Comparing adjustment to an ostomy for three groups

OSTOMY CARE S E C T I O N EDITOR: G w e n Turnbull, RN, BS, C E T N

Cornpar ng Adjustment to an Qstorny for Three Groups B a r b a r a Pieper, PhD, RN, CS, CETN, FAAN, C a r o l Mikols, MSN, RN, CS, CETN, a n d Toni R e n e e D a w s o n Grant, MSN, R N

hree groups of persons with fecal ostomies (those with permanent ostomies as a result of disease (n = 13), those with temporary ostomies as a result of disease (n = 16), a n d those with temporary ostomies as a result of trauma (n = 18)) w e r e interviewed with various instruments to explore the psychosociol i m p a c t of an ostomy. The three groups did not differ significantly with respect to their scores on the Psychosocial Adjustment to Illness Scale, the Reintegrotion to Normal Living index, or the Meaning in Life Scale. Those with a temporary ostomy as result of trauma h a d significantly higher EscapeAvoidance, Positive Reappraisal, Accepting Responsibility, a n d Plonful Problem Solving subscores on the Ways of Coping instrument. The differences in coping scores m a y relate to adjustment to the violent act at the some time as the ostomy. These observations a d d to ostomy research because research about persons with temporary ostomies, especially those c a u s e d by a gunshot injury, is scarce. (J WOCN 1996;23:197-204)

T

Each year, more than 100,000 persons in the United States undergo ostomy operations. I Regardless of the cause for its creation, a person with an ostomy faces many challenges. Numerous studies have examined persons with ostomies, 2-25 but comparative studies examining the causes and durations of ostomies are lacking. This research compared the psychosocial impacts of a fecal ostomy for three groups of persons: those with permanent ostomies as a result of disease, those with temporary ostomies as a result of disease, and those with temporary ostomies as a result of trauma.

LITERATURE REVIEW Research studies about persons with fecal ostomies have examined psycho-

logic states, quality of life, body image, and patient concerns. These investigations have focused primarily on persons with permanent ostomies as a result of cancer or inflammatory bowel disease. Depression is a frequently reported psychologic response to having an ostomy. 2-9 Depression may occur at the time of operation and decrease with times In contrast, long-term adaptation for a person with a colostomy may include continued depression, worry, and altered work capacity2 Depression may be affected by the type of ostomy a person has. Thomas and coworkers 6-8 examined psychiatric and social outcomes of persons who underwent ostomy creation a few days after operation, 3 months after operation, and 12 months after operation. Fifteen persons (22%) had moderate or severe psychiatric symptoms at 12 months, similar to the symptoms reported at 3 months. 6" 8 Denial and stoic acceptance predominated as the coping styles for the physical illness, whereas stoic acceptance and fighting spirit were used to cope with the ostomy. 7 Difficulty coping with the ostomy was a significant determinant for psychiatric disturbance/ Persons with colostomies have reported scores on quality of life instruments only slightly higher than those of persons who were receiving chemotherapy. 1° A m o n g persons who have undergone colectomy for chronic ulcerative colitis, quality of life has been rated higher than before ostomy creation? 1 McLeod and associates ~2 reported quality of life findings for 273 persons who had inflammatory bowel disease and underwent conventional ileostomy creation. Of these persons, 74% stated that they were living normal, unrestricted lives, and 80% considered themselves to be in good health. Functioning of the ileostomy did affect the person's physical and emotional well-being, ability to perform

Dr. Pieper is an associate professor and clinical nurse specialist, College of Nursing, Wayne State University, Detroit. Ms. Mikols is a retired clinical nurse specialist from the Detroit area. Ms. Grant is a nurse practitioner, Detroit Receiving Hospital, St. Antoine, Detroit. Supported in part by the Wound, Ostomy and Continence Nurses Society. Reprint requests: Barbara Pieper, PhD, RN, CS, CETN, FAAN, Associate Professor, Wayne State University, 5557 Cass Ave., Room 337, Detroit, M148202. Copyright© 1996by the Wound, Ostomy and Continence Nurses Society. 7071-5754/95 $5.00 + 0

21/I/73503 197

JWOCN

198

Pieper, Mikols, and Grant

July 1996

work and daily activities, and overall outlook on life. Rubin 13 examined quality of life in a similar group of patients, including persons with cancer. Some patients with ostomies reported modification of dietary patterns to regulate ostomy function, altered work capacity, changed social life, impaired sexual function, and feelings of stigma from the loss of the anus. Rubin 13 stressed the importance of counseling and teaching throughout the perioperative experience, as well as during outpatient follow-up visits. Rheaume and Gooding TM interviewed 26 subjects from United Ostomy Association groups. The lowest quality of life score was in relationship to physical wellbeing, which included fear of odor and leakage. Klopp ~5 also noted that as concern with ostomy-related sensory phenomena (sound, odor) increased, satisfaction with body image and self-concept decreased. Common concerns of persons with ostomies are fear of odor, restricted social lives, restricted leisure and employment, sexual problems, and emptying and cleaning the pouch. 2"6-8.14, 16, 19Additional concerns expressed by persons with ileostomies were perineal w o u n d care, peristomal skin irritation, and food blockage) 9 Investigators have reported that persons with ileostomies tend not to isolate themselves, feel handicapped, feel insecure in the presence of others, or have impaired work capacity. 2° Methods used to cope with sensory phenomena were (1) to think through different ways of solving problems, (2) to hope that things would get better, (3) to look at the problem objectively, (4) to set specific goals, and (5) to maintain control over living with an ostomy. Trust, autonomy, and psychosocial discomfort may change with time for the person with an ostomy. 21 In examining the psychologic adjustment to colostomy, Wade 22 included persons who had temporary ostomies. Single and widowed men had better emotional health than did the women she studied. Depression and anxiety were associated with physical symptoms such as fatigue, pain, and backache. At a 10-week postsurgical interview, persons who had temporary ostomies and were not exposed to an ET nurse were less informed about stoma care, assessed their quality of life as significantly lower, and had not resumed their social lives. Wade 22 concluded that the person with a temporary ostomy mer-

its further consideration, and Dudas 23 observed that nurses have the responsibility to help all persons with ostomies adapt to change and to function independently. Deeny and McCrea 24 used unstructured interviews to examine human needs and the ways they were fulfilled for six persons with fecal ostomies. Nurses were perceived as helping patients with physical needs (physical comfort, sleep, food, and eating), but they were not seen as sufficiently helpful with psychologic needs (information, self-esteem, self-concept, and autonomy) and social needs (relationships with others, resuming social roles, and sexual activity). Other studies have also reported that patients and spouses need more ostomy self-care and sexuality information during hospitalization and at postdischarge visits. 4, 25 Teaching and counseling after discharge have been associated with independence, competence with ostomy care, involvement in activities outside the home, and improvement in feelings about self76 Information about adjustment to ostomy by victims of violence is lacking in the literature. Pieper 27 completed a retrospective, descriptive study of demographic and perioperative variables associated with persons who had fecal ostomies as a result of violence rather than disease. Victims of violence tended to be young, single men who had minimal income and lacked health insurance. In addition to coping with a change in body image, they needed to adjust to other physical and psychologic impairments caused by the stabbing or shooting, as well as to the violent event itself. In summary, investigators have examined the impact of fecal ostomies on various aspects of life. Ostomy research must be examined in terms of date of completion because of continuing improvement in ostomy equipment and greater availability of ET nurses for teaching and counseling. 28 Concerns have also been raised regarding methods of data collection, quality of instruments, and sample sizes. 28 These studies have tended to include persons with permanent ostomies associated with cancer or inflammatory bowel disease. Only one study could be found that identified persons with temporary ostomies as participants. No studies could be found that examined adjustment, coping, or quality of life for victims of violence with ostomies.

JWOCN Volume 23, Number 4

Pieper, Mikols, and Grant

19g

T a b l e 1. Description of subscales on the PAlS a n d m e a n scores for the three study groups M e a n scores Possible Subscale

Description

Health Care Orientation Concerned with person's health care posture--perception of health care professionals, quality of health information, expectations about treatment Vocational Environment Impact of disorder an vocational adjustment, such as work, school, or home Domestic Environment Problems in adaptation experienced by person and family unit in response to

Trauma

score

Mean

range

score

DT

DP

Mean n

score

Mean n

score

n

F

p

8-32

28.06 18 29.19 16 27.53 13 1.75 NS

6-24

16.07 14 15.47 15 18.2

10 1.96 NS

8-32

27.44 18 26.38 13 28.2

10 0.99 NS

6-24 5-20

20.82 17 20.38 13 19.78 9 0.19 NS 18.28 18 18.19 16 18.67 12 0.19 NS

6-24 7-28

19.17 18 18 16 19.23 13 0.48 NS 23.82 18 22.69 16 22.85 13 0.08 NS

person's illness

Sexual Relationship Extended Family Relationships

Social Environment Psychological Distress

Changes in quality of sexual functioning Changes in relationships with extended family members Current social and leisure time activities Dysphoric thoughts and feelings--depression, anxiety, hostility, self-esteem and body image problems

NS, Not significant.

To better understand adjustment to ostomy for persons with temporary and permanent diversions, four research questions were posed: 1. Are there differences in psychosocial adjustment among persons who have permanent ostomies as a result of disease, those with temporary ostomies as a result of disease, and those with temporary ostomies as a result of trauma? 2. Are there differences in coping among persons who have permanent ostomies as a result of disease, those with t e m p o r a r y ostomies as a result of disease, and those with temporary ostomies as a result of trauma? 3. Are there differences in reintegration to normal living among persons who have permanent ostomies as a result of disease, those with temporary ostomies as a result of disease, and those with t e m p o r a r y ostomies as a result of trauma? 4. Are there differences in meaning in life among persons who have permanent ostomies as a result of disease, those with t e m p o r a r y ostomies as a result of disease, and those with

temporary ostomies as a result of trauma?

METHODS Instruments Four previously tested instruments were used for this study. These were the Psychosocial Adjustment to Illness Scale (PAIS),z9 Ways of Coping, 3° Reintegration to Normal Living (RNL) Index91 and Meaning in Life ScaleY The PAIS consists of 45 items. Each question is rated on a 4-point scale, and scores are s u m m e d across a domain. The PAIS has seven domains of psychosocial adjustment in coping with an illness: (1) health care orientation, (2) vocational environment, (3) domestic environment, (4) sexual relationship, (5) extended family relationships, (6) social environment, and (7) psychologic distress (Table 1). The predictive validity of the PAIS has been examined with diseases and with various other instruments and found appropriate. 29 Reliability scores tend to be high, with interrater reliability total PAIS scores ranging from 0.83 to 0 . 8 6 . 29 Reliability coefficients for domain scores range from 0.12 to 0.93, depending on the study groupY

JWOCN

Pieper, Mikols, and Grant

200

July 1996

T a b l e 2, Description of subscales, m e a n scores, and significance of the Ways of Coping instrument

Subscale

Possible score range

Description

Escape-Avoidance Distancing Positive Reappraisal Confrontive Coping

Self-Controlling Accepting Responsibility

Seeking Social Support Planful Problem Solving

Wishful thinking and behavioral efforts to escape or avoid problem Cognitive efforts to detach self and to minimize significance of situation Effortsto create positive meaning by focusing on personal growth Aggressive effortsto alter situation (suggests s o m e degree of hostility and risktaking) Effortsto regulate feelings and actions Acknowledges role in problem, with concomitant theme of trying to put things right Effortsto seek informational, tangible, and emotional support Effortsto create positive meaning by focusing on personal growth

M e a n scores Trauma (n - 17)

DT (n - 16)

DP (n = 13)

F

p

0-24

9.76

5.68

5.8

4.84

0.013

0-18

7.94

7.06

7.31

0.41

NS

0-21

13.65

10.44

7.15

7.90

0.001

0-18

6.41

4.69

3.38

2.93

0.06

0-21 0-12

8.82 4.94

7.38 3.94

6.77 2.38

1.08 3.23

NS 0.05

0-18

8.35

7.94

6.23

0.80

NS

0-18

8.0

7.25

4.76

4.11

0.02

NS, Not significant.

T a b l e 3. Description of subscales, m e a n scores, and significances of RNL Index

Subscale

Description

Daily Functioning

Items about mobility, self-care abilities, daily activities, recreational activities, social activities, family role Items about comfort with relationships, comfort with social self, and life events

Perception of Self Total

M e a n scores

Possible score range

Trauma (n = 18)

DT (n = 16)

DP (n [] 13)

F

8

0-80

56.6

54.0

51.4

0.46

NS

3

0-30

22.6

24.6

23.4

0.41

NS

]1

0-110

79.2

79.64

74.8

0.20

NS

No. of items

p

NS, Not significant.

The Ways of Coping instrument consists of 60 items that examine behavioral and cognitive coping strategies that may be used in stressful times. Items are rated on a 4-point scale ranging from zero (not used) to 4 (used a great deal). Higher scores indicate more frequent use of a coping strategy. The instrument provides eight subscale scores: Escape-Avoidance, Distancing, Positive Reappraisal, Confrontive Coping, Self-Controlling, Accepting Responsibility, Seeking Social Support, and Planful Problem Solving (Table 2). Cronbach's c~ coefficients for the eight subscales range from 0.61 to 0.79. 30 Folk-

man and Lazarus 3° report face and construct validity as appropriate and consistent with theoretic predictions. The RNL Index measures the degree of reintegration or well-adjusted living achieved by patients after an incapacitating illness as a part of quality of life? 1 Reintegration to normal living is defined as the reorganization of physical, psychologic, and social characteristics of a person into a harmonious whole. 3~ The scale consists of 11 items that form two subscales determined by factor analysis: Daily Functioning and Perception of Self (Table 3). Items are rated on a 10-point

JWOCN Volume 23, Number 4

scale. Content validity was rated appropriately by professional experts21 Cronbach's ct has been reported as greater than 0.90 for patients, significant others, or health professionals completing the form. Construct validation of the RNL Index was 0.72 when compared with a quality of life scale completed b y the same patientsd I The Meaning in Life Scale consists of 13 items rated on a 5-point scale. It was developed to assess the sense of purpose, beliefs, and faith of patients; it therefore yields an assessment of the subjective worth of remaining life. 32 Cronbach's ct has been reported to be 0.78. 32 Demographic information obtained from patients and from medical records was related to the person's background and medical and surgical histories.

Methodology The study consisted of two data-collection periods. Before the participants' discharge from the hospital but after ostomy teaching had been completed, the study was explained, signed consent was obtained, and demographic information was obtained. This phase of the research required approximately 15 minutes. At least 2 weeks after discharge (mean 7 weeks, SD 5 weeks), subjects were contacted and the second interview was completed by an arranged appointment or by telephone. The second interview, which included the PAIS, Ways of Coping, RNL Index, and Meaning in Life Scale, took an hour; subjects were paid $15 after completion of both interviews. The study was a p p r o v e d by the Wayne State University Institutional Review Board for Protection of H u m a n Subjects.

Participants Participants met the following criteria: (1) a willingness to participate and to sign for research consent, (2) ability to understand and respond in English, (3) age 18 years or older, (4) colostomy or ileostomy operation for disease or for gunshot or stab injury. All ostomy operations were done during the hospitalization in which the patient was recruited to participate in the research. Persons were not included if they were paraplegic or quadriplegic, severely ill either physically or mentally, or had a urostomy. Data were collected from March 1991 to July 1993. The participants were obtained from referrals to ET nurses

Pieper, Mikols, and Grant

T a b l e 4. D e m o g r a p h i c characteristics of p a r t i c i p a n t s Variable

n

%

Male Female Marital status Married Not married Ethnicity Black White Other Education Less than high school High school Some college Unknown Employment Employed Not e m p l o y e d Retired

36 11

76.5 23.5

20 27

42 58

29 16 2

62 34 4

11 28 7 1

23.5 59.6 15 1.9

22 17 8

46.8 36.2 17

Sex

Age ranged from 18 to 78 years (mean 43.5, SD 18.9).

for teaching. Four urban hospitals and one rural site were used to obtain participants. The initial sample consisted of 64 persons. Of those, 47 persons completed the second interview. Seventeen persons provided fictitious telephone numbers or were not available at the addresses provided; these could not be reached for the second interview. The data analyses included 47 persons (73.4% of the total sample), 36 men and 11 women. Most were unmarried (58%), had at least a high school education (75%), were unemployed or retired (53%), and were black (62%). The mean age was 43.5 years (SD 18.9 years; Table 4). The three study groups included persons who had a temporary ostomy as result of a gunshot injury (n = 18, trauma group), a temporary ostomy as result of disease (n = 16, DT group), or a permanent ostomy as result of disease (n = 13, DP group). Hospitalization characteristics are presented in Tables 5 and 6. The types of diseases included diverticulitis (n = 10), cancer (n = 9), perirectal abscess (n = 3), bowel abnormalities (n = 3), ulcerative colitis (n = 2); data were missing in two cases. Ostomy types included 38 colostomies and nine ileostomies.

201

202

JWOCN July 1996

Pieper, Mikols, and Grant

Table 5. Categoric breakdown of hospitalization characteristics of participants Variable Reason for ostomy Gunshot injury, temporary stoma Disease, temporary stoma Disease, permanent stoma Stoma type Colostomy Ileostomy Insurance Medicaid and indigent health care Private None Medicare

n

%

18 16 13

38.3 34 27.7

38 9

81 19

20 12 8 7

42.6 25.5 17 14.9

Statistical Analysis Analysis of variance was used to examine differences in all study scores among the three groups. If a significant difference (p < 0.05) was found, Duncan's Multiple Range test was used to document where the difference occurred. The numbers in each group varied because failure of a person to answer an item deleted an entire score from analyses.

RESULTS PAIS The mean scores for the PAIS subscales are presented in Table 1. According to responses to this tool, all participants had high perceptions of health care and health care workers; were adjusting to work, school, or home; were getting along well in the home environment; had positive sexual functioning, were getting along well with extended family; were participating in social activities; and were not psychologically distressed. Significant differences in PAIS scores were not evident among the three groups.

Ways of Coping Coping scores tended to be at the low end of the scales. Four of the subscales demonstrated significant differences among the three groups (Table 2). The trauma group had significantly higher Escape-Avoidance scores than those of the DT and DP groups. The trauma group also had significantly higher Positive Reappraisal scores than the DT and DP groups, and significantly higher Accepting Re-

sponsibility scores than the DP group. The trauma and DT groups had significantly higher Planful Problem Solving scores than the DP group.

RNL Index The mean scores for the RNL Index are presented in Table 3. All scores were higher than the middle possible score. Significant differences in the RNL Index were not achieved among the three groups.

Meaning in Life Scale The highest possible score in the Meaning in Life Scale is 65. All groups--trauma (mean 55.2), DT (mean 57.6), and DP (mean 53.7)--had high Meaning in Life Scale scores. Scores did not differ significantly among the three groups. All groups considered life remaining to be worthwhile.

DISCUSSION Because of the number of people being saved by medical technology, psychosocial adjustment and coping with a chronic condition are important considerations. 29 Persons with ostomies must adjust to a change in the elimination process as well as to altered body image. The results of this study indicate more similarities than differences among the three ostomy groups. The persons in the three groups tended to have a high degree of psychosocial adjustment. They rated the services offered by health care providers as helpful. They rated adaptation to home environment high and did not note changes in relationships with extended family members. Generally, sexual relationships and social activities did not change appreciably, and psychologic distress was low. Vocational adjustment was not seriously affected because most participants were not employed before Operation. The results are similar to those of McLeod and associates I2, who reported that a high percentage of persons with ileostomies were leading a normal, unrestricted life. Coping is a complex process. Persons in this study were asked to examine their coping methods with respect to the ostomy. Those in the trauma group had significantly higher Escape-Avoidance, Positive Reappraisal, Accepting Responsibility, and Planful Problem Solving sub-

JWOCN Pieper, Mikols, and Grant

Volume 23, N u m b e r 4

scores. Although the difference was not statistically significant, the other coping subscores were also higher for the trauma group. The trauma group used more wishful thinking to escape their health problems. They often spoke of how gunshot injury changed their lives and wished that it had not occurred. They said that they tried to learn from the situation, creating positive meaning from the event. They acknowledged their roles in the events leading up to their ostomies and used focused efforts to solve problems related to their care. The Ways of Coping instrument was administered one time; changes in coping with time cannot be deduced from this study. RNL Index and Meaning in Life Scale scores were comparable for the three study groups. Although the scores were not at the top of the scales, these persons were able to function in daily activities and perceived life and self in a positive manner. This study was unique in comparing three groups of persons with fecal ostomies. Persons with a temporary ostomy included those who underwent operation as a result of disease or a gunshot injury. Psychosocial factors for these two groups were compared with those of persons with permanent ostomies. Scant research is available about the persons with temporary ostomies. Persons who have an ostomy as a result of a violent injury are generally not discussed in the ostomy literature. Violence is a major health care problem in the United States. Assault injuries occur at a rate of 11.1 per 1000 adult population. 33 Because of its holistic approach, nursing research adds a unique perspective to violence research, but most nursing research about the responses to violence has been in the area of partner abuse. 33Research about abdominal trauma has focused on the pathology of the physical injury and the morbidity related to ostomy takedown. More research is needed to examine adjustment to the ostomy as well as to other aspects of life for victims of violence. Sixty-two percent of the participants in this study were black, a population often not well represented in ostomy studies. Ostomy research should be broadened to include more ethnically diverse groups, as should ostomy teaching materials. This study adds to research about black men during a stressful event.

203

Table 6. M e a n h o s p i t a l i z a t i o n c h a r a c t e r i s t i c s of p a r t i c i p a n t s Variable

n

Range

Number of operations during hospitalization Critical care stay (days) Length of stay (days)

37

1-8

1.6

1.4

31 47

1-39 5-57

3.1 16.6

7.2 12.3

The sample for this study was small. It was difficult to contact persons to arrange the second interview. Some did not have telephones, were traveling, or changed their place of residence. Contacting subjects is time-consuming in a longitudinal study and must be budgeted into the research proposal. All persons in this study were taught by ET nurses. This teaching may have positively affected their levels of adjustment and coping. Persons with temporary ostomies were treated the same as persons with permanent ostomies with respect to teaching content and practice. This teaching strategy may explain w h y this study's results differed from Wade's results22; Wade concluded that persons with temporary ostomies did not receive sufficient teaching. Research about the person with an ostomy must continue as a means of enhancing care provided by ET nurses. These studies should include multiple sites to obtain large samples. Longitudinal studies that examine changes and needs with time should be developed, with a sufficient budget for data collectors to make these contacts. Ostomy research must extend beyond persons with permanent ostomies and examine the needs of those with temporary ostomies as a result of disease, injury, or violence, as well as persons with special needs such as those with spinal cord injury or mental illness. We thank Diane Singer, BSN, RN, CETN, and Ann Laska, BSN, RN, ET for assistance in data collection. REFERENCES 1, Joachim G. Teaching ostomy care to nursing students, J Enterostom Ther 1990;17:249-51. 2. Pryse-PhillipsW. Follow-up study of patients with colostomies. Am J Surg 1971;122:27-32. 3. Wirsching M, Druner HU, Herrmann G. Results of psychosocial adjustment to long term colostomy. Psychother Psychosom 1975;26:245-56. 4. Eardley A, George WD, Davis F, Schofield PF,

Mean

SD

JWOCN 204

Pieper, Mikols, and Grant

July 1996

Wilson MC, Wakefield J, et al. Colostomy: the consequences of surgery. Clin Oncol 1976;2:277-83. 5. Kelfikangs-Jarvinen L, Loven E, Moiler C. Psychic factors determining the long-term adaptation of colostomy and ileostomy patients. Psychother Psychosom 1984;41:153-9. 6. Thomas C, Madden F, Jehu D. Psychosocial morbidity in the first three months following stoma surgery. J Psychosom Res 1984;28:251-7. 7. Thomas C, Turner P, Madden F. Coping and outcome of stoma surgery. J Psychosom Res 1988;32:457-67. 8. Thomas C, Madden F, Jehu D. Psychological effects of stomas. I. Psychosocial morbidity one year after surgery. J Psychosom Res 1987;31:311-6. 9. Druss RG, O'Connor JF, Stern LO. Psychologic response to colectomy. II. Adjustment to a permanent colostomy, Arch Gen Psychiatry 1969;20:41927. 10. Padilla GV, Grant MM. Quality of life as a cancer nursing outcome variable. ANS Adv Nurs Sci 1985;8:45-60. 11. Druss RG, O'Connor JF, Prudden JF, Stern LO. Psychologic response to colectomy. Arch Gen Psychiatry 1968;18:53-9. 12. McLeod RS, Lavery IC, Leatherman JR, Maryland PA, Fazio VW, Jagelman DG, et al. Factors affecting quality of life with conventional ileostomy. World J Surg 1986;10:474-80. 13. Rubin GP. The quality of life with a stoma. BrJ Hosp Med 1987;38:300-3, 306. 14. Rheaume A, Gooding BA. Social support, coping strategies, and long-term adaptation to ostomy among self-help group members. J Enterostom Ther 1991;18:11-5, 15. Klopp AL. Body image and self-concept among individuals with stomas. J Enterostom Ther 1990;17:98-105. 16. Coe M, Kluka S. Concerns of clients and spouses regarding ostomy surgery for cancer. J Enterostom Ther 1988;15:232-9. 17. Kobza L. Impact of ostomy upon the spouse. J Enterostom Ther 1983;10:54-7.

18. Gloeckner MR, Starling JR. Providing sexual information to ostomy patients. Dis Colon Rectum 1982;25:575-9. 19. Kelly MP. Coping with an ileostomy. Soc Sci Med 1991;33:115-25. 20. Martinsson ES, Josefsson M, Ek AC. Working capacihz and quality of life after undergoing an ileostomy. J Adv Nurs 1991;16:1035-41. 21. Ramer L. Self-image changes with time in the cancer patient with a colostomy after operation. JET Nurs 1992;19:195-203. 22. Wade BE. Colostomy patients: psychological adjustment at 10 weeks and 1 year after surgery in districts which employed stoma care nurses and districts which did not. J Adv Nurs 1990;15:1297-304. 23. Dudas S. Rehabilitation of the patient with cancer. J Enterostom Ther 1991;18:61-7. 24. Deeny P, McCrea H. Stoma care: the patient's perspective. J Adv Nuts 1991;16:39-46. 25. Gloeckner MR. Parmer reaction following ostomy surgery. J Sex Marital Ther 1983;9:182-190. 26. Watson PG. Postoperative counseling for cancer/ostomy patients. J Enterostom Ther 1983; 10:84-91. 27. Pieper B. Persons who have stomas: violent injury versus disease. JET Nurs 1992;19:7-] 1. 28. Tomaselli N, Jenks J, Morin KH. Body image in patients with stomas: a critical review of the literature. JET Nurs ]991;18:95-7. 29. Derogatis LR. The psychosocial adjustment to illness scale (PALS). J Psychom Res 1986;30:77-91. 30. Folkman S, Lazarus RS. Manual for the ways of coping questionnaire. Pale Alto, California: Consulting Psychologist Press, 1988. 31. Wood-Dauphinee S, Williams JI. Reintegration to normal living as a proxy to quality of life. J Chron Dis 1987;40:491-4. 32. Warner SC, Williams JI. The meaning in life scale: determining the reliability and validity of a measure. J Chron Dis 1987;40:503-12. 33. AAN Expert Panel on Violence. AAN working paper: violence as a nursing priority: policy implications. Nurs Outlook 1993;14:83-92.

A v a i l a b i l i t y o f J o u r n a l b a c k issues

As a service to our subscribers, copies of back issues of Journal of WOCN for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $10.00 per issue. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or more. Please write to Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, or call 800-453-4351 or 314-453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues may be purchased from UMI, 300 N. Zeeb Rd., Ann Arbor, M148106, 313 -761-4700.