Rehabilitation NURSING

Bags and Blogs: Creating an

Winner of the
2011
Ostomy Experience for
Writers’ Award
Nursing Students
Karen S. Reed, MSN DHSc RN CNL CRRN
KEY WORDS
blogs Background: There are well over three-quarters of a million people living in the United States with an ostomy. These
ostomy individuals experience many physical and emotional challenges which nurses should address during the in-patient
simulation hospitalization experience.
Purpose: The purpose of this educational activity was to provide undergraduate nursing students with a simulated
undergraduate nursing
laboratory experience which allowed the student to discuss and experience some of the challenges of living with an
education
ostomy.
Method: Small group work, an experiential learning activity, and blogging were used to foster the cognitive, psychomo-
tor, and affective development of the nursing students.
Results: All 134 students participated in the small group work and blogging experience and over 100 students partici-
pated in the experiential learning activity of wearing an ostomy bag overnight with the bag containing a small amount
of simulated fecal material.
Discussion: The impact of the simulated experience is evident in the depth of awareness and emotion expressed in the
blogs. The students collectively acknowledged the value of the activity and the impact the gained awareness had on their
careers as nurses.
Conclusion: The use of social technology and the provision of learning activities, not available on the clinical unit, can
have a significant impact on the cognitive, psychomotor, and affective development of nursing students.

Introduction Background
In 2000, there were approximately 800,000 people Nursing students are directed to view their patients’
living in the United States with an ostomy (Turnbull, needs holistically, but it is personal observation that
2008) with an anticipated annual increase of 3% per students typically view patient needs within the
year. Nursing care for a person with an ostomy can timeframe of a patient's immediate needs post-dis-
involve multiple challenges, which affect an individ- charge from an acute care setting. This is under-
ual's physical and emotional well-being. Challenges standable, given that the average length of stay for a
include disturbed body image, ineffective health non-federal short-stay hospital in 2007 was 4.8 days
maintenance, ineffective sexuality, risk for constipa- (Centers for Disease Control and Prevention [CDC],
tion/diarrhea, risk for impaired skin integrity and n.d.), thus limiting the time nursing students are
risk for social isolation (Ackley & Ladwig, 2008). exposed to addressing the long-term needs of any
Pittman et al. (2008) noted that successful adapta- one patient. This limited exposure is confounded
tion to a colostomy is more likely when an individual with the challenges facing nursing students in
is provided with instructions in self-care and acquiring a body of knowledge that entails psycho-
psychological support is given. Such support is a motor, cognitive, and affective skills and learning.
feature of rehabilitation nursing. Rehabilitation Nursing students must learn beyond the cognitive
nurses influence individuals, families, and commu- and psychomotor aspects of caring for individuals
nity attitudes and perceptions when there is a loss of with an ostomy; therefore, they must have exposure
function (Preston, 1994). If it is believed that rehabili- to learning activities, which assist students in devel-
tation nursing is a philosophy, not a place (ARN, oping strategies addressing these individuals’ emo-
n.d.), then it is critical to have nursing faculty who tional needs and sense of well-being.
embrace the philosophy of rehabilitation nursing to
integrate the concepts of our specialty into the Purpose
educational activities and experiences of nursing David Kolb, who asserts individuals “construct
students. abstract representations from concrete experiences”

62 Rehabilitation Nursing  Vol. 37, No. 2  March-April 2012

(p. 985), first proposed the theory of experiential important as students, aside from personal conver-
learning. He describes the learning cycle as com- sations with friends, do not typically discuss this
posed of concrete experiences, reflective observa- subject verbally, in a large group setting or with
tion, abstract conceptualization, and active strangers. The presentation groups demonstrated
experimentation (Laschinger, 1990). Although not a the behaviors one would expect when subject con-
nursing theory, experiential learning is a middle tent on sexual activity is presented: nervous gig-
range theory allowing for adaptation and applica- gling, blushing, and lack of direct eye contact with
tion in nursing education (Lisko & O'Dell, 2010). It the audience. However, toward the end of the small
is typical for nursing students in a simulated lab group presentations, the presentations changed
setting to have concrete learning experiences by tone and became a platform for active and interac-
practicing the psychomotor skills associated with tive discussions on how a nurse should broach the
an ostomy appliance. However, inclusion of social subject of body image and sexuality and how a
activities enhances the empathy of the nursing stu- nurse can discuss recommendations without creat-
dents when participating in a simulated ostomy ing an impression of his or her own personal sex
experience (Stover, 2010). life. If nurses are expected to provide holistic health
Empathy is a key component of the therapeutic education and information, it is important for stu-
relationship between patients and nurses. It is the dent nurses to have the opportunity to practice
nurse's sense of empathy that allows the nurse to delivering this type of intimate information in a
recognize the uniqueness of a patient's situation comfortable, supportive learning environment.
and care of the patient in a holistic manner (Stover, The second learning activity was an optional
2010). A simulated ostomy experience was one. Students were provided the opportunity of
designed to assist nursing students in moving earning bonus points on their quiz grade for that
beyond the typical psychomotor skills learned in a week if they wore an ostomy appliance home over-
laboratory setting to developing personal insight night and wrote a blog about the experience the
and appreciation for the psychosocial impact an next day. Students who did not wish to participate
ostomy has on the sexual health and quality of life were offered the opportunity of responding to
of individuals. blogs for bonus points. The blog page was located
on the course website and only the students and
Materials and Methods faculty with access to that course had access to the
The simulation experience was designed using entries. Students were not given a specific word
small group work, an experiential learning activity count nor did the blog require use of references.
and blogging to foster a nursing student's cogni- Students understood that their name would be seen
tive, psychomotor, and affective development. The when the blog was posted. The sole purpose of the
first learning activity centered on the role of the blog was to convey the students’ feelings and expe-
nurse as a therapeutic agent in discussing sensitive riences during the next 16–20 hours.
issues with an ostomy patient. Rehabilitation Students were provided markers to create their
nurses recognize sexuality as a basic human need own “stoma.” It was up to each student to decide
and operate within a model of care, which encour- the location of the stoma, its size and its color. Use
ages conversation on the impact of illness or dis- of humor as a therapeutic modality was evident as
ability on an individual's sexuality. Yet, sexuality is there were many stomas drawn using the univer-
a subject many nurses find embarrassing, generally sity's colors. Each student, in the role of the nurse,
uncomfortable, and difficult to address (Jankowiak, taught his or her partner, the “patient,” the steps in
2009). So, if not within one's nursing studies, how applying an ostomy wafer and attaching a bag. Stu-
does a nursing student develop a comfort level dents had the opportunity of “blinging” the ostomy
conducive to assisting patients experiencing bags, which was a frequently shared suggestion in
an altered body image or a sense of impaired the earlier learning activity. The experience was
sexuality? made more real as each ostomy bag contained
Students, in small groups of four to five, approximately 90 ml of simulated fecal material
designed posters identifying strategies, which created by using chocolate pudding, oatmeal, and a
could be used by individuals with ostomies to pro- small amount of fake fecal odor. While the fecal
mote a positive body image as well as foster a posi- odor was not strong enough to permeate the
tive sense of sexuality. Each small group then clothes, it was noticeable when one's nose was in
presented their poster, sharing their ideas from the close proximity of the ostomy bag and the mere
front of the classroom to the other students. Presen- thought of its presence created more than a few gri-
tation from the front of the classroom was deemed maces.

Rehabilitation Nursing  Vol. 37, No. 2  March-April 2012 63

Bags and Blogs: Creating an Ostomy Experience for Nursing
Students

Discussion Box 4. Excerpt of a Student Blog

There were 134 students enrolled in this nursing
“When I got home, I tried figuring out ways to tuck
course and over 100 students chose to participate in it away under my clothes, but I figured, ‘Ahh what
wearing an ostomy appliance overnight. Reflective the heck, just let it hang out!’ That soon changed
writing or journaling has been identified as a bene- when I went to XXXX restaurant, and realized my
new lack of social confidence. With all these
ficial method in the learning process (Blake, 2005; college students around my age, I knew they
Boud & Walker, 1998). Journaling is one method for would look at my ‘bag of poop’ and most likely
promoting student transference of theory into prac- judge me. I felt immediately inadequate, even
though I had no reason to. I can only imagine what
tice (Noveletsky, 2006) and has been found effective people with real colostomies have trouble dealing
by students and faculty (Epp, 2008). Goals of reflec- with.”
tive writing include developing affective skills and
gaining the perspective of others (Blake, 2005). The
term blogging is used to describe this activity as the activity. The blogs contained stories of the discomfi-
journal entries were not paper submissions, but ture felt taking public transportation or riding a
were submitted on an electronic board, visible to bike home while wearing white scrubs and the ost-
more individuals than the instructor. The blog omy appliance. Several students faced strong nega-
entries were stunning in their depth and passion. tive reactions from non-nursing major roommates
As an educator and as a rehabilitation nurse, it was (Box 1) and two students described how their boy-
exciting beyond words and emotionally touching to friend or spouse reacted when seeing the ostomy
see the realization, the compassion, and the profes- bag (Box 2). One student described how this learn-
sional maturity that emerged from this learning ing experience created an opportunity for the cou-
ple to engage in frank dialogue the challenges a
relationship faces when one of the partners experi-
Box 1. Excerpt of a Student’s Blog ences a chronic illness or permanent injury and
“Throughout this whole experience, what whether or not their relationship was strong
interested me the most were the reactions I enough for such challenges. Students shared how
received from my roommates and friends.
Comments like, ‘Eewww, that is soo nasty, why
they either avoided their normal evening activities
would you do that to yourself,’ were all I heard. (Box 3) or faced the challenge of adapting the activ-
This made me think of the reaction that people ity or clothing wearing the ostomy appliance
living with ostomies have to deal with. They don’t
have the choice of simply removing it the next
(Box 4). Out of the entire participating group, only
morning at 8 AM. This is something that they have two students reported their ostomy bags leaked
to face and learn to live with. This experience “fecal contents” on their beds or clothing, although
allowed me to be on the inside looking out,
instead of being on the outside looking in.”
many students shared an uncomfortable “aware-
ness” of the ostomy bag throughout the night and
experienced worry that it would break open. The
only negative physical experiences reported were
Box 2. Excerpt of a Student Blog
some cases of skin tenderness when students
“….most interesting part of the experience came removed the ostomy wafer. All students had been
when I was with my boyfriend. I showed him the encouraged to prep the skin prior to application of
bag and he had a very supportive opinion of the
bag. … it was a new addition to deal with but it did the ostomy wafer using either a barrier device or
not hinder the intimate setting. I only ran into wipes. However, not all students chose to do so
problems when I woke up. I arrived on campus at and blog entries reflected their chagrin the next
8AM and was told by another girl my bag had
leaked. It indeed had spilled all over my white tank morning when removing the ostomy wafer. With-
and embarrassment was spared because I knew it out fail, the students evaluated the experience as
was pudding, but I can only imagine how it would the best learning activity they had experienced in
feel if another person was to point out an actual
leakage to a patient.” the simulated lab setting and the positive impact
the experience had on their nursing practice. The
anecdotal feedback from the participating students
Box 3. Excerpt of a Student Blog is supported in the literature by a study showing
that students with an affinity for social learning as
“…. Although the bag was tucked beneath my well as those preferring solitary learning activities
sweats, it would creep up and start flailing around
under my shirt. So I would have to awkwardly benefit from a simulation-enhanced learning expe-
shove it back into my pants. It was a good learning rience (Fountain & Alfred, 2009).
experience and helped me gain some insight into There was no assessment or critique provided on
the lifestyle of an ostomy patient.”
the students’ reflections of the ostomy experience,

64 Rehabilitation Nursing  Vol. 37, No. 2  March-April 2012

nor was a particular nursing model or framework ARN (n.d.). A Definition and Brief History of Rehabilitation
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Pittman, J., Rawl, S., Schmidt, C., Grant, M., Ko, C., Wendel,
About the Author C. et al. (2008). Demographic and clinical factors related
to ostomy complications and quality of life in veterans
Karen S. Reed, MSN DHSc RN CNL CRRN, is Clinical with an ostomy. Journal of Wound and Ostomy Continence
Assistant Professor of Nursing at the University of Florida, Nursing, 35(5), 493–503.
College of Nursing, P.O. Box 100187, Gainesville, FL Preston, K. (1994). Rehabilitation nursing: A client-centered
32610. Address correspondence to ksreed@ufl.edu. philosophy. American Journal of Nursing, 94(2), 86–70.
Stover, C. (2010). Use of a confluent education strategy to
develop empathy in nursing students. Journal of Nursing
Education, 49(12), 719–720.
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Ackley, B., & Ladwig, G. (2008). Nursing Diagnosis Handbook: Retrieved August 30, 2011, from http://www.o-wm.com/
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delphia, PA: Mosby.

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