Teaching the adult ostomy patient

Patients who have undergone the cre-ation of an ostomy must cope with a

life-changing event with variable meanings.For example, a gastrointestinal diversionmay represent a chance at better health anda more normal lifestyle for patients withinflammatory bowel disease because theyare no longer threatened by unpredictablebouts of acute abdominal pain and severediarrhea. For others, a fecal stoma repre-sents a sudden change occurring soon aftera diagnosis of advanced colon cancer.Similarly, a patient who undergoes a uri-nary diversion because of intractable incon-tinence or interstitial cystitis may view thestoma as an opportunity for better health,whereas it may represent an acute negativeevent for a patient recently diagnosed withbladder cancer. Regardless of the reason forthe ostomy, patients undergoing this proce-dure face an altered self-concept and bodyimage. They must also learn new ways ofcaring for their bodies, along with changesin lifestyle. Identifying the right time andtechnique for teaching patients with a newostomy presents a tremendous challengefor WOC nurses. Nevertheless, judiciousapplication of basic principles of teachingand learning can be applied to ensure effec-tive incorporation of the cognitive and psy-chomotor skills needed to manage a newostomy.

APPLYING TEACHING/LEARNING PRINCIPLESTO NURSING PRACTICE

Although almost any nurse can repeat aformal definition of teaching, many nursesfail to distinguish between teaching andinforming (“I told him how to change the

dressing”) or admonishing (“Do not eatfoods that cause gas”). Although thesetypes of statements are often incorporatedinto the teaching process, the informationthey convey will not be received and accept-ed unless the patient is actively engaged inthe process of learning. Learning may bedefined as a change in behavior. Further, thenurse must realize that the patient’s nod-ding in agreement does not necessarilyimply that the information being presentedis either acceptable or accepted. Patients canbe said to have learned when they canunderstand, accept, and see as importantthe information and techniques the nurseteaches and when they can not only per-form the skills but also incorporate the newknowledge and attitudes into daily life pat-terns. For patients with a new ostomy,learning occurs when they can perform theskills needed to manage a stoma and incor-porate this new knowledge and attitudeinto daily living.

Teaching can be conceptualized as a spe-cial form of communication; it is an exam-ple of goal-directed interaction. However,teaching is effective only if the goal is mutu-ally acceptable to both the teacher (nurse)and the learner (patient). As in any facilita-tive communication pattern, it is importantthat the nurse approach the interaction in aprofessional manner. The interaction shouldbe friendly, but it is not based on friendship.Rather, it is based on a set of expectationsheld by both the nurse and the patient. Thepatient expects the nurse to be knowledge-able, competent, and willing to provide thecare and information needed. The nurseexpects the patient to be willing to learn andto make changes in personal care habits andlifestyle. This relationship depends on mutu-al respect and trust; the patient should feel

Helen S. O’Shea, RN, PhD, isProfessor, BSN Program Coordinator,and Chair of Adult and Elder HealthDepartment, Nell Hodgson WoodruffSchool of Nursing, Emory University,Atlanta, Georgia.

Reprint requests: Helen S. O’Shea,RN, PhD, Nell Hodgson WoodruffSchool of Nursing, Emory University,531 Asbury Circle, Atlanta, GA30322.

Copyright © 2001 by the Wound,Ostomy and Continence NursesSociety.

1071-5754/2001/$35.00 + 0

21/1/112085doi:10.1067/mjw.2001.112085

Teaching the Adult Ostomy PatientHelen S. O’Shea, RN, PhD

47

Ostomy education is based on principles of adult learning, including assessment of thelearners’ readiness, ability, and need to learn. Such teaching incorporates specificstrategies designed to promote cognitive, affective, and psychomotor learning andstrategies to overcome potential cultural barriers. In addition, modifications may beincluded to meet the needs of aged or disabled patients who have cognitive deficitsor low literacy skills. Finally, ostomy education must include an evaluation of its effec-tiveness. This article reviews general guidelines for planning, implementing, and evaluat-ing patient education for adult patients with ostomies.(J WOCN 2001;28:47-54.)

free to express concerns and reveal igno-rance without fear of judgment, and thenurse should exercise caution when usingthe power he or she holds to build or de-stroy the learner’s self-confidence.

Nursing practice involves a great deal ofincidental and planned teaching. For exam-ple, every time a nurse answers a questionor explains the events associated with aspecific procedure, he or she is involved inincidental teaching. Similarly, responses toquestions about diet, exercise, rest, sleep,safety, and stress reduction comprise inci-dental teaching that often applies to morethan just the individual patient. Using thisapproach, the WOC nurse can incidentallyteach health promotion practices that bearlittle direct relationship to ostomy care ormanagement but retain the potential forimproving the overall health of the patient.In contrast to incidental instruction, plannedteaching is designed to meet the need of aspecific patient or family for information. Itis based on a set of predetermined goalsand is tailored to meet the needs of the indi-vidual and the situation. For professionalnurses, teaching may be designed to ensurethat patients are fully informed before theygive consent for treatment or surgery andthat they are knowledgeable about post-procedural care. For WOC nurses teachinga patient with a new ostomy, plannedteaching includes selection of a pouchingsystem, pouch changes, and peristomalskin care.

TYPES OF LEARNINGEducators recognize 3 types of learning:

cognitive, affective, and psychomotor. Forthe purpose of this article, a brief overviewof the taxonomies described by Redman1

will be used as a basis for reviewing learn-ing principles underlying successful pa-tient education following creation of anostomy.

Cognitive LearningCognitive learning requires complex

understanding of both concrete and abstractconcepts. Although it is often equated withliteracy, cognitive learning can occur in theabsence of the ability to read and write. Thisobservation is important for WOC nurseswho have patients with a new stoma andlimited literacy skills. On the other hand, itis unwise to assume that the ability to readand write implies the ability to comprehendprinted materials and verbal explanationsprovided during ostomy instruction. I have

observed that the use of terminology that isfamiliar to nurses but foreign to patientswho lack knowledge of our technical vocab-ulary is the most common mistake nursesmake when teaching patients. Correct ana-tomic terms can certainly be used, but thenurse should explain the meaning of theterms and make sure the patient under-stands how to use the terms correctly.

Bloom2 describes 6 successive stages ofcognitive learning: knowledge (informa-tion recall), comprehension (understand-ing events or phenomena), application(putting knowledge and understanding touse), analysis (breaking down materialinto component parts to see the relation-ship between these parts), synthesis (as-sembling information in novel ways), andevaluation (judgment of the worth or effec-tiveness of an action or a decision). Whenteaching ostomy care, WOC nurses mustremember that it is not enough for thepatient to be able to define and describe thecare of the ostomy. Instead, the patient willalso need to understand the mechanismsof physiologic function as they relate to theostomy, principles of skin care, the func-tion and purpose of the appliance, andclean technique. Once patients know andcomprehend the essential information,nurses must help them progress to theapplication level so that they can takeappropriate steps to maintain skin integri-ty and proper fit of the appliance. Onlyafter patients gain confidence in their abil-ity to apply this knowledge will they beready to progress to analysis and synthe-sis, allowing them to solve routine prob-lems related to the ostomy and its care.Evaluation, the final stage of cognitivelearning, is typically achieved after patientshave lived with the ostomy for a pro-longed period of time. When patients achieve this level of learning, not only arethey able to independently perform osto-my care, but they also can assess and eval-uate the effectiveness of the care they areproviding and recognize when consulta-tion with the WOC nurse is indicated.

Affective LearningAffective learning is related to attitudes,

feelings, and values.1 Like cognitive learn-ing, affective learning has been describedas a series of 5 progressive steps. The firststep is receiving or attending; it occurswhen the person becomes aware of factorsthat have emotional overtones and is opento new experiences and to behaving innew ways. For patients with ostomies, re-

Educatorsrecognize 3

types oflearning:

cognitive,affective, andpsychomotor.

JWOCN48 O’Shea January 2001

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JWOCNVolume 28, Number 1 O’Shea 49

ceiving or attending occurs when they areopen to hearing information about care ofthe ostomy and achieve some level ofacceptance that changes must occur regard-ing self-care. This level of affective learn-ing often begins with the willingness toview the stoma for the first time.

The second stage of affective learning isresponding, which is defined as a commit-ment to behave in a new way. For patientswith ostomies, responding may be indicat-ed by a willingness to participate in emp-tying or changing the appliance. The thirdstage, valuing, is characterized by recogni-tion that a change in behavior is worth-while, for example, recognizing that self-care of the ostomy is an advantage thatleads to greater independence and a returnto a more normal life. The fourth stage,organizing, requires incorporation of thenew behavior into one’s lifestyle. Patientswith ostomies exhibit organization whenthey are able to perceive the stoma as bet-ter than the alternatives of intractable,severe symptoms of inflammatory boweldisease or a malignancy and to combinethis knowledge with proactive planningfor a return to normal living. The finalstage in affective learning requires theinternalization of a new behavior so com-pletely that it becomes an integral part ofthe person’s being. This stage is observedin persons whose lifestyle is not impededby the presence of the ostomy and whoaccept it as an integral part of the self.

Typically, affective learning is more diffi-cult than cognitive learning for persons witha new ostomy. Patients with an ostomy facenot only their attitude toward the physicalchanges that have resulted from surgery, but also the attitudes of family members,friends, co-workers, and health care pro-viders.3 We are taught from childhood thathuman excrement is dirty and that problemsdealing with elimination are not a topic ofpolite conversation. Therefore, overcomingnegative feelings about the ostomy is nosmall task. This helps nurses understandwhy cognitive learning proceeds morerapidly than affective learning for patientslearning to manage a new stoma.

Psychomotor LearningPsychomotor learning requires the mas-

tery of motor skill.1 Learning a new motorskill requires a mental image of how theskill is performed and the neuromuscularability to execute the technique. Providedthe learner possesses both the cognitiveand neuromuscular requirements, learning

a new motor skill is rapidly accomplishedand easily evaluated. The stages of psy-chomotor learning are logical and progres-sive. The first stage is perception, which isdefined as an awareness of what is to bedone. When applied to teaching a patient tomanage a new stoma, a demonstration ofostomy equipment is typically necessaryfor the patient to form the necessary mentalimage. The second stage is characterized bya readiness to try the task. For patients withan ostomy, this is viewed as the initialattempt at a return demonstration. Thethird stage is guided response. When teach-ing ostomy care, tasks are initially per-formed under direction while allowing fortrial and error. The fourth stage, mecha-nism, occurs when the person has attainedsome level of skill and some of the stepsbecome habit. A fifth stage, adaptation,occurs when the person is able to changethe procedure in response to a new situa-tion. For example, upon being faced withthe inability to obtain the appliance that heor she usually uses, the patient who hasreached the adaptation stage would be ableto modify another pouch for temporaryuse. The final stage, origination, is charac-terized by new techniques of accomplish-ing a particular skill. This stage may bemore characteristic of the WOC nurse com-pared with the patient who has an ostomy.

Learning StylesLearning styles have only recently re-

ceived attention from educational theorists.4Learning styles refer to a person’s prefer-

Typically,affective

learning ismore difficult

thancognitive

learning forpersons with

a newostomy.

BOXEssential knowledge characterizingsuccessful ostomy education1. What is an ostomy? How does an osto-

my work, and how does its functioncompare with normal elimination?

2. What was the underlying condition thatresulted in the decision to perform stomasurgery?

3. How does one care for the stoma andthe surrounding skin?

4. How does one apply, empty, clean, andremove the appliance?

5. Where does one purchase the suppliesrequired for pouch changes and relatedostomy management? What is the costof these supplies?

6. What changes in diet, fluid intake, sleep,rest, and exercise habits are demandedby the presence of the ostomy?

7. How will having the ostomy affect sexualactivity, social life, work, and recreation?

8. How do others cope with such drasticchanges in their bodies?

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ences for receiving new information, suchas how material is presented, and the opti-mal environment for teaching. The bestknown categories are auditory learners,who prefer to learn by listening, and visuallearners, who prefer reading or observing.Patients learn in different ways, and themajority use more than one strategy whenlearning new material. Although it is un-likely that ostomy nurses will have time toadminister a learning preference test beforeplanning patient teaching, they can gainsome knowledge about learning styles byasking the patient whether he or she learnsbetter by reading about a new topic or bylistening to someone explain it. The re-sponse helps determine whether plannedteaching should begin with a brief explana-tion combined with appropriate printedmaterials to read before the next teachingsession or a lengthy explanation during theinitial session reinforced by printed materi-als for future reference. Regardless of thepatient’s learning style, the WOC nursemust remember that psychomotor skills canonly be learned through repeated practice.

Important differences are revealed whencomparing principles of learning appliedto adults compared with children (seereviews by Knowles5,6). For example,adults are more likely to be independentthan dependent, and they usually resistbeing told “what to do” in a manner simi-lar to that used for teaching children.Adults also seek to actively participate indetermining what they need to know. Theyneed to feel that they have responsibilityfor their own learning, and they are able todetermine their own progress in learning.

Compared with children, adults use awealth of previous life experiences as aresource for learning. Whenever possible,the WOC nurse can improve the processof learning by helping the patient makeconnections between the informationbeing presented and prior experiences. Forexample, nurses can build on prior experi-ence with chronic wound care or knowl-edge of the relationship between dietaryintake and elimination. Prior experienceusing sealants or solvents in a job orhobby can also be used as a starting pointwhen explaining the application of anostomy pouch. Even previous experiencewith diaper rash can establish a connect-ing point when teaching about skin care.

Adults also want learning to be problemfocused and relevant to their current situ-ation. Compared with children, adultstend to exhibit less interest in general infor-

mation that is not immediately applicableto their current condition. This character-istic can make teaching the mechanics ofostomy care easier than teaching the dietarychanges that may not be relevant until thepatient goes home.

Other learning principles apply equallyto adults and children.4 These principlesinclude the importance of motivation andthe presence of periodic plateaus in thelearning curve that necessitate breaks inlearning sessions. Knowledge about osto-my care cannot mastered all at once, re-gardless of the patient’s motivation. Inaddition, motivation tends to wane whenthe learner is overwhelmed by the amountof material to be mastered. These latterprinciples help explain why all the in-struction a patient with an ostomy needscannot be completed in a single session.

A final learning principle relates to therole that anxiety plays in the learningprocess. A mild to moderate level of anxi-ety increases alertness and is believed toenhance learning. A patient who is apa-thetic displays little interest in the envi-ronment and is unable to take in the stim-ulus related to the teaching. In contrast,highly anxious patients are unable to ben-efit from teaching because they are unableto block out irrelevant stimuli and havegreat difficulty processing information.

THE TEACHING PROCESSThe steps in the teaching process are

very similar to the steps in nursing pro-cess.1 In the nursing process, the nurseuses assessment, diagnosis, planning, im-plementation, and evaluation. When thenursing diagnosis indicates a knowledgedeficit related to wound or ostomy care,the WOC nurse applies the teaching pro-cess in which the steps are assessment, set-ting learning objectives, planning the teach-ing, implementation of the teaching plan,and evaluating the effectiveness of theteaching.

AssessmentIn the case of the teaching process,

assessment includes gathering data aboutthe patient’s need to learn, emotionalreadiness to learn, and experiential readi-ness to learn. Assessing the patient’s needto learn includes determining what he cur-rently knows or believes he knows abouthow to care for and manage his ostomy. Inaddition, the nurse needs to determinewhat the patient wishes to know and how

Patients learnin different

ways, and themajority usemore than

one strategywhen

learning newmaterial.


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this desire compares with what the nursethinks he must know (Box).

Assessing the patient’s emotional readi-ness to learn may at first glance seem like aluxury that nurses can no longer afford inthis age of managed care. Nevertheless,without some knowledge of the patient’semotional readiness to learn, valuable timeand effort may be lost. Emotional readinessincludes an assessment of the patient’s abil-ity and willingness to put forth the effortneeded to learn. If the patient is depressed,angry, highly anxious, or withdrawn, teach-ing results in little learning. A patient whodoes not yet recognize the need to learn orhas difficulty accepting help from otherswill also find learning difficult. Other emo-tional impediments to learning include aperception that the ostomy symbolizes acomplete loss of control, a perception thatthe nurse is not a reliable source of infor-mation, or a perception that the nurse isdisinterested in his or her welfare.

Assessing the patient’s experiential read-iness to learn helps the nurse to determineoptimal teaching strategies and the timingof instruction. Assessment of experientialreadiness requires evaluation of the pa-tient’s developmental status, chronologicage, cognitive ability, language skills, edu-cational level, and previous experiencewith ostomy management or similar con-ditions. The patient’s mental and physicalstatus also merit assessment. Is she alert, oris she confused or sedated? Is she restedand physically comfortable, or restless andin pain? The nurse must also assess for thepresence of motor disabilities that renderself-management of the ostomy difficult orimpossible. For example, does the patienthave impaired sight or hearing likely tocomplicate ostomy teaching?

The assessment of learning readiness alsoincludes an evaluation of resources neededto achieve self-care. These resources includeadequate housing with plumbing and a safewater supply, family or friends who arewilling and able to provide assistance ifneeded, reasonable access to ostomy sup-plies, and sufficient financial resourcesto permit the patient to actually followthrough with the nurse’s instructions.

Setting ObjectivesThe second step of the teaching process

is determining learning objectives. Theobjectives provide a road map allowingboth the patient and nurse to know whenthey have arrived at the destination. Aswith a road map, there is often more than

one way to make the journey. Learning ob-jectives that are acceptable to the patientwill allow the teaching to be done effective-ly and efficiently. Using the analogy of theroad map, the trip will be more efficient ifboth the nurse and patient travel in thesame vehicle and avoid unnecessary sidetrips. In addition, the journey will not occurif the patient feels he is being pushed aheadtoo quickly or if the nurse feels she is con-stantly looking over her shoulder to see ifthe patient is keeping up. To be effective,the learning objectives must be patient-cen-tered, realistic, achievable, and acceptableto the patient. They should not be cumber-some, but they should be sufficiently spe-cific to clearly define expectations for boththe patient and the nurse. If written proto-cols for teaching exist, they are likely toinclude learning objectives. These predeter-mined objectives can be reviewed by thenurse and the patient for relevance andapplicability to the individual situation.

ImplementationOnce objectives have been determined, a

plan for the teaching activities is construct-ed and teaching strategies are implement-ed. The choice of teaching strategies de-pends on the patient’s learning preferencesand available instructional materials. Forexample, anatomic models and samplepouches are often useful, as are written orcomputer-based interactive teaching mate-rials. The teaching plan also addresseshow much to teach and the timing of thisinstruction. Knowledge of follow-up visitsand plans for postdischarge home carehelps the WOC nurse decide what must betaught during the initial hospital courseand what instruction can be incorporatedinto follow-up visits. Prior to hospital dis-charge, the patient must have adequateinformation to be able to manage the osto-my safely at home and recognize problemsthat may be resolved through telephoneconsultation compared with those thatrequire immediate medical attention. Ideal-ly, the WOC nurse knows who will beresponsible for follow-up teaching; how-ever, a written summary of teaching of-ten must substitute for telephone or face-to-face consultation. This documentationshould include any teaching that was de-liberately delayed for follow-up visits anda summary of content the WOC nurse inthe acute care setting believes is most like-ly to require reinforcement.

The best time to implement specific as-pects of the teaching plan also must be indi-

Assessing thepatient’s

emotionalreadiness tolearn may atfirst glanceseem like aluxury that

nurses can nolonger affordin this age of

managedcare.

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vidualized. Ideally, teaching is planned sothat it will not be interrupted by routineevents such as meals or morning care. Inaddition, a time is selected when the pa-tient is most likely to be awake, alert, andrested. If a family member or friend of thepatient is to be included in the teaching ses-sion, the session should be scheduled at atime when all participants can be present. Ifthe instruction is to be done as part of a fol-low-up appointment, it is probably best toschedule a time for it so that the patient isnot worrying about missing her turn to seethe doctor instead of paying attention tothe information being presented.

Teaching materials are organized using a“simple to complex” taxonomy. Basic infor-mation such as definitions of medicalterms are taught initially, followed bymore complex skills and knowledge need-ed to master self-care of the ostomy. Never-theless, when organizing content for anadult learner, it is critical to omit materialsalready familiar to the patient in order toengage and hold his or her attention.

Ongoing assessment of the patient’sresponse to instruction is essential whenteaching ostomy care. The nurse shouldwatch for verbal and nonverbal clues indi-cating comprehension of the material. Thepatient can be encouraged to becomeinvolved in the teaching process by givinghim or her permission to interrupt at any time with questions. Similarly, in-volvement in psychomotor instruction is enhanced by frequent pauses to allowquestions or a step-by-step return demon-stration. The WOC nurse should providepositive feedback and correct errorspromptly by explaining why the action isincorrect, how it differs from the correctaction, and why the correct action is mosteffective. When teaching, the nurse shouldremain alert to signs of fatigue, frustration,or increasing anxiety. Ideally, each sessionshould be concluded before the patient’sattention begins to slip. This strategy is pre-ferred because it leaves the patient wantingmore information, rather than teachinguntil the patient wants nothing more thanfor the nurse to leave him or her alone.

EvaluationSeveral options may be used to evaluate

the effectiveness of ostomy teaching. Themost direct method is to ask the patient ifhe has questions or if there is informationhe would like repeated or explained in adifferent way. If the learner responds thatall is clear and he has no questions, the

nurse may ask several probing questionsto evaluate critical knowledge. For exam-ple, the nurse may ask, “What would youdo if your skin became red and painful?” Amore indirect method can be used to eval-uate the patient’s understanding of dietaryconsiderations. The WOC nurse can askthe patient to identify recent food and bev-erage choices from the hospital menu. Thebest method for evaluating psychomotorskills is completed by observing how thepatient performs a pouch change.

Long-term evaluation of teaching effec-tiveness is completed during follow-up. Inthis setting, the WOC nurse should observethe condition of the peristomal skin, thepatient’s report of her ability to managethe appliance, and her progress toward re-establishing activities of daily living suchas work or leisure activities.

Whereas an absence of problems gener-ally implies effective teaching, the occur-rence of complications does not necessarilyindicate that teaching has been ineffective.Rather, the patient may be well-informedbut choose not to implement parts of teach-ing. When problems or preventable com-plications occur, the patient’s cognitiveunderstanding should be reassessed. If thepatient demonstrates accurate knowledgeof ostomy care despite, further assessmentof affective learning is indicated to deter-mine reasons for noncompliance.

SPECIAL POPULATIONSTeaching Aged Patients

As the proportion of people older than65 years continues to grow, the proportionof older patients with ostomies is alsoincreasing.7 Although physiologic and cog-nitive changes occur with advanced age, itis inaccurate to expect that every elderlypatient will require special teaching tech-niques. Instead, individual assessment ofthe patient’s physiologic and cognitivefunction is indicated to identify whetherteaching strategies will require modifica-tion. For example, assessment of gross andfine motor skills is indicated to determinewhether the patient is likely to have diffi-culty opening packaged equipment, cleans-ing the skin, applying a skin protectant,and placing or emptying a pouch. Thepatient should also assessed for visual orhearing impairment followed by appropri-ate alteration of teaching strategies.

Although elder patients are effectivelearners, I have observed that they often

Ongoingassessment ofthe patient’sresponse toinstruction is

essentialwhen

teachingostomy care.


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require a longer period of time to learn.Therefore, when teaching aged patients,particularly very old persons, it is impor-tant to remember that their reaction time isslowed and to plan for the additional timeit will take to instruct them. An elderly per-son’s long-term memory may be betterthan his or her recent memory, and thusrelating ostomy teaching to previous learn-ing or experience is particularly effective inthis population. Principles of adult learningare relevant when teaching aged patients;whereas they are willing to learn knowl-edge and skills needed to maintain inde-pendence, they are rarely interested inextraneous facts. In addition, older patientsare likely to experience fatigue sooner com-pared with middle-aged adults, and thusteaching sessions should be relatively brief.

Instruction should take place in a quietenvironment for elders with a hearingimpairment. The door should be closedand radios or televisions turned off. Anyaudible fan should also be switched offwhile instruction is taking place. The nurseshould face the patient and enunciate clear-ly, using simple rather than complex sen-tences. Written materials are provided tocomplement verbal teaching, and a flipchart may be useful in certain cases. If thepatient uses a hearing aid, the nurse shouldensure that it is in place and activated priorto teaching, even if this requires reschedul-ing a session until the hearing aid is madeavailable. Whereas clear enunciation is crit-ical, elders often have difficulty hearinghigher pitched sound, and thus speakinglouder is often not necessary or helpful.

In the aged person, impaired eyesightmay be attributable to diminished vis-ual acuity and reduced peripheral vision.Instruction is enhanced by using materialswith larger print and blue or cream-col-ored paper that reduces glare when placedunder direct lighting. Fortunately, the easewith which font sizes can be changed inword processing programs makes produc-ing large-print teaching materials mucheasier that it once was. WOC nurses canalso reduce glare when demonstratingskills by moving away from windowsreceiving sunlight during teaching ses-sions. For patients with significant visualimpairment, the use of magnifying lensesand bright lights may be critical.8

Teaching Illiterate PatientsTeaching ostomy care to a patient who

cannot read at all or who has limited litera-cy skills poses a particular challenge for

WOC nurses. Nevertheless, it is essential toremember that illiteracy is not synonymouswith a lack of intelligence. Most adults whoare unable to read are fully aware of theirlimitation and often go to great lengths tohide their illiteracy from others. Within thiscontext, it is especially important to avoidbehavior that compromises the patient’sself-esteem. Therefore, if the nurse suspectsthe patient cannot read, it is best to verifythis perception in a manner that preservesthe patient’s dignity and privacy and mod-ify teaching strategies appropriately. Forexample, effective alternatives to printedmaterials include verbal explanation, pic-tures, graphics, audiotapes, videotapes,models, and demonstrations. The nursemay use a color coding or numbering se-quence to compensate for an inability toread labels. Arrows indicating progressionfrom one illustration to the next can helpthe patient follow a multiple step proce-dure in the intended order. Regardless ofthe alternative strategies used, an ongoingassessment of the patient’s understandingis critical. Readers who encounter numer-ous illiterate patients may find the bookTeaching Patients with Low Literacy Skills9

particularly useful.

TEACHING CULTURALLYDIVERSE PATIENTS

Patients whose culture, values, andbeliefs differ markedly from those of thenurse present yet another challenge toeffective ostomy teaching. Provision ofspecific information about different cul-tures is beyond the scope of this article,but general guidelines will be reviewed.

Planned teaching for a patient fromanother culture begins with an assessmentof how closely the individual is affiliatedwith his or her culture of origin.10 For anew immigrant, the connection may bequite close, whereas second- or third-gen-eration immigrants may maintain onlyminimal affiliation. In addition to consult-ing the published literature and colleagues,the nurse should ask the patient and his orher family to explain or describe culturalpractices that may influence compliancewith routine teaching about ostomy care.For example, in some cultures it is unac-ceptable for a female teacher to give direc-tions to a male learner. Similarly, if dietaryor hygienic practices conflict with specificaspects of the teaching plan, the nurseshould negotiate an acceptable compro-

Teachingostomy careto a patientwho cannotread at all or

who haslimited

literacy posesa particular

challenge forWOC nurses.

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mise, based on a sensitivity to cultural dif-ferences, if indicated.

The nurse should carefully consider theinfluence of cultural differences on osto-my management before designing a teach-ing plan. If the cultural practice is useful,support it; if it is harmless, it can beaccepted or ignored. However, a culturalpractice that poses a potential risk tohealth should be confronted with a care-ful explanation of the nurse’s reserva-tions. If the practice is likely to harm theperson, the nurse should discourage itsuse, while maintaining the realization thatthe patient and family ultimately retainthe right to alter behaviors based on theirimpact on health. The key to success isacceptance of the legitimacy of the otherperson’s beliefs, respect for his or herautonomy, and genuine concern for thepatient’s welfare.

TEACHING PATIENTSWHO DO NOT SPEAKENGLISH

When the patient’s primary language isnot English and the nurse does not speakthe patient’s primary language, additionalbarriers must be overcome before effectiveteaching can begin. If the patient speakssome English or the nurse is partially flu-ent in the patient’s native language, thenurse may overcome language barriersthrough the use of simple sentences andprecise terminology. In addition, a verbalexplanation of any procedure must be fol-lowed with a return demonstration to en-sure comprehension. The WOC nurse alsomay choose to use pictures and graphics tosupplement written materials.

If the patient speaks no English and thenurse in not familiar with his or her nativelanguage, a translator will be needed.Because the translator must be accept-able to the patient, it may be necessary toascertain whether gender and rank areimportant factors in translator selection.The use of simple language and preciseterminology is important when teachingthrough a translator. The nurse also mustremember to speak directly to the patientand not to the translator. The patient maynot be able to understand the words, buthe often will understand the body lan-guage and the tone used to present themessage. The nurse should also remem-ber to speak at a normal conversationalvolume; raising the volume of speech will

not render the language any more com-prehensible to the patient, and this behav-ior may be misinterpreted as hostile orauthoritarian.

When teaching with the assistance of atranslator, the nurse should remember topause for translation. Comprehension canbe evaluated by requesting that the trans-lator ask the patient to repeat instructions,followed by word-for-word translation ofthe patient’s response.

SUMMARYTeaching patients with an ostomy is a

complex process that requires careful assess-ment, planning, and evaluation. Becauselearning must occur in all 3 domains—cognitive, affective, and psychomotor—the nurse must use a variety of teachingstrategies as well as ongoing assessmentof comprehension and acceptance of newinformation and techniques. Limited time,cost constraints, and the need to teach anincreasingly diverse and aging populationpose further challenges to effective osto-my education. Nevertheless, applicationof well-established principles of teachingand learning can make the process effi-cient, effective, and satisfying for both thepatient and the nurse.

REFERENCES1. Redman BK. The process of patient education(6th ed). St Louis: Mosby; 1988. p. 65-80.2. Bloom BS. Taxonomy of educational objectives:the classification of educational goals. Hand-book I: cognitive domain. New York: David McKayCo, Inc; 1977.3. Aron S, Carraareto R, Prazeres SMJ, deCerqeeiraAPB, Santos VLCdeG. Self-perceptions about havingan ostomy: a postoperative analysis. OstomyWound Manage 1999:45;46-62.4. Van Hoozier H, Bratton B, Ostmoe P, Weinholtz D,Craft M, Albanese M, et al. The teaching process:theory and practice in nursing. Norwalk (CT):Appleton-Century–Crofts; 1987.5. Knowles MS. Androgogy in action. San Fran-cisco: Jossey Bass; 1984.6. Knowles MS. The adult learner: a neglectedspecies (4th ed). Houston (TX): Gulf; 1990.7. Ebersole P, Hess P. Toward healthy aging. StLouis: Mosby; 1998.8. Jeffries CM, MacKay AT. Improving stoma man-agement in the low-vision patient. J WOCN 1997;24:302-10.9. Doak CC, Doak LG, Root JH. Teaching patientswith low literacy skills (2nd ed). Philadelphia: JBLippincott; 1996.10. Zoucha R, Zamarripa C. The significance ofculture in the care of the client with an ostomy. JWOCN 1997;24:270-6.

When thepatient’sprimary

language isnot English

and the nursedoes notspeak thepatient’sprimary

language,additional

barriers mustbe overcome

beforeeffective

teaching canbegin.


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Teaching the adult ostomy patient