La experiencia de portar un estoma digestivometasíntesis cualitativa y análisis de diagnósticos de enfermería. The experience of having a digestive stoma: qualitative metasynthesis and analysis of nursing diagnoses

Abstract

ABSTRACT Introduction Digestive stomas are one of the most common end results for patients with colorectal cancer. The formation of a stoma not only affects the individual physically, it also has an important impact on a patient emotionally and socially. Stoma formation requires the patient and his or her family to adapt to a new lifestyle and to cope with the new stoma through acceptance of its new role. From the moment of a diagnosis which will result in the creation of a stoma, patient care is handled primarily by nursing professionals, who guarantee comprehensive care throughout the process. In this sense, roles of specialist advanced nursing practice have been described that focus on the care of these patients. The main purpose of this thesis was to analyze the phenomenon of digestive stoma in a holistic way identifying the factors involved in the way people suffer from this problem. For this purpose, qualitative research was used, with the addition of a secondary research design allowing us to obtain a generalizable theoretical explanation while also taking into account common aspects present in different cultural contexts in which this phenomenon can be developed. Additionally, this study documents the opinion of experts in the subject with the purpose of understanding the relevance that these dimensions have in the care of these patients. Finally, we would like to offer a useful tool to nursing professionals, especially to stoma care nurses. Once the above objectives were achieved, a nursing taxonomy was elaborated based on care plans. This thesis develops a pilot study on frequency of nursing diagnoses and related factors. Aims The general purpose described above was achieved through the following objectives: (1) To explore the ways in which the experience of having a digestive stoma causes problems that influence patient’s emotional and social spheres (2) To analyze the scientific literature available using qualitative research on the experience of having a digestive stoma (3) To describe the relevant conditions for caring for patients with a digestive stoma from the opinion of experts in the field (4) To identify which nursing diagnoses are prevalent in the care of patients with a digestive stoma (5) To analyze the sociodemographic and clinical factors which may influence the frequency of diagnoses Methodology This thesis is divided into four studies. First, a bibliographical phase was created that focuses on the analysis of scientific articles based on qualitative methodology (objectives 1 and 2, studies 1 and 2); in a second phase, a study with experts was developed through consensus methods (objective 3, Study 3); finally there is an empirical phase with a reduced sample of subjects (objective 4 and 5, Study 4). Study 1 is central to the work of this thesis. It provides a systematic review of qualitative research based on the experiences of people with digestive stoma. A search was made in different relevant health sciences databases. It covered the period between 2002-2015. Within the synthesis, meta-synthesis were employed using the procedures described by Sandelowsky. Concretely, a metasummary was done and it was completed by calculating the effect size. The metasummary was based on a categorical scheme. It was the result of a previous preliminary investigation in which part of the members of the research team associated with this thesis participated. Statements were obtained from each thematic category. The effect size was calculated in each statement, with a final result obtained by dividing the number of articles in which the statement appeared among the total articles included in the review. This work is complemented by Study 2 in which a bibliometric analysis of the scientific production was carried out in order to determine the countries producing the most literature, authors of relevance, areas of knowledge from which these works are developed and other bibliometric parameters of interest. This analysis was performed on articles between the period of 2002-2013. The findings in study 1 (categories and thematic statements) were reviewed by nursing experts in stoma care through modified DELPHI. Their task was to assess the clinical relevance of the previously identified issues for which each expert assessed the intensity of the described situations present in their practice. Subsequently it was compared with the effect size described in the metasinthesis. Finally, an observational, descriptive and cross-sectional study was carried out on a study of 50 patients. The nursing diagnoses present in the sample were studied and their frequency was compared according to sociodemographic and clinical variables. This was done with bivariate and multivariate statistical procedures. The diagnoses were included in an elaborated care plan with the findings of the previous studies, however these works are not part of this thesis. Results Study 1. A total number of 1982 participants participated in the 95 selected studies. These took place in Australia, Brazil, China, Denmark, Iran, Portugal, Spain, Sweden, UK, Uruguay and the USA. Data was grouped into nine categories: "Description of the disease process and creation of the stoma", "Factors that affect coping of the news of the ostomy", "Meaning and experience of the new body reality", "Evaluate other aspects of life after change", "Strategies developed to deal with the situation", "Social and occupational impairment", "Family involvement and participation in the process "," Assistance received" and “Relationship with health professionals”. The results reinforced with only slight discrepancies the explanatory "Triple A model: Acceptance, Adaptation, Selfcare (“Autonomía” in Spanish)”. It sustains the three main categories that define the progression of patients suffering from digestive stoma. Study 2. A total of 108 articles were analyzed. These had an average number of four authors. In areas of knowledge, nursing stands out with 63.89% of the total production analyzed. Research was predominant in universities (61.11%) and in 42.59% of the articles there was no collaboration between different institutions. Regarding the country of origin of the main author, nearly half of the articles were written by Brazilian authors. The articles were published in 59 different journals, of which the most productive was "Journal of Wound, Ostomy & Continence Nursing (7.41%). With reference to the qualitative design, the presence of phenomenological studies (24.07%) was emphasized and regard to data collection semi-structured interviews (47.22%) was predominant. In relation to data analysis, content analysis was the most used (32.41%). Study 3. The results show that social affection was the most prominent issue. It emerged in almost half of the studies analyzed. It coincided with a high level of intensity based on the judgment of the experts. The category "Description of disease" and its corresponding thematic statements appeared with a high frequency indicator as well as with high relevance based on the experts’ opinion. Other relevant aspects were interaction with mutual-help groups, health education and consultation with professionals to improve self-care. Concern about changes in body image and sexual relations also appeared as prevalent aspects. In view of these results, an explanatory model was proposed whose central category is the “need for education of people with digestive stoma”, assuming that if mediated by nurses experts on stoma care this will have a positive impact on the promotion of self care. Also, this intervention, in combination with others (mutual help groups, etc.), would reduce the consequences derived from this process affecting the psychosocial sphere of the patient. This model was generated to complement the model described in study 1 and thus to provide a perspective from both the subject point of view and also the professionals involved in the process. Study 4. The included patients had a mean age of 63.98 years (Standar Desviation “SD” = 10.97, min = 41, max = 84). The distribution of the sample by sex was homogeneous. Based on the pathology for surgery, 39 (78%) cases were due to oncological pathology, compared to 11 (22%) with a different diagnosis. Regarding health care status, 22 (44%) subjects were in the surgical phase and 28 (56%) in continuity of care. This started from a care plan that contained 23 possible nursing diagnoses identified by the findings of previous studies. In 100% of the cases there was a diagnoses of "Readiness for enhanced health management” and "Deficient Knowledge". There were no cases of "Impaired comfort" and "Hopelessness". The rest of the diagnoses had variable frequency. Among the factors which had a significant behaviour, the state of health care in which the patient is (surgery or continuity of care). Thus the results adjusted for age and sex, showed that the next diagnoses are likelihood in the surgical period than in the period of continuity of care: “Anxiety" (OR = 9.53, p = 0.014), "Imbalance nutrition: less than body requirements" (OR = 9.82, p = 0.017) was higher in the surgical period and "Risk of activity intolerance" (OR = 4.54, p = 0.027). While the occurrence of the "Impaired of social interaction" (OR = 0.03, p = 0.005) and "Disturber body image” (OR = 0.25, p = 0.029). Conclusions People with digestive stoma face changes in their lives which affect their physical, functional, emotional and social spheres. From the moment of the intervention, the challenge for the patient is to achieve autonomy. This implies the development of strategies that allow them to accept their condition and to encourage selfcare. Various factors influence this process: cultural beliefs, family and social support, care management, economics, with information being one of the key factors in the process to face the stoma. Through bibliometric analysis of qualitative research generated on the experience of people with digestive stomas, it has been possible to verify that these investigations are carried out mainly in the area of nursing and by university institutions. The number of authors varies between two and four. Brazil and the United States are the countries that produce the most literature. Emphasis is given to eminently descriptive studies. The role of experts in stomatherapy is fundamental to guarantee effective coping with the problem and proper management of it. The role of health professionals should primarily be an educative function. The willingness for "Readiness for enhanced health management” and "Deficient Knowledge” are prevalent aspects in patients with digestive stoma. The relation between patients and health care providers will condition the appearance of other diagnoses. Similar to during the surgical period, attention should be paid to the patient's anxiety, nutritional status and possible intolerance to physical activity, as well as their capacity to deal with the new situation. Social relations and body image are aspects to be monitored in the medium and long term Keywords [MESH]: Colostomy; Ileostomy; Qualitative Research; Systematic Review; Experts opinion; Nursing processes.