Nursing Interventions to Promote Self-Care in a Candidate for a Bowel Elimination Ostomy: Scoping Review

Objectives: To identify nursing interventions, their characteristics, and outcomes for promoting self-care in candidates for a bowel elimination ostomy. Materials and methods: A scoping review was carried out based on the Joanna Briggs Institute’s recommendations. For this, studies published in Portuguese, English, and Spanish on the Web of Science, CINAHL, and Scopus databases and without a time limit were selected on November 9, 2020. Results: Of 2248 articles identified, 41 were included in this review. We identified 20 nursing interventions associated with the self-care of patients with an ostomy; most of them have gaps in their content, method, and frequency or dosing. More than 30 indicators were identified to assess the impact of nursing interventions; however, most of them were indirect assessments. Conclusion: There is scarce evidence regarding the different aspects that must be involved in nursing interventions for patients with a stoma. Moreover, there is no standardization in methods, frequency, or dosing of intervention. It is urgent to define the content, method, and frequency of nursing interventions necessary to promote self-care in patients with a bowel elimination ostomy and to use assessment tools that directly measure stoma self-care competence.


Introduction
The word ostomy derives from the Greek "stoma" and means "mouth" or opening, being understood as a surgical communication between an internal organ (intestinal or urinary) and the body surface (1). A bowel elimination ostomy is the exteriorization of a part of the intestine through the abdominal wall as an artificial outlet for feces, constructed from the mucous lining of the intestine (2).
Worldwide, about one million people annually undergo ostomy surgery (3). This number is expected to increase, given that the most likely diagnosis for a bowel elimination ostomy is colorectal cancer (4). Currently, colorectal cancer is the third most common type of cancer worldwide, with more than 1.9 million new cases per year (5), whose incidence is predicted to grow by 60 % as of 2040, with more than 3 million new cases per year (6).
A stoma construction is a life-changing event. While this surgery can have several positive effects, such as reducing symptoms and improving health, it can also adversely affect the person (7) physically, psychologically, socially, and spiritually. It may represent a potential threat to all aspects of the lives of people who must not only learn how to manage stoma care but also incorporate it in their daily lives (7)(8)(9)(10). How this event is experienced is conditioned by several factors, including stoma care competence (1,3,11).
Considering the various factors associated with the acceptance process and its impact on quality of life, literature was identified (12)(13)(14) sustaining that a systematic and complete care approach by a nurse from the preoperative phase to follow-up after hospital discharge significantly impacts these factors. In addition, the entire perioperative approach improves life quality, reduces health costs (7,15), and has a positive effect on the life of the person with an ostomy (13).
The nurse must give the right information to the right person at the right time to reduce some concerns expressed by the person/patient submitted to ostomy construction, being responsible for recognizing and responding to the educational needs of each one (16). Furthermore, the nurse plays an important supporting role for patients facing changes and their impact. These interventions help the person return to their previous life as soon as possible (7).
In an early stage of the educational process, the goal for the person undergoing a stoma surgery is to develop autonomy and selfcare, increasing their quality of life and achieving competence in all aspects of their self-care (17). Perioperative education is a key component in approaching a person with a stoma; however, evidence is lacking to support improved outcomes. It is crucial to carry out more in-depth studies using rigorous models to design a viable educational intervention that improves patient care and outcomes (15,18). Implementing intervention programs for the person with a bowel elimination ostomy, considering the different moments of nurse intervention, enhances the management of stoma care, emphasizing adaptation, problem-solving, self-efficacy, cognitive reformulation, and goal definition (19). The present review aims to know the nursing interventions promoting stoma self-care and their characteristics for candidates for a bowel elimination ostomy, from the preoperative phase to follow-up after hospital discharge. It also intends to explore the outcomes used to assess the impact of those interventions.

Materials and methods
A scoping review of the scientific literature was carried out following the methodology of Joanna Briggs Institute (20) and the guidelines established by the PRISMA model (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). For the research structuring and execution, a protocol was developed with information regarding the objectives of this review. The topics are the population to be included in the research, the formulation of the research question, the eligibility criteria, the strategy, and databases used to obtain the relevant information, the definition of topics for data extraction, and how the data would be condensed.
The definition of the starting question followed the strategic parameters P (Population), C (Concept), and C (Context), with the research being guided by the following questions: • What are the nursing interventions for promoting stoma self-care, from the perioperative period to follow-up after hospital discharge, for a candidate to a bowel elimination ostomy?
• What are the outcomes used to assess nursing interventions to promote bowel elimination ostomy self-care?
Firstly, a preliminary search for possible similar studies was carried out in the CINAHL database in August 2019. Secondly, we conducted another search on the Web of Science, CINAHL Complete, and Scopus databases on September 4, 2019, using combinations based on MeSH, Cinahl Headings, and natural language, as shown in Table 1. Given the time elapsed from research completion to the conclusion of article analysis, new research was carried out on November 9, 2020. (* stom * NOT tracheostom * NOT cystostom * NOT urostom *) AND ("model of care" OR "care model" OR model * OR "patient * education" OR "centered care" OR discharge *) AND nurs * (* stom * NOT tracheostom * NOT cistostom * NOT urostom *) AND ("model of care" OR "care model" OR model * OR "patient * education" OR "centered care" OR discharge *) AND nurs * (* stom * AND NOT tracheostom * AND NOT cystostom * AND NOT urostom *) AND ("model of care" OR "care model" OR model * OR "patient * education" OR "centered care" OR discharge *) AND nurs * The selection criteria for the articles were: studies that included people referred to or with a bowel elimination ostomy, either permanent or temporary, aged 18 years or older, and with a potential for regaining autonomy; addressed nursing interventions to promote stoma self-care; in in the preoperative, postoperative, or post-hospital contexts; were primary or secondary studies, qualitative or quantitative, published in Portuguese, English or Spanish, with no time limit.
The research carried out in the databases was loaded and grouped in the ZOTERO 5.0.96.3 software (21), and the duplicates were removed. Two researchers independently conducted the search in databases and the analysis and selection of the articles. In the case of disagreement on the inclusion of any article, a third researcher was consulted.
The title and abstract of the identified studies were evaluated in the first phase based on the pre-established eligibility criteria. Posteriorly, all articles included in the first phase were submitted to the analysis process after full reading. Figure 1 highlights the process of identifying and selecting the articles included in the review. Source: Prisma -Flowchart for scoping review (adapted) (22) Finally, two independent reviewers extracted data using the data extraction tool developed by the authors for this purpose according to the following aspects: year of publication; country where the research was carried out; objective of the research; type of study; methodological approach; nursing interventions, as well as the content, method, and dosing of interventions. Since this review does not collect deeply personal, sensitive, or confidential information from participants and uses documents accessible to the public as evidence, it does not require approval of an ethics committee.

Results
Of 2248 articles identified, 41 were included in the scoping review, with publication dates from 2004 to 2020: 24 % (10) in 2020, 19. Regarding the type of study, the majority are experimental (14) and quasi-experimental studies (6), followed by literature reviews without a defined method (10), systematic literature reviews ( All analyzed articles refer to nursing interventions in promoting self-care in a candidate for or a person with a bowel elimination ostomy. Some articles analyze the impact of nursing interventions on different indicators. Considering the elements that underlie the design of a nursing intervention (22), and to facilitate the reading and analysis of the references included in this review, Table 2 shows the interventions identified, as well as the content, method of administration, and dosing of each intervention, including amount, frequency, and duration. The syntax of interventions was adjusted to the Classification of Interventions for Nursing Practice (CIPE), version 2019, as it is an international language used to document nursing care. Performing the stoma location site (9,16,(23)(24)(25)(26)(27)(28) Preoperative Justifying and explaining to the user the choice of the stoma site (16,26) Face to face (26,27) One session (26) On the day of admission to the hospital (23,28) Encouraging the manipulation of ostomy devices (25) Preoperative Promoting interaction with people with a bowel elimination ostomy (25)
-On the 2nd post-op day, the user must autonomously change the ostomy bag (23,25,37), remove the device with help, clean stoma and skin, and cut the plate (23,37) -The user's involvement progressively increases until the device is removed, the stoma and skin are cleaned and dried, and a new device is inserted, ending the procedure with cutting the plate for the next exchange (23)(24)(25)37) Face to face (30, 42) Expository and demonstration method (45) Use of digital media -DVD / video (45) Use of an ostomy simulator (50) Starting as early as possible after surgery (42), e.g., first postoperative day (30) More than one session (42) or program based on user needs (30) Two days before discharge (41) Three sessions (45) or four sessions (50) --------One hour (45) After hospital discharge Face to face (53) Home visits (53) Use of smartphone application (31) Video call feature (53) The first month after discharge -four times a week (31) Twice a week until autonomy in self-care (53) Assessing stoma self-care competence (7,25,27,33,44,46,51,(53)(54)(55) Preoperative Changing the ostomy device (23) Use of a model (23) In the second session of two, at home (23) On the day of admission to the hospital (23) --------45 minutes to one hour (23)

Postoperativehospitalization
Eighteen topics considered minimal aspects for discharge, centered on knowledge and performance of stoma selfcare, stoma and skin self-surveillance, and resource management (55) --------At discharge (55) After hospital discharge Parameters of the self-care agency scale (ESCA) (44) Ability to properly perform stoma self-care (7,25,33,51) How ostomy products/accessories are used (7) to evaluate: -Peristomal skincare (25) -Adaptation of lifestyles to the presence of the stoma (25) -Ability of the user or family caregiver to identify and make decisions regarding possible complications: dehydration, intestinal occlusion, stoma or skin complications, peristomal skin, development of peristomal hernia (25) -Normal wear time of the effluent collecting device, always ensuring that the user is autonomous in stoma self-care or that the family caregiver can replace it (25) -Discussion of ostomy device exchange routines (27) -Nurse observing the patient remove and apply the device (27) -Skin cleansing ability (25) -Monitoring of intestinal elimination (51) Telephone contact (7,44,51,53,54,56,57) Face to face (27,44,46) Home visits (7,23,53,58) Hospital consultation (38,58) Use of mobile application (51) Sessions according to the needs of the user or family (25) First contact -within seven days of hospital discharge (25,54,58), can vary between the first 48h and the first two weeks (25,27,38,54,58) Once a week (7,44) for six months (7) The 2nd contact must occur between 14 to 20 days (54), the maximum interval being two, four, and six weeks after hospital discharge (25,27) If the level of autonomy in self-care is low on the 2nd contact, the 3rd contact should be made 23 to 27 days after discharge (54) Evaluating twice a week until autonomy in self-care (53) In the first six months -at least once a month (58) or with home visits every two weeks (53) or three months, six months, and one year after discharge (27) After six months -annual follow-up (58)

Intervention Time Content Method Dosing (quantity / frequency / duration) and moment
Training bowel elimination ostomy self-care (25,27,30,(41)(42)(43)45,47,59) Postoperativehospitalization Removal, hygiene, and cleaning procedure (50) Regularly training the cutout and, if possible, using pre-cutout devices (30) Practicing emptying the bag and changing the device (42) -Third post-op day: The patient, with supervision, removes the device, washes and dries the skin and stoma, and puts the new device on (23,37) -Fourth post-op day: The patient, without supervision, removes the device, washes, and dries the skin and stoma, and places the new device. Nurse validates at the end (23,37) -The plate exchange must be carried out by the patient autonomously on the 3rd or fourth post-op day (25) -Fifth and subsequent days: Training switching devices until autonomy (23,37) Face to face (23) Use of an ostomy simulator (50) Starting on the 1st postoperative day and scheduling remaining training based on the user's needs (30) All possible opportunities (42) In the 2nd and third training sessions (45) Four sessions (50) -------40 minutes (47) After hospital discharge Focused on problem-solving: -Peristomal skin problems -Selection of ostomy devices People with an ostomy who experience problems or difficulties share what actions they took to resolve them Focused on demonstrating problemsolving strategies (59) Face to face Group sessions managed by a nurse (59) Five sessions (59) -------One hour (59) Planning follow-up consultation after hospital discharge (7,23,27,31,34,41,43,44,46,52,58) Postoperativehospitalization + After hospital discharge Informing about follow-up contacts: -First contact: First seven days after hospital discharge (23,25,54,58), can vary between the first 48h to 72h and the first two weeks (25,27,38,46,52,54,58) -Second contact must occur between 14 to 20 days (54), the maximum interval, after the first contact being two, four, and six weeks after hospital discharge (25,27) or the first month after discharge -four times (31) or once a week (7,43,44,46) in the first six months (7) Second and third contact between three and six weeks after discharge (23) -Second and third month after discharge -15 in 15 days (31) -One, three (41) and 6 months after discharge (31,52) Home visit ten weeks after surgery (58) Home visits once a month for the first six months (7,31,58) After six months -annual contacts (52,58) For problem-solving / when requested by the user or health professional (34,43,52) Informing about the methodology of follow-up contacts: -Face to face (23,25,31) -Telephone contact (7,34,41,43,44,46) -Home visit (7,34,58) -Use of mobile application (31) -WeChat (43) Face to face (23,25,31) Telephone contact (7,34,41,43,44,46) One hour (41) Encouraging community interaction (25,31,54,59) After hospital discharge Focused on problem solving: -Peristomal skin problems -Selection of ostomy devices People with an ostomy who experience problems or difficulties share what actions they took to resolve them Focused on demonstrating problemsolving strategies (59) Face to face Group sessions managed by a nurse (59) One-hour sessions (59) Assessing for signs of stoma and peristomal skin complications ( Once a week for four to five months (44,46) or six months (7) Intervention Time Content Method Dosing (quantity / frequency / duration) and moment Encouraging stoma self-care (23,25,31,32,37) After hospital discharge Persuasion for stoma self-care ( After hospital discharge Verifying changes and solutions used for troubleshooting (33) Face to face (33) Source: Own elaboration We could identify 20 nursing interventions associated with the self-care of the patient with an ostomy. Those interventions are described at various times (pre-and immediate postoperative period, during hospitalization, and even after hospital discharge). We also found adequate interventions only at one point in the hospitalization period (pre-and post-hospitalization or discharge) or interventions performed at various times, with the following distribution: four interventions during the preoperative period, five interventions during postoperative inpatient, and 16 interventions after hospital discharge.
As for the implementation methods used, most contact is face-to-face (77 %), in the hospital (67 %), or at home (33 %). Other options are contact by telephone (10 %) or through a smartphone application (13 %).
The used resources in most interventions are in writing, with the most referenced information being in a leaflet format. Digital support is also employed, namely videos, photographs, or 2D animations. For teaching, instructing, and training interventions, simulators or models are a common approach.
In the analysis of the included articles, we identified indicators to assess the impact of one or more interventions. Table 3 shows the outcomes and the method used for their assessment -answering the second research question-, the outcomes of the nursing interventions for the promotion of stoma self-care, and the instruments used to assess these results. 16 Table 3. Outcomes and methods for assessing the impact of nursing interventions

Discussion
This paper is the first literature review to map nursing interventions centered on promoting the self-care of a candidate for or a person with a bowel elimination ostomy. The review showed that research is conducted within the scope of the definition of nursing interventions prescribed to the candidate or person with a bowel elimination ostomy, noting that most are experimental studies. However, those are more directed towards assessing methods for implementing nursing interventions, namely simulators (50), telephone contact (43,54), mobile apps (31), and multimedia resources (40).
Methods to improve the educational process of patients through information and communication technologies, such as computeraided education models, are evolving rapidly, and nurses play a central and privileged role in using these technologies to enhance and optimize their interventions for patients (49). The technology most referred to in the literature is a communication-only mobile phone application. However, technology, especially mobile technology, is being used by community nurses for various purposes, including knowledge sharing, reporting, and caseload planning (60). Advances in information technologies, such as smartphones and mobile applications, have created more opportunities for people to have information related to their health status available at any time or place according to their needs and preference.
As health professionals with exclusive intervention in promoting stoma self-care, nurses must develop content that integrates into different implementation methods, whether using mobile phone applications, videos, or interactive images. This content is the disciplinary knowledge of nursing.
For the challenges faced by health professionals and people with an ostomy regarding reduced hospitalization time and increased complex therapy, whether surgical or pharmacological, it is pertinent to develop instruments that facilitate and enhance the acquisition of stoma self-care competence. The literature maintains that self-care competence positively influences the adaptation process to the stoma (54) and life quality (28,43), reduces the incidence of stoma and peristomal skin complications (43,44), and increases self-efficacy (44) and confidence in self-care (45). It is also evident that the most significant difficulties experienced after discharge are related to insufficient knowledge and the capacity for self-care and pre-and postoperative care (10). The results promote the importance of the nurse's intervention in the three perioperative moments to develop the stoma self-care competence.
The designed nursing interventions presume the definition of the content, the method of administering it, and the dosing, which includes the intervention's frequency, duration, and intensity (22,61). However, no studies addressing these characteristics systematically and completely were identified. From the identified literature, specific interventions are mentioned without any reference to content, method, and dosing, namely "Encouraging the manipulation of ostomy devices," "Promoting interaction with people with a bowel elimination ostomy," "Assessing knowledge of stoma and peristomal skin complications," "Assessing the diet," "Assessing intestinal elimination," "Assessing the use of health resources" and "Informing about health resources." The content is the most described component in the remaining interventions and where there is the most significant consensus. Meanwhile, the administration method and dosing are referenced but is incomplete in most articles, with the dosing being the component of interventions with major discrepancies and less information available.
Within each intervention, we identified that they are repeated throughout the different administration moments (preoperative phase, postoperative hospitalization, or after hospital discharge). However, there are differences in the content and dosing of interventions at each moment.
In the preoperative period, concerning the method for the different interventions, these can be in person, via telephone, or both, the most common being only one face-to-face session on the eve of the surgery (24,26,(36)(37)(38)(39). Regardless of the interventions, method, and dosing, it is agreed that when performed preoperatively, they significantly impact the well-being of the person with a stoma, the reduction of complications, and the use of health resources (62,63). In addition, there seems to be a consensus among all authors on performing stoma site and the positive impact it has (62). In this context, "teaching about intestinal elimination ostomy" and "teaching about bowel elimination ostomy self-care" appear to be the most referenced preoperative interventions in the literature.
Concerning the interventions implemented in the postoperative period, during hospitalization, we found comparative studies between the use of the face-to-face expository method, face-to-face intervention combined with multimedia resources, or the exclusive use of multimedia methods. The results suggest that the use of multimedia tools can be used to implement the intervention. Nevertheless, it is enhanced when combined with the face-to-face intervention by the nurse (40,45). One aspect to be considered before the execution of any nursing intervention to promote self-care is to ensure that the patient is prepared and available without any discomfort or pain (42). The use of the internet has emerged as an intervention method with excellent cost-effectiveness in the following cases: "Teaching about bowel elimination ostomy," and "Teaching about bowel elimination ostomy self-care," (31,64).
Considering the approach after hospital discharge, the methods of implementing the interventions are telephone or face-to-face contact in the context of a consultation in a hospital or through home visits. Telephone contact emerges as an effective strategy in specific interventions such as "Assessing stoma self-care competence" and "Watching for signs of stoma and peristomal skin complications." These interventions have benefits regarding associated costs and health gains, scope of customer satisfaction, improved adaptation to the stoma, perception of self-efficacy, and reduced incidence of stoma or peristomal skin complications (54,56).
Consensus among the authors was identified regarding follow-up by a stoma nurse and early start of follow-up, namely in the first week after hospital discharge, being the non-face-to-face contact via telephone call one of the most mentioned methods (54,56,65).
The intervention "Planning a follow-up appointment after hospital discharge" is the one with more variable dosing options after discharge. However, the first six weeks are defined as the most vulnerable phase and require a closer intervention (25,27,44).
Some studies evaluated the impact that interventions, or a set of them, could have on specific indicators. From the analysis of Table  2, not all authors express how they evaluate the indicator in question, which emerges as a limitation to research rigor and replication.
In the review context, the indicators most sensitive to nursing interventions are highlighted, which we group into five categories: safety, economic, psychological well-being, functional status and, symptom experience (22).
In the sensitive results to nursing interventions and safety categories, the incidence of stoma and peristomal skin complications was considered, which stands out as the most common in the articles, followed by economic results as length of stay, the rate of hospital readmission, and the number of consultations.
For the psychological well-being category, indicators such as anxiety, depression, and negative emotions are used. The functional status category groups indicators such as adaptation and the capacity for self-care and indirect indicators such as user satisfaction. For the symptom experience category, no indicator is shown.
Considering the direct and autonomous intervention of nurses in promoting stoma self-care, they would be expected to use reliable and rigorous instruments to assess the level of stoma self-care competence (66). However, only three authors use direct indicators to assess the impact of nursing interventions on self-care competence (41,44,46), while the remaining indicators evaluate it indirectly. For assessing the impact of interventions, their contents, methods, and dosing on self-care competence, it is imperative to use direct indicators, that is, stoma self-care competence of and the dimensions comprising it (66).
Regarding the analyzed literature, the interventions and the contents to be included in the different moments of the perioperative period are defined; nevertheless, they are still poorly consolidated. It should be noted that the period after hospital discharge is the one that lacks the most evidence regarding the definition of nursing interventions, contents, and dosing, also emerging as the period of greatest vulnerability for the person with a new ostomy (67).
This review highlights evidence that can facilitate the intervention of nurses in providing care to the person proposed for stoma construction or after its construction. The results of this review must be examined in light of several limitations. The broad nature of our Boolean research phrase was intended to include the most significant number of studies, but did not cover all the databases and gray literature, certainly excluding some references.

Conclusion
Stoma self-care is enhanced by an appropriate nursing intervention from the preoperative moment, to the immediate postoperative period, to adjusted follow-up after hospital discharge. The promotion of self-care is a critical component in the recovery of people with an ostomy, with a significant impact on several indicators sensitive to the intervention of nurses, namely functional status, safety, and psychological and economic impact. The knowledge and use of these indicators are of crucial importance for, on the one hand, highlighting the condition of patients, and on the other hand, demonstrating the relevance of nursing care to the person.
While there is available literature that supports the nurse's intervention in elimination ostomy self-care, more research is needed on the definition of content, methods, and dosing of interventions, especially after hospital discharge where a more significant lack of information and vulnerability of the person with a new ostomy are detected.
There is no evidence to support the improvement in clinical results, suggesting that further studies should be carried out through rigorous programs to develop a viable educational intervention that improves the care provided to patients.
The use of multiple and indirect outcomes in assessing nursing interventions is beneficial to understand their impact on different areas; however, a direct indicator of the objective of the intervention should always be used. Thus, when evaluating interventions or intervention programs aimed at promoting stoma self-care, it is crucial to employ tools that directly assess self-care competence.

Conflicts of interest:
None declared.