised bag changes before going home. Obviously this needs to be assessed on an individual basis. In our questionnaire 84% of respondents stated they were confident to perform their stoma care before going home (Table 2).

A telephone call from the nurse specialist 48 hours after discharge identified that 9% of patients were still a little unsure of the discharge information they had been given in hospital. In some cases the nurse had to explain how to obtain stoma supplies. This highlighted the need to distribute information booklets to patients a few days before going home, rather than on the day of discharge. This booklet contains information on how to obtain stoma appliances, a step-by-step guide to changing a stoma, a list of frequently asked questions and answers, dietary tips and useful information and voluntary support group contact numbers. In total, 92% of respondents found the booklet useful and 71% found the telephone contact of value (Table 2). Comments included: 'The telephone call from the stoma-care nurse just adds to the care you feel you are receiving - all a good thing.'

The discharge standard states that each patient will receive a minimum of two home visits, the first during the initial week after discharge. Overall, 75% of patients felt that this was the right number of visits, 12% felt it was not enough and 13% did not respond. Patients are always encouraged to contact the nurse specialist if they have any problems to arrange a home visit, an appointment at the stoma clinic or a visit to the stoma-care department.

Since primary care groups were established in April 1999, closer working relationships between GPs, nurses and social services have promoted the delivery of a local service to meet local needs. The shift is now towards primary care as the leading force in health-care provision rather than secondary (hospital) care (Taylor, 1999). The nurse specialist also has an important role to play in the community. Patients undergoing stoma-forming surgery may need to spend only one or two weeks in hospital. The stoma-care service does not provide on-call cover and working hours are limited to Monday to Friday, 8am to 4pm. A service standard is a visit from the district nurse within two days of discharge. Overall, 90% of respondents received a visit from this service, and 61% were seen within two days. Some of the problems patients may need help with are listed in Box 1.

With the information gained from the questionnaire and including the written statements in the comments boxes, the stoma-care department was able to address any issues that needed attention, such as the need to distribute the discharge information booklet a few days before patients go home. This was undertaken following discussion with all the other members of the multidisciplinary team. The results and patient comments were also made available to the chief nurse at the trust and the surgical managers.

The service always aims to provide a quality service 'doing the right thing, for the right person at the right time and getting it right first time, every time' (Elcoat, 2000). The results of the questionnaire have enabled the nurse specialists to address care delivery and highlight clinical governance issues, ensuring that the stoma-care department is an environment in which clinical care flourishes.

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