Journal of Research in Nursing

0(0) 1–18
Jordanian ostomates’ health ! The Author(s) 2020
Article reuse guidelines:

problems and self-care ability sagepub.com/journals-permissions

DOI: 10.1177/1744987120941568
journals.sagepub.com/home/jrn
to manage their intestinal
ostomy: a cross-sectional study
Rami A Elshatarat
Assistant Professor, Department of Medical and Surgical Nursing, College of Nursing, Taibah University,
Kingdom of Saudi Arabia

Inas A Ebeid
Assistant Professor, Department of Psychiatric and Mental Health Nursing, College of Nursing, Taibah
University, Kingdom of Saudi Arabia
Lecturer, Psychiatric and Mental Health Nursing Department, Faculty of Nursing, Portsaid University,
Egypt

Khadega A Elhenawy
Assistant Professor, Department of Medical and Surgical Nursing, College of Nursing, Taibah University,
Kingdom of Saudi Arabia
Assistant Professor, Medical-Surgical Nursing Department, Faculty of Nursing, Menoufia University,
Egypt

Zyad T Saleh
Associate Professor, Department of Clinical Nursing, School of Nursing, The University of Jordan,
Jordan

Ahmad H Abu Raddaha

Associate Professor and Head of Nursing Department, Department of Nursing, College of Applied
Medical Sciences, Prince Sattam Bin Abdulaziz University, Kingdom of Saudi Arabia

Mohammed S Aljohani
Assistant Professor, Head of Department of Medical and Surgical Nursing, and Vice-Dean, Department
of Medical and Surgical Nursing, College of Nursing, Taibah University, Kingdom of Saudi Arabia

Abstract
Background: Ostomates have several physical, psychological and social health problems. These
problems negatively impact the ostomates’ quality of life.

Corresponding author:
Ahmad H Abu Raddaha, PhD, RN-BC Department of Nursing College of Applied Medical Sciences, Prince Sattam Bin
Abdulaziz University, PO Box 422, Al-Kharj, 11942, Kingdom of Saudi Arabia.
Email: a.aburaddaha@psau.edu.sa
2 Journal of Research in Nursing 0(0)

Aims: This study aims to identify Jordanian ostomates’ health problems and their self-care ability
to manage their ostomies.
Methods: This is a cross-sectional study. A convenience sampling method was used to recruit
168 Jordanian patients with intestinal ostomies. A self-report questionnaire was used to collect
the data.
Results: On average, the participants’ physiological ostomy-related problem scores were
8.76  2.37 (out of 13 problems) and the total score of self-care ability to manage their
ostomies was 16.56  2.62 (out of 24). About 22% of the participants had ‘moderately severe’
to ‘severe’ depression (nine-item Patient Health Questionnaire score 15) and 33.9% had
‘moderate’ to ‘severe’ anxiety (seven-item General Anxiety Disorder questionnaire score
10). About half of the participants had exposure to teaching and/or training about ostomy
care. About 85% of participants were willing to attend health education and training
programmes about ostomy care. There was a significant correlation between high ostomates’
self-care ability to manage their ostomies and a low number of physiological health problems
(r ¼ 0.67, p ¼ 0.04), a low depression (Patient Health Questionnaire 9) score (r ¼ 0.54,
p ¼ 0.039) and a low anxiety (seven-item General Anxiety Disorder questionnaire) score
(r ¼ 0.71, p < 0.027).
Conclusions: Health teaching and training about intestinal ostomy management, psychosocial
support, follow-up assessment and treatment for ostomy-related problems are recommended for
all ostomates.

Keywords
anxiety, depression, intestinal ostomy, Jordanian ostomates, ostomates’ self-care ability,
physiological ostomy-related problems

Introduction
Worldwide, colorectal cancer is the third most common cancer type among men and second
most common among women. In 2017, its incidence was about 1.8 million cases with about
896,000 deaths worldwide and a higher mortality rate in developing countries. Colorectal
cancer cases increased by 5% between 2007 and 2017 globally (Global Burden of Disease
Cancer Collaboration, 2019). In Jordan, colorectal cancer is the second most common type
of cancer in both genders, accounting for about 11% of all new diagnosed cancer cases
among Jordanians. In 2013, malignant tumors were the second leading cause of all deaths
(16.4%) in Jordan. Colorectal cancer alone accounted for 2% of all deaths in Jordan
(Ministry of Health Jordan, 2013).
Intestinal ostomy is a surgical procedure that creates an opening between the intestine and
the surface of the patients’ body to excrete waste products. In 2012, about 1.2 million
patients with colorectal cancer in the United States had an intestinal ostomy (United
Ostomy Associations of America, 2017). Worldwide, insertion of an intestinal ostomy is
increasing by about 3% each year (United Ostomy Associations of America, 2017).
Despite the importance of intestinal ostomy procedures for the survival of patients,
ostomates face several physiological and psychosocial health problems, including severe
gas and odour from the ostomy, pouch leakage, skin irritation, altered body image and
depression or anxiety. Ostomies also negatively impact ostomates’ occupational health,
Elshatarat et al. 3

daily life activities and quality of life (QOL) (Ayaz-Alkaya, 2019; Silva et al., 2017;
Vonk-Klaassen et al., 2016). Moreover, Muslim ostomates, who carry out their ablutions
and prayers five times a day, face several difficulties in practicing their worship and spiritual
activities (Karadag and Baykara, 2009; Iqbal et al., 2016).
The majority of patients with intestinal ostomies, particularly those with a permanent
ostomy, have several undiagnosed and untreated ostomy-related problems. Moreover, those
ostomates are at high risk of developing acute and chronic physical disorders, serious
psychological disorders such as depression and anxiety and threatening life events (Ayaz-
Alkaya, 2019; Recalla et al., 2013; Silva et al., 2017; Vonk-Klaassen et al., 2016; Rossella
et al., 2018). Furthermore, some ostomates live in areas with a lack of medical resources,
healthcare facilities and a shortage of qualified ostomy care specialists. Also, many
ostomates do not seek healthcare services until their ostomy-related problems are
significantly worsened (Vonk-Klaassen et al., 2016; Agarwal and Ehrlich, 2010). The
literature shows a significant positive impact of improving ostomates’ knowledge and self-
care abilities and competencies in taking care for their ostomies to reduce ostomy health-
related problems and complications (Ayaz-Alkaya, 2019; Hendren et al., 2015; Mohamed
et al., 2017; Recalla et al., 2013). Therefore, providing perioparative teaching and conducting
periodic continuing health education and training programmes about ostomy care are very
important and recommended for all ostomates to improve the ostomates’ knowledge and
skill to manage their ostomies and to prevent ostomy-related problems and complications
(Cheng et al., 2013; Elshatarat, 2020; Mohamed et al., 2017; Recalla et al., 2013).
The literature shows the importance of involving the ostomates and their families in the
nursing care plan, which requires cooperation between healthcare providers, including
nurses and physicians, the ostomates and their close family members (Gemmill et al.,
2011; Silva et al., 2017; WOCN, 2010). Nurses provide direct care, spend several hours
with the ostomates and are considered the backbone of the healthcare system. Literature
also showed that nurses can play a major role in assessing and managing ostomy-related
problems and provide health education and training on ostomy care for ostomates and their
families (Gemmill et al., 2011; United Ostomy Associations of America, 2017; WOCN, 2010;
Zhang et al., 2013). However, the literature also shows a lack of nurses’ knowledge and
competence about ostomy care and low self-confidence in their abilities and readiness to
provide health education and training about ostomy care to ostomates (Berti-Hearn and
Elliott, 2018; Cheng et al., 2013; Cross et al., 2014; Elshatarat, 2020). Therefore, it is very
important to provide continuous health education and training programmes on ostomy care
to nurses to ensure the successful implementation of nurses’ activities to achieve the delivery
of care plans to ostomates. Also, adopting international clinical guidelines in healthcare
settings is recommended to improve health professionals’ knowledge about recommended
ostomy care and to ensure treatment care plans are implemented based on evidence-based
practice and updated scientific research (Elshatarat, 2020; Gemmill et al., 2011; Hendren
et al., 2015; Subih and O’Neill, 2012; WOCN, 2010).

Study significance and objectives

Once discharged from hospital after the insertion of the intestinal ostomy, ostomates have to
take care of their ostomy themselves or with help from their families. Community health
nurses have a major role in educating ostomates about ostomy care. To carry out their roles
and organise strategies involving the patients and their families in this treatment plan, it is
4 Journal of Research in Nursing 0(0)

very important nurses are aware of the physiological and psychological ostomy-related
problems and assess patients’ self-care ability to take care of their ostomy (Ayaz-Alkaya,
2019; Vonk-Klaassen et al., 2016; WOCN, 2010). Also, reviewing national and international
published studies related to the assessment of ostomates may help nurses and other health
professionals establish a plan and make decisions regarding care (Ontario, 2009; Silva et al.,
2017; United Ostomy Associations of America, 2017; Vonk-Klaassen et al., 2016; WOCN,
2010).
A database search on the published studies of the assessment and the management of
ostomy-related problems in Jordan revealed no publications on ostomates’ health problems
and their experience in taking care of their ostomies in Jordan and in other Arab countries.
Therefore, the current study investigated Jordanian ostomates’ ostomy health-related
problems (including physiological and psychological) and their self-abilities and practice
in managing their ostomies.
The specific objectives of this study are to determine: (a) the participants’ ostomy-related
problems (including physiological and psychological); (b) the participants’ exposure to
previous education and training about ostomy care; (c) the participants’ abilities to take
care of their ostomies themselves; (d) the correlation between the participants’ ostomy-
related problems and their self-care abilities for their ostomies; and (e) the relationship
between participants’ demographics and clinical data and their self-care abilities for their
ostomies.

Methodology
Research design
A cross-sectional design was conducted to address the aims of the current study.

Research sample and setting

A convenience sampling method was used to recruit 168 ostomates from two private
hospitals in Amman, Jordan. These hospitals have a full range of medical and surgical
care, particularly for intestinal ostomy insertion and management.
The inclusion criteria of the current study were adult patients (18 years old) who had
intestinal ostomies for at least 12 months, were admitted to hospital to receive healthcare for
their ostomies or other health disorders and were Arabic language speakers. The exclusion
criteria were medically unstable patients and those who had mental or psychiatric disorders.
GPower software program (version 3) was used to estimate the effective sample size. The
researchers used the power of 0.80, significant p value of 0.05 and moderate effect size of
0.30. A minimum of 129 subjects was enough to achieve the satisfied power analysis. The
researchers invited 200 eligible participants to participate in this research. In total,
18 participants refused to participate and 14 questionnaires were removed because the
participants did not answer all the questions.

Data collection procedure and ethical considerations

Institutional Review Board approval was obtained at Al-Ghad International Colleges for
Applied Medical Sciences to conduct this current study. Before data collection, ethical
approval was obtained from the general medical managers and the directors of nursing at
Elshatarat et al. 5

the selected hospitals. The researchers obtained the names of eligible participants from the
head nurses at the selected settings. A written consent form was signed by all patients who
decided to participate in the study. The participants were informed that taking part was
voluntary and their personal data were confidential and anonymous.
The data were collected by interviewing the participants in their room or in a private
room at the selected setting. Patients who preferred to answer independently were given a
questionnaire and asked to return the completed questionnaire to the researchers or drop it
in a closed box in the head nurse’s office at the selected setting.

Instruments
The researchers used a structured self-report questionnaire to address the study objectives.
The demographic data were obtained from the participants. The researcher used
participants’ medical records to identify their clinical data, including type of stoma,
location of ostomy and reason for ostomy insertion.
To identify physiological ostomy-related problems, the participants were asked: ‘during
2 weeks before the current hospitalisation, did you complain about any of the following
health problems?’ The researchers listed 13 ostomy-related problems (e.g. fatigue, abdominal
pain, abdominal gases, diarrhoea, etc.). Then the participants were asked to answer 1 ¼ yes if
they have the problem or 0 ¼ no if they did not have the problem. This subscale was adopted
from the City of Hope quality of life-ostomy questionnaire (Grant et al., 2004), particularly
the physical wellbeing subscale, and was modified according to this study’s objectives. The
validity and reliability of this subscale was documented (Grant et al., 2004).
The nine-item Patient Health Questionnaire (PHQ-9) was adopted from a previous study
to screen participants for major depression (Kroenke and Spitzer, 2002). The researchers
used the Arabic version of PHQ-9 in this study. The validity and reliability of the original
version and Arabic version of PHQ-9 were documented (Kroenke and Spitzer, 2002;
Kroenke et al., 2010). The participants’ responses on this scale were 0 ¼ not at all,
1 ¼ several days, 2 ¼ more than 50% of days and 3 ¼ nearly every day. The total score for
PHQ-9 ranges from 0 (no depression) to 27 (severe depression) (Kroenke and Spitzer, 2002;
Kroenke et al., 2010).
To assess the participants’ general anxiety disorders, the Arabic version of the seven-item
General Anxiety Disorder (GAD-7) questionnaire was used (Spitzer et al., 2006). The
validity and reliability of the original English version and the Arabic version of GAD-7
were also documented (Kroenke et al., 2010; Spitzer et al., 2006). The patients’ responses for
GAD-7 were similar to their responses for PHQ-9. The total score of GAD-7 ranges from 0
(no anxiety) to 21 (severe anxiety) (Kroenke et al., 2010; Spitzer et al., 2006).
To address the second objective of this study, participants were asked to report if they had
been exposed to previous theoretical education or clinical training programmes about
ostomy care during the last 12 months. Moreover, all the participants were asked to
report their willingness to participate in education and training programmes about
ostomy care in the future. Those who received teaching and training about ostomy care
were asked to report the source (including nurses and physicians) and the strategy (e.g.
handout, online or multimedia materials) for these teaching and training programmes.
These questions about participants’ exposure to health education and training
programmes about ostomy care were adopted from previous studies (Ran et al., 2016;
da Silva et al., 2014).
6 Journal of Research in Nursing 0(0)

A structured scale containing eight items was used to rate the participants’ self-care ability
and practice in changing and irrigating the ostomy pouch, taking care of the peristomal skin
and wearing clothes over the ostomy. The participants’ responses were 3 ¼ ‘I am totally
independent in ostomy care’, 2 ¼ ‘I am partially independent in ostomy care’ and
1 ¼ ‘I am totally dependent on someone else in ostomy care (e.g. family members)’. To
identify the total score of participants’ self-care ability, all of these eight items were
summed. The highest participants’ total score indicates the highest independence level of
participants’ self-care ability to manage their ostomy. This scale was adopted from the
previous study (Cheng et al., 2013). The validity and reliability of this scale was
documented previously (Cheng et al., 2013).

Data analysis
SPSS software (version 21) was used for statistical data analysis. Frequencies and descriptive
statistics were used to describe the participants’ data. T-test analysis was carried out to
determine the relationship between the participants’ self-care abilities in managing their
ostomies and participants’ demographics and clinical data. Two separate analysis of
variance (ANOVA) tests were run to identify the relationship between the participants’
self-care abilities to manage their ostomies and the sources of education and training
programmes about ostomy care and teaching strategies for improving their self-care
abilities. Pearson’s correlation test was carried out to identify the association between the
participants’ ostomy-related problems (physiological and psychological) and their self-care
abilities in managing their ostomies. A p value <0.05 was pre-set as a significant relationship.

Results
Most participants were male (56%), middle-aged adults (41.1%), married (79.2%), had a
high school degree or above (72.6%), had a permanent ostomy (74.4%) and a colostomy
(66.7%). Cancer of colon or rectum (54.8%) was the most frequent reason for the insertion
of their intestinal ostomy (Table 1).
On average, the participants had nine physiological ostomy-related problems (out of 13)
during the 2 weeks before hospitalisation. The most frequent problems were abdominal gas
(76.2%), odour from ostomy (70.8%) and abdominal pain (67.9%). Almost half of the
participants (48.8%) had more than three of these physiological problems. About 32.1%
of the participants had no or minimal depression and 27.4% had mild depression. Also,
20.8% of the participants had no or minimal anxiety. Many participants (45.2%) had mild
anxiety (Table 2).
Table 3 shows about half of the participants were exposed to previous education and
training about ostomy care. Among them, only 37.8% of the participants (n ¼ 37/98) were
exposed to an education or training programme by nurses alone. Perioperative teaching
(70.4%) was the most common teaching strategy for educating and training the
participants about ostomy care. About 85% of the participants are willing to participate
in education and training programmes about ostomy care in the future.
Most participants reported they were independent in preparing all the necessary
equipment to apply a new ostomy pouch (45.8%). About 40% of participants reported
they were totally dependent on others (such as a family member) in caring for their
peristomal skin and cleaning and drying their soiled pouch. The average score of the
Elshatarat et al. 7

Table 1. Demographics and clinical data.

Variables n %

Gender
Male 94 56.0
Female 74 44.0
Age
18–29 years 19 11.3
30–39 years 31 18.5
40–49 years 28 16.7
50–59 years 69 41.1
60 years 21 12.5
Marital status
Single 35 20.8
Married 96 57.1
Widowed 23 13.7
Divorced 14 8.3
Level of education
Illiterate 17 10.1
Primary or secondary school 29 17.3
High school 74 44.0
College (diploma) or bachelor’s degree 39 23.2
Postgraduate (master or doctoral) degree 9 5.4
Unit ward
Intensive care unit (ICU) 57 33.9
Coronary care unit (CCU) 24 14.3
Medical/surgical department 87 51.8
Types of stoma
Permanent intestinal ostomy 125 74.4
Temporary intestinal ostomy 43 25.6
Location of ostomy
Ileostomy 56 33.3
Colostomy 112 66.7
Reason for ostomy insertion
Cancer colon or rectum 92 54.8
Intestinal obstruction 17 10.1
Inflammatory bowel disease 29 17.3
Trauma 18 10.7
Othersa 12 7.1
Age Mean (  SD)

42.4 7.3
a
Infectious enteritis, colonic polyp, etc.
SD: standard deviation.

patients’ self-care ability and practice in managing their ostomy was 16.56 (out of 24, the
highest total score that indicates the highest independence of the participants to take care for
their ostomies). The overall score of the participants’ self-care ability and practice was
calculated by dividing the participants’ total scores for all eight steps of ostomy care by
8 Journal of Research in Nursing 0(0)

Table 2. Physiological and psychological ostomy health-related problems.

Variables n %

A. Physiological ostomy-related health problems during

the last 2 weeks before hospitalisationa
1. General physical weakness 67 30.9
2. Fatigue 60 35.7
3. Sleep disorders 73 43.5
4. Abdominal pain 114 67.9
5. Abdominal gas 128 76.2
6. Sever odour from ostomy 119 70.8
7. Constipation 88 52.4
8. Diarrhoea 41 24.4
9. Leaking from the pouch (or around the appliance) 32 19.0
10. Superficial redness around the stoma 45 26.8
11. Itching or soreness around the stoma 64 38.1
12. Eczema around the stoma 27 16.1
13. Skin breakdown around the stoma 25 14.9
Total score of the physiological ostomy-related health problemsb Mean (  SD)

8.76  2.37
Number of the previous physiological ostomy-related health problems n %

No physiological problem 4 2.4

Only one physiological problem 9 5.4
Only two physiological problems 31 17.2
Only three physiological problems 42 25.0
Four physiological problems 82 48.8
B. Psychological ostomy-related health problems
during the last 2 weeks before the hospitalisation
1. Major depression severity (measured by Patient Health Questionnaire-9 scale)
None to minimal depression (total score ¼ 0–4) 54 32.1
Mild depression (total score ¼ 5–9) 46 27.4
Moderate depression (total score ¼ 10–14) 31 18.5
Moderately severe depression (total score ¼ 15–19) 24 14.3
Severe depression (total score ¼ 20–27) 13 7.7
2. Generalised anxiety disorder severity (measured by GAD-7 scale)
None-minimal anxiety (total score ¼ 0–4) 35 20.8
Mild anxiety (total score ¼ 5–9) 76 45.2
Moderate anxiety (total score ¼ 10–14) 34 20.2
Severe anxiety (total score ¼ 15–21) 23 13.7
a
Participants were able to select more than one choice, resulting in a total percentage >100.
b
Total score ranges from 0 (no problem) to 13 physiological ostomy-related health problems.
GAD-7: seven-item General Anxiety Disorder questionnaire; SD: standard deviation.

eight and the result rounded to an integral number. Only 28.3% of participants were
independent in taking care of all steps when managing their ostomies (Table 4).
Pearson’s correlation analysis (results are not shown in the tables) shows the participants
who had high ability to take care for their intestinal ostomies themselves were significantly
associated with having less physiological ostomy-related problems (r ¼ 0.67, p ¼ 0.035),
Elshatarat et al. 9

Table 3. Participants’ exposure to health education and training programmes about ostomy care.

Variables n %

Exposed to previous education and teaching about ostomy care 92 54.8

during the last 12 monthsa
Exposed to previous training programme about care during the 72 42.9
last 12 months
Source of previous education or training about ostomy care
during the last 12 months (n ¼ 98)
Nurses only 37 37.8
Physicians only 42 42.8
Physicians and nurses 21 21.4
Strategy for teaching or/and training participants about intestinal
ostomy carea (n ¼ 98)
Perioperative teaching by healthcare providers 69 70.4
Interactive material and multimedia education through the 18 18.4
internet, CD-ROM or DVD
Continuing education and training programmes 26 26.5
Handout materials 54 55.1
Othersb 12 12.2
Willing to participate in education and training programmes about 142 84.5
ostomy care in the future
a
Participants were able to select more than one choice, resulting in a total percentage >100.
b
Others: telephone follow-up, personal meetings, training at bedside, etc.

low depression (PHQ-9) score (r ¼ 0.54, p ¼ 0.039) and a low anxiety (GAD-7) score
(r ¼ 0.71, p < 0.027).
The results of t-test analyses show the participants who had a degree or higher level of
education, had a permanent colostomy, had an ostomy inserted for cancer and were exposed
to previous education and training programmes about ostomy care were significantly
associated with being more independent when caring for their ostomy. One-way ANOVA
test and Tukey post-hoc test revealed significant improvements of participants’ self-care
ability through providing teaching and training by the nurses alone (mean (SD) ¼ 18.59
(1.96), p ¼ 0.044), and by both physicians and nurses (mean (SD) ¼ 21.63 (2.14), p ¼ 0.035)
compared to providing education and training by physicians alone (mean (SD) ¼ 17.26
(2.38)). The result of a second ANOVA test shows a significant difference in the
effectiveness of teaching strategies on improving participants’ self-care ability of their
intestinal ostomies using four types of teaching strategy (f ¼ 68.42, p ¼ 0.034). Participants
who received more than one teaching strategy for education and training on ostomy care had
the highest score for their self-care ability for their intestinal ostomies (Table 5).

Discussion
This is the first study in Arab countries to investigate the association between Jordanian
ostomates’ health problems and self-care ability to manage their ostomies. Therefore, the
current study offers important data to develop clinical guidelines for improving healthcare
 10

Table 4. Participants’ self-care ability and practice in managing their intestinal ostomies.

The patients are The patients are totally

The patients are totally partially independent dependent on someone
independent in taking care in taking care of else to care of their ostomy
of their ostomy their ostomy (e.g. family members)
(coded as 3) (coded as 2) (coded as 1)
Participants’ self-care ability and practice n (%) n (%) n (%)

1. Gather and prepare all necessary equipment 77 (45.8) 49 (29.2) 42 (25.0)

2. Remove the soiled pouch 67 (39.9) 56 (33.3) 45 (26.8)
3. Clean, rinse and dry peristomal skin 35 (20.8) 65 (38.7) 68 (40.5)
4. Ostomy irrigation 39 (23.2) 66 (39.3) 63 (37.5)
5. Clean and dry soiled pouch 27 (16.1) 75 (44.6) 66 (39.3)
6. Apply and position the new appliance over stoma 43 (25.6) 60 (35.7) 65 (38.7)
7. Peristomal skin care 50 (29.8) 82 (48.8) 36 (21.4)
8. Wearing the clothes over ostomy pouch 69 (41.1) 73 (43.5) 26 (15.5)
Overall of the patients’ self-care ability and practicea 48 (28.3) 95 (56.4) 25 (14.3)
Total score of participants’ self-care ability and practice (ranges from 1 to 24)b Mean (  SD)

16.56  2.62
a
The participants’ total scores for eight steps for caring of their ostomy. The result has been rounded to an integral number.
b
Highest participant total score indicates highest participants’ self-care ability to manage their ostomy.
Journal of Research in Nursing 0(0)
Elshatarat et al. 11

Table 5. The relationship between participants’ demographics and clinical data and their self-care ability for
their intestinal ostomies.

Overall self-care ability t-test analysis

Variables Meana (SD) (t value) p valueb

Gender
Female 20.25 (2.45) 1.12 0.21
Male 19.52 (4.15)
Marital status
Has been married 18.91 (1.98) 4.74 0.09
Unmarried 20.05 (2.23)
Level of education
High school 18.37 (2.56) 3.75 0.04
Associate degree 22.43 (1.73)
Types of stoma
Temporary ostomy 17.15 (1.86) 7.48 0.02
Permanent ostomy 21.31 (2.43)
Location of ostomy
Ileostomy 19.31 (1.88) 4.62 0.06
Colostomy 17.7 (1.79)
Reason for insertion ostomy
Non-cancer cause 18.25 (1.38) 2.33 0.03
Cancer cause 21.24 (2.42)
Exposure to previous education
and teaching about ostomy
care during the last 12 months
No 16.63 (2.91) 5.07 0.02
Yes 21.85 (1.88)
Exposure to previous training
programme about care during
the last 12 months
No 18.01 (1.92) 6.25 <0.001
Yes 22.52 (2.08)
Sources of previous education Overall self-care ability ANOVA test p value
and training about Meana (SD) (f value)
ostomy care during the last
12 months

Nurses only 18.59 (1.96) 75.78 0.003

Physicians only 17.26 (2.38)
Physicians and nurses 21.63 (2.14)
Teaching strategies for improving
participants’ self-care of their
ostomies
Perioperative teaching 19.22 (2.17) 68.42 0.034
Interactive material and 18.43 (3.07)
multimedia education
Continuing education and 20.55 (2.85)
training programmes
Handout materials 16.77 (2.13)
Using more than one teaching 22.13 (3.41)
strategy
a
Mean is for all eight steps of ostomy care. The total score ranges from 3–24. Highest participants’ mean indicates highest
participants’ self-care ability to manage their ostomy.
b
Significant p value < 0.05 ¼ bold.
12 Journal of Research in Nursing 0(0)

for intestinal ostomies and managing ostomy-related problems. Also, they will be baseline
data for future research on the improvement of intestinal ostomy care.
Unfortunately, almost all of the participants (97.4%) had at least one physiological
ostomy-related problem during the 2 weeks before hospitalisation. About half of
participants had four or more physiological health problems, including abdominal pain,
severe odour and gas. Similarly, several previous studies documented that these
physiological problems were very common (United Ostomy Associations of America,
2017; Vonk-Klaassen et al., 2016). The overall clinical complication rate after intestinal
ostomy insertion ranges between 21% and 70 % (Shabbir and Britton, 2010).
Unfortunately, a large number of ostomates with these physiological health problems
remain untreated for several years and they do not seek healthcare services unless these
health problems are raised with them or become more complicated (Vonk-Klaassen et al.,
2016; Agarwal and Ehrlich, 2010).
In this study, 22% of the participants had ‘moderately severe’ to ‘severe’ depression
(PQH-9 15). Also, 33.9% had ‘moderate’ to ‘severe’ anxiety (GAD-7 10). These results
were similar or higher than the prevalence of depression and anxiety among ostomates in the
previous study (Jayarajah et al., 2016; Rafiei et al., 2017; Ayaz-Alkaya, 2019). Several studies
documented a high rate of psychosocial problems among ostomates. Between 16% and 26%
of ostomates experienced psychological symptoms immediately in the postoperative period.
The majority of these psychosocial problems were related to poor body image and
psychosocial adaptation, anxiety and depression (Ayaz-Alkaya, 2019; Jayarajah et al.,
2016; Rossella et al., 2018; Silva et al., 2017). Living with an intestinal ostomy requires
being attached to an ostomy bag all day, which negatively affects all aspects of ostomates’
QOL. These daily-life changes may be irreversible, depending on the ostomate’s clinical
condition, health professionals’ support, family members’ support and the use of coping
strategies and rehabilitation programmes (Ayaz-Alkaya, 2019; Silva et al., 2017). Therefore,
patients who undergo intestinal ostomy insertion surgery should be instructed about the
benefits, negative consequences and complications of the surgery. It is also recommended
that ostomates and family members are involved in decision making in the ostomy care
process, treatment plans and clinical situations (Silva et al., 2017). Literature showed that
early identification of psychological symptoms and using valid and reliable screening scales
(e.g. PHQ-9 and GAD-7) in healthcare settings are an effective approach for prevention and
management of psychological ostomy-related problems. Also, continuous follow-up,
screening and monitoring for psychological ostomy-related problems for all ostomates
during pre- and post-hospitalisation are strongly recommended (Ayaz-Alkaya, 2019;
Jayarajah et al., 2016; Kroenke and Spitzer, 2002; Silva et al., 2017). Those who have
psychological problems should be provided psychosocial support and referred to mental
care specialists to receive treatment (Ayaz-Alkaya, 2019; Silva et al., 2017). For example,
patients who have moderate depression (PHQ-9 score 10–14) should be considered for a
treatment plan that involves health professionals’ psychological support, counselling,
follow-up and/or pharmacotherapy. Also, patients who have ‘moderately severe’ (PHQ-9
score 15–19) to ‘severe’ (PHQ-9 score 20–27) depression should be considered for active
treatment or immediate treatment, respectively, which involves referring the client to mental
health specialists for initiation of pharmacotherapy and/or psychotherapy (Kroenke and
Spitzer, 2002; Kroenke et al., 2010).
Lack of patients’ exposure to education and training programmes about ostomy care is
not limited to this study, it was also documented in previous studies (Nieves et al., 2017;
Elshatarat et al. 13

Hendren et al., 2015; Ran et al., 2016). An interesting result of the current study shows the
majority of participants are willing to attend education and training programmes about
ostomy care in the future to improve their knowledge, self-abilities and skills to manage
their intestinal ostomies. These results also are consistent with the previous studies (Cheng
et al., 2013; Hu et al., 2014; Ran et al., 2016). Therefore, assertive strategies and policies
should be implemented to ensure all ostomates receive postoperative teaching and training
sessions before they are discharged from hospital (Hendren et al., 2015; Grant et al., 2013;
Gemmill et al., 2011). Furthermore, conducting continuous health education and training
programmes about ostomy are recommended for all those interested in participating in such
programmes to enhance their knowledge and skills to manage their ostomies (Cheng et al.,
2013; Grant et al., 2013; Ran et al., 2016).
In this study, only about 37% of participants received education on ostomy care from the
nurses. Moreover, many of the participants said they were unsatisfied with the nurses’
knowledge and skills in providing them teaching and training about ostomy care. Also,
they felt these health education and training sessions were not adequately useful to improve
their knowledge and skills about ostomy care. Similarly, the literature showed a deficit of
nurses’ knowledge and competencies about ostomy management and low self-efficacy in their
ability to educate the ostomates about ostomy care (Berry et al., 2007; Berti-Hearn and Elliott,
2018; Cross et al., 2014; Gemmill et al., 2011; Hendren et al., 2015).
Educating ostomates about ostomy care and providing psychosocial support is one of the
most important nursing roles for managing physiological and psychological health problems
among ostomates (Gemmill et al., 2011; Hendren et al., 2015; WOCN, 2010; Zhang et al.,
2013). To carry out these important roles and responsibilities, nurses should have enough
knowledge and competence in ostomy care and how to provide ostomates with health
education and training about caring for their intestinal ostomies. Literature shows that
nurses who were exposed to education and specialised in ostomy care can effectively
impact the prevention and management of ostomates’ health problems and complications
(Gemmill et al., 2011; Hendren et al., 2015; Ontario, 2009; WOCN, 2010; Zhang et al., 2013).
Therefore, nurse educators and ostomy nurse specialists (if available) in healthcare settings,
including hospitals, should collaborate to provide continuous health education and training
programmes for bedside nurses to improve their knowledge and skills about intestinal
ostomy care (Hendren et al., 2015; Grant et al., 2013; Gemmill et al., 2011). Also, bedside
nurses should be exposed to continuous health education and training programmes that
focus on improving their self-confidence and skills in providing teaching and psychosocial
support for ostomates and their families.
Unfortunately, there are few certified wound-ostomy nurse specialists and enterostomal
therapists in Jordan. So, bedside registered nurses in Jordan have complete responsibility for
intestinal ostomy care during the pre- and post-operative phases (Subih and O’Neill, 2012).
Bedside nurses are responsible for carrying out health assessments and nursing care for
ostomates such as preparing the patient for surgery, routine assessment and management
of health problems in the pre- and post-operative phases, and providing teaching and
training for ostomates about assessment and management of ostomy-related problems.
Therefore, it is essential to improve the curricula of undergraduate nursing programmes
in all nursing schools in Jordan to focus on pre- and post-operative care for intestinal
ostomies and nursing roles in providing counselling and psychosocial support for
ostomates (Subih and O’Neill, 2012). Also, hospitals in Jordan should conduct continuing
health education programmes for staff nurses to enhance their knowledge and skills about
14 Journal of Research in Nursing 0(0)

the updated evidence-based practice for caring for intestinal ostomies. Furthermore, the
Ministry of Higher Education in Jordan should establish post-graduate professional
programmes in ostomy and wound care specialty in Jordanian universities.
The results of this study showed that only one-quarter of the participants were
independent when taking care of their ostomies (all steps) and half of the participants had
some assistance from relatives to take care of their ostomies. These results were similar to the
previous Chinese study (Cheng et al., 2013). The literature showed that the ostomates with a
higher level of knowledge and self-confidence about ostomy care had higher independent
self-care abilities and skills to take care of their ostomy and better QOL (including physical
and psychological wellbeing) (Cheng et al., 2013; Hu et al., 2014; Mohamed et al., 2017;
Simmons et al., 2007). Also, Pearson’s correlation results in this study and the results of
previous studies showed the association between improving patients’ self-care ability to
manage their ostomies and reduced ostomy-related health problems and further
complications and decreased severity of depression and anxiety (Ayaz-Alkaya, 2019;
Cheng et al., 2013; Ran et al., 2016; Recalla et al., 2013; Silva et al., 2017). Therefore,
perioperative teaching and training before hospital discharge, continuous health education
programmes and follow-up care are recommended for all ostomates to improve their
knowledge and self-confidence in their ability to take care of their ostomy, reduce their
ostomy-related problems and positively enhance their QOL (Mohamed et al., 2017;
Hendren et al., 2015; Grant et al., 2013; Alansari et al., 2018; Berry et al., 2007).
In this study, the participants with permanent ostomy and colorectal cancer who were
exposed to education and/or training programmes were more likely to be independent when
taking care of their intestinal ostomies. The participants with permanent ostomy and
colorectal cancer in this and other studies were more exposed to health education and
training due to several visits to healthcare facilities (Mohamed et al., 2017; Nieves et al.,
2017; Vonk-Klaassen et al., 2016). Similarly, the previous literature showed that recurrent
exposure to teaching and training about ostomy care has significant improvement in
patients’ knowledge and self-care ability to manage their ostomies (Mohamed et al., 2017;
Hendren et al., 2015; Grant et al., 2013; Alansari et al., 2018). Providing perioperative
teaching and conducting continuous health education for ostomates after discharge from
hospital (including teaching the ostomates in an outpatient setting, patients’ home or by
telephone follow-up) were significantly associated with improving ostomates’ independent
self-care abilities and skills in managing their ostomy, reducing ostomy-related problems and
complications, enhancing their psychosocial adjustment with the inserted ostomy and
promoting their QOL (including physical and psychological wellbeing) (Hendren et al.,
2015; Grant et al., 2013; Zhang et al., 2013; Karadağ et al., 2003).
The results of this study show the significant effect of the collaboration of nurses and
physicians in teaching and training ostomates about ostomy care and in using more than one
teaching strategy to improve participants’ self-care abilities to manage their ostomies.
Similarly, the literature documented the importance of cooperation between physicians
and nurses, specifically the ostomy nurse specialists if available, in providing education
and training programmes (Hendren et al., 2015; Grant et al., 2013; Berry et al., 2007;
Haugen et al., 2006). Therefore, ostomates’ treatment plans in hospital and development
of perioperative teaching for ostomates should be carried out through the cooperation of
multidisciplinary staff including nurses, physicians and social workers.
The results of this study show the positive effect of using more than one teaching strategy
for improving ostomates’ ability to take care of their ostomy themselves, particularly
Elshatarat et al. 15

through the provision of perioperative teaching and continuous education and training
programmes. Similarly, previous studies recommend cooperating with healthcare
providers to provide health education and training programmes using all available
teaching strategies and resources, such as distributing written and multimedia educational
materials, provide perioperative teaching for ostomates and utilising broadcast media and
online resources (e.g. websites and social media) to promote their knowledge and self-care
abilities and skills to take care of their ostomy (Mohamed et al., 2017; Hendren et al., 2015;
Grant et al., 2013; Zhang et al., 2013; Berry et al., 2007).

Study limitations
Using a cross-sectional design does not help identify the cause and effect of the relationship
between the variables and cannot assess participants’ health problems and self-care abilities
and practices to take care of their ostomy over a period of time. Moreover, the use of a
convenience sampling method in this study may have resulted in selection bias of the sample
beyond the researchers’ control. Also, recruiting a sample only from the capital city of
Jordan (Amman) affects the generalisation of results to the Jordanian population.

Conclusion
Patients with intestinal ostomies have several physical and psychosocial health problems and
negative changes in their daily life activities. Moreover, intestinal ostomy-related problems
have a negative impact on ostomates’ QOL. The literature showed that physical and
psychological wellbeing is negatively affected by a lack of knowledge and self-care ability
and skill in ostomy care. Therefore, all ostomates are required to undergo perioperative
teaching and continuous health education and training about ostomy management to
improve their knowledge and self-care abilities. They are also in need of psychosocial
support from their relatives and healthcare professionals. Furthermore, professional
follow-up and counselling for ostomates are very important in preventing further ostomy-
related problems and complications. The results of this study may be helpful in developing
clinical guidelines for the care of ostomates. Also, this study will offer baseline information
for further experimental and clinical research about the management of intestinal ostomies.

Key points for policy, practice and/or research

. The results show a negative correlation between participants’ ostomy-related problems
and their self-care abilities to manage their ostomies.
. The majority of participants intended to participate in continuous health education
and training programs about ostomy care.
. All ostomates should be required to obtain health teaching and training about the
assessment and the management of their intestinal ostomy, psychosocial support, and
counselling regarding ostomy care to prevent further ostomy-related problems, and
improve their self-care abilities.
. Jordanian hospitals are recommended to develop continuous health educational
programs for the bedside nurse to enhance their experience about ostomy care.
16 Journal of Research in Nursing 0(0)

Acknowledgements
This publication was supported by the Deanship of Scientific Research at Prince Sattam Bin Abdulaziz
University, Al-Kharj, Saudi Arabia. The authors extend their thanks to Dr Omar A Al-Smadi for
English editing of this paper. The authors also thank all the participants in this study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Ethics
Official Institutional Review Board approval was obtained at Al-Ghad International Colleges for
Applied Medical Sciences to conduct this current study (2019/5). Before data collection, ethical
approval was obtained from the general medical managers and the directors of nursing at the
selected hospitals.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: This publication was supported by the Deanship of Scientific Research at
Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia.

ORCID iDs
Rami A Elshatarat https://orcid.org/0000-0003-3882-7196
Ahmad H. Abu Raddaha https://orcid.org/0000-0002-7193-835X

References
Agarwal S and Ehrlich A (2010) Stoma dermatitis: Prevalent
but often overlooked. Dermatitis 21: 138–147.
Alansari SK, Al Nagshabnandi EA and Abdulmutalib IA
(2018) The effectiveness of implementing a designed
educational protocol regarding knowledge among clients
with intestinal ostomy. Report and Opinion 10: 24–30.
Ayaz-Alkaya S (2019) Overview of psychosocial problems in
individuals with stoma: A review of literature. International
Wound Journal 16: 243–249.
Berry K, Carmel J, Gutman N, et al. (2007) ASCRS and
WOCN joint position statement on the value of preoperative
stoma marking for patients undergoing fecal ostomy surgery.
Journal of Wound Ostomy Continence Nursing 34: 627–628.
Berti-Hearn L and Elliott B (2018) A resource guide to
improve nursing care and transition to self-care for patients
with ostomies. Home Healthcare Now 36: 43–49.
Cheng F, Meng A, Yang L-F, et al. (2013) The correlation
between ostomy knowledge and self-care ability with
psychosocial adjustment in Chinese patients with a
permanent colostomy: A descriptive study. Ostomy Wound
Management 59: 35–38.
Cross HH, Roe CA and Wang D (2014) Staff nurse confidence
in their skills and knowledge and barriers to caring for
patients with ostomies. Journal of Wound Ostomy &
Continence Nursing 41: 560–565.
da Silva J, Sonobe HM, Buetto LS, et al. (2014) Teaching
strategies for self-care of the intestinal stoma patients.
Northeast Network Nursing Journal 15: 166–173.
Elshatarat RA (2020) Association between Jordanian
ostomates’ knowledge about intestinal ostomy care and their
ostomy health-related problems. Indian Journal of Public
Health 11: 1725.
Gemmill R, Kravits K, Ortiz M, et al. (2011) What do surgical
oncology staff nurses know about colorectal cancer ostomy
care? The Journal of Continuing Education in Nursing 42:
81–88.
Global Burden of Disease Cancer Collaboration (2019)
Global, regional, and national cancer incidence, mortality,
years of life lost, years lived with disability, and disability-
adjusted life-years for 29 cancer groups, 1990 to 2017: A
systematic analysis for the global burden of disease study.
JAMA Oncology 5: 1749–1768.
Grant M, Ferrell B, Dean G, et al. (2004) Revision and
psychometric testing of the City of Hope Quality of
Life–Ostomy Questionnaire. Quality of Life Research 13:
1445–1457.
Elshatarat et al. 17

Grant M, McCorkle R, Hornbrook MC, et al. (2013)
Development of a chronic care ostomy self-management
program. Journal of Cancer Education 28: 70–78.
Haugen V, Bliss DZ and Savik K (2006) Perioperative factors
that affect long-term adjustment to an incontinent ostomy.
Journal of Wound Ostomy & Continence Nursing 33: 525–535.
Hendren S, Hammond K, Glasgow SC, et al. (2015) Clinical
practice guidelines for ostomy surgery. Diseases of the Colon
& Rectum 58: 375–387.
Hu A, Pan Y, Zhang M, et al. (2014) Factors influencing
adjustment to a colostomy in Chinese patients: A cross-
sectional study. Journal of Wound Ostomy & Continence
Nursing 41: 455–459.
Iqbal F, Zaman S, Karandikar S, et al. (2016) Engaging with
faith councils to develop stoma-specific Fatawas: A novel
approach to the healthcare needs of Muslim colorectal
patients. Journal of Religion and Health 55: 803–811.
Jayarajah U, Samarasekera A and Samarasekera D (2016)
A study of postoperative anxiety and depression among
patients with intestinal stomas. Sri Lanka Journal of Surgery
34: 6–10.
Karadag A and Baykara ZG (2009) Colostomy irrigation: An
important issue for Muslim individuals. Asian Pacific Journal
of Cancer Prevention 10: 1189–1190.
Karadağ A, Menteş BB, Üner A, et al. (2003) Impact of
stomatherapy on quality of life in patients with permanent
colostomies or ileostomies. International Journal of
Colorectal Disease 18: 234–238.
Kroenke K and Spitzer RL (2002) The PHQ-9: A new
depression diagnostic and severity measure. Psychiatric
Annals 32: 509–515.
Kroenke K, Spitzer RL, Williams JB, et al. (2010) The patient
health questionnaire somatic, anxiety, and depressive
symptom scales: A systematic review. General Hospital
Psychiatry 32: 345–359.
Ministry of Health Jordan (2013) Annual Mortality Report in
2013. Amman, Jordan: Ministry of Health.
Mohamed SS, Salem GM and Mohamed HA (2017) Effect of
self-care management program on self-efficacy among
patients with colostomy. American Journal of Nursing 5:
191–199.
Nieves CB-dl, Dı́az CC, Celdrán-Mañas M, et al. (2017)
Ostomy patients’ perception of the health care received.
Revista Latino-Americana de Enfermagem 25.
Ontario RNAo (2009) Ostomy care and management: Clinical
best practice guidelines. Toronto, Ontario, Canada:
Registered Nurses’ Association of Ontario.
Rafiei H, Hoseinabadi-Farahani MJ, Aghaei S, et al. (2017)
The prevalence of psychological problems among ostomy
patients: A cross-sectional study from Iran. Gastrointestinal
Nursing 15: 39–44.
Ran L, Jiang X, Qian E, et al. (2016) Quality of life, self-care
knowledge access, and self-care needs in patients with colon
stomas one month post-surgery in a Chinese Tumor
Hospital. International Journal of Nursing Sciences 3:
252–258.
Recalla S, English K, Nazarali R, et al. (2013) Ostomy care
and management: A systematic review. Journal of Wound
Ostomy & Continence Nursing 40: 489–500.
Rossella DL, Gianluca LC, Antonella A, et al. (2018)
Psychological distress and quality of life in ostomy patients
with colorectal cancer: A systematic review of the literature.
Acta Medica Mediterranea 34: 1357–1363.
Shabbir J and Britton D (2010) Stoma complications: A
literature overview. Colorectal Disease 12: 958–964.
Silva NM, Santos MAd, Rosado SR, et al. (2017)
Psychological aspects of patients with intestinal stoma:
Integrative review. Revista Latino-Americana de Enfermagem
25: e2950.
Simmons KL, Smith JA, Bobb KA, et al. (2007) Adjustment to
colostomy: Stoma acceptance, stoma care self-efficacy and
interpersonal relationships. Journal of Advanced Nursing 60:
627–635.
Spitzer RL, Kroenke K, Williams JB, et al. (2006) A brief
measure for assessing generalized anxiety disorder: The
GAD-7. Archives of Internal Medicine 166: 1092–1097.
Subih MM and O’Neill TM (2012) Ostomy educational
program for nurses in Jordan. Ostomy Wound Management.
Online Exclusives. Available from http://www.o-wm.com/
content/ostomy-eduational-program-nurses-jordan.
United Ostomy Associations of America (2017) New Ostomy
Patient Guide America. Phoenix: United Ostomy
Associations of America.
Vonk-Klaassen SM, de Vocht HM, den Ouden ME, et al.
(2016) Ostomy-related problems and their impact on quality
of life of colorectal cancer ostomates: A systematic review.
Quality of Life Research 25: 125–133.
WOCN (2010) Management of the Patient With a Fecal
Ostomy: Best Practice Guide for Clinicians. Mount Laurel:
Wound Ostomy and Continence Nurses Society.
Zhang J-e, Wong FKY, You L-M, et al. (2013) Effects of
enterostomal nurse telephone follow-up on postoperative
adjustment of discharged colostomy patients. Cancer
Nursing 36: 419–428.

Rami A Elshatarat has a PhD in Nursing from the University of California, San Francisco.
Now he works as an Assistant Professor at Taibah University. Previously, he worked as
Assistant Professor and Chairman of the Nursing Department at Al-Ghad International
Medical Science for Applied Colleges.

Inas A Ebeid has a PhD in Psychiatric Nursing and Mental Health programme from Port
Said University, Egypt. Currently, she works as Assistant Professor at Taibah University
and Lecturer at Port Said University.

Khadega A Elhenawy has a PhD in Emergency Nursing from Menoufia University, Egypt.
Currently, she works as Assistant Professor and Assistant of the Head of the Department of
18 Journal of Research in Nursing 0(0)

Medical and Surgical Nursing at Taibah University, and Assistant Professor at Menoufia
University.

Zyad T Saleh has a PhD degree in Nursing from the University of Kentucky in the United
States. He is an Associate Professor at the Department of Clinical Nursing, School of
Nursing, University of Jordan.

Ahmad H Abu Raddaha is Associate Professor and Head of the Nursing Department at the
Prince Sattam Bin Abdulaziz University’s College of Applied Medical Sciences. He
completed his PhD in Nursing at University of California, San Francisco. In addition, he
is a certified critical care nurse and informatics nurse specialist.

Mohammed S Aljohani is an Assistant Professor and Head of the Department of Medical and
Surgical Nursing, and Vice-Dean of the College of Nursing at Taibah University. He holds a
PhD in Nursing from Monash University in Australia.