Use of an Application to Increase Self-Care Ability, Improve Quality of Life, and Decrease Stoma Complications in Patients With Ileocystoplasty or Ureterostomy Due to Bladder Cancer

Bladder cancer is the most common urothelial malignant tumor and was ranked as the 7th most common tumor among men and 17th among women in the United States in 2021.¹ Among the 330,000 new cases each year worldwide, approximately 30,000 people die of bladder cancer.² Bladder cancer can be divided into muscle-invasive bladder cancer and non–muscle-invasive bladder cancer. For both conditions, the European Urological Society recommends radical cystectomy as the preferred treatment.^3-5 However, due to the characteristics of urinary tract transitional epithelial cells, the recurrence rate of bladder cancer is relatively high.⁶

Bladder cancer is a serious health concern.^7,8 Considering the protection of kidney function and long-term quality of life, patients who undergo radical cystectomy often undergo urinary tract diversion at the same time.⁹ Common urinary diversion methods include ileocystoplasty and ureterostomy. Patients with a stoma face changes in daily life and the possibility of postoperative complications such as bleeding, swelling, peripheral inflammation, infection, and ulcers.¹⁰ In addition, body image changes and uncontrollable urine excretion may have serious negative effects on physical and mental health as well as social interactions, and life satisfaction can decline rapidly.¹¹

Postoperative health-related quality of life has received increasing attention for patients with bladder cancer who have undergone urostomy. For younger and fitter patients, health-related quality of life and body image may be the important considerations for them.⁴ A comparison between preoperative and postoperative patients confirmed that patients showed higher levels of anxiety and depression after surgery, which seriously affect quality of life.¹¹ Therefore, interventions are important to improve quality of life after hospital discharge.

WeChat (Tencent) is an instant messaging and social media application (app). The Chinese version of the app is the most popular instant messaging application in China and has been used in problem-based learning.¹² Its effectiveness has been researched by Li et al¹³ in relation to improving the dissemination of malaria health knowledge. Professionals can also use the app for cooperation or information-sharing.¹⁴ The app has been shown to be effective, sustainable, feasible, and widely accepted.¹⁵ Another similar app has been used to support self-management behavior in patients with chronic arthritis.¹⁶

In the current study, the authors used WeChat to add the real-time communication ability of social media to the daily care of patients after hospital discharge. The aim was to enhance the guidance and communication between doctors and patients and provide improved nursing interventions to increase self-care ability, improve quality of life, and decrease complications.

App content. The app allows individuals to create multiple user dialogs among their contacts. The initial group chat consisted of the self-management team (2 doctors, 1 head nurse, 6 registered nurses, and 2 enterostomal therapists). A QR code was shared with patients before hospital discharge so that they could join the group. All medical staff and patients were encouraged to use their real names. Health advice, including clinical and recovery instructions, was released weekly by the doctors, nurses, and therapists. Patients could ask questions using the @ function. They were also encouraged to share information about any problems and their surgery experiences using photos. App content is shown in Table 1.

Patients. From January 2019 to January 2021, 82 patients underwent ileocystoplasty and ureterostomy due to bladder cancer in the authors’ department. Patients and their caregivers who could not navigate the basic functions of mobile phone apps (n = 8) and those patients with cognitive communication and mental disorders (n = 7) were excluded from the study. Thus, 67 patients were enrolled and were randomly divided into a control group (35 patients) and an intervention group (32 patients).

Patients in the control group received regular telephone follow-ups when they were discharged from the hospital, once a week for 2 months and then once a month for the next 22 months; the patients in the intervention group used the app while receiving regular telephone follow-ups. Patients were assessed before hospital discharge by registered nurses; this included a psychological assessment. Nurses recorded patient information (eg, sex, age, stoma type, and stoma location) after surgery and classified, summarized, and established personal files for the patients. After discharge from the hospital, patients were guided online using various methods including written instructions, photos, on-site video, and online classrooms by the registered nurses at different times, stages, and steps using “groups” in the app.

The head nurse served as the team leader who trained, led, and was responsible for supervising the implementation of nursing interventions.

The control group. Regular telephone follow-ups were conducted when patients were discharged from the hospital and at once a week for the first two months, then once a month for the next 22 months.

The intervention group. Before discharge, the registered nurses evaluated the physical and mental state of each patient as well as education level and job. Then the patient or accompanying family members discussed with the team how to personalize and formulate a reasonable plan that was acceptable to the patient. The physicians drew up a management plan based on the patient’s evaluation results and included discharge education, daily diet, reasonable rest and activities, and rehabilitation function training. The registered nurse determined personalized discharge nursing guidance according to the doctor’s diagnosis and treatment plan, including distributing materials and videos related to self-management education to the patient or accompanying family members, explaining and demonstrating the content and knowledge of self-management education related to the disease, encouraging patients to act as a “personal nurse” for themselves to demonstrate each relevant operating procedure and method; instructing patients on how to conduct self-management; and ensuring that doctors’ instructions could be followed.

On the day of discharge, health care providers communicated with patients about the interventions and guided patients to scan QR codes on their mobile phones to join the group chat and build a continuing care file. The contents of the file included stoma type, stoma location, model of the product used, patient address, contact information, and date that the care plan was issued.

The self-management team carried out active telephone follow-up calls once a week in the first 2 months and then once a month thereafter in both groups, in accordance with the continuing care plan. For the intervention group, the registered nurse used the app to collectively guide patients to conduct home self-care, upload video courses, and use the Friends function to video call for individualized self-care guidance. The nurse also observed and evaluated patients’ self-care behavior and communicated with them and corrected any errors in self-care. As a part of the nursing intervention, patients in the intervention group were invited to participate in a meeting in the department of urology every 3 months to communicate their experiences. The members of the self-management team would also provide timely specific guidance when answering patient questions.

Self-care ability. Self-care ability was assessed based on the Self-care Ability Scale.¹⁷ The components of the scale include 4 subitems: self-concept (8 items), self-responsibility (6 items), self-care skills (12 items), and health knowledge level (17 items), for a total of 43 items. Scoring was performed using a 4-point system, of which 11 items were reverse scored, with a total score of 172 points. The higher the score, the stronger the self-care ability. The scale was evaluated after 24 months of intervention.

Stoma complications. Data on stoma complications (urinary tract infection, dermatitis around the stoma, urine leakage, wound exudate, swelling, skin flap necrosis) were collected during the 2 years after discharge.

Quality of life. Quality of life was evaluated using the Chinese version of the Stoma-QOL Quality of Life Scale for Stoma Patients,¹⁸ with a total of 20 items. A 4-point scale was used, with a full score of 80 points. The lower the score, the higher the quality of life. The quality of life was evaluated at discharge from the hospital and 24 months after the intervention.

Ethical considerations. The Ethics Committee of Wuhan University approved the research (approval number: WDRY2021-KS035), and all procedures were in accordance with national research ethical standards. All participants verbally agreed to participate and could withdraw from the study at any time for any reason. Private data, such as telephone numbers and related data, were deleted during analysis.

Statistical analysis. All statistical analyses were performed using SPSS 19.0 software (IBM). The statistical significance of the data was determined by the two-tailed unpaired student t test, and P < .05 was considered statistically significant.

There were 32 males and 3 females in the intervention group, with an average age of 58 ± 4.32 years. Twenty-six patients underwent ileocystoplasty, and 9 patients underwent ureterostomy. The control group consisted of 29 males and 3 females, with an average age of 60 ± 5.68 years. Twenty-five patients underwent ileocystoplasty, and 7 patients underwent ureterostomy. Every 10 patients (5 in the intervention group and 5 in the control group) were followed-up by one registered nurse, the other 7 patients were followed-up by the head nurse, and a health file card was established for each patient from the day of discharge. The 2 groups had no significant differences in demographics (control group: 35 of 67, 52.23%; intervention group: 32 of 67, 47.77%), disease course, or diagnosis (P > .05). No patients were lost to follow-up.

Self-care ability. Comparison of the self-care ability of the 2 groups showed that scores of the 4 items of self-care ability, self-care responsibility, self-concept, and health knowledge level of the intervention group were higher than those of the control group (Table 2), and there was a significant difference between the two groups (P < .05) (Figure 1).

Stoma complications. Common stoma complications included urinary tract infection, peristomal dermatitis, stomal edema, urine leakage, and bloody exudate from the wound. In the intervention group, there were 5 cases of urinary tract infection (16.66%), 1 case of peristomal dermatitis (3.33%), and 1 case of stomal bleeding (3.33%). In the control group, there were 3 patients with urinary tract infection (10.00%), 4 patients with peristomal dermatitis (13.33%), 2 patients with stomal edema (6.67%), 2 patients with urine leakage (6.67%), and 8 patients with stomal bleeding (26.67%) (Table 3). The incidence of complications was significantly higher than that of the intervention group, and the difference was statistically significant (control group: 19 of 32, 59.38%; intervention group: 7 of 35, 20.00%) (P < .05) (Figure 2).

Quality of life. There was no significant difference in the quality of life between the intervention and control groups at discharge. After the intervention, the quality of life score in the intervention group was significantly higher than the quality of life score at discharge (Table 4), and the difference from the control group after the intervention was statistically significant (P < .05) (Figure 3).

Urostomy and ureterostomy are important interventions in treating bladder cancer. Due to changes in urination methods, it is unrealistic for patients to master the correct physical and mental coping methods, which in turn prevent and control complications, during the hospitalization period.^19,20 After hospital discharge, image disorders, complications, impaired self-esteem, and social withdrawal can all contribute to impaired quality of life.²¹

In the current study, there were only 7 stoma complications in the intervention group, which was significantly different from the control group. The scores of the intervention group’s self-care ability were also significantly improved compared to the control group, and quality of life in the intervention group was significantly higher. The authors attribute these benefits to the use of an app that enhanced communication between doctors and patients and provided improved nursing interventions.

The use of an app with video call and picture functions can help make communication intuitive and visual, so that communication, observation, evaluation, feedback, guidance, and correction can be implemented.^15,22 The development of new interventions based on these findings is recommended.

This study has several limitations. It was conducted in a single hospital with a small number of patients. To improve the statistical significance and generalizability of the results, future studies should have larger sample sizes. Because most of the participants were older and not as familiar with the use of smartphones, their ability to provide feedback may have been hampered. This also could contribute to the collection of some information that was not timely.

Interaction with health care providers and other patients, via an app, improved patients’ self-care ability and quality of life in the current study. In addition, stoma complications were reduced. Future studies with larger sample sizes and patients of different ages are needed.

The authors thank the Department of Urology, Hubei General Hospital, First Affiliated Hospital of Wuhan University.

Rongrong Tan, RN, MSN¹; Li Wang, RN, BSc¹; Ruqin Xia, RN, BSc¹; and Hong Zheng, RN, MSc¹

¹Department of Urology, Renmin Hospital of Wuhan University, Wuhan, China

Address all correspondence to: Hong Zheng, RN, MSc, Department of Urology, Hubei General Hospital, First Affiliated Hospital of Wuhan University,
No. 238, Jiefang Road, No. 99, Zhangzhidong Road, Wuchang District, Wuhan, China; tel: 027-88999120; email: 1624090724@qq.com

This work was supported by the Department of Nursing, RenMin Hospital of Wuhan University (grant number: HL2020ZD-01).

none disclosed