Elaboration of an educational technology for ostomized patients : peristomal skin care

Rev Bras Enferm [Internet]. 2019;72(2):427-34. http://dx.doi.org/10.1590/0034-7167-2016-0024 ABSTRACT Objective: to describe the elaboration of an educational technology to support orientations on peristomal skin care for ostomized patients. Method: the research had a qualitative approach and used the Action-Research method; data was collected through the Focus Group technique, with eight ostomized patients. The data was analyzed through Thematic Content analysis. Results: the analysis generated for categories: the educational material as source of knowledge; difficulties in the peristomal skin care; peristomal skin self-care; and educational technology for ostomized patients. Based on these data, the Educational Technology was elaborated. After its validation, it will contribute to the prevention of peristomal dermatitis. Final considerations: we highlight the contribution of educational technologies in the context of health education and the role of this resource to promote health, prevent complications, develop skills and promote patient autonomy and confidence. Descriptors: Educational Technology; Health Education; Ostomy; Nursing; Focus Groups.


INTRODUCTION
Educational technology is a tool for learning purposes.When used by nurses, it involves the nurse-patient relationship, mainly in the health education process (1) .Technologies are processes implemented based on the daily experience of health care.Some are also derived from research for the development of a set of activities produced and controlled by human beings.They are used to generate and apply knowledge, to master processes and products and to transform empirical uses into scientific approaches (2) .The technologies developed by nurses must be aimed at facilitating their work and improving the quality of the care they provide.In the context of health, Educational Technologies are in the group of light technologies.They are important tools for educational work and for the patient care process (3) .An Educational Technology designed to guide ostomized patients is important, given that every year several people undergo surgical procedures that result in intestinal and/or urinary ostomy.This procedure generates concerns, fear, doubts and insecurity about the care required for the stoma and the peristomal skin, as well as for the exchange of the collection device.
The term ostomy or stoma means 'mouth' or 'opening' and refers to an opening performed through a surgical procedure (4) .This term is used to indicate an exteriorization of a hollow viscera, usually from the abdominal wall (in the case of an intestinal stoma), for the involuntary elimination of feces, due to the loss of sphincter control, requiring the use of a continuous device called stoma bag (4) .
Living with a stoma requires the person to adopt several adaptation measures and readjustments in daily activities.This includes learning self-care actions for the stoma and peristomal skin.The specific self-care actions for the ostomized patient are based on three factors: skin and stoma hygiene, observation of the stoma and peristomal skin, and collection device care (5) .The nurse needs technical, scientific and specialized knowledge to provide nursing care for people with a stoma and to provide guidance on self-care (6) .This professional carries the responsibility of integrating ostomized people and their families, providing answers to the main doubts regarding stoma care and daily care (7) .The quality of life of the ostomized patient is also influenced by peristomal skin alterations, such as peristomal dermatitis.Many factors can contribute to this, including self-care practice (8) .Dermatitis can be acute or chronic, primary or secondary, and is characterized by impaired peristomal skin integrity.The most frequent dermatological alterations are: erythema or irritation, erosion, pustules and even ulcerations (9) .
Peristomal dermatitis is the most frequent cause of impaired peristomal skin integrity.Its presence is disastrous for the wellbeing of the ostomized person and, consequently, for their rehabilitation (10) .The nurse is responsible for evaluating, caring, teaching and helping to maintain the integrity of the peristomal skin, using equipment adequate for the stoma and for the user, along with skin protecting accessories, which are of paramount importance in the prevention and treatment of dermatitis.Therefore, educational strategies are important in their professional practice, with the aim of preventing peristomal dermatitis and encouraging self-care.Given this scenario, we believe that the construction of an Educational Technology as a strategy and instrument for therapeutic support, with specific guidelines on peristomal skin care, will be a valid contribution, after its validation, for the prevention of peristomal dermatitis, aiming at a good adaptation of the collection devices, stimulating self-care and increasing quality of life.In addition, it will help family members and/or caregivers who also participate in this care, as well as the nursing professionals, since it will be an educational instrument to support the care provided to the ostomized patient.

OBJECTIVE
Describe the development of an Educational Technology for ostomized patients, with a focus on peristomal skin care and aimed at supporting patients in the prevention of peristomal dermatitis and reducing the incidence of this complication.

METHOD Ethical aspects
The research was developed in accordance with the regulations and norms of Resolution 466/2012 of the CNS/MS.Data collection began only with written approval from the Research Ethics Committee of the State University of Pará.

Theoretical-methodological framework and type of study
This is a study with qualitative approach.The Action-Research method was used, in a partnership with a group of ostomized patients, who reported problems related to peristomal skin selfcare, difficulties to deal with this problem and how they prevented peristomal dermatitis.This was the basis for the development of the Educational Technology for peristomal skin self-care.The Action-Research is designed and conducted in close association with an action or with the resolution of a collective problem, in which researchers and participants representing the situation or problem are involved in a cooperative or participatory manner (11) .In the exploratory phase of this research (11) , the problem situation and the possible interested parties were identified during the nursing consultations in the Health Care Service for the Ostomized Patient.The theme of the research also arised from these consultations (11) , where the ostomized patients with peristomal dermatitis and the family member/caregiver reported their difficulties in preventing, caring and treating dermatitis due to lack of orientation or knowledge.From then on, we took interest in the development of an educational technology in partnership with the ostomized patients.At the core of the elaboration of this technology were the seminars (11) , which were called Focus Groups, where we discussed the themes proposed by the group for the educational technology, which emerged from practice and experiences from ostomized patients (11) .During the meetings there were exchanges of knowledge and experiences between the researchers and participants, as well as between the patients themselves.During the planning phases (11) , which occurred in each meeting of the Focus group, the educational technology was elaborated, along with an educational intervention on adequate care for the stoma and peristomal skin.

Elaboration of an educational technology for ostomized patients: peristomal skin care
Carvalho DS, Silva AGI, Ferreira SRM, Braga LC.

Scenario of the Study
The study was carried out in the Health Care Service for the Ostomized Patient of the Unit of Specialized Referral in Health (URES) -Presidente Vargas, in the city of Belém/PA.The participants of the study were eight ostomized patients.The inclusion criteria were: patients with intestinal or urinary stoma, of both genders, who had already presented peristomal complications or who were experiencing it; older than 18 years; who knew how to read and write; living in the city of Belém/PA; who agreed to return to participate in the group meeting; who accepted to participate in the research and signed the Informed Consent Term (TCLE).

Data source
Data collection was carried out through a collective interview, using the Focus Group technique, complemented by the field diary.The choice for the Focus Group was due to the possibility of facilitating dialogue, interaction and exchange of experiences among the participants, which were key factors for the elaboration of an Educational Technology that would meet the needs of the group.The Focus Group is a way of collecting data directly from the speeches of a group.It allows the researcher to understand the reality experienced by this group, as well as the daily practices, attitudes and behaviors prevailing among individuals who share common traits (12) .The Field Diary is an instrument that allows a detailed recording of observations in the research field.It includes the description of the environment, the reflections and perspectives of the researcher, and his personal observations and discoveries during the data collection phase (13) .A script with four open questions was used in the Focus Group and in the construction of the Technology.

Data collection and organization
Four meetings with the group were held for the construction of the Educational Technology.

First Focus group meeting
The meeting was conducted as follows: thanking the participants for their presence; introducing the researchers; explaining the objectives of the study and how the meeting would be conducted; explaining the benefits of the study; explaining the need to record the meetings; ensuring anonymity and confidentiality of the data obtained.The researchers and the participants were identified with a name tag.After that, we conducted a game to introduce the participants, with the objective of promoting interaction between the patients and between the patients and the researchers.Then, the activities with the group began, with the presentation of the first question of the script (How do you see the use of an educational material that clarifies doubts about peristomal skin care?).The participants were encouraged one by one to comment or answer the question.The meeting was concluded with thanking, scheduling of the next meeting and a coffee-break for the participants.

Second Focus group meeting
The meeting was conducted as follows: distribution of nametags for each participant and researcher; thanking the participants for their presence; presentation of the summary of the 1 st meeting, presentation and explanation of the objectives of the 2 nd meeting.In the beginning of the activities with the group, the rest of questions of the script were presented and participants were encouraged to comment or answer them (What conditions interfere with peristomal skin care?How do you practice peristomal skin self-care?What subjects do you consider important for the educational material?).The meeting was concluded with thanking, scheduling of the next meeting and a coffee-break for the participants.

Third Focus group meeting
The meeting was conducted as follows: distribution of nametags for each participant and researcher; thanking the participants for their presence; presentation of the summary of the 2 nd meeting, presentation and explanation of the objectives of the 3 rd meeting.The activities with the group began with the group presentation and reading of the First Outline of the Educational Technology and an image activity, in which each participant could suggest/choose the most appropriate image to illustrate the Technology.This moment allowed adjustments and contributions regarding the content, along with suggestions of images.The meeting was concluded with thanking, scheduling of the next meeting and a coffee-break for the participants.

Fourth Focus group meeting
The meeting was conducted as follows: distribution of nametags for each participant and researcher; thanking the participants for their presence; presentation of the summary of the 1 st meeting, presentation and explanation of the objectives of the 2 nd meeting.The activities with the group began with the group presentation and reading of the Second Outline of the Educational Technology.In this moment, new adjustments and contributions were made by the participants on the: images/pictures, font size, content, a proper title for the technology, color of the pages, cover image and target audience of the Technology.A group activity was conducted to close the activities.The meeting was concluded with thanking, scheduling of the next meeting and a coffee-break for the participants.

Data-analysis
Data analysis began shortly after each meeting of the Focus Group.The material was analyzed according to the Thematic Content Analysis method.The recordings of the meeting were heard and the speeches of the participants were transcribed in full.The Field Diary was also read and observed.After the exhaustive and floating reading of the transcribed material, words and expressions were assigned to identify units of meaning and nuclei of meanings.To this end, tables were elaborated systematizing the main findings that gave rise to the thematic categories.Each thematic category was described and compared to the theoretical material.From this, we inferred what should be present in the educational technology.

RESULTS
The thematic categories emerged from the identification of units of meaning in the material produced in this research.We have the following categories:

Category 1: The educational material as source of knowledge
In this category, it was evidenced that participants perceived the educational material mainly as a source of knowledge on collection devices and protective accessories that should be used and how to use them.The participants considered the material useful for nursing professionals in the hospital area, who often demonstrate that they do not know and do not have experience in the care provided to ostomized patients, and therefore do not adequately guide patients and/or relatives, especially at the moment of hospital discharge.Knowing these devices and how to handle them is important for effective care.Therefore, this educational material will bring information to people and help them manage that reality.It is a way to guide the ostomized patients, the family member and the people who care for them, so the participants defined it as a very good material.Let's look at some speeches that demonstrate this perception.

It is good [...] what to do to improve and to know more [...] what we have to use and how to live with it, we have to understand what is our (Blue Topaz)
I think the material will be very important [...] because I believe that [...] who is in the area of nursing will certainly be interested in any material related to this, because they do not know, so they will learn... (Jade)

Category 2: Difficulties in the peristomal skin care
The analysis of the participants' speeches about the conditions that interfere with peristomal skin care revealed that most of them believed that there were no conditions that interfered with this care and that they already knew how to take care of the peristomal skin.They referred mainly to the period of hospitalization and to the beginning of their condition as ostomized, that is, the factors that interfered in this care were experienced in the postoperative period, at which point the ostomized patient and the family caregiver were very fragile, distressed, insecure and full of doubts related to the situation they were experiencing: ostomy.The difficulties during hospitalization were related to the limitations of the surgery and the impossibility of caring for themselves, as well as the little experience of the professionals with peristomal skin care and exchange of the collection device, which contributed to the onset of dermatitis, making the whole situation more distressing and painful, as we can observe in the participants' speeches: The difficulty was my lack of knowledge and the unpreparedness of the professionals who were there [...] I felt that the opening was so big that I felt it drip on my skin, it burned my skin... (Jade) We need, in the beginning of this phase after ostomy, a greater support, so I believe that a better support from professionals would be important, at least until adaptation occurs... (Diamond) The difficulties reported by the participants were experienced mainly in the postoperative period, which were difficult times due to the lack of knowledge about stoma care and exchange of the stoma bag, as well as to the discovery of something new that brought changes in body image and intestinal transit.

Category 3: Peristomal skin self-care
When encouraged to comment on how they performed peristomal skin self-care, most of the participants reported that they assumed the care, which shows that, after the first phase of suffering, denial, anguish, doubts, and fear, the patients try to adapt to the new condition -being ostomized.As time passed, they realized that they could become independent, that is, they could take care of themselves, even with some limitations.Then they felt apt and able to perform their own care, seeking independence and autonomy over their body.They mentioned that this care was learned after the nursing consultation in the Health Care Service for the Ostomized Patient, and that the Specialized Service stimulated the search for self-care and independence.We can observe the description of this care: The majority of participants already practiced self-care; however, two of the participants, even after some time of the ostomy, had not assumed this care and depended on a relative/caregiver to perform stoma hygiene and exchange the collection device.Therefore, it was observed that the ostomy time is not a factor that determines the practice of self-care by the patient, which is in fact influenced by insecurity, fear, limitations, acceptance, adaptation, as well as by the encouragement, interest and support from the family/caregiver and the guidance, teaching, support, encouragement and follow-up by the nurse.In the sections below, we can observe the comments of participants who did not practice self-care.

Category 4: Educational Technology for ostomized patients
In this category, the participants demonstrated interest in sharing their needs.Their speeches certainly portray more than the points investigated, also including the difficulties experienced in the daily life, demonstrating the distance between popular knowledge and the scientific knowledge of professionals.The suggestions of the participants supported the elaboration of the Educational Technology to be used in educational practice, as they represented the needs perceived by them, who have the practical experience.When asking the participants about the subjects to be included in the educational material, the following items were pointed out as important: dermatitis, types of dermatitis, hygiene care, myths and truths about stoma and peristomal skin care, feeding, products used for skin care, step by step guideline for changing the collection device.Then, based on these suggestions, it was possible to elaborate the Educational Technology.Through the meetings with the group, importance of the educational work of the nurse and the need to use educational technologies that guide and contribute to the clarification of the doubts of the patients and of their family members/caregiver in their day-to-day life was perceived.Let's look at some of the speeches on the subjects indicated for the educational material Based on the suggestions and contributions of the participants in the meetings, especially in the fourth meeting, and through the survey of peristomal skin care in the literature, it was possible to elaborate the Educational Technology, a material that may contribute to the prevention of peristomal dermatitis and encourage self-care.It is an instrument that can be used by nurses to support their educational practice.
The educational technology, a printed guide called "Ostomy without Mysteries", in its final version, was composed by the cover and 24 pages, with standard formatting size of 25 cm in height by 15 cm in width.Each page had up to 7 illustrations at most, with a total of 60 illustrations.The summary indicates the 10 topics included (Figure 1).

DISCUSSION
Having an educational and instructive material facilitates and standardizes the guidelines provided in health care.It is an instrument that assists in the daily routine of the patients and the family caregivers and serves as a complement to home care, since during hospitalization it is difficult to assimilate all the information about the care required for the ostomy and the collection device.This way, educational materials are sources of information and knowledge about health care.
Educational materials must be a complement to the verbal orientations given to patients, a support for information, orientations, explanations and an addition for the educational process that will contribute for the recovery of the patient (14) .They must contain correct information, since they will contribute to the construction of scientific and critical thinking, to the adoption of attitudes that minimize the risk of illness and to the strengthening of health promotion (15) .They serve as educational strategies to facilitate nurses' work in guiding patients and their families in the treatment, recovery and self-care processes (16) .
The care provided to the ostomized patient is focused on rehabilitation, aiming at enabling self-care in this new stage of life.It must be developed in a way that it encompasses the individuals in their integrality and individuality, in order to promote and facilitate their rehabilitation.In this care process, the preoperative consultation of the patient candidate for an ostomy is fundamental in their rehabilitation process.Nursing interventions at this point are intended at familiarizing the patient with the stoma and with the collection device and initiating the educational process, in order to provide a better adaptation in the postoperative period (17) .Postoperative education should be systematic for the patient to feel safe for discharge.In this phase, the patient is already ostomized and is very debilitated, sensible, fragile and with many doubts regarding stoma care, adaptations required and their new condition of life.
Nurses have an important role in health education, which is reinforced at all stages of the ostomy care process, but begins in the preoperative phase, when the teaching-learning process is used.In this moment, the nurse must establish a bond with the patient and with the family member/caregiver, to favor their understanding of the real situation and support the search for adaptations (18) .The first change of the collection device is another important moment for the patient and for the family member/caregiver who will assist in this task, and it should be considered by the nurse, whether a stomal therapist or not, as the initial demonstration of activities included in stoma and peristomal skin self-care (19) .From then on, self-care training should be progressive, so that the patient and/ or family member can perform it after discharge.For this reason, at the time of discharge, the nurse should offer written guidelines on care, some collection devices to use until the patient can arrange them, and also refer the patient to existing resources in the community for the continuity of care.The empathic relationship between the nurse and the patient represents a place of shelter where the patient can share his concerns, doubts and longings.Therefore, the nurse must be trained and prepared to guide and provide specialized and good quality care, which contributes to the adaptation of the ostomized patient, who goes through a process of changes resulting from the ostomy (20) .The specific self-care actions for the ostomized patient are based on three factors: skin and stoma hygiene, observation of the stoma and peristomal skin, and collection device care, which requires careful attention for correctly cutting the adhesive base, so that there is no accumulation of residues in the skin, which would contribute to the onset of peristomal dermatitis (21) .On the day of changing the collection device, the adhesive base should preferably be removed during bathing, as it is easier to remove, and it should be done gently to avoid damaging the peristomal skin.The hygiene of the stoma and of the peristomal skin must be done carefully, with soap and water, using pieces of clean, soft and moist cotton cloth, without scrubbing, making sure to remove residues from the skin and from the edges of the stoma.After cleaning and rinsing, the skin should be thoroughly dried, as excessive moisture interferes with the adhesion of the adhesive base and causes maceration of the skin.Hairs in the peristomal skin should not be removed with blades, but trimmed with curved scissors (21) .Sunbathing was another care mentioned by the participants.It is a fundamental care both for the prevention and treatment of peristomal dermatitis.This basic care can be done on the peristomal skin and it should occur, whenever possible, during the exchange of the collecting equipment, lasting 15 to 20 minutes, in the morning, without forgetting to protect the stoma with moist gauze (22) .
It was noticed that most of the participants of the research already knew how to properly do their own hygienic care with the stoma and peristomal skin, as well as how to change the collection device, that is, they were already practicing self-care.This is a result of the work of the nurse in the Health Care Service for the Ostomized Patient, who gradually transfers/teaches these care actions to the ostomized patient and the family member/ caregiver.Ostomy care is based on a self-care philosophy and is focused on the patients' autonomy, self-confidence, personal responsibility and personal initiative.The nurse must search for strategies that favor the education provided for the ostomized patients and their family.In addition, this professional must be prepared to offer professional support for the physiological recovery and rehabilitation of this patient (23) .
The self-care activity represents the power, competence or potential of the person to engage in their own care.It is a human characteristic that is developed in the daily life, through a spontaneous learning process.This ability must accompany the life cycle, beginning in childhood, reaching its peak in adulthood and declining with old age, conditioned to factors such as age, development, life experience, socio-cultural orientation, health and available resources (24) .Therefore, nurses must take these factors into account in their professional and educational practice, assessing the demands of self-care and designing intervention plans consistent with the expectations and possibilities of the individual and/or family caregiver.It is important to understand the changes that occur in the patients' lives and how they experience the whole process in order to properly plan the nursing interventions.
The participation, interaction and involvement of the ostomized patients were essential in the choice of subjects included in the Educational Technology.These interactions, associated with commitment and participation in health promotion, are an important premise of the Action-Research method, which is aimed at constructing knowledge in a collective and participatory way, searching for solutions for a problem that requires intervention and change.The adoption of a participatory, communicative and collective approach is recommended for the elaboration of educational materials (25) .The whole process, from elaboration until the use of educational material, must be conducted in a participatory manner, with active subjects in the teaching-learning process, whether they are nursing students, health professionals or health care users.The relationship established must be horizontal and should stimulate and enable exchanges of experiences, criticalreflective thinking and collective construction of knowledge, with subjects that can multiply knowledge and transform reality (26) .Therefore, educational materials have an important role in the health education process, since, besides facilitating the transmission of knowledge, they are a readily available resource for consultation whenever any doubts regarding care arise.

Limitations of the study
A limitation of this study was the absence of urostomy patients in the Focus group.For this reason, it was not possible to assess the knowledge, experiences and peristomal skin care practiced by this group.This information would be very important for the educational material, since urostomy and colostomy patients have very different characteristics regarding the elimination of residues.These characteristics are related to the onset of dermatitis.The fact that the urostomy patient has an uninterrupted flow of urine and a frequent need to go to the bathroom and empty the collection bag might have been the reason for their absence in the meetings.Therefore, a larger number of participants, including urostomy patients, could generate more information and contributions for the elaboration of the educational material.

Contributions to the area of nursing, health or public policies
We believe that the construction of an educational technology (guide) as a strategy and instrument for therapeutic support, with specific guidelines on peristomal skin care for ostomized patients, will contribute to the prevention of complications (peristomal dermatitis), aiming at a good adaptation of the collection devices, stimulating self-care and increasing quality of life.In addition, it will help the family members and/or caregivers, who also participate in this care, as well as the nursing professionals, since it will be an educational tool to assist and support the care to the ostomized patient.

FINAL CONSIDERATIONS
Based on the Action-Research method and using the Focus Group technique in this research, it was possible, in a partnership with the participating subjects, to elaborate an Educational Technology that will later serve as a guideline to assist in the peristomal skin care, contributing to the prevention of peristomal dermatitis.It was a rich and pleasant construction due to the participation of the group, and at each meeting there was interaction, dialogue, involvement and exchange of knowledges and experiences, enabling the achievement of the objectives of the study, and consequently, the elaboration of an Educational Technology.The group was very spontaneous, and the participants expressed their perception, knowledge and opinions about the difficulties experienced along with their family members regarding stoma and peristomal skin care and exchange of collection devices.When commenting on the conditions that interfere with peristomal skin self-care, most emphasized the conditions that made this care difficult at the beginning, after surgery, when they first dealt with their new condition and were fragile, scared, insecure, full of doubts and with limitations due to surgery.They described the step-by-step peristomal skin care on the day of changing the collection equipment, demonstrating knowledge, experience and skill in care.Then, based on the contributions, knowledge, and experiences of the participants in peristomal skin care and on scientific information, it was possible to elaborate the Educational Technology, focused on their reality.
An Educational Technology built with the interaction of popular and scientific knowledge can contribute to health education and incentive self-care.In this sense, we can highlight the contribution of Educational Technologies in the context of health education and the role of this resource to promote health, prevent complications, develop skills and promote patient autonomy and confidence.As part of the interdisciplinary team responsible for health education, the nurse must participate in the process of elaboration, development and evaluation of educational material.After its validation, this educational material, as a health education strategy, is expected to provide orientations and information on peristomal skin care for the ostomized patients, their family/caregivers and nursing professionals.It also can be used as an ally in home care, encouraging self-care.
It is normal, I take my bath, I remove it myself [...] I wash it with soap and water, I use gauze to wipe, I use a cotton swab to clean it, I apply the white ointment.[...] I leave the skin without the plate for 30 minutes, to breathe, and sometimes I stay out in the sun for about 10 minutes... (Ruby) I remove it in the shower.I use soap, cleaning the skin [...] The shower helps me clean, I use the mirror and the cotton swab to help remove the feces.The feces irritate the skin [...] you leave the skin out in the sun, and if you can't, you let it breath a couple minutes without the plate... (Blue quartz)

Figure 1 -
Figure 1 -Summary of the guideline "Ostomy without mysteries" All the subjects we discussed here are important [peristomal dermatitis, types of dermatitis, care and hygiene] [...] it is good to know what we have to use [...].(Blue Topaz) I suggest the topic myths and truths about stoma and peristomal skin care [...] the use of the handheld shower, which many people fear [...] that only a nurse can perform this care, and this is not true, we can do it ourselves [...] the person can practice self-care, change the plate [...] because we have the impression that there will always be a nurse [...] because we think it is the same as changing a dressing [...].(Jade)