Assessment of Prelicensure Undergraduate Baccalaureate Nursing Students: Ostomy Knowledge, Skill Experiences, and Confidence in Care

Care of the patient with an ostomy is included in the curriculum of prelicensure nursing programs, but no studies examining student nurses’ knowledge about stoma care have been published. The purpose of this project was to examine the ostomy knowledge, experiences, and confidence of nursing students in order to assess and improve the curriculum.At the end of the fall 2016 semester, students enrolled in 3 separate nursing courses in an undergraduate program were asked to participate in a project to examine students’ ostomy knowledge, their experiences, and their confidence in providing care. This project was undertaken to explore the college’s ostomy curriculum. Participation was voluntary, and no student who was willing to participate was excluded. Students completed a 50-question knowledge test, answered questions about the frequency of performing ostomy-related skills, and rated their confidence in providing ostomy care. Responses were examined with descriptive and inferential statistics. Of 189 possible participants, 138 completed the questionnaires and included mostly women (113, 81.9%); participant mean age was 27.26 ± 6.22 years. The mean number of correct knowledge responses was 35.66 (71.32%); 66 participants (47.8%) reported no experience caring for a patient with an ostomy. The most common skills performed in clinical rotations were emptying (49) and changing (24) the pouch. A scale of 1 to 5 was used to evaluate 6 confidence items, with students having a mean confidence score of 19.54 ± 5.20. They had the most confidence in their ability to empty a pouch and to size and fit the pouching and the least confidence in teaching and community resources. Confidence was related to the number of skills performed in the lab (r = .32; P <.001), the number of skills performed in clinical practice (r = .38; P <.001), and ostomy knowledge scores (r = .23; P <.007). Total correct knowledge scores did not differ significantly by year in the educational program. Based on the results of this survey, it was concluded that students had a beginning knowledge about ostomy care and very limited clinical experience, yet confidence in providing ostomy care was high. Curriculum adjustments were implemented, including strategies for increasing ostomy knowledge, opportunities to provide care, and confidence; these need further investigation in prelicensure undergraduate nursing programs. The effect of curriculum adjustments remains to be evaluated.

Knowledge about the care of patients with an ostomy typically begins in undergraduate nursing educational programs. This foundational nursing education is critical; more than 750 000 Americans are living with an ostomy and more than 130 000 new ostomy surgeries occur in America yearly.¹ As many as 70% of persons with a stoma experience a stomal or peristomal complication.^2,3 The nursing care and teaching of patients with an ostomy require specific knowledge and skills.⁴ The Wound Ostomy Continence Nurses (WOCN) Society, the American Society of Colon and Rectal Surgeons, and the American Urological Association recommend preoperative and postoperative ostomy education be provided by a wound ostomy continence (WOC) nurse.^5-7 According to a number of studies done with surgical patients, pre- and postoperative teaching of persons with a stoma has been linked to a decrease in length of hospital stay, decrease in time to stoma care proficiency, a reduction in use of community resources postdischarge, and improvements in adjustment and quality of life.^8-10 However, due to a number of factors, including limited availability of WOC nurses and a decreasing length of stay secondary to improved surgical techniques and enhanced recovery after surgery programs, this may not always be possible.^11,12 Thus, nursing students, as future registered nurses, also need to have basic ostomy knowledge, be able to perform ostomy care/skills at a beginning level, and have confidence in their ability to perform ostomy care. Examining prelicensure undergraduate students’ ostomy knowledge, ostomy skill, and confidence in providing ostomy care is critical. The purpose of this assessment project was to examine prelicensure baccalaureate undergraduate nursing students’ knowledge about ostomy care, their ostomy skill experiences, and their confidence in providing ostomy care. This assessment project was conducted to examine ways to improve the curriculum regarding ostomy teaching in a prelicensure undergraduate baccalaureate nursing program. 

Research regarding prelicensure baccalaureate students’ ostomy knowledge, experiences with ostomy care, and confidence in providing ostomy care was not found. Therefore, literature about registered nurses’ knowledge, experiences, and confidence with patients with an ostomy was examined; even this research literature was scarce. 

Gemmill et al¹¹ explored acute care oncology nurses’ knowledge and attitudes in the care of patients with an ostomy; 21 nurses of varying educational backgrounds and levels of experience completed a questionnaire designed to assess their knowledge and attitudes. Nurses’ average score on the ostomy knowledge survey was 77%, and most nurses (80%) felt confident in their ability to assess patients with an ostomy well enough to care for the patient. However, only 30% of these same acute care oncology nurses felt they received adequate inservices/staff education to keep knowledge up-to-date, and most (70%) expressed concern about how prepared patients were to care for themselves at home. The authors¹¹ simultaneously surveyed patients who had undergone ostomy surgery and who were cared for on the same acute care units as the nurse participants; 12.5% of patients identified the education received from nurses postoperatively as being useful. Interestingly, 60% of these patients stated that most of the education they received did not occur in the hospital during the postoperative period but instead in the preoperative clinic setting. 

Duruk and Uçar¹³ examined staff nurses’ (N = 100) knowledge and perceived responsibility for providing ostomy care. Approximately 43% stated they cared for a patient with a stoma on a regular basis, and approximately 30% indicated they were willing to receive additional training required for specialization in this practice. Out of 54 items that measured knowledge of ostomy care, the mean score was only 24.9. Therefore, despite regularly caring for patients with a stoma, knowledge was inadequate. A majority of these nurses also indicated that either the physician or a company representative was primarily responsible for ostomy education, and 26% believed ostomy care and education were the responsibility of the clinic nurse or ostomy nurse.

Cross et al⁴ examined the staff nurses’ confidence in their skills, their knowledge of ostomy care, and barriers to care for the patient with an ostomy. The authors received completed questionnaires from 576 nurses with varied educational levels. Greater confidence in ostomy care knowledge was associated with more education, years of nursing experience, higher frequency of providing ostomy care, and knowing how to obtain and use supplies. Nurses’ had the most confidence in emptying an appliance and the least in teaching nutrition. Nurses’ greatest concern was the potential to hurt the patient. The authors concluded continuing education about ostomy care may increase nurses’ confidence in providing ostomy care. 

The purpose of this project was to examine ostomy knowledge, ostomy skill experiences, and confidence in providing ostomy care among prelicensure baccalaureate undergraduate nursing students. This project was performed to identify gaps in the teaching of theoretical and clinical ostomy content in an undergraduate educational program with the goal to inform teaching and learning in the curriculum. Graduates of prelicensure programs need to have ostomy care knowledge to facilitate patient teaching and reinforce the teaching performed by WOC or other specialty nurses. 

 The following questions were asked:

1. What is the ostomy knowledge level of prelicensure undergraduate baccalaureate nursing students? What ostomy knowledge questions have a high correct response and which have a low correct response?

2. How many and what types of ostomy care experiences do prelicensure baccalaureate undergraduate nursing students have in the learning and/or simulation laboratory and clinical practice?

3. How confident are prelicensure undergraduate baccalaureate nursing students in providing ostomy care?

Participant enrollment and procedure. At the end of the fall 2016 semester, faculty told students across the 3 years of the prelicensure undergraduate baccalaureate educational program about the project during a clinical post-conference session for the students in fundamentals and medical-surgical nursing courses and after the lecture for the critical care course. Students were invited to participate in the assessment project and were told the purpose of the project, details of the survey, and that responses were anonymous. Students were informed the goal of the project was to improve the curriculum about the care of the person with an ostomy. They were free to respond or not respond to items on the survey. Because participation or nonparticipation was both voluntary and anonymous, students were assured their course grade would not be affected. Each student responded to the survey 1 time. All students in the selected courses were asked to participate; there were no exclusion criteria. The survey was paper/pencil and took approximately 30 minutes to complete. 

Design. This project was developed as a curricular assessment project, used a survey methodology, and was conducted by 2 faculty. Because this was not a human subjects research study, it was determined that Institutional Review Board approval was not required. The authors assessed a component of an internal educational program in terms of student knowledge, skill, and confidence in the care of a person with an ostomy. The faculty used the students’ responses to this project to examine course content and learning experiences to enhance stoma care teaching. 

Participants. Students in this project were enrolled in either a traditional or a second career/accelerated baccalaureate program. The content and experiences in both programs are the same; the second career program progresses at a faster pace. Potential clinical experiences with patients who have an ostomy occur across the curriculum in this baccalaureate prelicensure nursing program. 

Students in their first year of nursing take a fundamentals of nursing course. During this course, they receive a 1-hour basic lecture about the anatomy and functioning of fecal and urinary ostomies, pouch emptying and changing, diet, fluids, self-care, sexuality, and mental health. Because this is the first nursing course, ostomy complications and peristomal skin changes are not discussed. The lecture content follows the nursing fundamentals textbook,¹⁴ which has sections about meeting the needs of patients with bowel or urinary diversion. The textbook incorporates text and pictures about the person with an ostomy and the care required. During laboratory practice (3 hours), students handle ostomy pouching systems and measure and apply a pouch to a mannequin. Pouch selection is limited to either a 1- or 2-piece drainable appliance. Use of accessory products such as paste or barrier rings is not included. During the clinical experience, which takes place on a variety of medical-surgical units in a number of acute care hospitals (6.5 hours per week), students may be assigned patients who have an ostomy. However, patient assignments are dependent on the patient population at the assigned unit as well as faculty preference in the selection of patients.

Students in the second year of the program take 2 separate yet related medical-surgical nursing courses. Course content includes two 1- to 2-hour sessions during class time that focus on care of the patient with urinary and intestinal disorders. This includes discussion of the management of patients with urinary and fecal diversions but only in relation to specific disease processes. For example, colostomies are discussed as an outcome of treatment for colon cancer. Clinical experiences occur in an acute care setting for 6.5 hours per day, 1 day per week, on a variety of medical-surgical units. As with students in the first year of the program, hands-on experience with a patient with an ostomy is inconsistent. The course includes a simulation laboratory experience on the care of a patient who has both an ileostomy and heart failure. This simulation requires the student to change an ostomy pouching system as well as integrate the concepts of fluid and electrolyte balance; however, the focus of the simulation is on the cardiac condition, not ostomy management. As in the first year of the nursing program, ostomy complications and skin changes are not discussed and the focus is on the immediate physical care of the patient as opposed to psychosocial or discharge needs.

Students in the third year of the prelicensure program take a course focused on critical care. The critical care course contains lecture content about the critically ill patient but does not include content specific to the care of a patient with an ostomy or a clinical component. Students in this year also take 2 additional courses (leadership and immersion); these courses include clinical experiences but course content does not focus on the person with an ostomy.

Across all years, the clinical sites for courses vary in the types of patients that students encounter. For example, 1 clinical site might have primarily postoperative patients while another clinical site’s patient population may have a cardiac focus. Students’ assignments are based on a combination of course objectives, faculty preference, and available patients. Therefore, despite course objectives, there may not be a patient with a urinary or fecal diversion on the assigned unit or the faculty may not choose the patient with an ostomy for any number of reasons. 

Survey instruments. The study authors used questions based on established questionnaires and developed new survey instruments for this assessment. The first part included basic demographic questions (gender, age) and asked participants to state which nursing course they currently were enrolled in.

Zimnicki-Pieper Knowledge Test. The Zimnicki-Pieper Ostomy Knowledge Test (Z-POKT) was developed based on a review of the literature and professional experience to measure ostomy knowledge. The Z-POKT consists of 50 true-false-do not know items. This type of test format is quick for students to answer and easy to score. If study participants did not know an answer, they were asked to not guess but to check do not know. Questions with a do not know response or items left blank were considered wrong when tabulating scores. The total Z-POKT score was obtained by tabulating the number of correct answers. 

Before the Z-POKT was used for the study, 12 WOC nurses were asked to evaluate the appropriateness of the questions for ostomy knowledge for prelicensure students enrolled in a baccalaureate nursing program. These nurses did not give suggestions for items to be revised, added, or removed from the test. All gave a global response that the test was appropriate. The Z-POKT’s Cronbach’s alpha was 0.75 on this initial use.

 The Ostomy Skills section lists 5 skills: measure stoma, cut pouching system, change pouching system, empty pouching system, and apply paste or barrier ring. Students distinguished between the described tasks they performed in the learning and/or simulation laboratory and those tasks they performed in clinical practice with patients by placing a check mark in the box by the item. The checked items were tabulated for a total number of skills performed in each setting. 

In the Confidence with Ostomy Care section, students were asked to rate their confidence using an adaptation of 1 section of the City of Hope Staff Survey on Ostomy Care¹⁵ that included knowledge of different types of pouching systems, determining fit and size of a pouching system, applying an ostomy pouch, emptying an ostomy pouching system, teaching ostomy care for self-care at home, and advising the patient about community resources. They completed the thought, I feel confident in my… or I feel confident that I can…. Each was scored 1 (strongly disagree) to 5 (strongly agree). Total confidence scores could range from 6 (low) to 30 (high).

Statistical analysis. Responses to the survey were entered into an Excel file. The file was converted for analysis by the IBM Statistical Package for the Social Sciences (SPSS Statistics, (Armonk, NY). Responses were primarily examined using descriptive and correlational statistics; when appropriate, inferential statistics also were used for comparisons. The project intention was not to compare ostomy knowledge, skills, and confidence by year in the program. However, because information about this topic is so limited, some outcomes were compared by program year using analysis of variance. 

Student participants. Of the 189 possible student participants, 138 students completed the surveys; the majority were women (113, 81.9%), and mean age of participants was 27.26 ± 6.22 years. Sixty-six (66) students (48.2%) reported they never cared for a patient with an ostomy, 51 (37.2%) reported caring for 1 to 2 patients with an ostomy, and 20 (14.6%) cared for 3 or more patients with an ostomy.

Students’ knowledge. The Z-POKT correct scores ranged from 12 to 45; the mean number of knowledge items answered correctly was 35.66 (71.32%). Items with the highest number of correct responses on the Z-POKT are presented in Table 1 and included conditions requiring ostomy surgery (96.4%), information related to emptying the pouch and removing and applying a pouching system (96.4%), foods causing gas (95.7%), and when to empty a pouching system (94.9%). Items with the lowest number of correct responses on the Z-POKT are presented in Table 2 and included moldable paste is like glue (8%), knowledge of neobladders (16.7%), knowledge of internal anal reservoir (18.1%), and whether a permanent colostomy is created during an abdominal perineal resection (27.5%). Total Z-POKT correct scores (mean ± standard deviation) by year included sophomores (36.54 ± 4.51), juniors (34.43 ± 6.33), and seniors (35.3 ± 4.68); these scores did not differ significantly by year in the baccalaureate educational program.

Prelicensure undergraduate students’ experiences performing ostomy care. The mean number of ostomy experiences performed in the learning and/or simulation laboratories was 3.06 ± 1.75. The most common learning and/or simulation experiences were measuring stoma size (102) and changing the pouching system (100). The mean number of ostomy care experiences performed during clinical practice was 0.99 ± 1.62. The most common clinical experiences were emptying the pouching system (49) and changing the pouching system (24). The number of students who performed ostomy care skills in either the learning and/or simulation laboratory or clinical practice is presented in Table 3. Neither the number of learning and/or simulation laboratory experiences nor direct patient ostomy care experiences was significantly related to Z-POKT scores. Skill laboratory and/or simulation laboratory experiences did not differ significantly by year in the program. Students in the second year (mean 1.63) performed significantly more ostomy skills in clinical practice than those in the first year/fundamentals course (mean 0.58) or third year (mean 0.95) (F[2, 137] = 6.36; P = .002). 

Prelicensure students’ confidence in performing ostomy care. Prelicensure undergraduate students’ confidence scores ranged from 6 to 30; the mean confidence score was 19.54 ± 5.20. Item confidence scores are shown in Table 4. Student confidence was highest in terms of ability to empty a pouch (mean 3.82 ± 1.07) and to size and fit a pouching system (mean 3.55 ± 0.99). Student confidence was lowest in ostomy teaching (mean 2.86 ± 1.11) and community resources (mean 2.64 ± 1.05). Higher confidence in ostomy care was significantly related to higher number of skills performed in the learning and/or simulation laboratories (r = 0.3; P <.001), higher number of ostomy skills performed in clinical practice (r = 0.38; P <.001), and higher knowledge scores on Z-POKT (r = 0.23; P = .007). Students in the first-year fundamentals course (mean 20.64) had significantly higher mean confidence scores than second-year (mean 18.76) or third-year (17.45) students (F[2, 134] = 3.86; P  = .024). 

Prelicensure baccalaureate undergraduate nursing students’ ostomy knowledge, skill experiences, and confidence in providing ostomy care were examined. To the authors’ knowledge, this is the first project to examine these factors. Mean ostomy knowledge levels were low (71%). Almost 50% of students had no experience caring for a patient with an ostomy. Most experiences that students had were obtained in a skills or simulation laboratory. In clinical practice, students primarily emptied or changed the appliance. Confidence levels were at the midpoint of the scale. Students in the first course had significantly higher confidence, possibly due to the amount of content in that course in relation to ostomy care. 

 Cross et al⁴ noted the nursing care of patients with ostomies requires specific skills. Students in the current project had few opportunities to provide ostomy care for hospitalized patients. These findings with students are not much different from studies that included registered nurses. Even registered nurses had concerns about ostomy experiences. Gemmill et al¹¹ reported only 30% of oncology nurses (576) felt that they cared for enough patients with ostomies or received adequate in-services/staff education to maintain their skills. Due to the lack of opportunities to provide care, many nurses expressed concern that ostomy patients were poorly prepared for discharge. 

 Having confidence in their ability to provide ostomy care was approximately a midpoint score for nursing students in this project. In contrast, Gemmill et al¹¹ reported 80% of acute care oncology nurses felt confident in their abilities to provide ostomy care. Cross et al⁴ reported nurses’ greatest confidence was in emptying an appliance and the lowest was in teaching nutrition. Similarly, students in the current study also had the highest confidence in emptying an appliance and the lowest confidence in ostomy teaching and in the use of community resources. Cross et al⁴ concluded that continuing education about ostomy care may increase nurses’ confidence in providing ostomy care. The current authors also found higher student confidence in ostomy care was related to a higher number of skills performed in skills laboratory, higher number of ostomy skills performed in clinical practice, and higher knowledge scores. 

Knowledge about ostomy care is important for patient teaching and the provision of safe patient care. Because they did not have data linking students’ knowledge with patient teaching and safe care, the current authors looked at literature available about nurses. In its outcome criteria for discharging patients with a new ostomy from acute and home care, the WOCN Society¹⁶ states teaching the patient/caregiver is paramount; thus, nurses’ knowledge and confidence in that knowledge is critical. Because not all clinical facilities have access to a nurse certified in ostomy care, all nurses need to have knowledge of ostomy care to facilitate patient teaching and identify resources for patients to provide continued support. Such education is imperative because pre- and postoperative teaching for ostomates has been linked to positive health outcomes, including a decrease in length of stay, decrease in time to stoma care proficiency, a reduction in use of community resources postdischarge, and an improvement in adjustment and quality of life.^8-10 

Gemmill et al¹¹ explored acute care oncology nurses’ ostomy knowledge; their average knowledge score was 77%. This is not much different from the current study’s students’ average score of 71%. Cross et al⁴ reported only 12.5% of patients identified the education received from nurses postoperatively as being useful; this may be because nurses lacked knowledge and confidence. Cross et al⁴ also found higher confidence in ostomy care knowledge was associated with more education, years of nursing experience, higher frequency of providing ostomy care, and knowing how to obtain and use supplies.

Effect on curriculum. This assessment project had a positive effect on the authors’ curriculum. More ostomy equipment, such as appliances and stoma models, was added to the learning and simulation laboratories to allow students to better practice preparing and applying the pouching system. This encouraged all course faculty to refresh their own knowledge of ostomy management and to reinforce content taught in lecture about ostomy care. Due to time constraints in all courses, an effective way to incorporate content on peristomal skin and ostomy complications has yet to be found. This is despite the literature reporting that more than 75% of persons living with an ostomy develop peristomal skin problems.¹⁷ For example, Taneja et al¹⁸ reported 36.7% of their study participants had a peristomal skin complication in the 90-day period following the surgery, and the total health care costs were almost $80 000 higher for persons with peristomal complications.¹⁸ 

Given the amount of material that must be covered in nursing courses, prelicensure baccalaureate programs must explore educational strategies for incorporating ostomy content. For example, in addition to simulation experiences, wearing an ostomy appliance for a day has been used as a strategy to teach ostomy care to nursing students.^19-21 Some students used the experience to explore emotions and to blog the experiences²¹; others wrote a self-reflection of the experience.²⁰ Because not all ostomy-related education can take place in the prelicensure period, this study highlights the need for collaboration between prelicensure programs and their clinical partners in order to provide future and current nurses with the education and experiences needed to care for this unique patient population. 

This project had limitations. Students volunteered to participate; thus, they may not represent all students’ knowledge, experiences, and confidence. The sample size was small, especially for the third-year students. Because this was a 1-time project, it is not known whether changes to the learning experiences or knowledge occurred in a specific course or across the curriculum. A longitudinal project would provide additional information that may enhance curricular design, including how to best level the knowledge and experiences specific to ostomates across the curriculum. Finally, the project examined only factual knowledge and technical skills and did not examine students’ perceptions of the patient or the provision of care with dignity. Further research, such as replication of the study in other institutions/programs, is needed with nursing students in terms of ostomy care as well as the transition of the student to the registered nurse role.

Nursing students need knowledge to assess patients with ostomies, to educate patients/family members regarding ostomy care, and to develop strategies for effective self-care. The purpose of this project was to examine ostomy knowledge, experiences, and confidence of nursing students in order to assess and improve the curriculum. In this study, students, like many nurses, indicated they have few opportunities to provide care to patients with ostomies. This lack of experience may contribute to students having a low level of knowledge and a lack of confidence in their ability to provide care to the patient with an ostomy. Although the project helped inform the curriculum, more research is needed to examine nursing student knowledge at other institutions, integration of the new content into the curriculum, effective teaching strategies, and the impact of these changes as students’ transition to the role of the registered nurse.

Potential Conflicts of Interest: none disclosed

Dr. Zimnicki is an Assistant Professor, Clinical; and Dr. Pieper is a Professor/Nurse Practitioner, College of Nursing, Wayne State University, Detroit, MI.

Please address correspondence to: Katherine Zimnicki, DNP, RN, CWOCN, College of Nursing, Wayne State University,5557 Cass Avenue, Detroit, MI 48202; email: av2284@wayne.edu.