Retrospective Cohort Study on the Effect of Professional Nursing Intervention on Clinical Outcomes after Colostomy in Middle-aged and Elderly Patients

Colostomy (a form of enterostomy) is widely used in the management of rectal and colon cancers, creating an abdominal opening that diverts fecal flow and restores defecation when the distal bowel is diseased or obstructed^1,2. While the procedure addresses oncologic and functional indications, it also reshapes daily living. The impact can be especially pronounced in middle-aged and elderly patients, whose recovery may be slower due to age-related physiological decline and multimorbidity³.

Beyond physical adaptation, long-term reliance on an ostomy pouch can impose psychological burdens-such as stigma, lowered self-esteem, anxiety, and depressive symptoms-which interact with practical challenges of stoma self-management⁴. Inadequate stoma and peristomal skin care further increases the risk of early complications (e.g., wound infection, peristomal dermatitis, stenosis), prolonging recovery and worsening patient experience^5,6. These realities underscore the central role of nursing in supporting safe self-care, complication prevention, and reintegration into daily life⁷.

However, conventional nursing approaches are often fragmented, insufficiently parameterized, and slow to detect subtle physical or psychological changes, which may lead to suboptimal outcomes⁸. Reports on comprehensive/continuing ostomy nursing have highlighted these gaps and the need for standardized, multi-component pathways^9,10.

This study evaluates a standardized, multi-module professional nursing pathway tailored to middle-aged and elderly colostomy patients, parameterized with explicit frequencies, durations, red-flag thresholds, and follow-up checkpoints. This population-focused, pathway-based evaluation in a real-world retrospective cohort provides practice-proximal evidence linking concrete nursing modules to validated outcomes.

In a single-center retrospective analysis (January 2022-December 2023), we compared 1 month outcomes between patients receiving routine care and those receiving the professional pathway. Outcomes included self-care ability (Self-Care Ability Assessment Scale, ESCA)¹¹, anxiety (Self-Rating Anxiety Scale, SAS)¹², depression (Self-Rating Depression Scale, SDS)¹³, quality of life (City of Hope Quality of Life-Ostomy Questionnaire, COH-QOL-OQ)¹⁴, complication rates¹⁵, and nursing satisfaction¹⁶.

The study obtained institutional ethics approval before any data abstraction and ensured de-identification of all records (Approval No.: 2023-YZ-061). Written informed consent was obtained from all participants prior to data collection and follow-up. All procedures complied with institutional infection-prevention and privacy policies throughout care delivery and data handling.

Materials and equipment

Prepare two- or one-piece ostomy pouches (flat and convex), skin barriers, moldable rings, adhesive aids and removers, protective film or powder, ostomy scissors, a stoma measuring guide, sterile 0.9% saline, gauze, gloves, printed and audiovisual education materials, tele-follow-up tools, and quality-check forms.

Study design and groups (Retrospective)

An overview of the retrospective study design, cohort assignment, and assessment time points is shown in Figure 1. Identify all eligible patients aged ≥45 years who underwent colostomy between January 2022 and December 2023 at the study center. Apply predefined inclusion and exclusion criteria as follows, and confirm availability of baseline and 1-month outcome records. Include patients aged ≥45 years who underwent colostomy at the study center between January 2022 and December 2023 and had complete baseline records and documented 1-month follow-up outcome assessments. Exclude patients with missing key baseline variables or 1-month outcomes, those who underwent stoma reversal or major reoperation within 1 month, those unable to complete the ESCA/SAS/SDS/COH-QOL-OQ assessments due to severe cognitive/communication impairment, and those transferred to another facility or lost to follow-up before the 1-month assessment. Categorize patients according to the care they actually received into a routine-care cohort and a professional-pathway cohort; note that grouping reflects real-world practice rather than random assignment.

Pre-discharge education

Provide two one-to-one education sessions of 15-20 min each, spaced at least 24 h apart. Explain ostomy anatomy and function, daily self-care steps, red-flag signs and actions, diet and activity progression, and indications for contacting the care team. Demonstrate pouch change and require a complete return demonstration using a six-step checklist (cut, clean, measure, apply, press, check). Issue printed and visual materials and set the target of independent pouch change in ≤20 min without missed steps. Verify mastery before discharge.

Stoma and peristomal skin care

Replace the pouch every 3-5 days or as soon as leakage occurs. Cut the baseplate opening 1-2 mm larger than the stoma diameter, apply the system, and press evenly for 1-2 min to secure adhesion (or follow manufacturer instructions where they differ). Clean the peristomal area with 30-50 mL of warm water or 0.9% saline and avoid irritants or soap residue. Position the patient to minimize contamination during changes; trim hair if required to improve sealing. Verify that the appliance remains leak-free for ≥72 h and that the peristomal skin is intact, dry, and free of an erythematous rim >1 cm. If erythema exceeds 1 cm, if moisture-associated damage or erosion is present, or if there is suspected infection (pain, heat, purulent drainage, or fever ≥38 °C), escalate care promptly: reinforce with barrier film plus convex system and ring and reassess within 48 h; obtain a wound swab/culture and arrange same-day surgical review when infection is suspected. If stenosis is suspected due to pencil-thin output or obstructive symptoms, arrange a colorectal assessment within 48 h and avoid forceful probing. For high-output stoma >1200 mL/24 h, initiate fluid and electrolyte support and adjust diet, then reassess within 24 h.

Nurse-led psychological support

In both cohorts, anxiety and depression were assessed using the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) at baseline and at 4 weeks as study outcomes. For the routine-care cohort, psychological care followed usual practice, which consisted of brief emotional reassurance during routine ward rounds and discharge education, provision of standard written instructions, and referral to mental-health services at the clinician's discretion when marked distress was identified; no structured, scheduled psychological sessions or tracking tools were routinely implemented. In contrast, the professional nursing pathway cohort received a standardized nurse-led psychological support module consisting of weekly 15 min sessions for 4 weeks that included cognitive restructuring focused on negative automatic thoughts, 3-5 min of breathing relaxation training, and a planned pleasant activity to be practiced daily; adherence was documented on a tracking card. Participants were referred to mental-health services when SAS/SDS scores met moderate or higher thresholds or when clinically indicated.

Lifestyle and diet

Advise loose clothing to avoid stoma irritation and restrict lifting >5 kg during the first 4 weeks. Progress physical activity from 2000-4000 steps/day in week 1 to 6000-8000 steps/day by week 4 as tolerated. Implement a low-residue, small-frequent-meals plan during weeks 1-2, then reintroduce gas-producing or high-fiber foods one at a time from week 3 while observing tolerance for 48 h after each new item. Ensure daily fluid intake of 1500-2000 mL unless contraindicated. Confirm the absence of nausea, bloating, or diarrhea during reintroduction and that bowel function remains stable.

Discharge guidance and follow-up

Provide written checklists for stoma change steps, red-flag signs, and points of contact. Schedule a week-1 tele-follow-up of about 10 min and week-2 and week-4 clinic or video reviews. Collect outcome scales and complication logs at scheduled contacts and reinforce techniques if leakage or skin issues recur. At the week-4 review, confirm independent technique and adherence to the pathway.

Outcome measures and assessment schedule

Assess outcomes at baseline (T0) and 1 month (T1). Measure self-care ability using the Self-Care Ability Assessment Scale (ESCA) with total and subscale scores. Evaluate psychological status using SAS and SDS standard scores. Assess quality of life using the City of Hope Quality of Life-Ostomy Questionnaire (COH-QOL-OQ) with total and domain scores. Record early complications, including infection, stenosis, bleeding, peristomal dermatitis, and high output, and calculate a composite incidence. Evaluate nursing satisfaction at T1 with a four-level scale (very satisfied, basically satisfied, generally satisfied, dissatisfied) and report as n (%). Ensure that all scales are completed at both time points and that any adjudication of complications is documented.

Data management and quality assurance

Train nursing staff in the use of checklists and documentation. Audit approximately 10% of records for completeness and internal consistency. When feasible, separate outcome assessment from day-to-day caregivers to reduce measurement bias, and record protocol deviations with corrective actions. Conclude the pathway after completion of the 4-week follow-up, verification of outcomes, and closure of the quality-control log.

Statistical analysis

Analyze data with SPSS 25.0 (or equivalent). Summarize continuous variables as mean (SD) or median (IQR) after Shapiro-Wilk testing and choose independent-samples t tests or Mann-Whitney U tests; accordingly, summarize categorical variables as n (%) and compare using χ² or Fisher's exact tests. Report two-sided p-values with α = 0.05 and provide effect sizes with 95% confidence intervals (e.g., Cohen's d for continuous outcomes; risk ratio or risk difference for binary outcomes). For primary outcomes, perform ANCOVA or multivariable regression adjusted for prespecified baseline covariates (e.g., age, sex, key comorbidities). Control multiple comparisons where applicable (e.g., Benjamini-Hochberg FDR). Conduct sensitivity analysis for missing data handling and model specifications. State all software and package versions.

Clinical characteristics (Table 1)

A total of 80 eligible patients were included and categorized retrospectively according to actual care received. Baseline characteristics were well balanced: there were no significant between-group differences in age, sex, ostomy appliance type, residence, educational level, or household income (all p > 0.05; Table 1). Descriptive statistics are provided as mean (SD) for continuous variables and n (%) for categorical variables (Table 1).

Pre-discharge education and self-care ability (ESCA; Table 2)

Before intervention, ESCA total and subscales did not differ between cohorts (p > 0.05; Table 2). At 1 month, both cohorts demonstrated higher ESCA scores relative to baseline, but the professional-pathway cohort showed significantly larger gains in the total score and in key subscales-self-concept, motivation, information acquisition/curiosity, and inhibition of passive behavior (all p < 0.05; Table 2). Table 2 reports within-group changes, between-group contrasts, effect sizes, and 95% confidence intervals. These results parallel bedside competency checks documented in the pathway (return-demonstration of pouch change), supporting the educational module's effectiveness (Table 2).

Stoma and peristomal skin care, technique mastery, and early events (Table 2)

Consistent with the standardized cutting/pressing/cleaning regimen, the professional-pathway cohort achieved more frequent leak-free wear times of ≥72 h and fewer peristomal skin problems during the 1st month, reflected in lower stoma/peristomal complication rates (p < 0.05). Improvements in ESCA subdomains related to technical self-care also favored the professional pathway (Table 2), indicating that parameterized technique training translated into measurable behavior changes.

Nurse-led psychological support and psychological status (SAS/SDS; Table 3)

Anxiety and depression scores decreased from baseline in both cohorts at 1 month, with significantly greater reductions in the professional-pathway cohort (all p < 0.05; Table 3). Table 3 provides absolute and relative changes with 95% confidence intervals and corresponding between-group statistics. The direction and magnitude of change align with the delivered brief CBT components and scheduled contacts (Table 3).

Lifestyle and diet for quality of life (COH-QOL-OQ; Table 4)

Quality-of-life totals and domain scores improved in both cohorts, with the professional-pathway cohort exhibiting significantly higher post-intervention scores across mental/psychological status, physical functioning, and social roles (all p < 0.05; Table 4). These domain-level advantages are consistent with structured diet progression, activity targets, and intolerance monitoring embedded in the pathway (Table 4).

Complications within 1 month and unplanned utilization (Table 5)

The composite incidence of early postoperative complications was lower in the professional-pathway cohort than in the routine-care cohort (p < 0.05; Table 5). Component analyses indicated fewer stoma/peristomal events, particularly infection, dermatitis, and stenosis, in the professional-pathway cohort (Table 5). Any unplanned contacts related to stoma problems also trended lower in the professional-pathway cohort, as summarized in Table 5.

Discharge guidance, follow-up, and nursing satisfaction (Table 6)

At 1 month, overall nursing satisfaction was higher in the professional-pathway cohort, with a greater proportion of satisfied/very satisfied responses on the four-level scale (p < 0.05; Table 6). Table 6 reports distributions as n (%) together with the corresponding test statistics.

Collectively, the results support the hypothesis that a standardized, multi-module professional nursing pathway yields superior short-term outcomes, spanning technical self-care, psychological status, and quality of life, compared with routine care in middle-aged and elderly colostomy patients (Table 1, Table 2, Table 3, Table 4, Table 5, and Table 6).

Compared with routine care, the professional-pathway cohort achieved greater 1 month improvements in ESCA, SAS/SDS, and COH-QOL-OQ, and experienced lower early stoma/peristomal complication rates, along with higher nursing satisfaction (Table 1, Table 2, Table 3, Table 4, Table 5, and Table 6).

Data availability:

The dataset underlying this study is publicly archived on the Zenodo platform, with the DOI 10.5281/zenodo. 17626148 (link: https://doi.org/10.5281/zenodo.17626148).

Figure 1: Overall schematic of the retrospective study design and assessment timeline. Eligible patients (≥45 years) who underwent colostomy between January 2022 and December 2023 were screened and allocated to routine care or the professional nursing pathway based on the care actually received (non-random). Outcomes were assessed at baseline and at 1 month, including ESCA, SAS, SDS, COH-QOL-OQ, complication rates, and nursing satisfaction. Abbreviations: ESCA, Self-Care Ability Assessment Scale; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale; COH-QOL-OQ, City of Hope Quality of Life-Ostomy Questionnaire. Please click here to view a larger version of this figure.

Table 1: Sociodemographic and clinical characteristics at baseline. Values are Mean (SD) or n (%). Group sizes: routine-care, n = 40; professional-pathway, n = 40. p-values from an independent-samples t-test for continuous variables and χ2 test (or Fisher's exact test) for categorical variables. No between-group differences were observed at baseline (all p > 0.05). Two-sided tests, α = 0.05. For continuous outcomes, use t tests or ANCOVA with baseline adjustment (report MD, 95% CI, and effect sizes); for categorical outcomes, use χ2 or Fisher's exact test (report RR/RD with 95% CI), where assumptions are violated, report non-parametric alternatives.

Table 2: Self-care ability at baseline and 1 month assessed by the Self-Care Ability Assessment Scale (ESCA). Totals and subscales (self-concept, motivation, information acquisition/curiosity, inhibition of passive behavior) are reported as mean (SD) with within-group changes and between-group contrasts (mean difference, MD) plus 95% CI and effect sizes (Cohen's d) where applicable. Both cohorts improved, with significantly larger gains in the professional-pathway cohort (all p < 0.05). Two-sided tests, α = 0.05. For continuous outcomes, use t tests or ANCOVA with baseline adjustment (report MD, 95% CI, and effect sizes); for categorical outcomes, use χ2 or Fisher's exact test (report RR/RD with 95% CI), where assumptions are violated, report non-parametric alternatives.

Table 3: Psychological status at baseline and 1 month assessed by the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS). Scores are mean (SD); lower values indicate fewer symptoms. Within-group changes and between-group contrasts are shown with MD (95% CI) and effect sizes. Reductions in SAS and SDS were significantly greater in the professional-pathway cohort (all p < 0.05). Two-sided tests, α = 0.05. For continuous outcomes, use t tests or ANCOVA with baseline adjustment (report MD, 95% CI, and effect sizes); for categorical outcomes, use χ2 or Fisher's exact test (report RR/RD with 95% CI), where assumptions are violated, report non-parametric alternatives.

Table 4: Quality of life at 1 month assessed by the City of Hope Quality of Life-Ostomy Questionnaire (COH-QOL-OQ). Totals and domain scores-mental state, psychological health, physical functioning, and social roles-are presented as mean (SD) with between-group contrasts and 95% CI. The professional-pathway cohort achieved significantly higher post-intervention totals and domain scores (all p < 0.05). Two-sided tests, α = 0.05. For continuous outcomes, use t tests or ANCOVA with baseline adjustment (report MD, 95% CI, and effect sizes); for categorical outcomes, use χ2 or Fisher's exact test (report RR/RD with 95% CI), where assumptions are violated, report non-parametric alternatives.

Table 5: Early postoperative complications within 1 month. Composite and component outcomes (e.g., stoma/peristomal infection, dermatitis, stenosis, bleeding, high-output) are reported as n (%) with between-group comparisons (risk ratio or risk difference with 95% CI, and corresponding tests). The overall incidence was significantly lower in the professional-pathway cohort (p < 0.05). Two-sided tests, α = 0.05. For continuous outcomes, use t tests or ANCOVA with baseline adjustment (report MD, 95% CI, and effect sizes); for categorical outcomes, use χ2 or Fisher's exact test (report RR/RD with 95% CI), where assumptions are violated, report non-parametric alternatives.

Table 6: Patient nursing satisfaction at 1 month (four-level scale). Distributions are n (%) for very satisfied, basically satisfied, generally satisfied, and dissatisfied, with summary satisfied/very satisfied proportions and between-group comparisons (χ2 or Fisher's exact test; 95% CI for proportion differences). Overall satisfaction was higher in the professional-pathway cohort (p < 0.05). Abbreviations: ESCA = Self-Care Ability Assessment Scale; SAS = Self-Rating Anxiety Scale; SDS = Self-Rating Depression Scale; COH-QOL-OQ = City of Hope Quality of Life-Ostomy Questionnaire; MD = mean difference; CI = confidence interval; d = Cohen's d. Two-sided tests, α = 0.05. For continuous outcomes, use t tests or ANCOVA with baseline adjustment (report MD, 95% CI, and effect sizes); for categorical outcomes, use χ2 or Fisher's exact test (report RR/RD with 95% CI), where assumptions are violated, report non-parametric alternatives.

Colostomy can restore bowel function for patients with colorectal disease but disrupts daily life and psychosocial well-being, particularly in middle-aged and elderly patients with comorbidities¹⁷. This study found that, compared with routine care, a standardized, multi-module professional nursing pathway was associated with greater 1 month improvements in self-care ability (ESCA), psychological status (SAS; SDS)¹⁸, and quality of life (COH-QOL-OQ), alongside lower early complication rates and higher nursing satisfaction^19,20. These findings align with prior work showing that structured, nurse-delivered education and follow-up can enhance ostomy self-management and reduce complications.

Several pathway components plausibly contributed to the observed benefits²¹. First, parameterized pre-discharge education with return-demonstration likely improved technical proficiency in pouch changing and troubleshooting, which is reflected in higher ESCA scores and fewer early stoma/peristomal events^22,23. Second, standardized stoma and skin-care procedures-such as cutting baseplates 1-2 mm larger than the stoma, pressing to secure adhesion, and early escalation based on red-flag thresholds- may have curtailed leakage-related skin damage and infection^24,25. Third, brief, nurse-led cognitive-behavioral elements appear consistent with the reductions in SAS/SDS scores, echoing evidence that low-dose, skills-focused encounters can alleviate procedure-related anxiety and depressive symptoms in surgical populations^26,27. Finally, graded activity and diet progression, along with intolerance monitoring, likely supported broader improvements in COH-QOL-OQ domains by normalizing routines and reducing symptom uncertainty^28,29.

The results extend the literature in three ways. They focus on a population-middle-aged and elderly colostomy patients-with distinct rehabilitation needs; they evaluate a pathway that is explicitly parameterized (specified frequencies, durations, thresholds, and checkpoints) to aid reproducibility; and they link concrete nursing modules to validated patient-reported and clinical outcomes in a real-world retrospective context³⁰. These practice-proximal features complement prior reports of comprehensive ostomy nursing programs and may facilitate implementation in busy colorectal units³¹.

From a clinical standpoint, adopting a standardized pathway can help teams operationalize high-risk moments (e.g., first post-discharge week), unify technique and escalation rules, and embed brief psychological support into routine nursing time³². These elements are consonant with established self-management and chronic-care frameworks in nursing, which emphasize structured education, monitoring, and timely intensification of support³³. Practical implementation will require staff training, checklist use, and tele-enabled contacts to maintain adherence while limiting clinic burden³⁴.

Limitations

This was a single-center retrospective study with a modest sample size, which limits causal inference and generalizability. Grouping reflects the care actually received, so residual confounding and selection bias cannot be excluded, despite baseline comparability. Follow-up was restricted to 1 month; the durability of benefits is unknown, and late complications were not captured. Some sociodemographic variables (e.g., detailed socioeconomic status or caregiver factors) were incompletely recorded, and patient-reported satisfaction may be subject to response bias. Although ESCA, SAS/SDS, and COH-QOL-OQ are widely used, their measurement properties in very old adults or in specific cultural contexts warrant continual verification. Finally, outcomes were assessed within routine workflows rather than under blinded conditions.

Alternative and complementary approaches

Future research should include multicenter prospective studies-ideally randomized or stepped-wedge designs-with longer follow-up (e.g., 3, 6, and 12 months) to evaluate durability and late complications. Mixed-methods designs could add qualitative interviews to capture lived experience and pathway acceptability, while pragmatic trials could test tele-nursing and digital adherence tools. Stratified analyses by comorbidity (e.g., diabetes, high-output stoma) and social support could identify subgroups needing intensified modules. Cost-effectiveness evaluations would further inform scale-up decisions.

Conclusions

A standardized, parameterized professional nursing pathway was associated with better short-term self-care capacity, psychological well-being, and quality of life, and fewer early complications and higher nursing satisfaction than routine care in middle-aged and elderly colostomy patients. Integrating structured education, stoma-skin protocols, graded lifestyle guidance, brief psychological support, and scheduled follow-up into usual practice appears clinically meaningful and feasible; rigorous prospective studies are warranted to confirm effectiveness, define durability, and optimize tailoring.