Day in the life of a Stomal Therapy Nurse

Meet Maree O’Conner, a Colorectal & Stomal Therapy Nurse. She shares with you all the MUST KNOW information about being a stomal therapy nurse. With experience as a Clinical Nurse Specialist in New Zealand, experience in the Middle East as a senior clinical nurse lead and her current role as a wound management clinical coordinator in the Northern Territory…she brings a wealth of knowledge!

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Why I decided on a Nursing Career

I remember a family friend made me a nurse’s dress up when I was about 7 and I was quite delighted by it. I had spent a bit of time in hospitals as a child; maybe that made a difference, I’m not sure. It wasn’t until I was nearly through high school that I really thought I wanted to go into nursing; a friend’s sister had gone into nursing and it sounded great, and the thought of making a difference to people always held an interest for me, so I applied.

Why did you choose stomal therapy & colorectal nursing?

People often ask, “why on earth would you want to work in Stomaltherapy”? – with a look of abhorrence on their faces. Stomaltherapy, colorectal and functional bowel nursing is not seen as sexy and exciting like ICU, ED, and the like. I usually answer with “well it’s better than sputum that’s for sure!”. Seriously though, Stomaltherapy nursing has provided me with the most awesome career. A career where you can tangibly see the difference you make in people’s lives.

To have a stoma is confronting, stressful, challenging, and frightening for people. To be able to prepare people pre–operatively assists hugely in decreasing some of these feelings and gives them hope and confidence in themselves and in the health professional’s ability to get them back on their feet and into normal life.

The stomaltherapist also has the the opportunity to apply surgical knowledge and skills for early identification of post-op complications, long term complications and to assist in trouble shooting complex situations. It is also extremely rewarding to follow people through the whole care pathway to reversal of stoma and resumption of normal continence.

Bowel disorders

Bowel disorders affect people from newborn to the very elderly which also adds interest. When I first started seeing neonates I was terrified of those tiny babies! While working in Qatar, these teeny tiny little premies at 26 weeks etc. became the norm and I loved working with them and the team. Working alongside consultants, the surgical team, the ward team, the labs, radiology, gastro and so many more in such a collegial way is also very rewarding and demonstrates the huge team involved in health care.

Colorectal conditions

Colorectal conditions are also a life-altering experience. Australia and NZ are both in the top 25 countries of bowel cancer rates in the world. To be involved with bowel cancer patients, to help them access the best of care is rewarding, and knowledge of the disease and treatments is interesting and constantly evolving. There can be issues related to treatment and their side effects; I was recently on an International Consensus Panel to define a syndrome known as “Low Anterior Resection Syndrome” that can affect patients who have rectal cancer treatment – looking at the whole picture is important and interesting. Ensuring patients are well informed is imperative.

Faecal Incontinence

Faecal incontinence sounds awful but imagine how much more awful it is for the sufferer. Severe constipation can be just as debilitating. The causes of these are wide and varied and affect people from all walks of life. To be able to help people regain control and/or find ways of managing these issues effectively helps them to regain their quality of life.

Inflammatory Bowel Disease

Inflammatory Bowel Disease like Crohn’s and Ulcerative Colitis are also very nasty conditions that can have a profound effect on people’s lives. These are often people in their teens and early adult life, and it can be hugely confronting and debilitating at a time that is usually fun and exciting. The challenge of working with sick teens is another aspect I thoroughly enjoy.

Stoma care encompasses so much more

There is so much more to stoma care than the stoma itself. It encompasses bowel health, skin and wound care, the bowel conditions themselves (eg. bowel cancer, inflammatory bowel disease, diverticular disease, short bowel syndrome, trauma, congenital conditions), complex wounds, product knowledge, purchasing constraints, education for patients and staff, nutrition, continence, adjuvant therapies, patients coping mechanisms, human behaviour, belief systems, grief, loss and more.

I always say with stomal therapy nursing you can make it as big or as small as you like, and for job satisfaction why wouldn’t you make it about the whole picture?! In NZ, we are fortunate to be able to follow through the whole journey and stoma patients are monitored regularly at least 2 yearly as per the Ministry of Health. We are also responsible for stoma supply, and this means judicial use of products and patients can easily access help, advice, and review. Services are run slightly differently here in Australia.

There are opportunities to develop other skills too, by being a committee member in professional nursing bodies. These assist with skill development including running meetings, lobbying government, increasing organisational profile, conference planning, educational opportunities, and professional networking. These are all really great ways to increase knowledge and skills, so get on board and seize those opportunities!

My Nursing Career thus far

I started nursing a very long time ago, I was just old enough to make the cut and trained “the old-fashioned way” through a hospital-based nursing program.

Nursing has provided me with an awesome career. I started out as a surgical ward nurse, and after a brief stint in oncology I discovered I enjoyed the rapid turnover of patients that surgical nursing provided and a focus on assisting patients to recover as quickly as possible. I also enjoyed the high pace, hi-tech and rapidly changing situations, so this took me back to surgical. Even early on in my career I found working with patients who had or were going to have a stoma created really rewarding, and I discovered that there was so much more to it than just teaching people how to change a pouch.

I worked as a nurse educator for a while for the surgical units in a 400 bed tertiary hospital in NZ, supporting new staff and providing educational opportunities and updates for the team. I learned a lot, hopefully the staff I worked with did too! During this time, I undertook a certificate in Stomaltherapy Nursing, which included continence and wound care. It was more empowering to undertake study learning WOCN (Wound Ostomy and Continence Nursing) than just one facet of it and having an internationally recognised qualification is extremely important for career opportunities. A colleague at the time suggested I just do one component of the course- this would have been a huge mistake and I was fortunate to have a supportive manager to enable me to undertake the whole course.

While having children (4) I undertook study and upgraded my nursing qualifications from NZ Registered General and Obstetric Nurse to a Bachelor of Nursing and then went on to obtain a Post-graduate Diploma in Professional Nursing Practice (High Distinction). Nursing is so good for providing opportunities that can fit well with work/life balance, in the way of part time and shift work.

When my children were small, I did a stint as a night nurse in a private hospital surgical ward and also worked as a clinical lecturer in the BN program which was both stressful and rewarding. Monitoring the practice of nursing students in busy surgical wards to ensure a safe and high standard of care was not always easy, albeit enjoyable most of the time. However, Stomaltherapy nursing kept calling me back.

When my youngest was about 3 months old I was back in Stomaltherapy with the hours of work rapidly growing. While I was breastfeeding, I was able to bring her along with me which back then was pretty uncommon, but much appreciated from my point of view. Having supportive and flexible managers makes such a difference to staff retention and a positive work environment.

As with many nursing roles, Stomaltherapy can be quite draining over time and the opportunity to work as a Clinical Nurse Manager in an Older People’s Health Unit arose. Many principals of rehab fit well with Stomaltherapy patient rehab so some aspects were familiar, while there was also opportunity to learn huge amounts about rehab and ageing. Once again, though, Stomaltherapy called me back and the lure of a role I had lobbied for was looking more likely!

Creation of a colorectal nurse role

For a long time, I had lobbied hospital management about needing a Colorectal nurse role, as I had noticed patients often had difficulty navigating the complex care pathway for colorectal cancer and suffered from treatment side effects that were not always addressed by busy medical staff. This role finally came to fruition, and I was lucky enough to work 50/50 in both roles. So much of my Stomaltherapy knowledge translated to colorectal patients and it was exciting to establish this new nursing service in our hospital with another colleague.

Medical staff were predominantly supportive, and the role involved triaging against national standards for colonoscopy, ordering and following up on complex procedures and investigations, developing care pathways, establishing and running nurse led clinics for follow up, attending multidisciplinary meetings, referring to other services and more. Alongside this, another nursing colleague and I worked with our colorectal specialists establishing a Functional Bowel Disorder clinic for people with faecal incontinence and constipation/pelvic floor issues. There is always more to learn, and I discovered that I had the interest and skills in developing services!

My time in the Middle East

Finally, once my kids were off my hands, I had the most amazing opportunity to go to the Middle East (Doha Qatar) and develop the stoma and wound service for a 400 bed “greenfield” hospital. This was one of the most exciting, challenging, and amazing experiences of my career! I was told by a senior surgeon there that it was imperative I sourced the right type and number of products to ensure patients would have appropriate and ongoing supplies. This was just as Qatar had gone into a political blockade and things were taking a long time to get there!

Qatar is an “emerging” country, with cultural differences and a Muslim majority. Setting up this service involved supply chain management, establishing relationships with company representatives to assist with obtaining said supplies, writing service plans, specifications, staff education packages, writing up educational booklets for patients and their families (in both English and Arabic), establishing nurse-led clinics, inpatient care, pressure area prevention programs and products and so much more.

There were over 90 nationalities on hospital staff, and we learned some great communication tools to ensure we were all “on the same page”. Bringing together so many people with so many different experiences in healthcare was fascinating and challenging, bringing all this together, amazing!  I worked with health professionals from around the world, including from Mayo Clinic, Great Ormond St Clinic, a U.S. short bowel team; people with mind-blowing credentials and knowledge. I was so fortunate that my career had seen my gain much experience to assist me in this role. Once this service was established, I seized an opportunity to work in Central Australia with a predominantly Indigenous population.

A day in the life of a stomal therapy nurse?

Nursing is like a box of chocolates, right? You never know quite what you are going to “get” from day to day. A day in the life of a stomal therapy nurse would usually start by checking referrals and planning the day, followed by seeing inpatients for stoma reviews, support, and stoma care education, possibly home visiting clients, travelling to remote clinics (NZ), providing staff education, attending MDTs, looking up lab results, following up on consumables, seeing company reps, attending meetings, answering staff queries, and providing a lot of telephone advice.

When I was working in NZ, we provided a 7-day on-call service for urgent stoma issues; particularly pre-op siting of “acutes”, as siting the position for the stoma is a key part of patient success. It provides a chance to increase understanding, decrease fear, impart confidence, and evaluate a site for the stoma that is visible to the patient and has a flat surface area to help achieve a reliable pouching surface. This service was shared between 2 of us until 9pm at night so it was quite a tie, but a service we believed to be important. To be honest though, I really enjoy no longer being “on call”!

A little bit about ostomy

The most common type of stomas are Ileostomy, Colostomy and Urostomy (Ileal Conduit). Those less common are Cecostomy and Jejunostomy.

Ostomy is a Greek word and mean mouth or opening, the word in front of this gives a hint as to what part of the bowel it is made from. Ileal Conduit uses the Ileum as a conduit for urine by having the ureters implanted into a piece of Ileum with one end bought to the surface, and usually the bladder is removed.

Nowadays, many stomas are temporary, with reversal surgery being more common. For some people, though, it can be a significant adjustment to resume satisfactory bowel function.

Things to think about

For nurses caring for people with a stoma, it is important to be cognisant of your reaction to the stoma – patients watch health professionals like a hawk, if you screw up your nose or look stressed or revolted by the stoma, patients will lose confidence. It is important to be honest and kind; “yes it will smell when we empty the pouch or remove the pouch, but that is like anyone going to the loo”.

Try to normalise it as much as possible without undermining feelings the patient may have.

The cause of the stoma may influence patients’ reactions. For some it provides wellness and relief from constant abdominal pain, faecal urgency and frequency, anaemia, fatigue and major medications (for example, those with IBD that has not responded to medical therapies). Other people may have had a sudden event like a bowel obstruction with no time to come to terms with the need for a stoma, so it comes as a shock. Being aware of all these factors makes a difference to how you approach the person- and keeps it interesting!

A little about wound management days

Wound care days are similar – checking referrals, following up on queries, bedside nurse education, assessing wounds and advising and assisting on wound management. Thorough documentation is an important aspect of both roles, as is imparting information to patients about other issues e.g. diet, activity, and referring to other appropriate health professionals. Providing colleagues with information and education, meeting with company reps and keeping abreast of current wound care trends and knowledge is also important.

Wounds, Dressings, and Information

There is a lot of good information readily available on wound care and several ways to assess wounds (for example, colour is one way and the well know acronym T.I.M.E. is another). In general, wounds need to be moist to heal and so the adage “if a wound is dry- add moisture, if a wound is wet- remove moisture, and if it is moist maintain it”, is a good one – as is written in the literature. Think about the products you are using, if you are adding a moisture-based product there is not much point in covering it with an absorbent dressing!

Consider keeping the wound free from contamination from the outside – gauze doesn’t do this. Product knowledge is an important aspect of helping you choose a suitable dressing. The exciting thing about wound care is that wounds are dynamic and so as the wound changes, the wound management changes too. A general rule of thumb is- if a wound has not progressed within 2 weeks of using a regime, then change what is being done. Give patients a realistic time frame to achieve improvement or healing, work with your patient to find solutions that work for them. If you are not sure, look things up on a site like Up To Date; your institution’s guidelines; or call your specialist nurse!

Holistic care

I think I am a little old fashioned (and I know nurses on wards are under pressure), but I truly believe that if you are uncertain about your patient’s history and why they are in a hospital/a health care facility, you really cannot look after them properly.

Bowel function may be impacted by diet, fluids, exercise, time, knowledge, cognition, beliefs around bodily functions, medications, past experiences, surgery, environment, and safety. Regarding wound management, nutrition, environment, medications, belief systems, products, wound type, oxygenation, and comorbidities are some of the things that influence wound healing.

It is also rewarding to know your patient and to provide holistic care, rather than to simply complete a task. Holistic care does not mean doing everything yourself but being aware of, and facilitating care. Health issues, relationship issues, and belief systems impact patient’s wellbeing and influence choices and behaviours. Every interaction with a patient is an opportunity – don’t miss it!

Education and leadership for colleagues

Engaging with nursing colleagues to assist with knowledge and capacity building is what we do as senior nurses. Nurses need to see how nurses make a difference, influence care and impact health care. Being involved with nurse education assists with this- it also provides them with support to grow their practice and provide quality care.

Role modelling quality care helps grow others practice and inspires other nurses in developing their practice. In my view, the more that people have a good understanding of the care they are giving, the better they can advocate for their patients, provide quality thoughtful and educated care, resulting in better patient outcomes and enhanced patient satisfaction. It is also much more enjoyable.

Need for Education and Training

Nurses receive very little undergraduate training on wound and stoma care. It would be useful to have more education, so nurses have some knowledge and confidence in this area to underpin their practice. For example, it would help nurses to understand the importance of Pressure Injury prevention and the significant role nurses play in this quality standard indicator. Skin is the largest organ in the body, it is important to health! Knowledge is power, giving nurses the opportunity to provide informed care, use appropriate products cost effectively, and promote healing.

COVID-19

I am fortunate in that where I am currently living has not been directly impacted by COVID 19 itself, but indirectly from the “fall out” of it, in the way of staffing shortages (many staff have moved to be closer to family, and travel is so tricky now there is not the number of international nurses around as prior to COVID-19). We all know how short staffing affects quality nursing care.

However, I think more globally stoma, colorectal and wound care have been affected. This may be through patients not seeking assessments due to the difficulty of obtaining appointments, and a reduction in face-to-face appointments which may delay diagnostics and treatment. The development of more telehealth opportunities means some assessments and care can be done through this mechanism, but there are times when a face-to-face, hands-on assessment is required.

Future Developments

I think digital technologies will continue to develop with more point of care testing becoming available. Wound management strategies are always developing which keeps it interesting and potentially less invasive surgeries and treatments will develop over time. I think we will see huge developments in gene therapy and “Precision Medicine” in the future – exciting times!

If I was in charge of Nursing and Midwifery

I would like to see a stronger voice for bedside nursing, increased value of the day-to-day nursing care that goes on, as it is the backbone of health care. Make it real, keep it real. Keep nurses safe, from physical harm, from mental anguish related to the exhausting worry of not enough time and unmet tasks, from the threat of punitive action, from sexism and undervaluing the role. Make it a career that is attractive to young people. We have a global shortage of nursing with no sign of improvement, and at the moment that doesn’t seem too surprising. I sometimes worry that with the development of more academic programs being delivered online, we lose sight of the art of nursing, we need both the science and the art to provide a quality service. 

I would like to see more development of services with the people requiring them rather than for them. I believe working in partnership in a way that engages people in their care and delivering it in a way that works best for them achieves more positive outcomes. Bring it back to the people, (the patients), the people (patient’s loved ones), the people (those caring for them). As a Maori proverb says the most important thing is “He Tangata, He Tangata He Tangata ; the people, the people, the people”, in this instance the patients, their families and those caring for them.

Thank you for the opportunity to share my experiences and passion for Stoma/Colorectal and wound management nursing with you.