Accepted: 7 May 2018

DOI: 10.1111/jocn.14515

ORIGINAL ARTICLE

Effects of a home care mobile app on the outcomes of

discharged patients with a stoma: A randomised controlled
trial

Qing-Qing Wang1,* | Jing Zhao2,* | Xiao-Rong Huo3 | Ling Wu4 | Li-Fang Yang5 |
Ju-Yun Li6 | Jie Wang1

1
Department of Fundamental and
Community Nursing, School of Nursing,
Aims and objectives: To explore the effects of a home care mobile app on the out-
Nanjing Medical University, Nanjing, China comes of stoma patients who discharged from hospital.
2
Treatment Room, Jiangsu Province Background: Patients with a newly formed stoma experience many difficulties after
Hospital, the First Affiliated Hospital of
Nanjing Medical University, Nanjing, China surgery. Mobile application (app) has the potential to help patients self-manage their
3
Jiangsu Nursing Association, Nanjing, diseases and adjust to the changes in their lives and is a convenient way to ensure
China
the continuity of care. However, there is a lack of studies about the effects of a
4
Wound Care Center, Nanjing Drum Tower
Hospital, Nanjing, China mobile app on the transitional care for improving discharged stoma-related health
5
Ostomy Outpatient Clinic, Jiangsu Cancer outcomes.
Hospital, Nanjing, China
Design: A randomised controlled trial.
6
Department of Gastroenterological
Oncology Surgery, Jiangsu Province
Methods: A total of 203 patients with a permanent stoma in tertiary hospitals in
Hospital of Traditional Chinese Medicine, China were randomly assigned into two groups. Patients in the control group
Nanjing, China
(n = 103) received routine discharge care. Patients in the intervention group
Correspondence (n = 100) received home care via a mobile app besides routine care. The psychoso-
Jie Wang, Department of Fundamental and
Community Nursing, School of Nursing,
cial adjustment level, self-efficacy scale and stoma complications incidence were
Nanjing Medical University, 101 Longmian measured in the follow-up period and compared between the two groups. Data
Avenue, Nanjing 211166, Jiangsu, China.
Email: wangjienjmu@126.com.
were collected at four time points: before intervention (baseline), at 1, 3 and
6 months after discharge.
Funding information
Qing Lan Project of Jiangsu provience
Results: The psychosocial adjustment level and stoma self-efficacy score of the
(2016); the Chinese Nursing Association, intervention group were significantly higher than those of the control group, respec-
Grant/Award Number: ZHKY201511; the
Key Discipline Development Project of
tively, at 1-, 3- and 6-month follow-up (all p < 0.05). The incidence of stoma compli-
Jiangsu Province, China, Grant/Award cations in the intervention group was tending to reduce at 1, 3 and 6 months after
Number: JX10617801
discharge.
Conclusion: The findings indicated that follow-up care at home via a mobile app
can effectively improve the psychosocial adjustment level, self-efficacy scale and
other related outcomes of stoma patients.
Relevance to clinical practice: The home care mobile app is an effective interven-
tion to support the psychosocial adjustment and self-efficacy of stoma patients after
discharge. It ensures the continuity of care and provides nursing guidance for the
patients timely.

*These authors contributed equally to the work.

3592 | © 2018 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2018;27:3592–3602.
WANG ET AL.
KEYWORDS
home care, mobile app, psychosocial adjustment, self-efficacy, stoma
1 | INTRODUCTION
Colorectal cancer (CRC) is the fourth leading cause of cancer-related
deaths worldwide, and the global burden of CRC is expected to
increase more than 2.2 million newly diagnosed cancer cases and
1.1 million cancer deaths by 2030 (Arnold et al., 2017). With increas-
ing incidence and mortality, CRC is one of the top five most commonly
diagnosed cancers in China, and it is estimated that about 376,300
patients have been diagnosed with colorectal cancer and 191,000 died
from this cancer in 2015 (Arnold et al., 2017; Chen et al., 2016).
Enterostomy continues to be a major surgical treatment and a life-sav-
ing procedure for CRC in a variety of methods currently. According to
statistics provided by Dai, Huo, Wu, and Yang (2014), patients with a
permanent stoma accounted for 75.0% (1,682/2,242) after surgery in
Jiangsu Province, China. In other words, these patients have to learn
to live with a permanent stoma for the rest of their lives.
1.1 | Background
Stoma patients may experience physical, psychological and social
challenges after discharge (Hoon, Chi, & Hong-Gu, 2013). Individuals
with a stoma have to face physical problems such as leakage, local
skin irritation and offensive odour (Boraii, 2017). Studies have found
that ostomates have significantly higher depression, poorer social
function and more problems with body image than patients without
stoma, which may negatively affect their interpersonal relationships
and quality of life (Krouse et al., 2007; Ross et al., 2007).
How patients adjust to these changes has been an important
aspect of transitional care. However, levels of adjustment have
shown little change over the years in spite of the increasing number
of stoma care methods (Brown & Randle, 2005; Simmons, Smith,
Bobb, & Liles, 2007). Studies also have demonstrated that self-effi-
cacy in stoma care is an essential variable predicting positive adjust-
ment and quality of life (Raingruber, 2011; Simmons et al., 2007).
Due to the changes in stoma appliance technology and shorter
hospital stay in the current healthcare environment, patients and
their families do not have enough time to become proficient in
stoma care during their hospitalisation (Zhang et al., 2013). In other
words, long-term education and support after discharge are neces-
sary for ostomates. Enterostomal therapy (ET) nurses play an impor-
tant role in the continuity of care for stoma patients from hospital
to home. They can help patients cope with the diagnosis, teach prac-
tical skills in stoma care and provide supportive counselling (Comb,
2003). Nonetheless, in China, transitional care for discharged
patients with stoma has been proved to be inadequate. One reason
is that the number of Chinese ET nurses is estimated at 600, which
is far from meeting the needs of patients and clinical work (Wang,
| 3593
What does this paper contribute to the wider
global clinical community?
• This study provides evidence to support that nurse-led
follow-up care via a mobile app can be effective to
improve psychosocial adjustment, self-efficacy and other
stoma-related outcomes of discharged patients.
• Mobile phone technology may be a part of the transi-
tional care to deliver psychosocial interventions to stoma
patients and share enterostomal therapy (ET) nurses’
work pressure in clinical practice.
Ma, Zheng, & Li, 2013). In China, there have been more than 1 mil-
lion individuals with permanent stoma and an average of approxi-
mately 156,000 new cases each year (Yang, Yan, & Qin, 2016), and
a total of 1–2 full-time ET nurses should be available in a general
hospital with more than 500 beds (Wang et al., 2013). Another is
that specialised stoma care started rather late in China. Specialised
stoma care was introduced to China in 1988, and ET nurses had
been trained and certificated since 2011 (Wang et al., 2013; Yu,
2005). In addition, in other countries, the continuity of stoma care
includes transferring from hospitals to community health centres.
Despite the rapid development of community nursing in China,
nurses working in the community are incapable of providing profes-
sional stoma care for patients at home (Yang et al., 2016).
The advances in mobile technology such as smartphones and
mobile apps have created more opportunities for individuals to get
health-related treatments anytime or anywhere. It has been reported
that 92.5% of people in China own a smartphone in 2016 (CNNIC
2016). In the United States, 93% of adults patients with gastroen-
teropathy at an academic medical centre were smartphone owners
and most of them were interested in using health-related apps (Zia,
Le, Munson, Heitkemper, & Demiris, 2015). Furthermore, previous
studies have demonstrated the potential benefits and efficacy of
using the mobile apps as the primary intervention for disease pre-
vention or self-care conducted in diabetes, obesity and cancer
patients (Fukuoka, Gay, Joiner, & Vittinghoff, 2015; Pretlow, Stock,
Allison, & Roeger, 2015; Stinson et al., 2015). However, information
about the feasibility and effectiveness of mobile apps for discharged
patients with a stoma is limited.
1.2 | Aim of the study
This study aims to assess the effectiveness of the follow-up care
enhanced with a home care mobile app on the psychosocial
3594 | WANG
adjustment, self-efficacy and stoma-related complications of patients
with a stoma who discharged from hospital.
1.3 | Theoretical framework
The theoretical framework of this study is guided by Bandura’s self-
efficacy theory (Bandura, 1977). Self-efficacy refers to the confidence
in one’s ability to carry out tasks. A strong correlation between
adjustment and self-efficacy has been reported (Simmons et al.,
2007). Personal self-efficacy is derived from four factors: perfor-
mance accomplishments, vicarious experience, verbal persuasion and
physiological states. “Performance accomplishments” is based on
mastery experiences (Bandura, 1977). If ostomates master practised
skills of stoma care, they will have strong efficacy expectations to
repeat successful performance. “Vicarious experience” comes from
seeing others. Stoma patients can have belief in achieving improve-
ment in performance when they observe ET nurses and peers per-
form accomplishments without adverse outcomes. “Verbal
persuasion” includes suggestions and support from family and health-
care professionals. “Physiological states” involves emotional reactions
such as anxiety, stress and fear, which can affect ostomates’ self-effi-
cacy in coping with challenges after discharge, need to be paid atten-
tion to in the intervention (Bandura, 1977). These strategies will be
involved in the home care mobile app interventions to enhance the
adjustment and self-efficacy of discharged stoma patients.
2 | MATERIALS AND METHODS
2.1 | Study design
This study was a single-blind, randomised controlled trial. Partici-
pants were randomly assigned to receive routine discharge care
combined with either the home care mobile app or periodic outpa-
tient follow-up. Data collections of study participants were com-
pleted before discharge (baseline) and at 1, 3 and 6 months after
discharge.
2.2 | Ethical considerations
Ethical approval was given by the Jiangsu Province Hospital Ethics
Committee (the First Affiliated Hospital of Nanjing Medical Univer-
sity Committee). Participants’ privacy was protected by nonidentifi-
able information. All participants provided written informed consent.
2.3 | Setting and participants selection
The research was carried out in 10 tertiary general hospitals in Nan-
jing and its surrounding areas, east of China between January 2016–
November 2016. All the hospitals opened stoma outpatient clinics,
and each had certificated ET nurses who provided stoma care ser-
vices for at least 3 years. All participants were recruited from inpa-
tient wards of these hospitals. The inclusion criteria were as follows:
(a) diagnosed with primary colorectal cancer or other digestive and
ET AL.
urinary tumours, and having a permanent stoma after surgery; (b) at
least 18 years of age; (c) able to read and speak Mandarin; and (d)
own a smartphone and willingness to use the mobile app after dis-
charge if randomised to the mobile app group; The exclusion criteria
include the following: (a) having other types of cancer; (b) having
visual, hearing and/or cognitive impairments/mental disorders; (c)
alcohol or drug abuse; and/or (d) dying or having any surgical com-
plication leading to a delay of more than 48 hr before attaining
stoma proficiency after discharge.
The sample size was estimated based on the self-efficacy score
between the intervention and control groups (Zhang et al., 2013).
The difference in the self-efficacy score between the two groups
was 7.5, with a standard deviation of 15.17, 90% power at a 5% sig-
nificance level (2-sided), the minimum sample size is 86 per group
(Machin, Campbell, Tan, & Tan, 2011; Zhang et al., 2013) Given the
15% dropout rates, we calculated that a minimum sample size of
198 (99 in each group) would be required for the study. A total of
232 participants meet the inclusion criteria, and 212 patients were
randomised using the Research Randomiser into either intervention
group (n = 106) or a control group (n = 106). The Research Ran-
domiser generated a set of 53 unique numbers ranging from 1–106.
Participants took a number from the envelope. If the selected num-
ber corresponded to any generated number, he/she would be
assigned to the intervention group, or else, to the control group. At
the end of the study, six patients from the intervention group and
three patients from the control group were excluded (Figure 1).
2.4 | Intervention
2.4.1 | Control group
The stoma patients in the control group were given similar routine
care provided by the 10 hospitals, including the written and verbal
health education on preoperative preparation, stoma surgery and
postoperative stoma care. At discharge, ET nurses offered teaching
information and support for patients, including selection of pouching
appliances, drug instructions, health education and follow-up with
the ET nurse at 1, 3 and 6 months after discharge in the outpatient
clinics.
At each outpatient follow-up, both stomas and patients needed
to be assessed. The condition of stoma and peristomal skin, nature
and volume of effluent, date of pouch appliances and stoma compli-
cations were recorded by ET nurses. Moreover, ostomates were pro-
vided practical information about stoma self-care, and patients who
were capable of carrying out self-care were encouraged to regularly
clean and change their pouch appliances at home. In addition, ET
nurses encouraged ostomates to attend actively the Ostomy Patients
Club and to maintain contact with other patients; convinced patients
that they could return to their ordinary lives; and awareness of the
patients’ psychological states and minimised negative emotions,
when possible. They also used pictures, papers and flash to illustrate
and reinforce the information. Patients were also provided with a
number to call if they have any questions after discharge.
WANG ET AL.
Assessed for eligibility (n = 232)
Baseline data collection
Randomized (n = 212)
Home care mobile app intervention group (n = 106)
Routine discharge care
Home care mobile app follow-up
Lost to follow-up (n = 6)
Not want to continue the intervention at 3months (n = 2)
Readmission at 3 months (n = 2)
Could not be contacted at 6 months (n = 2)
Analysed (n = 100)
Complete data collection at 1, 3 and 6 months
FIGURE 1 Flow chart of the study participants
2.4.2 | The home care mobile app intervention
group
The participants in the intervention group were given the same rou-
tine care as the control group pre- and postoperatively. ET nurses
taught patients and their family members how to use the home care
mobile app before discharge. The home care mobile app was designed
and developed for the discharged stoma patients by the research
team and an information technology company in May 2015. Patients
could receive stoma care from ET nurses through this mobile app at
home, not just going to an outpatient clinic. The Major function mod-
ules of this mobile app were as follows: (a) appointment: The app
users were able to complete the basic personal and medical informa-
tion and make an appointment with the ET nurse; (b) photograph diag-
nosis: The ET nurses could make a diagnosis based on the patients’
uploaded stoma photographs; and (c) consultation: Patients were able
to contact their ET nurses for help and support (Figure 2). This mobile
app was used to supplement the outpatient follow-up. Participants
were required to deliver their stoma photographs and essential medi-
cal information to ET nurses through the mobile app at 1, 3 and
6 months after discharge. According to these data, ET nurses made a
diagnosis of stoma condition. If patients were in good condition or
| 3595
Excluded (n = 20)
Not meeting inclusion criteria (n = 6)
Refused to participate (n = 10)
Other reasons (n = 4)
Control group (n = 106)
Routine discharge care
Periodic outpatient follow-up
Lost to follow-up (n = 3)
Readmission at 3 months (n = 2)
Could not be contacted at 6 months (n = 1)
Analysed (n = 103)
Complete data collection at 1, 3 and 6 months
they were able to complete self-care under the direction of ET nurses
online, they did not need to go to the outpatient clinic again.
The educational and psychosocial follow-up intervention program
based on the mobile app was guided by Bandura’s self-efficacy the-
ory (Bandura, 1977) and a previous study protocol (Lim, Chan, Lai, &
He, 2015). The main contents of intervention protocol included (a)
stoma care skills accomplishments: providing a guidance in stoma
care step-by-step and the measures to prevent common stoma com-
plications; (b) vicarious experience: encouraging patients to partici-
pate in the Ostomy Patients Club or sharing successful self-care
experiences of other stoma patients; (c) verbal persuasion: promoting
acceptance of a stoma, changing dysfunctional behaviours, boosting
self-confidence and encouraging patients to resume a normal life
and work; (d) emotional states: relieving patients’ negative emotions,
such as anxiety, depression and fears. These strategies were sent in
text, voice or video through the mobile app.
In the first month after discharge, there would be four weekly
smartphone sessions. The 1-month follow-up focused on solving
stoma problems, encouraging open communication and teaching prac-
tical skills of stoma care face-to-face through this app. In the next
2 months, biweekly sessions took place to share successful stoma care
experiences, promote acceptance of stoma and enhance patients’ self-
3596 | WANG
(a) (b)
FIGURE 2 Intervention mobile app screens for users. (a) Main screen, (b) Consultation screen [Colour figure can be viewed at wileyonlinelib
rary.com]
efficacy. The monthly sessions conducted to find new physical and
psychological issues, minimise negative feelings and help patients
return to normal life in the last 3 months. Furthermore, during the 6-
month follow-up period, if patients met any physical, psychological
and social problem after discharge, they could get individualised sup-
port and advice from ET nurses within 24 hr using this mobile app.
A total of 10 certified ET nurses who had a minimum of 3 years’
stoma care experience were involved in this study. They were
trained in the theoretical framework and intervention protocol
before conducting the study. We offered reading materials on study
protocol, routine care methods and the home care mobile app
instructions to the ET nurses. The experienced investigators
attended the study to ensure consistency with intervention. An
experienced programmer was assigned to the research to guarantee
the mobile app in normal condition.
2.5 | Outcome measurements
The four outcome measures in this study included patients’ demo-
graphic and clinical characteristics, psychosocial adjustment, stoma
self-efficacy and stoma-related complications.
2.5.1 | Demographic and clinical characteristics
The demographic variables were age, gender and health insurance.
Clinical data including disease, cost, stoma site and type were col-
lected from hospital medical records.
2.5.2 | Ostomy psychosocial adjustment
The Ostomy Adjustment Inventory-23 (OAI-23) was a self-report
scale developed by Simmons, Smith, and Maekawa (2009). The scale
consisting of four factors and 23 items was used to assess psychoso-
cial adjustment in stoma patients. Items were rated on a five-point
Likert scale (0–4). Twelve negative items were scored reversely.
Higher scores indicated better adjustment. The reliability of OAI-23
ET AL.
For example:
Patient X at 1-month follow-up asked:
"The skin surrounding the pouch application area
was inflamed, what should I do?”
The ET nurse viewed text and pictures, and then
replied to the patient by voice:
"From your description and pictures, I considered
you suffered from peristomal irritant dermatitis,
which was related to faeces leakage. Treatments
include careful cleaning of the skin with warm water,
drying, and the application of stoma powders, pastes
and protective creams. Moreover, the diameter of the
ostomy bag opening must be adapted to the stoma."
(Cronbach’s alpha = 0.93; test–retest (r) = 0.83) was also reported
(Simmons et al., 2009). Xu, Cheng, and Dai (2010) translated and
developed the scale in China. The revised Chinese version of the
scale consisted of 20 items with the scores varying from 0–80 and
had acceptable reliability (Cronbach’s a = 0.8686; test–retest
(r) = 0.68) (Xu et al., 2010). The Cronbach’s a coefficient of 0.87 was
measured in our study.
2.5.3 | Stoma self-efficacy
The self-efficacy level of stoma patients was measured using Stoma
Self-Efficacy Scale (SSES, Bekkers, van Knippenberg, van den Borne,
& van Berge-Henegouwen, 1996). The SSES had two subscales,
Stoma Care Self-Efficacy (13 items, Cronbach’s a = 0.94) and Social
Self-Efficacy (9 items, Cronbach’s a = 0.95). The correlation between
the two scales was 0.73. Respondents chose one of five categories,
ranging from “not at all confident” to “extremely confident.” The
scores were in the range from 22–110. Higher scores referred to
higher levels of self-efficacy. In this study, we used the Chinese ver-
sion of the SSES, which was translated and validated (Cronbach’s
a = 0.97) by Wu, Chau, and Twinn (2007). The alpha coefficient for
the Chinese SSES in our research was 0.96.
2.5.4 | Stoma complications
The preset list including common stoma complications was used by
ET nurses. It contained mucocutaneous separation, stoma necrosis,
peristomal dermatitis, retraction, prolapsed, stenosis and parastomal
hernia (Shabbir & Britton, 2010). Each complication was measured to
“yes” and “no.”
2.6 | Data collection and statistical analysis
During hospitalisation, patients who met the study criteria were
invited to participate. They all received oral and written study explana-
tion from ET nurses. They were told that their decision did not affect
WANG ET AL. | 3597

the routine care they would be given. If patients consented to volun- T A B L E 1 Demographic and clinical characteristics of the
tarily participate in the study, they were asked to provide standard intervention and control groups
demographic information. Patients in the intervention group were Intervention Control
required to own a smartphone and install the home care mobile app. (n = 100) (n = 103)
Variables n (%) n (%) v2/t p
Patients’ baseline data including demography, medical records,
psychosocial adjustment, self-efficacy and stoma complications were Age (Mean  SD; 56.95  14.88 59.18  14.14 1.10 0.27a
years)
collected by ET nurses and the investigator 1 or 2 days before dis-
Gender
charge. A total of 212 patients agreed to take part in the study. At
1, 3 and 6 months after discharge, data were collected again. Male 62 (62.00) 67 (65.05) 0.20 0.65b

Patients in the control group were asked to complete the question- Female 38 (38.00) 36 (34.95)

naires when they returned to the outpatient clinics. At the same Healthcare insurance
time, patients in the intervention group completed data collection Yes 85 (85.00) 79 (76.70) 2.25 0.13b
online through the mobile app. No 15 (15.00) 24 (23.30)
Data were analysed using IBM SPSS Statistics for Windows, ver- Disease
sion 22.0 (IBM SPSS Data Collection, New York, NY, USA). The relia- Rectal cancer 65 (65.00) 67 (65.05) 3.90 0.27b
bility of scales was tested by Cronbach’s alpha coefficients in this Colon cancer 11 (11.00) 18 (17.48)
study. Descriptive statistics were used to describe all outcome vari- Bladder cancer 6 (6.00) 2 (1.94)
ables. Demographic and clinical characteristics of intervention
Other 18 (18.00) 16 (15.53)
patients and controls were compared using Student’s t test, Mann–
Stoma site
Whitney U test, chi-square test, or Fisher’s exact test when appro-
Colostomy 74 (74.00) 82 (79.61) 1.73 0.42b
priate. Kolmogorov–Smirnov test was used to examine whether the
Ileostomy 18 (18.00) 17 (16.51)
data presented normal distribution. Differences in normally dis-
Other 8 (8.00) 4 (3.88)
tributed continuous variables between two groups were evaluated
Stoma type
using Student’s t test or Mann–Whitney U test based on the results
of the homogeneity variance test. Categorical variables were com- End ostomy 88 (88.00) 91 (88.35) 0.01 0.94b

pared between two groups by chi-square/Fisher’s exact test. One- Loop ostomy 12 (12.00) 12 (11.65)

way analysis of variance (ANOVA) of repeated measures was used Notes. p-value of independent samples t test among two groups. bp-
a

to explore between-group (intervention vs. control), within-group value of chi-square/Fisher’s exact test among two groups.

(baseline and three times of postdischarge follow-up) and interaction

(group * time) effect. All statistical analyses were two-sided, and
p < 0.05 was considered statistically significant.
3 | RESULTS
3.1 | Demographic and clinical characteristics of the
study population
Baseline characteristics of the study population are presented in
Table 1. Participants’ mean ages were 56.95 years for the interven-
tion group and 59.18 years for the control group. Males constituted
62.00% of the intervention group and 65.05% of the control group.
The majority of participants in both two groups were diagnosed with
colorectal cancer and had an end ostomy. There were no significant
differences in the baseline characteristics between the two groups
(all p > 0.05).
3.2 | Effectiveness of the home care mobile app
follow-up
3.2.1 | Ostomy psychosocial adjustment
At baseline, it was found no differences in ostomy psychosocial
adjustment scores between the intervention and control groups
(t = 1.87, p = 0.06). However, the intervention group had signifi-
cantly higher scores than that of the control group at 1-month
(t = 7.17, p < 0.001), 3-month (t = 12.28, p < 0.001) and 6-month
(t = 14.36, p < 0.001) follow-up, respectively. Both the intervention
and control groups had significant within-group improvement over
time in adjustment scores (F = 1112.74, p < 0.001). And the overall
between-group difference was also statistically significant
(F = 81.21, p < 0.001). The ANOVA results of repeated measures
showed significant interaction effect of group and time on ostomy
adjustment (F = 79.56, p < 0.001; Table 2).
3.2.2 | Stoma self-efficacy
There was no significant difference in SSES scores between the
intervention and control groups at baseline (t = 0.20, p = 0.84).
However, the intervention group had significantly higher SSES scores
when compared with the control group, respectively, at 1 month
(t = 2.81, p = 0.01), 3 months (t = 6.72, p < 0.001) and 6 months
(t = 10.84, p < 0.001) after discharge. As shown in Table 2, both the
two groups had increasing SSES scores over time, and the improve-
ment was significant (F = 682.21, p < 0.001). The between-group
difference (F = 23.16, p < 0.001) and interaction effect
(group * time) (F = 49.58, p < 0.001) in SSES scores were also statis-
tically significant.
3598 | WANG ET AL.

T A B L E 2 Analyses of the psychosocial adjustment and self-efficacy of stoma patient’s pre- and postintervention
After discharge
Between Interaction
MeanSD
Baseline Within group groups effect
Variables Mean  SD 1 month 3 month 6 month F (p) F (p) F (p)
Ostomy adjustment score 1112.74 (0.000a) 81.21 (0.000a) 79.56 (0.000a)
Intervention (n = 100) 39.31  10.47 51.32  8.43 64.36  5.94 70.80  4.64
Control (n = 103) 36.34  12.07 41.23  11.43 49.81  10.41 54.54  10.48
Stoma self-efficacy scale 682.21 (0.000a) 23.16 (0.000a) 49.58 (0.000a)
Intervention (n = 100) 54.64  15.57 66.08  12.53 80.57  9.78 92.10  7.78
Control (n = 103) 54.15  19.13 60.21  16.94 69.07  14.27 75.50  13.38

Note. ap < 0.001, based on one-way analysis of variance (ANOVA) of repeated measures.

study indicated that patients in the mobile app intervention group

3.2.3 | Stoma complications
There was no significant difference in the stoma complication rate
between the intervention and control groups at baseline (v2 = 0.23,
p = 0.63). The intervention group had a lower incidence rate of stoma
complications than the control group at 1-month (v2 = 0.39, p = 0.53),
3-month (v2 = 0.68, p = 0.41) and 6-month (v2 = 0.71, p = 0.40) fol-
low-up after discharge, but all the differences were not statistically sig-
nificant (Table 3). Table 3 also shows the most common type of stoma
complications was peristomal dermatitis in this study.
4 | DISCUSSION
This study suggested that the home care mobile app can be applied
in discharged patients with a permanent stoma. Findings from this
had better levels of psychosocial adjustment and stoma self-efficacy
after discharge compared with the control group. Other study also
reported similar results. Karabulut, Dinc, and Karadag (2014) revealed
that stoma patients who had weekly planned group meetings with ET
nurses, could had better ostomy adjustment and received psychologi-
cal support effectively. Cheng, Xu, Dai, and Yang (2012) found that
the Expert Patient Program, which was a small group intervention to
increase participants’ self-efficacy and self-management, could
improve discharged colostomy patients’ psychosocial adjustment and
self-efficacy levels. The follow-up care was provided by ET nurses in
these previous studies of Cheng et al. (2012) and Karabulut et al.
(2014). In our study, ET nurses consistently played a dominant role in
the transitional stoma care, and they offered health education and
nursing services for patients through the mobile app. Semistructured
interviews also reported that patients benefited from the nurse-led

T A B L E 3 Analyses of stoma complications in the intervention and control population

Intervention (n = 100) Control (n = 103)
n (%) n (%)

Variables Baseline 1-month 3-month 6-month Baseline 1-month 3-month 6-month

Stoma complications
No 84 (84.00) 72 (72.00) 76 (76.00) 77 (77.00) 89 (86.41) 70 (67.96) 73 (70.87) 74 (71.84)
Yes 16 (16.00) 28 (28.00) 24 (24.00) 23 (23.00) 14 (13.59) 33 (32.04) 30 (29.13) 29 (28.16)
v2 = 0.23a, v2 = 0.39b, v2 = 0.68c, v2 = 0.71d,
p = 0.63a p = 0.53b p = 0.41c p = 0.40d
Types of stoma complications 16 (100) 28 (100) 24 (100) 23 (100) 14 (100) 33 (100) 30 (100) 29 (100)
Mucocutaneous separation 6 (37.50) 5 (17.86) 3 (12.50) 6 (26.09) 3 (21.43) 4 (12.12) 5 (16.67) 3 (10.34)
Stoma necrosis 2 (12.50) 1 (3.57) 2 (8.33) 0 (0) 1 (7.14) 1 (3.03) 1 (3.33) 1 (3.45)
Peristomal dermatitis 5 (31.25) 12 (42.87) 11 (45.83) 9 (39.13) 8 (57.15) 18 (54.55) 17 (56.67) 17 (58.61)
Stoma retraction 1 (6.25) 3 (10.71) 0 (0) 0 (0) 1 (7.14) 3 (9.09) 2 (6.67) 2 (6.90)
Stomal stenosis 0 (0) 2 (7.14) 2 (8.33) 3 (13.04) 0 (0) 1 (3.03) 1 (3.33) 1 (3.45)
Stomal prolapse 0 (0) 2 (7.14) 2 (8.33) 2 (8.70) 0 (0) 2 (6.06) 1 (3.33) 1 (3.45)
Parastomal hernia 0 (0) 1 (3.57) 1 (4.18) 1 (4.34) 0 (0) 2 (6.06) 2 (6.67) 2 (6.90)
Other 2 (12.50) 2 (7.14) 3 (12.50) 2 (8.70) 1 (7.14) 2 (6.06) 1 (3.33) 2 (6.90)

Notes. v2 and p-values, comparing between the intervention and control groups at baseline. v2 and p-values, comparing between the intervention and
a b

control groups at 1 month after discharge. cv2 and p-values, comparing between the intervention and control groups at 3 months after discharge. dv2
and p-values, comparing between the intervention and control groups at 6 months after discharge.
WANG ET AL.
telephone follow-up program, which helped them solve stoma care
problems and shorten the adaptation period (Zheng, Zhang, Qin,
Fang, & Wu, 2013). The stoma complication rate was 23.0%–32.0%,
and the most common complication was peristomal dermatitis in this
study, which were similar to the previous studies (Richbourg, Thorpe,
& Rapp, 2007; Shabbir & Britton, 2010). Moreover, the incidence of
stoma complications in the intervention group was slightly lower than
that in the control group at 1-, 3- and 6-month follow-up, but the dif-
ferences were not statistically significant. Zhang et al. (2013) showed
the patients who received nurse telephone calls had significantly
fewer stoma complications at 1 and 3 months postdischarge com-
pared with the control group. Nonetheless, to some extent, our find-
ing reflected patients in the mobile app intervention group could get
more convenient and timely transitional care from ET nurses.
It took the ostomates approximately 5 min to input the stoma
information and photographs through the mobile app. And the pho-
tographs were reviewed by ET nurses to assess the condition of
stoma and peristomal skin. The app allowed patients to submit data
frequently and provided more information than telephone or outpa-
tient follow-up care did. Engel et al. (2011) compared the accuracy
rate for free flap monitoring between remote smartphone photo-
graphic assessments and in-person examinations, and they found
that the photography assessment had a comparable accuracy rate
and a shorter response time compared with the in-person visit. As a
result, developing stoma complications were observed in real-time
and allowed for the early detection prior to scheduled outpatient fol-
low-up. In addition, smartphone monitoring was likely to invoke the
patients’ interest in their condition and make them willing to raise
questions and contact to their ET nurses. The increased contacts
may lead to significantly fewer stoma complications during a longer
follow-up period than that in the present study.
Previous studies have shown that telemedicine is an effective
measure to ensure the continuity of care, for example, telephone fol-
low-up. Data of patients could be transmitted to healthcare profes-
sionals over a telephone line to assess condition, manage symptoms
and provide care (Bohnenkamp, McDonald, Lopez, Krupinski, &
Blackett, 2004; Zhang et al., 2013; Zheng et al., 2013). Furthermore,
positive and effective psychosocial interventions could be conducted
to improve patients’ adjustment and quality of life by nurse special-
ists’ telephone follow-up (Hoon et al., 2013).
With the development of mobile technology, smartphones and
mobile apps have been popular healthcare tools. A growing number
of recent studies have shown the potential benefits of using mobile
apps as self-management or combined with interventions. Fukuoka
et al. (2015) found that the mobile app was cost-effective and con-
venient to deliver proven weight-loss interventions to type 2 dia-
betes mellitus. The smartphone app was also capable of recording
eating patterns to assess energy intake among young adults (Pender-
gast, Ridgers, Worsley, & McNaughton, 2017). Armstrong, Coyte,
Brown, Beber, and Semple (2017) showed that follow-up care man-
agement could be delivered by a mobile app instead of in-person fol-
low-up visits during the first 30 days after ambulatory breast
reconstruction operation.
| 3599
Mobile technology improves patient access to such healthcare
professionals anytime/anywhere. However, most of previous stud-
ies still have depended on telephone follow-up (Bohnenkamp et al.,
2004; Zhang et al., 2013; Zheng et al., 2013). In our study, we did
something new as follows: (a) It is the first time that a mobile app
has been used as the platform for medical diagnosis and treatment
among discharged stoma patients; (b) we conducted a randomised,
controlled clinical trial to explore the effects of follow-up care
delivered via a mobile app on the outcomes of ostomates. Given
the shortage of ET nurses and the lagging development of commu-
nity nursing in China (Wang et al., 2013; Yang et al., 2016), the
utilisation of the home care mobile app was a new modality of
out-hospital nursing for monitoring progression, evaluating progno-
sis, providing follow-up care, assisting in self-management and
delivering psychosocial interventions, especially for ostomates who
had mobility difficulties or lived in remote regions. Unlike tradi-
tional outpatient nursing, patients with a permanent stoma could
receive real-time feedback on their individual results. Using these
data, they could evaluate the potential benefits of psychosocial
interventions and easily communicate observations to ET nurses. In
addition, this technology tools as part of the transitional care could
share some pressure of ET nurses in clinical practice. Thus, future
studies could expand participant population to explore the effect of
the home care mobile app, for example, individuals who have tem-
porary stomas.
The optimal time of closure remains unclear. Robertson, Puckett,
Vather, Jaung, and Bissett (2015) suggested that temporary stomas
were closed between 8–12 weeks (Robertson et al., 2015). However,
Ogilvie, Dietz, and Stocchi (2012) found that the median time to clo-
sure ostomy was 6.3 months after surgery. Like individuals with per-
manent stomas, patients with temporary ostomies experienced a
sudden and significant change in body image that affected both
physical and psychosocial states before ostomy closure. Previously
published studies suggested that the main disadvantages of tempo-
rary stoma included high stoma output, dehydration and a high rate
of postoperative complications, including stoma prolapse, parastomal
hernia, wound infection and incisional hernia (Edwards, Leppington-
Clarke, Sexton, Heald, & Moran, 2001; Law, Chu, & Choi, 2002).
Moreover, it has been reported that stoma self-efficacy and quality
of life were significantly impaired in patients with temporary stomas
(Silva, Ratnayake, & Deen, 2003; Su et al., 2016). Healthcare provi-
ders may need to strengthen efforts to help patients with temporary
stomas adapt their daily living and maintain a positive mental atti-
tude. Our findings have provided a huge basis that can be further
examined in temporary stoma patients.
The home care mobile app examined in this study is currently
only available to registered and authorised Android phone users in
China. The use of smartphone apps as a tool to conduct research is
still in its infancy. Future studies are required to ensure the true
potential of the home care mobile app. Given the features of this
app, we believe it can be translated into other languages and gener-
alisable to the similar group of patients in other countries in the long
term.
3600 | WANG
5 | CONCLUSION
Our study suggests that home care the follow-up by ET nurses was
an effective and easily accessible to stoma patients who need sup-
port for adjustment after discharge. Moreover, being an easy applica-
tion, it can be performed at home by the patient and caregiver.
Compared with the routine discharge care, the transitional care pro-
vided via a mobile app could significantly enhance the psychosocial
adjustment and self-efficacy of discharged patients with ostomy by
improving stoma self-care ability, boosting confidence, changing dys-
functional behaviours and providing emotional and health education.
The information of our study can be used to guide the development
of other convenient and potentially low-cost transitional care for
patients who need support for adjustment and rehabilitation after
treatment.
6 | LIMITATIONS OF STUDY
There are notable limitations to our study. One of the major limita-
tions is that participants who are lack of experience with smart-
phones and mobile apps may face technological challenges. For
example, poor picture quality directly affected ET nurses’ diagnoses
and may result in incorrect assessment. When this happened,
patients were required to uploaded photographs again or changed
another smartphone with high quality. For another example,
patients may turn off the voice or video call accidentally due to the
unstable mobile network. In addition, although personal health
information was anonymised, it cannot be totally immune from per-
sonal identifiers associated with patient data. Therefore, further
studies are required to ensure privacy and solve these technical
problems. Second, although a standard protocol was piloted and ET
nurses followed the continuity of care via a home care mobile app
after discharge, the patients’ compliance might be out of the
researcher’s control. Third, participants may not be blinded to the
interventions in this study as they were likely to be aware of differ-
ent interventions that they were receiving. Thus, there is call for
more extensive research in the area using stringent RCT designs,
and double-blind where possible, to confirm the value of this app
and to minimise the risk of bias. Lastly, only Chinese-speaking
adults were enrolled in our study; thus, our findings may not gener-
alise to other populations.
7 | RELEVANCE TO CLINICAL PRACTICE
This randomised controlled study was the first to examine the
effects of follow-up care via a mobile app in discharged patients
with a stoma. It provided the evidence that the home care mobile
app was a safe and convenient way to deliver proven psychosocial
interventions to ostomates. This new mode of follow-up care can be
used as part of transitional care and could share ET nurses’ work
pressure in clinical practice.
ET AL.
ACKNOWLEDGEMENTS
This work was supported in part by the Chinese Nursing Association
(ZHKY201511), Qing Lan Project and the Key Discipline Develop-
ment Project of Jiangsu Province, China (Nursing, JX10617801). We
thank all students, doctors and nurses who participated in this work.
CONFLICT OF INTERESTS
The authors declare that they have no conflict of interests associ-
ated with the study.
CONTRIBUTIONS
All authors made substantial contributions to editing and drafting of
the manuscript. Study design and data collection: Jie Wang, Jing
Zhao and Xiao-Rong Huo. App development, study design, data col-
lection and quality control: Qing-Qing Wang, Jing Zhao, Xiao-Rong
Huo, Ling Wu, Li-Fang Yang and Ju-Yun Li. Statistical analysis: Qing-
Qing Wang, Jing Zhao and Jie Wang. Manuscript preparation and
writing: Qing-Qing Wang and Jie Wang. All authors read and
approved the final manuscript.
ORCID
Jie Wang http://orcid.org/0000-0001-7159-5839
REFERENCES
Armstrong, K. A., Coyte, P. C., Brown, M., Beber, B., & Semple, J. L.
(2017). Effect of home monitoring via mobile app on the number of
in-person visits following ambulatory surgery: A randomized clinical
trial. JAMA Surgery, 152, 622–627. https://doi.org/10.1001/jamasurg.
2017.0111
Arnold, M., Sierra, M. S., Laversanne, M., Soerjomataram, I., Jemal, A., &
Bray, F. (2017). Global patterns and trends in colorectal cancer inci-
dence and mortality. Gut, 66, 683–691. https://doi.org/10.1136/
gutjnl-2015-310912
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral
change. Psychological Review, 84, 191–215. https://doi.org/10.1037/
0033-295X.84.2.191
Bekkers, M. J., van Knippenberg, F. C., van den Borne, H. W., & van
Berge-Henegouwen, G. P. (1996). Prospective evaluation of psy-
chosocial adaptation to stoma surgery: The role of self-efficacy. Psy-
chosomatic Medicine, 58, 183–191. https://doi.org/10.1097/
00006842-199603000-00013
Bohnenkamp, S. K., McDonald, P., Lopez, A. M., Krupinski, E., & Blackett,
A. (2004). Traditional versus telenursing outpatient management of
patients with cancer with new ostomies. Oncology Nursing Forum, 31,
1005–1010. https://doi.org/10.1188/04.ONF.1005-1010
Boraii, S. (2017). A descriptive study to assess quality of life in Egyptian
patients with a stoma. Ostomy Wound Manage, 63, 28–33.
Brown, H., & Randle, J. (2005). Living with a stoma: A review of the liter-
ature. Journal of Clinical Nursing, 14, 74–81. https://doi.org/10.1111/
j.1365-2702.2004.00945.x
Chen, W., Zheng, R., Baade, P. D., Zhang, S., Zeng, H., Bray, F., & He, J.
(2016). Cancer statistics in China, 2015. CA: A Cancer Journal for Clin-
icians, 66, 115–132. https://doi.org/10.3322/caac.21338
WANG ET AL.
Cheng, F., Xu, Q., Dai, X. D., & Yang, L. L. (2012). Evaluation of the
expert patient program in a Chinese population with permanent
colostomy. Cancer Nursing, 35, E27–E33. https://doi.org/10.1097/
NCC.0b013e318217cbe9
CNNIC (2016, August 3). The 38th statistical report on the development of
China’s Internet Network, China Internet Network Information Center.
Retrieved from http://www.cnnic.net.cn/gywm/xwzx/rdxw/2016/
201608/t20160803_54389.htm
Comb, J. (2003). Role of the stoma care nurse: Patients with cancer and
colostomy. British Journal of Nursing, 12, 852–856. https://doi.org/10.
12968/bjon.2003.12.14.11409
Dai, X. D., Huo, X. R., Wu, L., & Yang, L. F. (2014). The clinical character-
istics of patients undergoing enterostomy in Jiangsu province and
inspiration for nursing care. Chinese Journal of Nursing, 49, 448–451.
https://doi.org/10.3761/j.issn.0254-1769.2014.04.016
Edwards, D. P., Leppington-Clarke, A., Sexton, R., Heald, R. J., & Moran,
B. J. (2001). Stoma-related complications are more frequent after
transverse colostomy than loop ileostomy: A prospective randomized
clinical trial. British Journal of Surgery, 88, 360–363. https://doi.org/
10.1046/j.1365-2168.2001.01727.x
Engel, H., Huang, J. J., Tsao, C. K., Lin, C. Y., Chou, P. Y., Brey, E. M., &
Cheng, M. H. (2011). Remote real-time monitoring of free flaps via
smartphone photography and 3G wireless Internet: A prospective
study evidencing diagnostic accuracy. Microsurgery, 31, 589–595.
https://doi.org/10.1002/micr.20921
Fukuoka, Y., Gay, C. L., Joiner, K. L., & Vittinghoff, E. (2015). A novel dia-
betes prevention intervention using a mobile app: A randomized con-
trolled trial with overweight adults at risk. American Journal of
Preventive Medicine, 49, 223–237. https://doi.org/10.1016/j.amepre.
2015.01.003
Hoon, L. S., Chi, S. C., & Hong-Gu, H. (2013). Effect of psychosocial
interventions on outcomes of patients with colorectal cancer: A
review of the literature. European Journal of Oncology Nursing, 17,
883–891. https://doi.org/10.1016/j.ejon.2013.05.001
Karabulut, H. K., Dinc, L., & Karadag, A. (2014). Effects of planned group
interactions on the social adaptation of individuals with an intestinal
stoma: A quantitative study. Journal of Clinical Nursing, 23, 2800–
2813. https://doi.org/10.1111/jocn.12541
Krouse, R., Grant, M., Ferrell, B., Dean, G., Nelson, R., & Chu, D. (2007).
Quality of life outcomes in 599 cancer and non-cancer patients with
colostomies. Journal of Surgical Research, 138, 79–87. https://doi.org/
10.1016/j.jss.2006.04.033
Law, W. L., Chu, K. W., & Choi, H. K. (2002). Randomized clinical trial
comparing loop ileostomy and loop transverse colostomy for faecal
diversion following total mesorectal excision. British Journal of Sur-
gery, 89, 704–708. https://doi.org/10.1046/j.1365-2168.2002.02082.
x Administration, 13, 770–772.
Lim, S. H., Chan, S. W., Lai, J. H., & He, H. G. (2015). A randomized con-
trolled trial examining the effectiveness of a STOMA psychosocial
intervention programme on the outcomes of colorectal patients with
a stoma: Study protocol. Journal of Advanced Nursing, 71, 1310–1323.
https://doi.org/10.1111/jan.12595
Machin, D., Campbell, M. J., Tan, S. B., & Tan, S. H. (2011). Sample
size tables for clinical studies, 3rd ed. Hoboken, NJ: Wiley-
Blackwell.
Ogilvie, J. J., Dietz, D. W., & Stocchi, L. (2012). Anastomotic leak after
restorative proctosigmoidectomy for cancer: What are the chances of
a permanent ostomy? International Journal of Colorectal Disease, 27,
1259–1266. https://doi.org/10.1007/s00384-012-1423-9
Pendergast, F. J., Ridgers, N. D., Worsley, A., & McNaughton, S. A.
(2017). Evaluation of a smartphone food diary application using
objectively measured energy expenditure. International Journal of
Behavioral Nutrition and Physical Activity, 14, 30. https://doi.org/10.
1186/s12966-017-0488-9
| 3601
Pretlow, R. A., Stock, C. M., Allison, S., & Roeger, L. (2015). Treatment of
child/adolescent obesity using the addiction model: A smartphone
app pilot study. Childhood Obesity, 11, 248–259. https://doi.org/10.
1089/chi.2014.0124
Raingruber, B. (2011). The effectiveness of psychosocial interventions
with cancer patients: An integrative review of the literature (2006–
2011). ISRN Nursing, 2011, 638218. https://doi.org/10.5402/2011/
638218
Richbourg, L., Thorpe, J. M., & Rapp, C. G. (2007). Difficulties experi-
enced by the ostomate after hospital discharge. Journal of Wound,
Ostomy and Continence Nursing, 34, 70–79. https://doi.org/10.1097/
00152192-200701000-00011
Robertson, J. P., Puckett, J., Vather, R., Jaung, R., & Bissett, I. (2015).
Early closure of temporary loop ileostomies: A systematic review.
Ostomy Wound Manage, 61, 50–57.
Ross, L., Abild-Nielsen, A. G., Thomsen, B. L., Karlsen, R. V., Boesen, E.
H., & Johansen, C. (2007). Quality of life of Danish colorectal cancer
patients with and without a stoma. Supportive Care in Cancer, 15,
505–513. https://doi.org/10.1007/s00520-006-0177-8
Shabbir, J., & Britton, D. C. (2010). Stoma complications: A literature
overview. Colorectal Disease, 12, 958–964. https://doi.org/10.1111/j.
1463-1318.2009.02006.x
Silva, M. A., Ratnayake, G., & Deen, K. I. (2003). Quality of life of
stoma patients: Temporary ileostomy versus colostomy. World Jour-
nal of Surgery, 27, 421–424. https://doi.org/10.1007/s00268-002-
6699-4
Simmons, K. L., Smith, J. A., Bobb, K. A., & Liles, L. L. (2007). Adjustment
to colostomy: Stoma acceptance, stoma care self-efficacy and inter-
personal relationships. Journal of Advanced Nursing, 60, 627–635.
https://doi.org/10.1111/j.1365-2648.2007.04446.x
Simmons, K. L., Smith, J. A., & Maekawa, A. (2009). Development and
psychometric evaluation of the Ostomy Adjustment Inventory-23.
Journal of Wound, Ostomy and Continence Nursing, 36, 69–76.
https://doi.org/10.1097/WON.0b013e3181919b7d
Stinson, J. N., Jibb, L. A., Nguyen, C., Nathan, P. C., Maloney, A. M.,
Dupuis, L. L., & Johnston, D. L. (2015). Construct validity and reliabil-
ity of a real-time multidimensional smartphone app to assess pain in
children and adolescents with cancer. Pain, 156, 2607–2615.
https://doi.org/10.1097/j.pain.0000000000000385
Su, X., Qin, F., Zhen, L., Ye, X., Kuang, Y., Zhu, M., & Wang, H. (2016).
Self-efficacy and associated factors in patients with temporary
ostomies: A cross-sectional survey. Journal of Wound, Ostomy and
Continence Nursing, 43, 623–629. https://doi.org/10.1097/WON.
0000000000000274
Wang, L., Ma, R., Zheng, X. W., & Li, S. (2013). Thinking about training
and utilization of enterostomal therapist in China. Journal of Nursing
Wu, H. K., Chau, J. P., & Twinn, S. (2007). Self-efficacy and quality of life
among stoma patients in Hong Kong. Cancer Nursing, 30, 186–193.
https://doi.org/10.1097/01.NCC.0000270704.34296.86
Xu, Q., Cheng, F., & Dai, X. D. (2010). Evaluation of reliability and validity
of the revised Chinese version of Ostomates’ Adjustment Inventory-
23. Jiangsu Medical Journal, 36, 1647–1649.
Yang, A., Yan, M., & Qin, Y. (2016). The development status of special-
ized nursing in ostomy care both in China and abroad. Chinese Nurs-
ing Research, 3, 117–120. https://doi.org/10.1016/j.cnre.2016.06.
014
Yu, D. H. (2005). Enterostomal therapy in China: Status and advances.
Chinese Journal of Nursing, 40, 415–417.
Zhang, J., Wong, F. K. Y., You, L., Zheng, M., Li, Q., Zhang, B., & Liu,
J. (2013). Effects of enterostomal nurse telephone follow-up on
postoperative adjustment of discharged colostomy patients. Cancer
Nursing, 36, 419–428. https://doi.org/10.1097/NCC.0b013e31826fc
8eb
3602 | WANG ET AL.

Zheng, M. C., Zhang, J. E., Qin, H. Y., Fang, Y. J., & Wu, X. J. (2013).
Telephone follow-up for patients returning home with colostomies:
How to cite this article: Wang Q-Q, Zhao J, Huo X-R, et al.
Views and experiences of patients and enterostomal nurses. European
Journal of Oncology Nursing, 17, 184–189. https://doi.org/10.1016/j.e Effects of a home care mobile app on the outcomes of
jon.2012.05.006 discharged patients with a stoma: A randomised controlled
Zia, J. K., Le, T., Munson, S., Heitkemper, M. M., & Demiris, G. (2015). trial. J Clin Nurs. 2018;27:3592–3602. https://doi.org/
Download alert: Understanding gastroenterology patients’ perspec-
10.1111/jocn.14515
tives on health-related smartphone apps. Clinical and Translational
Gastroenterology, 6, e96. https://doi.org/10.1038/ctg.2015.25