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

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

(p. 985), first proposed the theory of experiential
learning. He describes the learning cycle as com-
posed of concrete experiences, reflective observa-
tion, abstract conceptualization, and active
experimentation (Laschinger, 1990). Although not a
nursing theory, experiential learning is a middle
range theory allowing for adaptation and applica-
tion in nursing education (Lisko & O'Dell, 2010). It
is typical for nursing students in a simulated lab
setting to have concrete learning experiences by
practicing the psychomotor skills associated with
an ostomy appliance. However, inclusion of social
activities enhances the empathy of the nursing stu-
dents when participating in a simulated ostomy
experience (Stover, 2010).
Empathy is a key component of the therapeutic
relationship between patients and nurses. It is the
nurse's sense of empathy that allows the nurse to
recognize the uniqueness of a patient's situation
and care of the patient in a holistic manner (Stover,
2010). A simulated ostomy experience was
designed to assist nursing students in moving
beyond the typical psychomotor skills learned in a
laboratory setting to developing personal insight
and appreciation for the psychosocial impact an
ostomy has on the sexual health and quality of life
of individuals.
Materials and Methods
The simulation experience was designed using
small group work, an experiential learning activity
and blogging to foster a nursing student's cogni-
tive, psychomotor, and affective development. The
first learning activity centered on the role of the
nurse as a therapeutic agent in discussing sensitive
issues with an ostomy patient. Rehabilitation
nurses recognize sexuality as a basic human need
and operate within a model of care, which encour-
ages conversation on the impact of illness or dis-
ability on an individual's sexuality. Yet, sexuality is
a subject many nurses find embarrassing, generally
uncomfortable, and difficult to address (Jankowiak,
2009). So, if not within one's nursing studies, how
does a nursing student develop a comfort level
conducive to assisting patients experiencing
an altered body image or a sense of impaired
sexuality?
Students, in small groups of four to five,
designed posters identifying strategies, which
could be used by individuals with ostomies to pro-
mote a positive body image as well as foster a posi-
tive sense of sexuality. Each small group then
presented their poster, sharing their ideas from the
front of the classroom to the other students. Presen-
tation from the front of the classroom was deemed
important as students, aside from personal conver-
sations with friends, do not typically discuss this
subject verbally, in a large group setting or with
strangers. The presentation groups demonstrated
the behaviors one would expect when subject con-
tent on sexual activity is presented: nervous gig-
gling, blushing, and lack of direct eye contact with
the audience. However, toward the end of the small
group presentations, the presentations changed
tone and became a platform for active and interac-
tive discussions on how a nurse should broach the
subject of body image and sexuality and how a
nurse can discuss recommendations without creat-
ing an impression of his or her own personal sex
life. If nurses are expected to provide holistic health
education and information, it is important for stu-
dent nurses to have the opportunity to practice
delivering this type of intimate information in a
comfortable, supportive learning environment.
The second learning activity was an optional
one. Students were provided the opportunity of
earning bonus points on their quiz grade for that
week if they wore an ostomy appliance home over-
night and wrote a blog about the experience the
next day. Students who did not wish to participate
were offered the opportunity of responding to
blogs for bonus points. The blog page was located
on the course website and only the students and
faculty with access to that course had access to the
entries. Students were not given a specific word
count nor did the blog require use of references.
Students understood that their name would be seen
when the blog was posted. The sole purpose of the
blog was to convey the students’ feelings and expe-
riences during the next 16–20 hours.
Students were provided markers to create their
own “stoma.” It was up to each student to decide
the location of the stoma, its size and its color. Use
of humor as a therapeutic modality was evident as
there were many stomas drawn using the univer-
sity's colors. Each student, in the role of the nurse,
taught his or her partner, the “patient,” the steps in
applying an ostomy wafer and attaching a bag. Stu-
dents had the opportunity of “blinging” the ostomy
bags, which was a frequently shared suggestion in
the earlier learning activity. The experience was
made more real as each ostomy bag contained
approximately 90 ml of simulated fecal material
created by using chocolate pudding, oatmeal, and a
small amount of fake fecal odor. While the fecal
odor was not strong enough to permeate the
clothes, it was noticeable when one's nose was in
close proximity of the ostomy bag and the mere
thought of its presence created more than a few gri-
maces.
Rehabilitation Nursing  Vol. 37, No. 2  March-April 2012 63
Bags and Blogs: Creating an Ostomy Experience for Nursing
Students
Discussion
There were 134 students enrolled in this nursing
course and over 100 students chose to participate in
wearing an ostomy appliance overnight. Reflective
writing or journaling has been identified as a bene-
ficial method in the learning process (Blake, 2005;
Boud & Walker, 1998). Journaling is one method for
promoting student transference of theory into prac-
tice (Noveletsky, 2006) and has been found effective
by students and faculty (Epp, 2008). Goals of reflec-
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
journal entries were not paper submissions, but
were submitted on an electronic board, visible to
more individuals than the instructor. The blog
entries were stunning in their depth and passion.
As an educator and as a rehabilitation nurse, it was
exciting beyond words and emotionally touching to
see the realization, the compassion, and the profes-
sional maturity that emerged from this learning
Box 1. Excerpt of a Student’s Blog
“Throughout this whole experience, what
interested me the most were the reactions I
received from my roommates and friends.
Comments like, ‘Eewww, that is soo nasty, why
would you do that to yourself,’ were all I heard.
This made me think of the reaction that people
living with ostomies have to deal with. They don’t
have the choice of simply removing it the next
morning at 8 AM. This is something that they have
to face and learn to live with. This experience
allowed me to be on the inside looking out,
instead of being on the outside looking in.”
Box 2. Excerpt of a Student Blog
“….most interesting part of the experience came
when I was with my boyfriend. I showed him the
bag and he had a very supportive opinion of the
bag. … it was a new addition to deal with but it did
not hinder the intimate setting. I only ran into
problems when I woke up. I arrived on campus at
8AM and was told by another girl my bag had
leaked. It indeed had spilled all over my white tank
and embarrassment was spared because I knew it
was pudding, but I can only imagine how it would
feel if another person was to point out an actual
leakage to a patient.”
Box 3. Excerpt of a Student Blog
“…. Although the bag was tucked beneath my
sweats, it would creep up and start flailing around
under my shirt. So I would have to awkwardly
shove it back into my pants. It was a good learning
experience and helped me gain some insight into
the lifestyle of an ostomy patient.”
64 Rehabilitation Nursing  Vol. 37, No. 2  March-April 2012
Box 4. Excerpt of a Student Blog
“When I got home, I tried figuring out ways to tuck
it away under my clothes, but I figured, ‘Ahh what
the heck, just let it hang out!’ That soon changed
when I went to XXXX restaurant, and realized my
new lack of social confidence. With all these
college students around my age, I knew they
would look at my ‘bag of poop’ and most likely
judge me. I felt immediately inadequate, even
though I had no reason to. I can only imagine what
people with real colostomies have trouble dealing
with.”
activity. The blogs contained stories of the discomfi-
ture felt taking public transportation or riding a
bike home while wearing white scrubs and the ost-
omy appliance. Several students faced strong nega-
tive reactions from non-nursing major roommates
(Box 1) and two students described how their boy-
friend or spouse reacted when seeing the ostomy
bag (Box 2). One student described how this learn-
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-
ences a chronic illness or permanent injury and
whether or not their relationship was strong
enough for such challenges. Students shared how
they either avoided their normal evening activities
(Box 3) or faced the challenge of adapting the activ-
ity or clothing wearing the ostomy appliance
(Box 4). Out of the entire participating group, only
two students reported their ostomy bags leaked
“fecal contents” on their beds or clothing, although
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
some cases of skin tenderness when students
removed the ostomy wafer. All students had been
encouraged to prep the skin prior to application of
the ostomy wafer using either a barrier device or
wipes. However, not all students chose to do so
and blog entries reflected their chagrin the next
morning when removing the ostomy wafer. With-
out fail, the students evaluated the experience as
the best learning activity they had experienced in
the simulated lab setting and the positive impact
the experience had on their nursing practice. The
anecdotal feedback from the participating students
is supported in the literature by a study showing
that students with an affinity for social learning as
well as those preferring solitary learning activities
benefit from a simulation-enhanced learning expe-
rience (Fountain & Alfred, 2009).
There was no assessment or critique provided on
the students’ reflections of the ostomy experience,
nor was a particular nursing model or framework
assigned to guide the process. The blogs generally
exhibited judgmental reflectivity (Mezirow, 1981)
whereby the students became aware of value
judgments and the subjective nature of those judg-
ments. This level of reflectivity is described as one
of consciousness, of asking questions, recognizing
emotional dimensions, and empathizing with
others.
Conclusion
This learning activity was designed to assist nurs-
ing students in developing the collective skill set,
cognitive, psychomotor, and affective, required to
reduce an ostomate's sense of social isolation and
promote therapeutic nurse/ patient discussions. It
provided nursing students with a learning opportu-
nity not possible in a clinical setting. The utilization
of social technology students were familiar with
and the use of simulation in a safe, nonthreatening
manner, fostered student insight and elevated con-
fidence transferable to the clinical environment in a
manner which will affect positive patient outcomes
throughout the students’ nursing careers.
About the Author
Karen S. Reed, MSN DHSc RN CNL CRRN, is Clinical
Assistant Professor of Nursing at the University of Florida,
College of Nursing, P.O. Box 100187, Gainesville, FL
32610. Address correspondence to ksreed@ufl.edu.
References
Ackley, B., & Ladwig, G. (2008). Nursing Diagnosis Handbook:
An Evidence-Based Guide to Planning Care (pp. 37–38). Phila-
delphia, PA: Mosby.
ARN (n.d.). A Definition and Brief History of Rehabilitation
Nursing. Glenview, IL: Association of Rehabilitation
Nurses. Retrieved August 30, 2011, from http://www.reha
bnurse.org/about/content/definition.html.
Blake, T. (2005). Journaling: An active learning technique.
International Journal of Nursing Education Scholarship, 2(1),
1–13.
Boud, D., & Walker, D. (1998). Promoting reflecting in profes-
sional courses: The challenge of context. Studies in Higher
Education, 23(2), 191–214.
CDC (n.d). Hospital Utilization. Atlanta, GA: Centers for
Disease Control and Prevention. Retrieved August
30, 2011, from http://www.cdc.gov/nchs/fastats/hospital.
htm.
Epp, S. (2008). The value of reflective journaling in undergrad-
uate nursing education: A literature review. International
Journal of Nursing Studies, 45(9), 1379–1388.
Fountain, R., & Alfred, D. (2009). Student satisfaction with
high-fidelity simulation: Does it correlate with learning
styles? Nursing Education Perspectives, 30(2), 96–98.
Jankowiak, M. (2009). Sexuality in nursing facilities. Provider,
35(1), 33–35.
Laschinger, H. (1990). Review of experiential learning theory
research in the nursing profession. Journal of Advanced
Nursing, 15(8), 985–993.
Lisko, S., & O'Dell, V. (2010). Integration of theory and prac-
tice: Experiential learning theory and nursing education.
Nursing Education Perspectives, 31(2), 106–108.
Mezirow, J. (1981). A critical theory of adult learning and edu-
cation. Adult Education, 32(1), 3–24.
Noveletsky, H. (2006). Reflective practice: Empowering nurs-
ing knowledge. In L. C. Andrist, P. Nicholas and K. Wolf
(Eds.), A history of nursing ideas (pp. 409–415). London:
Jones and Bartlett.
Pittman, J., Rawl, S., Schmidt, C., Grant, M., Ko, C., Wendel,
C. et al. (2008). Demographic and clinical factors related
to ostomy complications and quality of life in veterans
with an ostomy. Journal of Wound and Ostomy Continence
Nursing, 35(5), 493–503.
Preston, K. (1994). Rehabilitation nursing: A client-centered
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.
Turnbull, G. (2008). Ostomy Statistics: The $64,000 Question.
Retrieved August 30, 2011, from http://www.o-wm.com/
content/ostomy-statistics-the-64000-question.
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