Retrospective analysis of the effectiveness of self-care education for intestinal stoma in patients after colorectal cancer surgery

Abstract

BACKGROUND

Colorectal cancer patients often require an intestinal stoma after surgery, but face difficulties in self-care. Systematic education aims to enhance their caregiving abilities and improve rehabilitation outcomes.

AIM

To explore the impact of systematic self-care education on the nursing effectiveness of patients with intestinal stoma following colorectal cancer surgery.

METHODS

A retrospective analysis was conducted on the medical records of 100 patients who underwent colorectal cancer surgery with intestinal stoma creation at Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, from May 2022 to May 2025. The patients were divided into two groups: A systematic education group (n = 50) and a routine nursing group (n = 50). The systematic education group received a structured educational program that included preoperative assessment, staged postoperative training, discharge planning, and continuous follow-up support. In contrast, the routine nursing group received standard postoperative care. The study compared differences in postoperative self-care ability, stoma quality of life (Stoma-QOL) scores, incidence of stoma-related complications, readmission rates, and nursing satisfaction between the two groups.

RESULTS

The self-care ability scores of the systematic education group at 1 month, 3 months, and 6 months post-surgery were significantly higher than those of the routine nursing group (P < 0.05). Similarly, the Stoma-QOL scores of the systematic education group at 1 week, 1 month, 3 months, and 6 months post-surgery were also significantly higher than those of the routine nursing group (P < 0.05). Repeated measures analysis of variance revealed statistically significant differences in self-care ability scores and Stoma-QOL scores between the two groups, considering time effects, inter-group effects, and interaction effects (P < 0.05). The total incidence of complications, including irritant dermatitis, parastomal hernia, and stoma prolapse, was 16.00% in the systematic education group, significantly lower than the 40.00% observed in the routine nursing group (P < 0.05). The stoma-related readmission rate in the systematic education group was 4.00%, compared to 18.00% in the routine nursing group (P < 0.05). Additionally, the total nursing satisfaction rate in the systematic education group was 96.00%, higher than the 80.00% in the routine nursing group (P < 0.05).

CONCLUSION

Systematic self-care education significantly improves the self-care ability of patients with intestinal stoma following colorectal cancer surgery. It reduces the incidence of complications and readmission rates while enhancing quality of life and nursing satisfaction. This approach is worthy of clinical promotion and application.

Key Words: Colorectal cancer; Intestinal stoma; Self-care; Nursing education; Retrospective analysis; Quality of life; Complications

Core Tip: This retrospective study verifies that systematic self-care education markedly boosts colorectal cancer patients’ intestinal stoma self-care ability, elevates stoma quality of life scores and nursing satisfaction, and reduces stoma-related complication incidence and readmission rates, warranting wide clinical adoption for stoma care.

INTRODUCTION

In recent years, several intervention models have been developed to improve self-care abilities in patients with intestinal stomas. These include structured nursing education programs, transitional care models, multimedia education, and internet-based follow-up interventions. Previous studies have demonstrated that systematic educational programs and continuous nursing interventions can significantly improve patients’ self-management abilities, reduce complications, and enhance their quality of life. For example, multimedia education and structured self-care training have been reported to significantly improve ostomy management skills and psychological adaptation in stoma patients. Furthermore, internet-based extended care and telemedicine follow-up models are increasingly used to provide continuous support after hospital discharge. However, the effectiveness of comprehensive, systematic self-care education programs that integrate preoperative preparation, postoperative skill training, and long-term follow-up requires further clinical verification.

Colorectal cancer is among the most prevalent malignant tumors worldwide with its morbidity and mortality rates ranking among the highest for all cancers. In recent years, changes in lifestyle and dietary habits have led to a steady increase in the incidence of colorectal cancer in China, making it a significant public health issue that poses a serious threat to national health[1,2]. For patients with low rectal cancer, acute intestinal obstruction or perforation caused by tumors necessitates surgical resection combined with the creation of an intestinal stoma. This approach is crucial for saving lives, relieving obstruction, and improving the cure rate[3,4]. However, studies have indicated[5,6] that patients with a stoma following colorectal cancer surgery face a range of stoma-related complications, including peristomal irritant dermatitis, parastomal hernia, stoma prolapse or retraction, and hemorrhage. These complications not only cause pain, discomfort, and increase the risk of infection but also contribute to anxiety, depression, social isolation, and a diminished quality of life.

The traditional postoperative nursing model often emphasizes acute-phase medical treatment and basic nursing guidance but tends to overlook the development of patients’ systematic, personalized, and continuous self-care abilities. When relevant training is provided, it is frequently superficial. Consequently, after discharge, patients may feel lost when confronted with practical issues such as daily stoma cleaning, ostomy bag replacement, and the early identification and management of complications. This lack of preparedness can lead to improper handling of their condition, which may aggravate their health or introduce new risks[7,8]. To address this gap, this study conducted a retrospective analysis of the medical records of 100 patients who underwent colorectal cancer surgery and intestinal stoma creation at Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, from May 2022 to May 2025. The aim was to explore and analyze the clinical effectiveness of systematic self-care education, thereby providing practical evidence for optimizing nursing strategies.

MATERIALS AND METHODS

Study subjects

Following approval from the Medical Ethics Committee of the hospital, a total of 100 patients who underwent radical resection for colorectal cancer, accompanied by the creation of either a permanent or temporary intestinal stoma, were retrospectively enrolled as study subjects. These procedures were conducted in the Department of Gastrointestinal Surgery at Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, between May 2022 and May 2025.

Inclusion criteria: Patients aged 18 years or older; those with a pathological confirmation of colorectal adenocarcinoma via postoperative histopathological examination; individuals who underwent radical surgery with stoma creation during the specified timeframe and provided informed consent; patients with complete clinical data and follow-up records; and those possessing clear consciousness, along with basic cognitive and communicative abilities.

Exclusion criteria: Patients who underwent emergency surgery without standardized preoperative consultation and assessment; individuals with concurrent severe organ failure or advanced malignancies; those suffering from severe mental illness or cognitive impairments that hindered participation in the educational program; and patients who died from non-stoma-related causes or were lost to follow-up shortly after surgery.

Based on the stoma care education modality received during hospitalization, the patients were categorized into two groups: The systematic education group (n = 50) and the routine nursing group (n = 50). No statistically significant differences were observed between the two groups concerning age, gender, tumor stage, stoma type, and other baseline characteristics (P > 0.05), as presented in Table 1.

Table 1 Baseline characteristics of patients in the two groups, n (%).

Variable	Systematic education group (n = 50)	Routine nursing group (n = 50)	Statistical	P value
Age (years), mean ± SD	62.34 ± 10.53	64.12 ± 11.24	t = 0.819	0.415
Gender			χ2 = 0.164	0.685
Male	28 (56.00)	30 (60.00)
Female	22 (44.00)	20 (40.00)
BMI (kg/m2), mean ± SD	22.81 ± 3.14	23.22 ± 3.37	t = 0.631	0.529
Tumor location			χ2 = 0.164	0.685
Rectum	32 (64.00)	30 (60.00)
Colon	18 (36.00)	20 (40.00)
TNM stage			χ2 = 0.221	0.638
Stage II	34 (68.00)	36 (72.00)
Stage III	16 (32.00)	14 (28.00)
Stoma type			χ2 = 0.381	0.537
Ileostomy	32 (64.00)	29 (58.00)
Colostomy	18 (36.00)	21 (42.00)
Stoma nature			χ2 = 0.373	0.541
Temporary	25 (50.00)	28 (56.00)
Permanent	25 (50.00)	22 (44.00)
Complicated with diabetes mellitus			χ2 = 0.251	0.616
Yes	11 (22.00)	13 (26.00)
No	39 (78.00)	37 (74.00)

BMI: Body mass index; TNM: Tumor-node-metastasis.

Study methods

Routine nursing group: Patients underwent the hospital’s standard postoperative nursing procedures, which included the following steps: (1) Before surgery, the attending physician or nurse provided an oral explanation of the surgery’s necessity and the approximate location of the stoma; (2) Postoperative care focused on bedside basic nursing tasks performed by the responsible nurse. This included observing the stoma’s mucosal blood supply and the characteristics, as well as regularly cleaning the surrounding skin; (3) After the patient’s first spontaneous defecation, the nurse demonstrated how to change the ostomy bag, explaining key steps such as cleaning, measuring, and applying the bag on-site; (4) Before discharge, the nurse provided a simplified written version of the Stoma Care Guidelines to the patient and their family, along with discharge instructions; and (5) After discharge, the patient received information about the schedule for routine outpatient re-examinations and was advised to conduct telephone consultations or visit the outpatient department promptly in case of emergencies.

Systematic education group: Patients participated in a systematic self-care education program, implemented in several phases.

Preoperative phase (from admission to surgery): The attending physician or nurse conducted a one-on-one psychosocial assessment to understand the cognitive level, emotional state, and social support available to the patient and family. Using uniformly compiled illustrated manuals and 3D animation videos, medical staff explained the surgical principles of intestinal stoma, its expected appearance, physiological functions, and potential impacts on daily life to the patient and primary caregivers. The physician collaborated with the patient to select and mark the optimal stoma site on the abdomen, considering various positions (supine, sitting, bending over) while ensuring the area avoided skin folds, bony prominences, and waist belt lines.

Early postoperative phase (from surgery to first defecation): The attending physician or nurse conducted daily ward rounds to assess the stoma’s mucosal color, height, edema, and excrement characteristics while performing standardized cleaning and care of the peristomal skin. Patients and their family members were encouraged to observe at the bedside, with the nurse explaining key points of observation to lay the foundation for future skill learning.

Mid postoperative phase (from first defecation to before discharge): Once the patient’s vital signs stabilized and they were able to cooperate (usually on the 3^rd to 5^th day after surgery), the attending physician or nurse systematically explained the theoretical knowledge and operational key points of the full nursing process at the bedside, using either a stoma model or the patient’s own stoma. The medical staff demonstrated the procedures step by step and guided the patient in performing complete operational practice with the assistance of primary caregivers, providing on-site observation and error correction. Intensive training sessions were scheduled 1-2 times a day for 30-45 minutes to ensure patients could independently complete the core steps of stoma self-care.

Pre-discharge preparation (1-2 days before discharge): The attending physician or nurse assessed the mastery of basic self-care and emergency management skills by the patient and primary caregiver. A written discharge plan was collaboratively formulated, detailing the re-examination schedule and emergency contact information. Patients were encouraged to join the “Stoma Rehabilitation” WeChat group, which provided online Q&A services, skill videos, graphic analyses of common problems, and shared experiences from recovered patients.

Post-discharge continuous support (from discharge to 6 months after surgery): Follow-ups were conducted via telephone or WeChat video at 1 week, 1 month, 3 months, and 6 months post-discharge. These sessions inquired in detail about the patient’s daily stoma care, occurrence and management of complications, adaptation to diet and activities, psychological state, and social participation. For any identified issues during follow-ups, one-on-one online guidance and operational demonstrations were provided. An online “Stoma Care Experience Exchange Meeting” was held every two months, inviting recovered patients to share their self-care experience, answer questions from new patients, and foster a peer support network.

Outcome measures

Differences in postoperative self-care ability, stoma quality of life (Stoma-QOL) scores, incidence of stoma-related complications, readmission rate, and nursing satisfaction were compared between the two groups.

Stoma self-care ability: On the day of discharge, as well as at 1 month, 3 months, and 6 months post-surgery, the Chinese version of the Stoma Self-Care Ability Assessment Scale - validated for both reliability and validity - was utilized for evaluation. This scale includes items related to ostomy bag changing, skin care, identification of complications, and management of diet and activity. Scores range from 0 to 100, with higher scores indicating greater self-care ability.

Incidence of stoma-related complications: The incidence of stoma-related complications occurring within 6 months after surgery was documented, including irritant dermatitis, parastomal hernia, stoma prolapse, stoma retraction, stoma stenosis, and hemorrhage. The incidence rate was calculated using the formula: (Number of patients with complications/total number of patients) × 100%.

Quality of life: The Stoma-QOL was administered before surgery (baseline) and again at 1 week, 1 month, 3 months, and 6 months after surgery. This scale assesses dimensions such as psychology, physiology, social function, and stoma-related distress, with total scores ranging from 0 to 100. A higher score indicates a better quality of life.

Stoma-related readmission rate: The percentage of patients who experienced unplanned readmissions due to stoma or stoma-related complications - such as severe dermatitis, prolapse, incarcerated parastomal hernia, and obstruction - within 6 months after surgery was calculated.

Nursing satisfaction: At the 6-month postoperative follow-up, a self-designed nursing satisfaction questionnaire was used for investigation, adopting a 3-point Likert scale (very satisfied, satisfied, dissatisfied). The total satisfaction rate was defined as the proportion of patients who chose “very satisfied” or “satisfied”.

Statistical analysis

All statistical analyses were conducted using SPSS 26.0 software. Measurement data were assessed for normal distribution and are presented as mean ± SD. The independent samples t-test was utilized for comparisons between groups. Count data are expressed as n (%), with the χ² test employed for inter-group comparisons. A value of P < 0.05 was considered statistically significant.

RESULTS

Comparison of stoma self-care ability scores between the two groups at different time points

On the day of discharge, there was no statistically significant difference in self-care ability scores between the two groups (P > 0.05). However, at 1 month, 3 months, and 6 months after surgery, the self-care ability scores in the systematic education group were significantly higher than those in the routine care group (68.57 ± 9.36 vs 52.48 ± 10.74; 78.95 ± 8.47 vs 60.16 ± 11.59; and 85.64 ± 7.23 vs 63.85 ± 12.02, respectively; all P < 0.001). Repeated measures analysis of variance indicated that the time effect, inter-group effect, and interaction effect were all statistically significant (P < 0.05), as displayed in Table 2.

Table 2 Comparison of stoma self-care ability scores at different time points between two patient groups, mean ± SD.

Group	Case	On the day of discharge	1 month postoperatively	3 months postoperatively	6 months postoperatively
Systematic education	50	35.24 ± 8.12	68.57 ± 9.36	78.95 ± 8.47	85.64 ± 7.23
Routine nursing	50	34.83 ± 7.95	52.48 ± 10.74	60.16 ± 11.59	63.85 ± 12.02
t	-	0.251	8.278	9.126	10.843
P value	-	0.802	< 0.001	< 0.001	< 0.001
Time main effect		F = 320.157, P < 0.001
Main effect of group		F = 85.625, P < 0.001
Time × group interaction		F = 18.346, P < 0.001

Comparison of the incidence of stoma-related complications between the two groups

In the systematic education group, the total incidence of stoma-related complications in the systematic education group was 16.00% (8/50), which was significantly lower than 40.00% (20/50) in the routine care group (χ² = 7.111, P = 0.008) as illustrated in Table 3.

Table 3 Comparison of incidence of stoma-related complications between two patient groups, n (%).

Group	Number of cases	Irritant dermatitis	Parastomal hernia	Stoma prolapse	Stoma retraction	Stoma stenosis	Others (hemorrhage, etc.)	Total complications (rate)
Systematic education group	50	2 (4.00)	1 (2.00)	1 (2.00)	2 (4.00)	1 (2.00)	1 (2.00)	8 (16.00)
Routine nursing group	50	7 (14.00)	4 (8.00)	2 (4.00)	3 (6.00)	2 (4.00)	2 (4.00)	20 (40.00)
χ2	-	-	-	-	-	-	-	7.111
P value	-	-	-	-	-	-	-	0.008

Comparison of quality of life scores between the two groups

There was no statistically significant difference in the baseline Stoma-QOL scores between the two groups before surgery (P > 0.05). However, the Stoma-QOL scores for the systematic education group were significantly higher than those of the routine nursing group at 1 week, and at 1 month, 3 months, and 6 months post-surgery (P < 0.05). A repeated measures analysis of variance indicated that the time effect, inter-group effect, and interaction effect of the scores were all statistically significant (P < 0.05), as illustrated in Figure 1.

Figure 1 Changes in stoma quality of life scores over time in the two groups.

Comparison of readmission rate and nursing satisfaction between the two groups

The stoma-related readmission rate in the systematic education group was 4.00% (2/50), which was significantly lower than 18.00% (9/50) in the routine care group (P = 0.024). Additionally, the total nursing satisfaction rate in the systematic education group was 96.00%, which was notably higher than the 80.00% satisfaction rate in the routine nursing group (P < 0.05), as presented in Table 4.

Table 4 Comparison of readmission rates and nursing satisfaction between two patient groups, n (%).

Group	Case	Stoma-related readmission rate	Nursing satisfaction
			Very satisfied	Satisfied	Unsatisfy	Overall satisfaction rate
Systematic education group	50	2 (4.00)	38 (76.00)	10 (20.00)	2 (4.00)	48 (96.00)
Routine nursing group	50	9 (18.00)	22 (44.00)	18 (36.00)	10 (20.00)	40 (80.00)
t	-	5.128	-	-	-	6.061
P value	-	0.024	-	-	-	0.014

DISCUSSION

Intestinal stoma is a vital adjunctive procedure in colorectal cancer surgery, playing an essential role in saving patients’ lives. However, the presence of a stoma requires patients to manage this “abnormal” bodily opening for a considerable period, sometimes even for life, which profoundly alters their physiological functions and life trajectories[9,10]. Postoperative stoma care involves complex daily tasks such as wearing and changing ostomy bags, disposing of excreta, and maintaining peristomal skin. Additionally, it significantly impacts patients’ body image, self-esteem, social interactions, and overall quality of life, presenting long-term challenges in self-management[11,12]. Addressing how to assist stoma patients during the postoperative rehabilitation period - helping them acquire essential self-care skills, effectively prevent and manage complications, rebuild a positive mindset, and reintegrate into society - has become a pressing issue in the fields of colorectal surgery, stoma therapy, and transitional care[13,14].

The traditional nursing model typically emphasizes disease treatment and monitoring of physiological indicators during the acute postoperative phase. Training on self-care skills often consists of fragmented knowledge and simple operational demonstrations, which are inadequate for addressing the complex self-care needs of patients after discharge. This shortcoming can lead to frequent complications, increased readmission rates, and a decreased quality of life[15,16]. In January 2024, our hospital introduced a systematic self-care education program for stoma patients after colorectal cancer surgery, resulting in successful implementation outcomes.

The study’s results demonstrated that the self-care ability scores of the systematic education group at 1 month, 3 months, and 6 months post-surgery were significantly higher than those of the routine nursing group (P < 0.05). Moreover, repeated measures analysis of variance indicated statistically significant differences in time effect, inter-group effect, and interaction effect (P < 0.05). The systematic self-care education program included preoperative assessments, intraoperative collaborative explanations, staged practical training after surgery, and continuous support after discharge, creating a closed-loop process of “assessment-education-training-feedback-reinforcement”. This approach ensured that patients at various stages received targeted guidance and support[17,18].

In contrast to the routine nursing group, which provided only a single operational demonstration and distributed written guidelines during the mid-postoperative period, the systematic education group conducted psychosocial assessments and personalized health education preoperatively. These measures helped patients and their families develop a rational understanding of the stoma in advance, alleviating preoperative anxiety and fear and establishing a solid psychological foundation for subsequent learning[19,20]. Furthermore, the integrated approach of model demonstration combined with hands-on practice on the patient’s own stoma, utilizing the “explanation-demonstration-return demonstration” method, aligns with the cognitive principles of skill acquisition. This effectively overcomes the limitation of the traditional model, which often prioritizes theory over practice. Repeated practice fosters skill internalization and long-term retention, enabling patients to gradually master key operations such as trimming and applying the ostomy wafer and cleaning excreta, significantly enhancing their confidence and ability to perform self-care independently[21,22]. This finding aligns with research by Bian et al[23], which indicates that “structured self-care education can improve patients’ self-management confidence and ability by enhancing their cognitive level and skill mastery”.

Meanwhile, the incidence of complications and stoma-related readmission rates in the systematic education group were lower than those in the routine nursing group (P < 0.05), while the overall nursing satisfaction rate was higher (P < 0.05). This outcome corresponds with the findings of a meta-analysis by Liu et al[24], which suggests that “transitional care can significantly reduce the risk of surgical site infections and complications in colorectal cancer stoma patients”. The systematic self-care education program included preoperative skin assessment and stoma site marking, thereby preventing mechanical irritation and leakage due to improper stoma location after surgery. Standardized skin care and observation guidance during the early postoperative phase facilitated the early identification and management of skin abnormalities. A focus on proper pasting techniques and peristomal skin protection during intensive mid-term training reduced dermatitis and injuries caused by incorrect procedures. Regular follow-ups and remote guidance after discharge enabled timely intervention for potential issues and prevention of complication progression[25]. This comprehensive, preventive self-care education strategy has shifted nursing from “disease care” to “empowerment support”[26,27], alleviating patients’ physical discomfort while reducing readmissions and extra medical costs related to complications.

This study has several limitations. First, its single-center, retrospective design and relatively small sample size may limit the generalizability of the findings. Second, the retrospective design may have introduced selection and information biases. Third, the six-month follow-up period may not be sufficient to capture the long-term effects of systematic self-care education on stoma management and quality of life. In addition, nursing satisfaction was assessed using a self-designed questionnaire, rather than a validated, standardized instrument. Future research should include multicenter, prospective randomized controlled trials with larger sample sizes and extended follow-up periods to better evaluate the long-term effectiveness of systematic self-care education programs.

The study results also indicated that the Stoma-QOL scores of the systematic education group at 1 week, 1 month, 3 months, and 6 months after surgery were significantly higher than those of the routine nursing group (P < 0.05). Repeated measures analysis of variance revealed statistically significant differences in time effect, inter-group effect, and interaction effect (P < 0.05). This finding suggests that the quality of life for the systematic education group was superior to that of the routine nursing group at all postoperative time points, showing a consistent upward trend over time. This indicates that the systematic self-care education program effectively enhances the quality of life for stoma patients post-colorectal cancer surgery. Physiologically, the program equips patients with essential stoma care skills, effectively reduces complication rates, and significantly alleviates physical discomfort. Psychologically, it helps patients gradually build self-efficacy through achieving incremental goals, reducing negative emotions such as anxiety and depression associated with body image changes. Postoperatively, one-on-one online guidance addresses practical problems in real-time, boosting patients’ confidence in managing challenges. Additionally, establishing a peer support network through online “Stoma Care Experience Exchange Meetings” fosters a sense of belonging and social connection, encouraging patients to engage more actively in family life and social activities[28,29]. A survey by Krogsgaard et al[30] also indicated a positive correlation between the self-care ability of stoma patients and their quality of life.

CONCLUSION

In summary, systematic self-care education substantially improves both the self-care abilities and quality of life for patients with intestinal stomas following colorectal cancer surgery. This approach also reduces stoma-related complications and unplanned readmissions, while simultaneously increasing nursing satisfaction. These results suggest that a structured and ongoing self-care education program is an effective nursing strategy for supporting postoperative rehabilitation in patients with stomas. To confirm these findings and assess the long-term benefits of this intervention, further prospective studies across multiple centers are necessary.