Use simulation to help nurses better understand the patient experience.
- Care of patients in transition to living with an ostomy has been linked to better outcomes when psychological support is provided.
- Patient care delivered with empathy has been linked to improved experiences and outcomes.
- Empathy can’t be taught through traditional or procedural instructions but can emerge through simulation as a learning activity.
Over 700,000 people in the United States live with an ostomy and its potential challenges. According to Kahneman, studies have shown that some patients express a willingness to have a shorter life without an ostomy. In addition, some who’ve had their ostomy reversed describe living with it as awful and being willing to give up their remaining life to not return to it. However, according to Reed, providing psychological support along with self-care instructions can result in better outcomes and attitudes as patients transition to living with an ostomy.
Simulation and empathy
Nursing educators strive to use teaching strategies that develop empathy. Unlike technical nursing skills (such as inserting or removing a catheter), educators can’t teach empathy through direct, traditional, or procedural instruction. Simulation provides a safe and controlled environment for learning nursing skills across all domains—cognitive, psychomotor, and affective. Empathy lies in the affective domain.
Ostomy management: Nuts and bolts for every nurse’s toolbox
Empathy relies on understanding an experience from another’s perspective. A simulated learning activity such as wearing an ostomy bag for a day, in combination with reflective writing in preparation for debriefing, provides an opportunity for developing empathy, which is linked to improved patient experiences and outcomes. However, a simulation such as this should never be confused with actually living with an ostomy.
Our study
Kerr shared how to create a simulated ostomy experience for undergraduate students in a campus setting. Our study replicated that work with 120 licensed practical nurses taking a junior-level medical-surgical course in an online Bachelor of Science in Nursing program. We aimed to help the students develop empathy in ostomy care.
Nurses in the simulated learning activity wore a provided ostomy bag for a day or for as long as tolerable. The activity occurred over a predetermined week at a place of the student’s choosing (home, community, workplace). We mailed ostomy supplies to participating nurses along with self-care instructions, similar to what patients receive at discharge. They also received information about the responsible disposal of ostomy supplies after the simulation.
Any students with a concern about wearing an ostomy appliance (for example, a known allergy to adhesive) could skip the simulation. However, they still had access to the online group debriefing, which occurred via reflective writing and discussions.
Debriefing
Debriefing, considered the most important part of simulation, offers an opportunity for reflective learning and change in feelings, thoughts, and behaviors. After the ostomy simulation period, participating students submitted their first original post. We asked them to comment on their success with applying and removing the simulated ostomy bag, the number of hours they wore it, and its impact on them physically, mentally, emotionally, and socially. We also asked them to reflect on how their experience might translate into nursing practice. In addition, we encouraged the students to review and respond to posts from other participants.
Results
The university’s Institutional Review Board approved the use of existing archival data from the 2017 med-surg course as part of this research. Three major themes emerged from that data analysis: physical concerns, interpersonal interactions, and introspection and empathy, as well as community engagement as an important subtheme.
Physical concerns. Participants reported mild physical concerns. They described skin irritation (the most frequent physical concern) as discomfort; a few reported mild skin redness and itchiness. Participants also shared the discomfort associated with the pulling of hair during bag removal.
Sleeping with the ostomy bag ranked as the second most common discomfort. Some (those who augmented the simulation by placing something in the bag to represent output as well as those who didn’t) also described considering the mental burden a person with an ostomy might experience with regard to a potential overnight leak.
Other physical concerns involved distracting sounds the ostomy bag made (“rubbing” or “crinkling”), completing activities of daily living (taking a bath or shower), making simple movements (sitting down or wearing a seatbelt), making complex movements (working out at the gym), and modifying clothing choices (from fitted to loose). Other topics that emerged in debriefing discussions included pregnancy and breastfeeding, as well as how pets might damage the ostomy bag or site during play.
Interpersonal interactions. Participants described a sense of hyperawareness experienced in social situations. Many nurses discussed how different and self-conscious they felt around family, friends, workmates, and even strangers depending on where they chose to simulate wearing an ostomy bag. The most sensitive interpersonal interaction in relation to negative shifts in self-awareness involved a significant other or romantic/love interest. Conversations about intimacy and sex seemed to raise more questions than answers regarding anticipated implications on quality of life.
Some nurses took the simulation activity as an opportunity to have new and meaningful conversations with people in their lives. In the case of significant others or romantic/love interests, they initiated conversations about what life could be like if either required an ostomy. Where family or friends engaged, participants described teachable moments that allowed them to educate loved ones about ostomies and why a person might need one. Others made efforts to teach their children (from toddlers to teenagers) about ostomies.
For participants who wore the simulated ostomy bag at work (most frequently a healthcare facility), many described surprise, curiosity, and support from their colleagues. Overall, discussions of interpersonal reactions centered around not being one’s normal self, wanting to hide or not be seen, and feeling embarrassed. Shame might be the best word to describe how most participants felt.
Introspection and empathy. Many of the students who participated in the ostomy simulation hadn’t anticipated how emotional they’d find the experience. In general, they reflected on the simulation as enlightening. Some referred to shifting perceptions of their body image. They also expressed a preference for social isolation.
Social withdrawal or limitation of interpersonal interactions appeared to widen the participants’ considerations of day-to-day experiences that patients with ostomies must navigate. Such considerations ranged from planning meals to schedule a routine for ostomy output, making adaptations for physical movements (such as regular hygiene practices), observing medical restrictions (including lifting restrictions, which might also affect work), and projecting dread of an ostomy bag leaking fecal content or smelling malodorous in public spaces.
The original posts from the participants and in subsequent debriefing discussions showed evident empathy. Some nurses went further to identify a possible demographic and subpopulation (young women), which they thought might experience enhanced challenges when first wearing an ostomy bag. The participants noted that the empathy they felt toward this demographic might stem from the fact that they could see themselves (primarily young women) in that position. The students frequently described feelings of empathy and compassion for those with an ostomy.
The debriefing sessions included discussion of recommendations to support those with ostomies. Those recommendations included incorporating individual and/or group therapy. Some revealed personal experiences in which they supported someone in their life with an ostomy who attended therapy.
Community engagement. The participants identified community engagement as a subtheme in their debriefing posts. The simulated ostomy experience provided them with a safe point of entry to engage their communities and community members about a historically sensitive subject. Many people will find initiating conversations about living with an ostomy uncomfortable. The more education and awareness members of a community have about ostomies, the more likely those with ostomies will receive local assistance, including psychological support and a sense of belonging and acceptance.
Grow empathy
Empathy remains a nursing value. The ostomy wearing simulation serves as an example of a practical and reproducible learning activity that has the potential to grow empathy in current and future nurses.
Robert Owegi is an associate professor at Indiana State University in Terre Haute. Rhonda Reed (retired) was the school of nursing’s learning resource center director and technology coordinator.
American Nurse Journal. 2025; 20(3). Doi: 10.51256/ANJ032544
References
Hood GD, Haskins TL, Roberson SC. Stepping into their shoes: The ostomy experience. J Nurs Educ. 2018;57(4):233-6. doi:10.3928/01484834-20180322-08
Hovan HM. Ostomy basics. Am Nurse J. 2022;17(9):96-102.
Kahneman D. Thinking, Fast and Slow. New York, NY: Farrar, Straus and Giroux; 2011.
Kerr N. Ostomate-for-a-day: A novel pedagogy for teaching ostomy care to baccalaureate nursing students. J Nurs Educ. 2015;54(8):445-9. doi:10.3928/01484834-20150717-04
Reed KS. Bags and blogs: Creating an ostomy experience for nursing students. Rehabil Nurs. 2012;37(2):62-5. doi:10.1002/RNJ.00011
Key words: ostomy care, empathy, simulation
