For many people, having a stoma formed is part of a planned or ‘elective’ operation. It’s the job of health professionals, such as myself, to make sure that patients receive all the information they might want or need about their surgery, and that it is delivered in a format that they can understand. This is never more important than when being counselled about upcoming surgery that will result in formation of a stoma.
Old school
Often, our patients want to know as much detail about their operation and their future stoma as possible. Before the COVID-19 pandemic, our hospital had an established Surgery School for colorectal patients, who were due to have planned surgery on their bowel. The patients attended before their operation as part of the Enhanced Recovery After Surgery (ERAS) pathway.
Surgery School was an informal 40-minute workshop delivered by a physiotherapist, an anaesthetist and a colorectal nurse specialist. Patients were invited to attend prior to their scheduled operation, with usually three or four patients attending each week, often with a friend or relative for support. Surgery School was not mandatory, but patients were strongly encouraged to attend, and, from April to October 2019, more than half (55%) of our 173 patients did attend. Those who didn’t attend were asked why, and the reasons they gave included work commitments, childcare issues and occasionally a language barrier.
Enhanced recovery aims to get patients up and moving soon after surgery
Our curriculum
At the workshop, we shared tips and tricks with patients to help their surgical experience run more smoothly. We also aimed to empower patients over their journey in the hospital.
The physiotherapist demonstrated how to deep breathe effectively using a spirometer, which was provided. They also provided education about the importance of increasing exercise tolerance before an operation and how to access the initiatives available to support them to achieve this.
From a medical perspective, the anaesthetist highlighted the risk of chest infection as a consequence of not mobilising and using the spirometer in the days immediately after the operation, discussing how this might complicate and prolong their hospital stay. The patients were reminded of the negative impact that smoking and drinking alcohol have on the body and how this might affect recovery from surgery.
The colorectal nurse covered what to expect in the days leading up to, and following, the operation, as well as discussing the importance of an appropriate diet before and after bowel surgery. They also highlighted the importance of patients adopting an active, rather than passive, role in their recovery.
Understanding Enhanced Recovery After Surgery (ERAS)
Enhanced recovery is an evidence-based approach that helps people recover more quickly after having major surgery. Enhanced recovery is sometimes referred to as rapid or accelerated recovery. It aims to ensure that patients:
• Are as healthy as possible before receiving treatment
• Receive the best possible care during their operation
• Receive the best possible care while recovering.
Having an operation can be both physically and emotionally stressful. Enhanced recovery programmes try to get you back to full health as quickly as possible. Research has shown that the earlier a person gets out of bed and starts walking, eating and drinking after having an operation, the shorter their recovery time will be.’
Source: www.nhs.uk/conditions/enhanced-recovery/
Tour and rapport
Following the workshop, we gave a tour of the inpatient colorectal ward, which allowed patients the opportunity to familiarise themselves with where they would be recovering after their operation.
It was wonderful to meet patients in this relaxed format. We found that, when patients came back in for their operation, the rapport and trust was well-established, and this in turn enhanced their motivation to engage with their recovery.
Talking about stomas was encouraged at Surgery School, and often patients would share their experiences with each other, as some attendees were having new stomas formed, while others were having theirs reversed. We gave patients practice packs, which included a pretend stoma and stoma bags to look at and play around with. Patients usually appeared pleasantly surprised when they saw a stoma bag for the first time. Any preconceived perceptions of an ugly, re-usable rigid contraption were instantly dispelled!
Feedback from Surgery School attendees
‘A key component of the seminar was being with people who were going through the same as me. That was underscored again when we went up to see the ward. Here were people who were on the other side of what I was about to endure. It was strangely uplifting. It gave me confidence.’
‘There was some doubt over whether or not I would require a stoma. I was given the option of taking an ostomy kit away with me to get used to it. However, I’m someone who prefers to deal with things as they arrive and so chose not to take up the offer.’
‘The “enhanced recovery after surgery” spawned another mnemonic for me. I was fearful going into that first seminar. That fear made me want to “forget everything and run”. Afterwards, I was prepared to “face everything and recover”.’
Hearing back
Over the years, we found that many of our patients appreciated having the opportunity to mentally and physically prepare for surgery. They felt that it broke down their fears of having a new stoma and turned what could have been a negative experience into a relatively positive one. This was recognised by the wonderful feedback we received from patients who attended Surgery School.
Of course, it is each patient’s choice if they wish to receive information about stomas before their operation. Many people adopt the ‘I will deal with it if it happens’ approach, and this should always be respected.
New school
When the COVID-19 pandemic began, in order to protect our patients, we had to change the format of Surgery School. As with many aspects of our new lives, Surgery School is now delivered virtually in the form of a group video call. The same content is covered as before, minus the ward tour. The number of elective operations at our hospital has gone down significantly, so only one or two patients have attended Surgery School each week.
This online format has been a welcome alternative to the in-person workshop. However, we have found that attendees have been less interactive, both with us health professionals and with each other, during the call.
My advice
My advice to anyone who is due to have bowel surgery, with or without stoma formation, is the following: this is a unique situation to you and no question is a silly question when you are preparing for surgery and life with a new stoma. Never be afraid to contact the stoma nurses at your hospital if you have questions in the run up to your surgery; they will be delighted to help.
Finally, I believe peer support is invaluable, so ask your stoma nurse or a stoma support group if they can put you in touch with someone who has been in your position and understands first-hand what you’re going through. Equally, if you have a stoma and you want to provide support to others, do contact your stoma nurse team or support group—you could make all the difference to someone.
Catherine Jones is a Colorectal Clinical Nurse Specialist, with a focus on Enhanced Recovery, at University Hospital Birmingham