clinical 

Examining stoma care guidance for 

nurses 
Abstract There are over 100 000 people in the UK with a stoma (Black, 2009), termed ostomates or ostomists. It 
can be assumed that adaptation to life with a stoma can be difficult, and ostomates express fears that the stoma 
appliance will be noisy or leak (Salter, 1992; Ayaz and Kubilay, 2009). Ostomates may also worry about 
reintegrating aspects of their previous lifestyle, including work and sexual relations (Krouse et al, 2009). There are 
many ways that people with a stoma, be it temporary or permanent, can be helped to adjust to their stoma. This 
article aims to examine the guidance and literature available to nurses in relation to stoma care. 

T 
here colostomy, although are three the ileostomy latter main can types and also of stoma: be urostomy, termed the 
Jennie Burch, Enhanced Recover Nurse, St Mark’s Hospital, Harrow 
an ileal conduit (Black, 2013). A colostomy is 
jburch1@nhs.net 
formed  from  the  colon  and  will  pass  flatus  and  formed  faeces  which  are  collected  in  a  closed  appliance.  However,  there  are 
alternatives,  such  as  colostomy  irrigation  and  plugs,  which  wash  out  or  hold  back  the  faeces, respectively, thereby negating the 
need  for  the  constant  wearing  of a conventional colostomy appliance. An ileostomy is formed from the ileum and will pass loose 
faeces  and  flatus,  which  is  collected  in  a  drainable  appliance.  A  urostomy  is  usually  formed  from  the  ileum  to  pass  urine  and 
small amounts of mucus into a drainable bag with a tap or bung fastening. 
The  formation  of  a  stoma  brings  about  a  change  to  the person’s body and his/her body image (Grant et al, 2013), and as such, 
adaptation  to  life  with  a  stoma  can  be  assumed  to  be  difficult.  Ostomates express fears that the stoma appliance will be noisy or 
leak  (Salter,  1992;  Ayaz  and  Kubilay,  2009),  or  they  may worry about reintegrating aspects of their previous lifestyle, including 
work and sexual relations (Krouse et 
∎ Ostomy ∎ Nursing care ∎ Guidelines ∎ Long-term care ∎ Preoperative care 
al, 2009). There are many ways that people with a stoma, be it temporary or permanent, can be helped to adjust. 
The  aim  of  this  article  is  to  examine  the  guidance  available  to  nurses  in  relation  to  stoma  care.  Based  on the guidance found 
and  on  the  author’s  clinical experience, it was found that several areas warranted further discussion, including the documentation 
available  to  nurses  to  guide  them  in caring for people with stomas, the preoperative and postoperative support that is available to 
ostomates,  and  how  a  safe  discharge  from  hospital  can  be  ensured.  Lastly,  more  information  is  required  on  how  nurses  can 
support  ostomates  in  learning  to  live  with  their  stomas,  both  physically  and  emotionally,  particularly  in  terms  of  resuming 
activities, intimacy, and longer-term nursing support. 
Guidance  documents  A  literature  search  on  stoma  care  guidance  was  performed,  with  limited 
research-based  evidence  being  found.  The  National  Institute  for  Health  and  Care  Excellence  (NICE)  had  no  specific  stoma 
guidelines,  although  various  guidelines  discuss  the  potential  need  for  a stoma, including the colorectal cancer guidelines (NICE, 
2014)  and  the  inflammatory  bowel  disease  guidelines  (NICE,  2015).  The  Royal  College  of  Nursing  (RCN)  (2003)  produced  a 
document entitled ‘Documentation in Colorectal and Stoma Care Nursing’, which was written for stoma specialist 

Key words 
This article has been subject to double-blind peer review 
Gastrointestinal Nursing vol 13 no 6 July/August 2015 17 
 
clinical 
nurses.  This  document  provides  guidance  on  how  and  what  should  be  documented,  including  the  documentation  of  telephone 
calls.  The  RCN  also  published  the  document  ‘Clinical  Nurse  Specialists  −  Stoma  Care’  (RCN,  2009),  detailing  the  role  of  the 
stoma specialist nurse. This publication helps to guide the specialist nurse in more specific areas of stoma care (Box 1). 
UK  stoma  specialist  nurses from the World Council of Enterostomal Therapists (2008) published ‘Role Descriptive of a Stoma 
Care  Nurse  Specialist’.  This  document  also  included  a  definition  of  the  role  of  the  stoma  specialist nurse and the stoma nurse’s 
scope  of practice, similar to the previous document. This publication also provides guidance on topics, such as leadership, as well 
as  specific  stoma  care  guidance  on  stoma  siting  and  caring  for  problematic  stomas,  to assist the stoma specialist nurse to define 
and undertake their role. 
The UK’s Association of Stoma Care Nurses (ASCN) (2013) published the ‘Stoma care nursing standards and audit tool’, 
addressing a number of issues, including: ∎ Making referrals as appropriate ∎ Preoperative preparation ∎ Postoperative care ∎ 
Discharge preparation ∎ Short- and long-term follow-up. 
The  ASCN  document  includes  advice  on  follow-up  and  assessment  of  how  someone  is  coping  with  his/her stoma, as there is 
evidence that intensive follow-up care provided by nurses will assist in this aspect (Pittman et al, 2009). 
In  addition  to these documents, a variety of books have been published for health professionals in the UK on the topic of stoma 
care.  The  most  recent  of  these  books  was  published  over  5  years  ago. These books include ‘Stoma Care’ (Burch, 2008), ‘Stoma 
Care and 
Rehabilitation’  (Breckman,  2005), ‘Stoma Care’ (Porrett and Mcgrath, 2005), ‘Holistic Stoma Care’ (Black, 2000), ‘Stoma Care 
Nursing: A Patient-centred Approach’ (Myers, 1996) and ‘Stoma Care Nursing’ (Elcoat, 1986). 
Pre-  and  postoperative  support  Preoperative  stoma  care  should  include  provision  of  specific  information  regarding care 
and  management  of  stomas  (NICE,  2014).  In  addition,  the  stoma  specialist  nurse  should  site  the  patient,  meaning  marking  the 
abdomen  where  the  surgeon  will  form  the  stoma  (Porrett  and  Mcgrath,  2005).  Stoma  siting  reduces  the  risk  of  postoperative 
complications  by  avoiding  a  poorly  positioned  stoma  (Rust,  2011).  Other  elements  of  preoperative  stoma  care  include 
preoperative  training  that  can  encompass  the  use  of  training  packs.  These  preoperative  training  packs  contain  artificial  stomas 
that  can  be  attached  to  the  abdominal  wall  with  adhesive,  to  enable  the  ostomate  to  commence  training  on  stoma  care  before 
he/she  undergoes  surgery.  In  the  preoperative  period  it  can  be  useful  for  the  patient  to  meet  other  ostomates  who  can  explain 
aspects  of  living  with  a  stoma  from  a  personal  perspective;  however,  this may not be achievable in all circumstances, such as in 
the event of emergency stoma-forming surgery. 
The  evidence-based  enhanced  recovery  pathway,  endorsed  by  the  Department  of  Health  (DH)  (2011),  results  in  a  shorter 
hospitalisation  time  (Nygren  et  al,  2013). Advantages include a 50% reduction in complications (Varadhan et al, 2010), although 
there  is  a  reduced  amount  of  time  for  the  patient  to  learn  about  stoma  care.  This  is  important,  as  research  shows  that  stoma 
training  is  essential  to  achieve  a  positive  effect  on  an  ostomate’s  quality  of  life  (Danielsen  et  al,  2013a),  and  body  image 
(Piwonka  and  Merino,  1999).  Preoperative,  as  well  as  postoperative,  training  enables  a  safe  discharge  home,  with  a  5-day 
hospital stay (Chaudhri et al, 2005; Bryan and Dukes, 2010). 
Discharge criteria Before being discharged home from hospital, ostomates need to be independent in 
their stoma care (Fiore et al, 2012). However, the results of research results carried out on patients with newly-formed stomas are 
conflicting. One study, carried out in Australia, shows that a third of 
Box 1. Role of the stoma care nurse 
To provide information and support for patients, their caregivers and relatives 
To provide preoperative care 
To provide care in hospital and continuing support 
To provide education and advice 
To work with relevant health care professionals 
To develop discharge plans 
To maintain quality of care through research and audit 
Source: Royal College of Nursing, 2009 
18 Gastrointestinal Nursing vol 13 no 6 July/August 2015 
 
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patients  were  not  confident  in  caring  for  their  stoma  (Stott  et  al,  2013),  while  another  carried  out  in  Hong  Kong  reports  that 
patients  did feel confident (Wu et al, 2007). In practice, being independent in one’s stoma care and feeling confident are often not 
synonymous. Within the UK’s enhanced recovery pathway, patients are safely prepared before being discharged home. 
Resuming  activities  When  discharged  home from hospital, it is advised that the ostomate initially avoids 
strenuous  activities  and certain food types (Black, 2000), but the timing of the resumption of such activities can be ambiguous. In 
a  study  by  Wu  et  al  (2007),  once  at  home,  patients  did  not  feel  confident  enough  to  resume  previous  activities,  such  as  lifting 
heavy  objects,  due  to  concerns  about  damaging  their  stoma, causing a parastomal hernia or feeling weak. Although this research 
was  undertaken  with  Chinese  patients,  ostomates  in  the  UK  also  have queries about when to resume activities or return to work. 
It  is  therefore  important  to  empower  ostomates,  helping  them  to  understand  when  to  rest  and that activities should be gradually 
reintroduced  (Burch,  2008).  Research  suggests  that using an abdominal support and undertaking abdominal exercises can help to 
prevent formation of a parastomal hernia (Thompson and Trainor, 2005; 2007). 
Life  with  a  stoma  Salter  (1992),  in  her  quality  of  life  research,  identified  that  ostomates  were 
concerned  about  the  stoma  appliance  being  noisy,  visible  or  leaking,  resulting  in  a  low self-esteem. However, this research was 
carried  out  many  years  ago when stoma appliances were less sophisticated. More recently, Erwin-Toth et al (2012) have reported 
that the quality of life of ostomates could be improved with effective management of stoma problems. Nichols and Riemer (2009) 
found a negative life satisfaction among those with the stoma, which also affected quality of 
life.  This  was  likewise  found  by  Cerruto  et  al  (2014),  who  reported  that  for  people  with  a  urinary  stoma,  their  satisfaction  is 
related  to  the  degree  of  adaptation  to  their  new life with their stoma. Reassuringly, Pittman et al (2009) report that quality of life 
improves most within the first 3 months following stoma formation, but continues to do so for the first year, with the preoperative 
level of quality of life being reached a year following surgery (Ito et al, 2012). 
Psychological  evaluation  of  new  ostomates  is  necessary.  This  was  recognised  over  two  decades  ago  by  Wade  (1990),  who 
reported  that  20%  of  ostomates  had  psychological  problems,  while  White  and  Hunt  (1997)  reported  that  a  quarter  of  patients 
experienced  significant  psychological  symptoms.  More  female  than  male  ostomates feel depressed (Wu et al 2007; Krouse et al, 
2009),  but  symptoms  generally  resolve  in  a  matter  of  months  (Notter  and  Chalmers,  2012).  Women  appear  to  adjust  better  to 
their  stoma,  potentially  due  to  being more engaged with coping behaviours, social support and spiritual activities than men (Li et 
al,  2012).  Pachler  and  Wille-Jørgensen  (2012)  challenge  the  assumption  that  ostomates  fare worse than people without a stoma. 
They compared quality of life for people with permanent colostomies for rectal cancer, with people with no stoma, and concluded 
both  groups  fare  equally  well.  It can therefore be seen that nurses need to be aware of psychological issues and make appropriate 
referrals where necessary. 
Advice  and  guidance  Some  ostomates  choose  to  locate information on the internet (O’Connor et al, 2010), 
while  others  learn  through  trial  and  error  (Beaver  et  al,  2010).  Wu  et  al  (2007)  suggest  that  ostomates  with  higher  levels  of 
education  have  better  coping  mechanisms,  as  they  can  access  assistance  more  easily.  Empowerment  to  access  suitable 
information and support, for example though official stoma support group websites is therefore essential. Some of the main stoma 
support websites can be found in Box 2. 
Resuming intimacy Krouse et al (2009) identified that at least 30% of ostomates lack confidence in 
sexual activities, a results also found by Wu et al (2007). Issues such as altered body image, anxiety, embarrassment or 
Box 2. Patient support groups 
www.iasupport.org 
www.stomasupport.org 
www.colostomyassociation.org.uk 
www.urostomyassociation.org.uk 
20 Gastrointestinal Nursing vol 13 no 6 July/August 2015 
 
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concerns  about  a  leaking  appliance  may  lead  to  changes  in  sexual  interest  or  avoidance  of  sexual  contact  (Ayaz  and  Kubilay, 
2009).  These  issues  can  be  overcome  by  discussion,  which  can  resolve  negative  feelings  of  loneliness,  frustration,  anger  and 
disappointment  (Ayaz  and  Kubilay,  2009).  Sexual  relations  and  intimacy can be difficult to discuss for both patients and nurses; 
nevertheless,  support  and  advice  is  necessary,  although  referral  for  more  assistance, to a specialist counsellor, for example, may 
be warranted. 
Family  and  friends  In  general,  family,  significant  others  and  friends  can  be  an  immense  source  of 
support,  although  Notter  and  Chalmers  (2012)  reported  that  40%  of  ostomates  restrict  social  activities  with  friends  and  family. 
Adaptation  to  their  altered  body  image  has  been  found  to  be  assisted  by  a  supportive  partner  (Salter,  1992)  and  acceptance  by 
friends  (Piwonka  and  Merino,  1999).  Krouse  et  al  (2009)  recognised  the  importance  of  social  support,  with  women  potentially 
being  more  concerned  with  issues,  such  as  isolation,  than  men.  The  nurse  can  facilitate  acceptance  by  involving  the  family,  as 
appropriate, in discussions or suggesting support groups. 
Health  professionals  Wu  et  al  (2007)  suggested  that  a  nursing  assessment  of  ostomates  enables 
identification  of  patients’  needs.  Krouse  et  al  (2009)  considered  that  early  evaluation  of  the  ostomate’s  psychological  state and 
long-term  follow-up,  including  examining  the  ostomate’s  social  wellbeing  and  spiritual  activities,  can  assist  adaptation  to  the 
stoma.  Nurses  should  provide  teaching,  counselling  and  reassurance,  and  offer  information  to  enable  patients  to  live 
independently  with  their  stoma.  Davenport  (2014)  suggests a clinical care pathway that includes telephone calls, home visits and 
regular  follow-up  appointments  for  the  first  year.  She suggests that a subsequent annual review of the ostomate that incorporates 
assessment of the stoma, lifestyle and the ostomy products used is important. 
Many  stoma  specialist  nurses  undertake  home  visits  in  the  immediate  postoperative  period  (ASCN,  2013).  At  this  visit,  the 
nurse establishes, among other aspects, how ostomates are coping. However, due to constraints, such as lack of staff 
or  funds,  this  is  not  a  nationwide  service,  and  only hospital follow-up is possible. It could be argued that, as patients who follow 
the  enhanced  recovery  pathway  are  in  a  better  state  of  health  after  surgery  compared  to  those  who  receive  traditional care, and 
that  ostomates  can  come  to  hospital  within  a  week  or  two  for  nursing  and  surgical follow-up care, home visits are therefore not 
necessary.  Nevertheless,  home  visits  can  be  important  for  assessing  home  conditions,  and  may  be  essential  for  housebound 
ostomates.  Other  options  for  follow-up  care  include  nurse-  led  telephone  follow-up  conversations,  which  have  been  shown  by 
research  to  enable  the  needs  of ostomates to be met (Zhang et al, 2012), and clinic appointments, which enable a physical review 
of the skin and stoma. 
Open  days  can  enable  ostomates  to  meet  other  ostomates,  see  new stoma products and renew links with their stoma specialist 
nurse.  Lastly,  patient  education  groups  have  been  effective  in  providing  information  and  support,  and  discussing  topics  of 
common  concern,  such  as  diet  (Sun  et  al,  2013).  Danielsen  et  al  (2013b)  found  that,  in  Denmark,  ostomates  wanted  group 
sessions to learn from each other and to help them to become self-empowered. 
Adjustment to the stoma can be assisted by intensive follow-up care, including a monthly nurse review (Pittman et al, 2009), as 
regular  contact  with  a  specialist  stoma  nurse  improves  health-related  quality  of  life  (Erwin-Toth et al, 2012). Ideally, ostomates 
should  receive  intensive  support  in  the  first  3  months  to  a  year  following  surgery  to  assist  with  adaptation  to  their  stoma. 
Furthermore,  as  patients  do  not  always  recognise  that  they  have  sore  skin  (Herleufsen  et  al,  2006),  a  yearly  follow-up  with  a 
nurse  is  advocated  to  ensure  the  patient  is  coping  well  with  his/her  stoma  and  not  encountering  problems  (Krouse  et  al, 2009). 
Unfortunately,  there  are  no  UK  standards  for  follow-up  care;  however,  there  is  increasing  evidence  to  demonstrate  the 
importance of follow-up care, with published literature stating that it should be an integral part of the stoma specialist nurse’s role 
(Davenport,  2014).  Even  in  the  US,  where  health  care  often  needs  to  be  self-funded,  the importance of follow-up care has been 
discussed  by  a  patient  (D’Orazio  and  Ozorio,  2008).  Therefore,  it  is  becoming  increasingly  difficult  to  see  why  long-term 
follow-up care is not mandatory for ostomates. 
22 Gastrointestinal Nursing vol 13 no 6 July/August 2015 
 
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Conclusion  It  is  clear  that  ostomates  require  various  support  systems  to help them cope with 
their  stoma.  These  may include health professionals, social networks and spiritual support. Learning to live with a stoma requires 
adjustment  to  the  changed  body  image  and  the  new  way  in  which  waste  is  eliminated.  There  is  evidence  to  show  that  a  good 
support system can aid the adaptation process. 
There  are  many roles that a nurse can play in the process of adaptation, including providing training on the practical care of the 
stoma  and  on  how  to  adapt  to  life  with  a  stoma.  Research  shows  that  adapting  psychologically  to  a  stoma  takes  time  and  that 
positive  intervention  from  health  professionals  is  necessary,  particularly  in  the  first  few  months to a year following surgery. No 
national  protocols  that  guide  nurses  in  giving  the  best  standard  of  stoma  care  were  discovered  in  the  literature;  therefore, more 
research is needed in this area. 
GN 
Declaration of interest The author has no conflict of interest to declare 
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