colostomy nursing care literature review

This website is intended for healthcare professionals

• { $refs.search.focus(); })" aria-controls="searchpanel" :aria-expanded="open" class="hidden lg:inline-flex justify-end text-gray-800 hover:text-primary py-2 px-4 lg:px-0 items-center text-base font-medium"> Search

Search menu

Allaert FA, Legrand L, Abdoul Carime N, Quantin C. Will applications on smartphones allow a generalization of telemedicine?. BMC Med Inform Decis Mak. 2020; 20:(1) https://doi.org/10.1186/s12911-020-1036-0

Babakhanlou R, Larkin K, Hita AG, Stroh J, Yeung SC. Stoma-related complications and emergencies. Int J Emerg Med. 2022; 15:(1) https://doi.org/10.1186/s12245-022-00421-9

Brug J, Conner M, Harré N, Kremers S, McKellar S, Whitelaw S. The transtheoretical model and stages of change: a critique: observations by five commentators on the paper by Adams, J. and White, M. (2004) Why don't stage-based activity promotion interventions work?. Health Educ Res. 2005; 20:(2)244-258 https://doi.org/10.1093/her/cyh005

Capilla-Díaz C, Black P, Bonill-de las Nieves C The patient experience of having a stoma and its relation to nursing practice: implementation of qualitative evidence through clinical pathways. Gastrointest Nurs. 2016; 14:(3)39-46 https://doi.org/10.12968/gasn.2016.14.3.39

Cengiz B, Bahar Z. Perceived barriers and home care needs when adapting to a fecal ostomy: a phenomenological study. J Wound Ostomy Continence Nurs. 2017; 44:(1)63-68 https://doi.org/10.1097/WON.0000000000000271

Choudhary M, Kaur H. Experiences of living with intestinal ostomy: A qualitative meta-synthesis. Indian J Palliat Care. 2020; 26:(4)421-427 https://doi.org/10.4103/IJPC.IJPC_21_20

Crawford D, Texter T, Hurt K, VanAelst R, Glaza L, Vander Laan KJ. Traditional nurse instruction versus 2 session nurse instruction plus DVD for teaching ostomy care: a multisite randomized controlled trial. J Wound Ostomy Continence Nurs. 2012; 39:(5)529-37 https://doi.org/10.1097/WON.0b013e3182659ca3

Ercolano E, Grant M, McCorkle R Applying the Chronic care model to support ostomy self-management: implications for oncology nursing practice. Clin J Oncol Nurs. 2016; 20:(3)269-274 https://doi.org/10.1188/16.CJON.20-03AP

Forsmo HM, Pfeffer F, Rasdal A, Sintonen H, Körner H, Erichsen C. Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal surgery. Int J Surg. 2016; 36:(Pt A)121-126 https://doi.org/10.1016/j.ijsu.2016.10.031

Fredrix M, McSharry J, Flannery C, Dinneen S, Byrne M. Goal-setting in diabetes self-management: A systematic review and meta-analysis examining content and effectiveness of goal-setting interventions. Psychol Health. 2018; 33:(8)955-977 https://doi.org/10.1080/08870446.2018.1432760

de Freitas PP, de Menezes MC, dos Santos LC, Pimenta AM, Ferreira AVM, Lopes ACS. The transtheoretical model is an effective weight management intervention: a randomized controlled trial. BMC Public Health. 2020; 20:(1) https://doi.org/10.1186/s12889-020-08796-1

Goldblatt J, Buxey K, Paul E, Foot-Connolly R, Leech T, Bell S. Study on the time taken for patients to achieve the ability to self-care their new stoma. ANZ J Surg. 2018; 88:(6)E503-E506 https://doi.org/10.1111/ans.14195

Gong E, Zhang Z, Jin X Quality, functionality, and features of Chinese mobile apps for diabetes self-management: systematic search and evaluation of mobile apps. JMIR Mhealth Uhealth. 2020; 8:(4) https://doi.org/10.2196/14836

Grady PA, Gough LL. Self-management: a comprehensive approach to management of chronic conditions. Am J Public Health. 2014; 104:(8)e25-e31 https://doi.org/10.2105/AJPH.2014.302041

Grant M, Ferrell B, Dean G, Uman G, Chu D, Krouse R. Revision and psychometric testing of the City of Hope Quality of Life-Ostomy Questionnaire. Qual Life Res. 2004; 13:(8)1445-1457 https://doi.org/10.1023/B:QURE.0000040784.65830.9f

Grant M, Sun V, Tallman NJ Cancer survivors' greatest challenges of living with an ostomy: findings from the Ostomy Self-Management Telehealth (OSMT) randomized trial. Support Care Cancer. 2022; 30:(2)1139-1147 https://doi.org/10.1007/s00520-021-06449-6

Kadu MK, Stolee P. Facilitators and barriers of implementing the chronic care model in primary care: a systematic review. BMC Fam Pract. 2015; 16:(1) https://doi.org/10.1186/s12875-014-0219-0

Krishnamurty D, Blatnik J, Mutch M. Stoma Complications. Clin Colon Rectal Surg. 2017; 30:(03)193-200 https://doi.org/10.1055/s-0037-1598160

Krouse RS, Grant M, McCorkle R A chronic care ostomy self-management program for cancer survivors. Psychooncology. 2016; 25:(5)574-581 https://doi.org/10.1002/pon.4078

Lim SH, Chan SWC, He HG. Patients' experiences of performing self-care of stomas in the initial postoperative period. Cancer Nurs. 2015; 38:(3)185-193 https://doi.org/10.1097/NCC.0000000000000158

Application of a health education program using micro video combined with situational experience for discharged patients with jejunal stoma tube. 2018. http://zh.zhhlzzs.com/EN/Y2018/V53/I12/1478 (accessed 10 March 2023)

NHS England. Self-management education. 2022. https://tinyurl.com/mw9dsjuy (accessed 9 March 2023)

Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997; 12:(1)38-48 https://doi.org/10.4278/0890-1171-12.1.38

Rosland AM, Heisler M, Piette JD. The impact of family behaviors and communication patterns on chronic illness outcomes: a systematic review. J Behav Med. 2012; 35:(2)221-239 https://doi.org/10.1007/s10865-011-9354-4

Salvadalena G, Colwell JC, Skountrianos G, Pittman J. Lessons learned about peristomal skin complications: secondary analysis of the ADVOCATE Trial. J Wound Ostomy Continence Nurs. 2020; 47:(4)357-363 https://doi.org/10.1097/WON.0000000000000666

Selçuk-Tosun A, Zincir H. The effect of a transtheoretical model–based motivational interview on self-efficacy, metabolic control, and health behaviour in adults with type 2 diabetes mellitus: A randomized controlled trial. Int J Nurs Pract. 2019; 25:(4) https://doi.org/10.1111/ijn.12742

Seo HW. Effects of the frequency of ostomy management reinforcement education on self-care knowledge, self-efficacy, and ability of stoma appliance change among Korean hospitalised ostomates. Int Wound J. 2019; 16:(1)21-28 https://doi.org/10.1111/iwj.13047

Shen H, Kleij R, Boog P Development and evaluation of an ehealth self-management intervention for chronic kidney disease patients in china: protocol for a mixed-method hybrid type 2 trial. BMC Nephrol. 2020; 21 https://doi.org/10.1186/s12882-020-02160-6

Song Q, Yin G, Guo X, Lv X, Yu K, Liu C. Effects of a self-management program for patients with colorectal cancer and a colostomy. J Wound Ostomy Continence Nurs. 2021; 48:(4)311-317 https://doi.org/10.1097/WON.0000000000000779

Sun V, Ercolano E, McCorkle R Ostomy telehealth for cancer survivors: Design of the Ostomy Self-management Training (OSMT) randomized trial. Contemp Clin Trials. 2018; 64:167-172 https://doi.org/10.1016/j.cct.2017.10.008

Vellone E, Barbaranelli C, Lee CS, Riegel B. Measures of self-care in heart failure: issues with factorial structure and reliability. Heart Lung. 2015; 44:(1)82-83 https://doi.org/10.1016/j.hrtlng.2014.08.008

Villa G, Manara DF, Brancato T Life with a urostomy: a phenomenological study. Appl Nurs Res. 2018; 39:46-52 https://doi.org/10.1016/j.apnr.2017.10.005

Wang SY, Chang TH, Han CY. Effectiveness of a multimedia patient education intervention on improving self-care knowledge and skills in patients with colorectal cancer after enterostomy surgery: a pilot study. Adv Skin Wound Care. 2021; 34:(2)1-6 https://doi.org/10.1097/01.ASW.0000725192.98920.c4

Wen SL, Li J, Wang AN Effects of transtheoretical model-based intervention on the self-management of patients with an ostomy: A randomised controlled trial. J Clin Nurs. 2019; 28:(9-10)1936-1951 https://doi.org/10.1111/jocn.14731

Werth SL, Schutte DL, Stommel M. Bridging the Gap. J Wound Ostomy Continence Nurs. 2014; 41:(6)566-572 https://doi.org/10.1097/WON.0000000000000081

Williams J. Patient stoma care: educational theory in practice. Br J Nurs. 2012; 21:(13)786-794 https://doi.org/10.12968/bjon.2012.21.13.786

The impact of stoma management education on the self-care abilities of individuals with an intestinal stoma

Staff Nurse, Nursing Department, Wuhan No.1 Hospital, China

View articles · Email Yani

Director of Nursing, Nursing Department, Wuhan No.1 Hospital, China

View articles

Charge Nurse, Department of Hepatobiliary Surgery, Wuhan No.1 Hospital, China

An intestinal stoma is a surgically formed exteriorisation of the large or small bowel on to the anterior abdomen wall, to enable faeces to be excreted from the body. Patients living with a stoma may encounter physical, psychological, and social barriers and challenges. Stoma self-management education is essential to improving self-care competence, and patients who perceive the benefits of self-management education show a better adjustment to living with a stoma. This literature review explored the effectiveness of patient education interventions in improving the self-care knowledge and skills of patients living with an ostomy. The findings from the nine studies reviewed showed that self-management education approaches are effective in improving patients' self-care. The application of different approaches to ostomy self-management education, such as a transtheoretical model, chronic care model, telehealth and multimedia-based programmes – helped improve patients' self-care ability. The review also found that patients needed at least 3 months to develop the skills and maintain their ability to self-care. In addition, two education sessions provided to patients in hospital pre-discharge appeared sufficient for improving and maintaining self-care abilities. Where patients received education in hospital post-surgery, 2 or 3 sessions over 7 days were found to be sufficient to provide them with stoma care skills. Education sessions based on the transtheoretical model and chronic care model or telehealth helped maintain and reinforce self-care behaviours following discharge.

Colostomy and ileostomy are the two most frequently performed types of intestinal ostomy, which is a surgically formed exteriorisation of the large or small bowel on to the anterior abdominal wall, to enable the excretion of faeces from the body. Despite advances in stoma surgery, postoperative complications occur in up to 30% of cases and remain a major concern ( Babakhanlou et al, 2022 ). Krishnamurty et al (2017) demonstrated that complications, which include skin mucosa separation, retraction, necrosis and parastomal abscess, often occurred within 30 days of surgery. Peristomal skin complications are the most frequent problems encountered in patients with an intestinal stoma, with estimates putting the incidence as high as 75% ( Salvadalena et al, 2020 ). A qualitative study by Werth et al (2014) found that 90% of patients considered that education during their hospital stay in self-management of their stoma was essential. The aim of self-management is to maintain a satisfactory state of health and health functioning through effective interventions, allowing patients to lead more independent and healthy lives ( Grady and Gough, 2014 ).

In the UK, self-management education ( NHS England, 2023 ), supported by quality standards on good practice in self-management education developed by the Quality Institute of Self-Management Education and Training (https://www.qismet.org.uk), involves helping patients to develop an understanding of their condition and develop personal self-management behaviours. In China, research on the self-management model has focused on diabetes, hypertension, psychiatric disorders and cancer pain management. It has been developed mainly in the form of adding self-management skills to health education, in combination with electronic health (eHealth) technology ( Gong et al, 2020 ; Shen et al, 2020 ).

Introduction

Several studies have shown that following the creation of a stoma patients may experience stigmatisation; having a stoma will also affect people's perception of their body image and sexuality, and impact on other physical and psychological issues ( Luo et al, 2018 ; Villa et al, 2018 ; Choudhary and Kaur, 2020 ). Following stoma creation, it can take 2–4 weeks for the individual to adjust and adapt to life after hospital discharge, and the many challenges patients experience can undermine their confidence in caring for their stoma, which in turn affects quality of life ( Lim et al, 2015 ; Capilla-Diaz et al, 2016 ).

Due to the complexity of stoma care and, in many cases, patients' limited stoma-related knowledge, demand for stoma education has been increasing over the past few years ( Cengiz and Bahar, 2017 ). In order to minimise discomfort and complications, as well as reduce the risk of hospital readmission, it is vital to support patients to independently master good self-care skills and to help them understand appropriate product selection and usage ( Williams, 2012 ). Forsmo et al (2016) suggested that nurse-led provision of pre-operative and postoperative stoma education is essential for ensuring independent self-care and enabling patients to maintain a good quality of life. Therefore, providing ostomy education for patients in the immediate postoperative period while they are still in hospital should be a key nursing activity, aiding acceptance of living with a stoma and promoting self-management. People who perceive the benefits of self-management education have shown better adjustment to living with a stoma and have a better quality of life ( Villa et al, 2018 ).

Nurses can choose from a number of models to deliver high-quality patient education on stoma self-management:

• Chronic care model: this model promotes effective collaboration between informed and engaged patients and well-prepared healthcare teams, leading to improved disease management and clinical outcomes ( Kadu and Stolee, 2015 )
• The transtheoretical model: this focuses on understanding individual behaviour change and how people move dynamically through five stages (pre-contemplation, contemplation, preparation, action and maintenance) ( Prochaska and Velicer, 1997 ). This model acknowledges that people may be unaware of the need to change. In the first two stages, patients are encouraged to consider and make a small change; they are next supported to move on and make plans in the preparation stage; they then actively engage in behaviour change for 6 months, and finally include the change in their daily routine, to maintain the new behaviour over 6 months ( Brug et al, 2005 )
• Self-education: this approach to patient education can take a number of forms. During hospitalisation, patient education can be delivered via individual or group sessions; following post-discharge it can be provided via telephone calls, telehealth education and home visits.

The literature review described below builds on patient self-management and psychological experiences, and the challenges they encounter, to examine the effectiveness and impact of self-management education on improving patient self-care and experiences after educational interventions.

The literature review set out to explore the following research question: how does ostomy self-management education influence the ability of individuals with an intestinal stoma to self-care? The objectives were to critically examine the effectiveness of different patient education interventions in improving their self-care knowledge and skills in managing their stoma.

Research studies can use a variety of approaches: quantitative, qualitative and mixed methods. In the case of this review, studies using quantitative methodology provided data on the effectiveness of self-management education in supporting an individual's abilities to improve their self-care skills, while those using qualitative approaches explored patients' lived experience after the delivery of self-management education; mixed-methods approach studies used both methodologies. The inclusion criteria included individuals with a stoma aged more than 18 years, with the intervention being ostomy self-management education, and the outcome assessment of competency in self-care ( Table 1 ).

Articles were sourced through Medline, CINAHL, the Cochrane Library and PubMed. The key words used in the search were ‘self-management’, ‘self-care’, ‘education’, ‘stoma’, ‘ostomy’, ‘colostomy’, ‘ileostomy’ and ‘enterostomy’. The database search used the search phrases ‘adult patient’ AND ‘stoma OR ileostomy OR colostomy OR ostomy OR enterostomy’ AND ‘self-management education OR stoma education OR self-care education’.

A total of 229 articles were found using the above search criteria. After removing duplicates and screening the remaining articles to ensure they evaluated educational interventions, nine articles remained. These included data on educational interventions and so were included for analysis.

The nine studies comprised six quantitative studies, one qualitative study and two mixed-methods studies. The Johns Hopkins Nursing Evidence-Based Practice model was used to appraise the evidence level and the quality of the nine studies. The primary aim of these articles was to explore the impact of stoma self-management education on patients' self-management behaviours or self-care abilities, including the impact on self-care knowledge and skills.

Three studies Ercolano et al, 2016 ; Krouse et al, 2016 ; Song et al, 2021 ) focused on providing ostomy self-management interventions based on the chronic care model with multidisciplinary team involvement. Another study ( Wen et al, 2019 ) used a transtheoretical model-based intervention on self-management education, with two ( Sun et al, 2018 ; Grant et al, 2022 ) conducting ostomy self-management education delivered using a the telehealth approach through videoconferencing. One study ( Wang et al (2021) used a DVD-based multimedia educational format. Moreover, Seo (2019) and Goldblatt et al (2018) investigated the relationship between the intensity and duration of stoma health education on patient self-care and the acquisition of relevant stoma knowledge and skills, respectively. Table 2 provides an overview of the selected studies, including their design and outcome measures.

The objectives of the review were to critically examine the effectiveness of patient education interventions in improving the self-care knowledge and skills of patients with an ostomy, and determine which educational approaches are effective in improving patients' self-care skills. A range of factors was demonstrated to influence the effectiveness of strategies in promoting self-care management. The review found that effective approaches included use of the self-education model of delivery, and depended on the time span over which education was delivered and the number of sessions, and family or caregiver influence over the intervention.

Model of stoma self-management

Transtheoretical model.

Wen et al (2019) applied the transtheoretical model to ostomy self-management education; the results showed the effectiveness of transtheoretical model-based ostomy education at 1 month, 3 months and 6 months after discharge in two patient groups. The researchers found that those in the intervention group who had received the transtheoretical model-based ostomy education moved to the action and maintenance phases of stoma care more rapidly, while more than 60% of the control group had not initiated stoma self-care behaviours at 3 month follow-up.

This result was consistent with the findings of studies by de Freitas et al (2020) and Selçuk-Tosun and Zincir (2019) , who found that patients might perform self-care behaviour in the later stage. However, in these studies, using the transtheoretical model of delivering education took patients 3–6 months to achieve self-care behaviour changes.

In addition, research reported by Wen et al (2019) found that patients in the intervention group were able to better master stoma care knowledge and perform stoma care independently compared with the control group. Using the transtheoretical model to develop and implement ostomy self-management education to help patients develop beliefs about behavioural change and transform them into positive health actions at different stages of their behaviour can significantly improve self-care, making it worthy of clinical application.

Chronic care model

Krouse et al (2016) conducted a mixed-methods study to explore how ostomy self-management education might influence the adaptation of patients to living with a stoma using the chronic care model. They used the City of Hope Quality of Life Ostomy (COH-QOL-O) questionnaire ( Grant et al, 2004 ) to assess the quality and effectiveness of the stoma self-management programme pre-intervention and post-intervention.

Outcome indicators were generally achieved and maintained throughout the project; however, behaviour changes had not significantly improved post-intervention, although they did improve at follow-up. Patients' motivation improved after the intervention and this was maintained at follow-up. The increase in motivation scores indicated that participants had gained knowledge, skills and confidence in managing their own health. Their physical and social health was also found to have improved considerably, both post-intervention and at follow-up. These findings suggest that the chronic care model is effective in embedding stoma self-care management behaviours over the longer term. This study also evaluated the quality of the education sessions based on the chronic care model, the feedback from patients and the scores received from participants regarding the educators, ostomate peers and the curriculum. The overall feedback was positive: some participants suggested that the education sessions might be better delivered in larger groups using visual aids.

Ercolano et al (2016) designed an ostomy self-management training programme based on the principles of the chronic care model, which involved health education in physical, emotional, social and spiritual aspects of self-care. The study required ostomy attendees to write down self-care goals – Fredrix et al (2018) , whose review looked at studies evaluating diabetes self-management interventions, suggested that the process of goal-setting can facilitate behavioural change and help people identify the goals they needed to achieve. Ercolano et al's (2016) qualitative study showed that participants chose fewer social and psychological-related goals compared with physical goals, and they were mainly focused on ostomy-related complications or barriers. From the patient's point of view, the chronic-care-model-based stoma self-management programme should focus on the physical aspects required to meet patients' target needs.

Education delivery

Caregiver support.

There is debate over whether to involve caregivers in ostomy self-management education programmes. In a study by Grant et al (2022) caregivers were included in self-management education. However, the recruitment criteria used by Sun et al (2018) highlighted that individuals with a regular caregiver should not be included in trials because in some cases having an over-reliance on a caregiver can compromise a patient's ability to self-care and consequently affect intervention outcomes.

Villa et al (2019) noted that the contribution of caregivers is that they can expend the effort and offer time and emotional support to help a loved one who is ill or disabled. The study by Rosland et al (2012) noted that patients with colostomies who did not have support and assistance from family and friends were more prone to poor adjustment following ostomy formation; the higher the level of caregiver support, the better a patient can control their chronic condition and better adhere to their self-management programme. However, Vellone et al (2015) stated that the care of patients by family members often shifts from giving recommendations to patients on how to perform self-care to instead directly providing care. This increases a patient's dependence on family caregivers and reduces self-care capacity. The role of family caregivers in improving patients' self-care needs to be investigated further, and more studies are required to demonstrate these consequences and explain them.

Sun et al (2018) , Wang et al (2021) and Song et al (2021) considered the delivery methods of ostomy self-management education. Sun et al's study (2018) focused on the telehealth approach in delivering ostomy health education, enabling participants with ostomies to be managed via electronic communication. The participants in this study received a distance stoma education course at home via videoconferencing. The results showed that stoma self-management training had a positive impact on an individual's physical, social and spiritual health needs and that the telemedicine approach contributed to the successful implementation of the stoma education course. The motivation and self-efficacy scores for patients' stoma self-care were significantly improved compared with four other outcomes (physical, psychological, social wellbeing and spiritual wellbeing), and were maintained 6 months post-intervention.

Research by Grant (2022) , which was a mixed methodology study, explored further the patients' challenges in living with an ostomy following completion of a self-management telehealth programme based on the intervention used by Sun et al (2018) . The qualitative aspect of Grant's (2022) study compared the challenges experienced by post-stoma patients who had received a telehealth intervention with those who had received usual care. The results revealed that postoperative treatment-related problems were common in both groups, but that the control group faced more social and psychological challenges.

Song et al's (2021) study was based on the use of a telehealth multimedia messaging app: they found that use of the app improved patients' ability to self-care and reduced the incidence of peristomal complications. Participants also showed satisfaction with the app-based intervention.

The research by Wang et al (2021) focused on using multimedia DVDs to deliver self-management education sessions. The findings post-intervention showed a significant improvement in postoperative self-care knowledge and skills among participants who had received the DVD intervention compared with the controls. The results contradicted the findings of a study by Crawford et al (2012) , which reported that the nursing instruction plus DVD method is as effective as face-to-face instruction by nurses alone, and more evidence is needed to identify the validity of using the combined DVD method. However, the generalisability of findings from studies focusing on telehealth interventions and the use of a multimedia app is likely to be limited due to disparities of access. For example, patients living in less economically developed communities may lack the smartphone technology required to access telemedicine ( Allaert et al, 2020 ). It is therefore important to take this factor into account when selecting an education programme of stoma self-care in a particular setting.

Number of education sessions

Seo (2019) focused on the effectiveness of the timing of the provision of ostomy management education on the self-care ability of ostomates. Two experimental groups were provided with reinforced ostomy education at different stages of their patient journey to identify optimal timing for delivering self-care education to patients. The results showed that those who received two or three sessions of ostomy self-management reinforcement education had higher scores in self-efficacy and ability to administer self-care. In addition, the scores increased when the number of education sessions increased from one to two, but when this was further increased from two to three, the study found that the scores remained the same or even decreased.

Based on this finding, it can be deduced that two ostomy self-management education sessions are sufficient to improve the self-care of ostomy patients and that more sessions would be unnecessary, given that a greater number of frequent educational sessions may reduce patients' independence and confidence in mastering self-care skills. Goldblatt et al (2018) investigated how long it took patients to achieve self-care ability, and the factors associated with this period. The findings of the study indicated that patients required around 7 days to achieve independence in self-care, and 71% of participants had developed self-care skills at discharge. The study also found that combined pre- and postoperative stoma education was more effective than post-surgery stoma education alone. The details of the educational content used in the studies reviewed are presented in Table 3 .

Overall, stoma self-management education can effectively improve patients' self-care skills. In terms of self-care formation time, Wen et al's (2019) findings suggested that transtheoretical model-based ostomy education takes about 3 months for stoma patients to develop and maintain self-care behaviour change, whereas Goldblatt et al (2018) found that patients were able to perform self-care independently within about 7 days. This result differs from Wen et al's (2019) findings because Goldblatt examined self-care only before discharge and did not monitor the acquired and maintained self-care skill post-discharge. Sun et al (2018) , Grant (2022) and Song et al (2021) all showed that telehealth and DVD-based ostomy education can help improve self-care ability. These tools can be applied according to an individual patient's needs and financial situation.

Seo (2019) suggested that two or three stoma self-management education sessions before patients leave hospital following surgery are sufficient to improve self-care abilities, while the stoma education sessions evaluated in several other studies remained at 3-4 sessions, similar to the experimental results of Seo (2019) .

In general, based on the findings of the studies reviewed, two or three health education sessions over 7 days were sufficient to empower patients to undertake stoma self-care. Further, education based on the transtheoretical model, chronic care model or a telehealth approach can help maintain and reinforce self-care behaviours following discharge.

• Two or three health education sessions over seven days are sufficient to empower in-hospital patients to undertake stoma self-care
• The transtheoretical model, chronic care model or the use telehealth can help maintain and reinforce self-care behaviours after discharge
• The role and involvement of family caregivers in ostomy self-management education programmes merits further research

CPD reflective questions

• If you were implementing a stoma self-care programme for patients, which education model would you choose? Why would you choose this model?
• In your practice, have two or three health education sessions over 7 days been sufficient to improve a patient's self-care skills, or have you found that more sessions over a different time span are more effective? Why do you think that might be?
• Consider the pros and cons of involving a patient's family members in an education programme for stoma self-management

• Open access
• Published: 07 May 2024

The impact of nurse’s sense of calling, organizational commitment, job stress, and nursing work environment on patient safety management activities in comprehensive nursing care service units during the covid-19 pandemic

• YeJi Lee   ORCID: orcid.org/0000-0001-8180-4091 1 &
• Won Ju Hwang   ORCID: orcid.org/0000-0002-0498-6183 1 , 2  

BMC Nursing volume  23 , Article number:  311 ( 2024 ) Cite this article

101 Accesses

Metrics details

As the number of COVID-19 patients rises, there has been a notable increase in the workload for nurses. However, medium-sized hospitals lacked standardized protocols or consistent approaches to address the specific working conditions of nurses. Furthermore, concerns about patient care have heightened as the issue of nursing shortages coincides with the expansion of the comprehensive nursing care services project.

This study aimed to investigate the factors that influence patient safety management activities, such as calling, organizational commitment, job stress, and nursing work environment, among comprehensive nursing care service unit nurses during the COVID-19 pandemic.

A conceptual framework based on the Job Demand-Resource model and literature review of patient safety management activities was used to develop structured questionnaires that were distributed to 206 participants working in 7 comprehensive nursing care service units of small and medium-sized hospitals with at least 300 beds in the S and K provinces. Data analysis was conducted using descriptive statistics, chi-squared tests, t-tests, ANOVA, and hierarchical regression with the SPSS/WIN 23.0 program.

The results showed that calling (β =.383, p<.001) and job stress (β= -.187, p =.029) significantly influenced patient safety nursing activities in comprehensive care service ward nurses. The explanatory power of the model was 26.0% (F= 6.098, p <.001).

Conclusions

Our findings suggest that comprehensive care service ward nurses' career, income, COVID-19 patient nursing anxiety, calling, and job stress were important factors that influence patient safety nursing activities. Therefore, it was essential to develop calling education programs and improve the nursing work system and establish a fair compensation system during the pandemic situation.

Peer Review reports

Introduction

In February 2021, the COVID-19 vaccine was introduced in South Korea, and vaccination was carried out starting with healthcare professionals and then vulnerable populations. Despite the increasing vaccination rates, the number of new COVID-19 cases continued to rise, with over 1,000 new cases per day since July 2021, leading the government to declare a "fourth wave" of the pandemic [ 1 ]. During the early stages of the COVID-19 outbreak, there was confusion in hospitals regarding the screening and admission process for COVID-19 patients, which led to the revision of the Infection Management Medical Law, resulting in nurses strictly adhering to respiratory infection control, standard precautions, and the use of personal protective equipment to focus on patient safety [ 2 ]. However, as the COVID-19 situation has continued long-term, studies have suggested a reevaluation of the "heroic" image of nurses under social pressure.

Comprehensive nursing care services aim to provide high-quality nursing care, with improvements in patient safety such as prevention of falls, pressure ulcers, medication administration, and infection control emphasized in medical institution evaluations. However, the expansion of comprehensive nursing care service units coincided with the COVID-19 situation, resulting in an increased workload for nurses in these wards. Therefore, due to the close relationship between the increased direct nursing activities and patient safety nursing activities in existing comprehensive nursing care service units, and the increased sense of responsibility for patient safety nursing activities due to the COVID-19 situation, it is necessary to explore methods to improve the quality of patient safety nursing activities by nurses in these wards.

Sense of calling is a mindset that goes beyond religious meaning and involves finding fulfillment in one's work and making socially significant contributions, recognizing the value of giving meaning to one's work and contributing to society [ 3 ]. Those who possess a sense of calling not only find satisfaction in their work, but also gain the strength to persevere through various obstacles [ 4 ]. Following the COVID-19 situation, the media has shown interest in nurses who care for patients with a sense of calling, but there has been a lack of diverse activities and accurate behavior descriptions of nurses [ 5 ]. However, the professional ethics of nurses who worked at COVID-19 screening clinics to prevent the spread of infectious diseases during crisis situations was a sense of calling [ 6 ], which can be seen as the driving force behind patient safety nursing activities.

Organizational commitment refers to an individual's willingness to work for and remain a member of the organization to which they belong and is an important variable that promotes efficient task performance among members, ultimately enhancing the organization's performance and quality of nursing services [ 7 ]. Particularly during outbreaks of novel infectious diseases, securing personnel and fostering close cooperation among medical personnel are essential to respond effectively [ 8 ]. Therefore, identifying factors that contribute to patient safety nursing activities, such as organizational commitment, is not only important for clinical nurses, but also necessary for the expansion and development of comprehensive nursing care services in small and medium-sized hospitals.

Implementation of comprehensive nursing care services has been reported to increase patient satisfaction and hospital reutilization rates compared to general hospital wards [ 9 ]. However, it also leads to an increase in job stress for nurses due to demands from patients who expect nursing services beyond their scope of work [ 10 ]. Additionally, it results in increased documentation for tasks like skin care, medication management, and more, adding to job stress [ 11 ] comprehensive nursing care services wards have nurses who constantly enter and leave patient rooms depending on their demands, as there is no primary caregiver staying with the patients. Given the easy transmission of COVID-19 through close contact, comprehensive nursing care service unit nurses are stressed by the risk of exposure to infection sources [ 12 ]. Therefore, nurses in comprehensive nursing care services wards are facing a double burden of existing workload and new expectations and responsibilities related to COVID-19 prevention measures.

The nursing work environment encompasses various aspects, including physical, relational, and managerial characteristics that enable nurses to provide professional care [ 13 ]. When comparing small and large hospitals operating comprehensive nursing care service units, small hospitals face difficulties in securing nursing staff due to lower salaries and poor working conditions, leading to a concentration of nursing personnel in large hospitals [ 14 ]. Thus, there is an increasing demand for safe and secure nursing services from hospital customers [ 15 ], while small hospitals' nursing staff shortages can lead to difficulties in providing quality nursing services.

Likewise, the COVID-19 pandemic broke out during the expansion of the comprehensive nursing care service project in small and medium-sized hospitals and nurses were working with sense of calling in this chaotic nursing environment. However, because there were no approved work guidelines and protocol for nurses, nursers had to bear work stress, so they left the field and threatened patient safety. Therefore, this study attempted to identify the relationships between nurses' sense of calling, organizational commitment, job stress, and nursing work environment, and the factors influencing patient safety nursing activities among nurses in small hospitals' comprehensive nursing care service units. The conceptual framework of this study was grounded in the Job Demand Resource (JD-R) Model proposed by Bakker and Demerouti [ 16 ], upon which the following research model was constructed (Fig.   1 ).

Research model applying the job demands-resources model

The purpose of this study was to identify the factors affecting patient safety nursing activities in the context of COVID-19 by investigating the relationship between the sense of calling, organizational commitment, job stress, and nursing work environment of nurses in small and medium-sized hospitals' comprehensive nursing care service units. To achieve this, the study aimed to examine the general characteristics, level of sense of calling, organizational commitment, job stress, nursing work environment, and patient safety nursing activities of nurses in comprehensive nursing care service units. Based on these findings, the study aimed to provide information on the relationship between sense of calling, organizational commitment, job stress, nursing work environment, and patient safety nursing activities, as well as the factors influencing this relationship.

Study design

The present study was a descriptive survey research designed to investigate the level of general characteristics, sense of calling, organizational commitment, job stress, and nursing work environment of nurses working in small and medium-sized hospital nursing care service units, and to identify their impact on patient safety nursing activities. Prior to the start of the study, approval was obtained from the Institutional Review Board (IRB) of K University under the reference number (KHSIRB-21-583).

Participants

The participants of this study were from seven small to medium-sized hospitals in the S and G metropolitan areas, each with a comprehensive nursing care service unit consisting of more than 100 beds and less than 300 beds. One of the hospitals was a specialized spinal joint hospital, while the other six were general hospitals. Since the COVID-19 outbreak, three hospitals have been operating COVID-19 residential treatment centers and dispatching nurses, two hospitals have been operating COVID-19 inpatient wards, and two hospitals have been monitoring COVID-19 patients who are under home quarantine. Newly employed nurses with less than one year of clinical experience were excluded as they were in a period of adjusting to the hospital organization, which could lead to decreased organizational commitment, based on previous studies [ 17 ]. The sample size of the participants was calculated using G*power 3.1, and the study targeted a total of 206 participants, considering a dropout rate, with 183 participants required for a regression analysis to explain the study's power with an effect size of 0.15, 18 independent variables, a significance level of 0.05, and a test power of 0.9. Sixteen questionnaires with unreliable responses were excluded, resulting in 190 questionnaires being used for analysis.

Sampling method

This study gathered data from February 24, 2022, to March 3, 2022, at seven small and medium-sized hospitals with nursing and nursing integrated service wards, each having 100 to 300beds. These hospitals have situated in S City and the Gyeongin region. The target demographic for the data collection was nurses, and an online survey was employed for this purpose. Owing to COVID-19 quarantine protocols, external visitors had not allowed at the hospitals. Therefore, the study's objectives and details were communicated to the nursing department over the phone, and explicit permission to collect data was obtained. The researcher provided the online link to the nursing department, and through the unit manager, the department distributed an online link to the structured mobile questionnaire to those who willingly agreed to participate in the study. The research subject's consent ensures that personal information was kept confidential during their participation in the research, granting them the right to refuse involvement even after the research has started. The research results were kept anonymous and will be exclusively utilized for research purposes. These findings were intended for both statistical purposes and potential publication. The process begins with a research consent form explaining that the survey can be conducted, and only those who have confirmed their consent online before the survey were directed to the survey participation. To deter fictitious participation in the web-based survey process, participants were required to respond to all items during the survey, and each question was configured to allow only one response to prevent multiple submissions. In cases where additional clarification was necessary, participants had the option to receive explanations over the phone. As compensation for the time taken due to participation in this study, a gift (online beverage voucher) was provided. Prior to delivering the gift, phone numbers collected before sending it were checked for duplicate participation, and phone numbers collected after the confirmation of sending the gift were discarded.

Demographic and work characteristics

Nurse’s Demographic and work characteristics were obtained by survey. Demographic and work variables included in the study were participants’ age, education level, work experience, income, increased workload after COVID-19, COVID-19 patient nursing anxiety, patient safety education experience, and institutional evaluation.

Patient Safety Nursing Activities

Patient safety nursing activities were measured using the tool developed by Park [ 18 ]. The tool consists of 24 items categorized into six domains: patient identification (4 items), communication among healthcare providers (5 items), high-risk medication management (2 items), accurate surgery and procedure verification (3 items), infection prevention (7 items), and fall prevention (3 items). Each item was rated on a 5-point Likert scale ranging from "never" (1) to "always" (5), with higher scores indicating higher levels of patient safety management activities. The tool demonstrated good reliability with a Cronbach's α of .87.

Sense of Calling

The Multidimensional Measure of Calling (MCM) developed by Hagmaier and Abele [ 19 ] was used to measure calling, which was adapted to Korean by Ha et al.[ 20 ]. The Korean version of the tool consists of 9 items, categorized into three dimensions: job-person fit and environmental fit (3 items), meaning and value pursuit (3 items), and transcendent summons (3 items). Each item was rated on a 6-point Likert scale ranging from "not at all" (1) to "very much" (6). The tool demonstrated good reliability with a Cronbach's α of .88.

Organizational Commitment

The measurement tool for organizational commitment used in this study was a three-factor organizational commitment scale that was validated for Koreans by Lee et al. [ 21 ], based on the organizational commitment tool developed by Meyer and Allen [ 22 ]. The scale consists of three sub-factors: affective, continuance, and normative commitment, and each item was measured on a 7-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (7). The reliability of the scale was confirmed with a Cronbach's α of .93.

The measurement tool for job stress used in this study was the Effort-Reward Imbalance (ERI) tool developed by Siegrist et al. [ 23 ]. The translation was confirmed by two bilingual experts who evaluated its linguistic and cultural suitability. Job stress was assessed by the validated Korean version of the original ERI questionnaire containing 23 items [ 23 , 24 ]. The reported internal consistency for the Korean version was satisfactory with 0.71 for effort and 0.86 for reward [ 24 ]. The effort and reward domains each have five items measured on a 5-point Likert scale, with the minimum score for effort being 6 and the maximum score being 30, while the minimum score for reward was 11 and the maximum score was 55. To analyze job stress, the ratio of the sum of effort items to the sum of reward items was calculated. As the number of items for effort and reward domains was different (6 and 11, respectively), the total score for the reward domain was multiplied by 6/11 = 0.545 to make the maximum score 1. A ratio of 1 indicates a balance between effort and reward, while a ratio less than 1 suggests that rewards were greater than the subjective effort, indicating no job stress, and a ratio greater than 1 indicates that rewards were lower than the subjective effort, indicating job stress.

Over commitment refers to excessive dedication to excessive work demands, with higher scores indicating more commitment due to excessive control demands. The scale for over commitment was measured on a 4-point Likert scale ranging from 6 to 24, with higher scores indicating greater commitment due to excessive control demands. The reliability of the scale was Cronbach's α of .71.

Nursing Work Environment

The nursing work environment was measured using the Korean version of the nursing work environment scale developed by Lake[ 25 ] and validated by Cho et al.[ 26 ] This scale consists of 29 items, organized into five sub-domains: patient surveillance (4 items), interprofessional communication (5 items), high-risk medication management (2 items), accurate procedure verification (3 items), infection prevention (7 items), and fall prevention (3 items). Each item was rated on a 4-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (4), with higher scores indicating more positive perceptions of the nursing work environment by the nurses. The reliability coefficient was Cronbach's α of .93.

Data collection

From February to March 2022, an online survey was conducted targeting nurses working in seven small to medium-sized hospitals in S city and the Gyeongin area that operate comprehensive nursing care service units with 100 to 300 beds. One of the seven institutions was a specialized hospital for spinal joint care, and the others were general hospitals with more than seven essential treatment departments. All medical institutions were private hospitals, and the operation of comprehensive nursing care service units began in 2017. After the COVID-19 outbreak, three of the institutions operated hospital beds for COVID-19 infected patients, and the rest were engaged in running care centers, dispatching personnel to COVID-19 dedicated hospitals, and monitoring COVID-19 high-risk individuals in self-quarantine. As per the COVID-19 prevention guidelines, external visitors were prohibited from entering the hospital, so the researchers explained the purpose and content of the study to the nursing staff over the phone and received permission for data collection. The researchers provided an online link to the nursing staff, who then provided a structured mobile survey link (Google) to the voluntary participants via the nursing staff. Participants received a compensation of a reasonable reward (online beverage voucher) for their participation in the study.

Statistical analysis

This study used SPSS Statistics 23.0 as the analytical tool for research problem and hypothesis testing. General characteristics of subjects were analyzed using descriptive statistics such as frequency, percentage, and mean. The level of significance of nursing job stress was analyzed by chi-squared test, and the means and standard deviations of sense of calling, organizational commitment, nursing job stress, nursing work environment, and patient safety nursing activities were calculated using descriptive statistics. Differences in patient safety nursing activities according to general characteristics were analyzed using t-tests and ANOVA, and post hoc tests were conducted using Scheffé test. Pearson's correlation coefficient was used to analyze the relationships between sense of calling, organizational commitment, nursing job stress, nursing work environment, and patient safety nursing activities. Finally, the hierarchical regression analysis was used to examine the effects of sense of calling, organizational commitment, nursing job stress, and nursing work environment on patient safety nursing activities.

Differences in patient safety nursing activities according to the general characteristics of study participants

The demographic characteristics of the participants are presented in Table 1 . Regarding the differences in patient safety nursing activities according to general characteristics, significant differences were found in the comprehensive nursing care service unit work experience (F=5.426, p <.001), income (F=3.805, p =.011), anxiety related to caring COVID-19 patients (F=2.795, p =.028), and institution evaluation experience (t=2.325, p =.021). In terms of the comprehensive nursing care service unit work experience (F=5.426, p <.001), those with less than 2 years of experience had higher patient safety nursing activity scores than those with 3-4 years of experience. Regarding income (F=3.805, p =.011), those with a monthly income of 351 million won or more had a higher patient safety nursing activity score, and a post-hoc test showed a significant difference between the income groups of 250 million won, 251-300 million won, 301-350 million won, and 351 million won or more. Anxiety related to nursing COVID-19 patients (F=2.795, p =.028) showed higher scores for those who reported "yes" (110.18±9.98 points), but there was no significant difference in the post-hoc test. Institution evaluation experience (t=2.325, p =.021) was associated with higher patient safety nursing activity among those who reported having evaluation experience. Educational level, work experience, position, increased workload after COVID-19, patient safety incident experience, and patient safety education experience within the past year were not significant (Table 1 ).

Degrees of sense of calling, organizational commitment, job stress, work environment, patient safety management activities

The overall average score of the participants' sense of calling, based on the nine questions, was 4.35 ± 0.85, with the highest average score in the area of the meaning and pursuit of work at 4.53 ± 0.91. The overall average score of the participants' organizational commitment, based on 18 questions, was 3.57 ± 1.17, with the highest average score in the normative sub-factor area at 3.63 ± 1.13. The participants' job stress was measured by 17 questions, with sub-factor areas of effort (3.58 ± 0.68), reward (1.74 ± 0.31), and the ratio of effort to reward ranging from a minimum of 0.51 to a maximum of 2.67, with an overall average score of 1.17 ± 0.35, which was higher than 1. Over commitment was measured by six questions, with an average score of 2.57 ± 0.60. The average score for the nursing work environment was 2.27 ± 0.46, with the highest average score in the area of collaboration between nurses and doctors at 2.44 ± 0.63, and the lowest average score in the areas of nursing manager's ability, leadership, and support for nurses at 2.14 ± 0.62. The average score for the participants' patient safety nursing activities was 4.77 ± 0.42, with the highest score in the area of fall prevention at 4.66 ± 0.46, and the lowest score in the area of high-risk medication management at 4.01 ± 0.76 (Table 2 ).

Association with job stress among study participants

In addition, a cross-analysis was conducted to identify variables associated with job stress among study participants. The analysis results showed that there was an association between age group and increased workload after the COVID-19 outbreak, with χ2 =9.089, p =.011. This suggests that there was a correlation between job stress and age group. The highest frequency of job stress was reported among individuals in their 20s, with 38.3% (49 individuals) reporting job stress. There was also an association between job stress and increased workload after the COVID-19 outbreak, with χ2 =7.523, p =.006. Job stress was reported as "yes" by 90.6% (116 individuals) of participants who experienced increased workload after the COVID-19 outbreak, which was the highest frequency reported (Table 3 ).

The correlation between nurses’ sense of calling, organizational commitment, job stress, nursing work environment, and patient safety management activities

The correlation between nurses' general characteristics, sense of calling, organizational commitment, job stress, working environment, and patient safety management activities were examined. Patient safety management activities showed a static correlation with sense of calling (r=.04), organizational commitment (r=.16), and working environment (r=.20). This means that higher sense of calling, organizational commitment, and better working environment led to higher levels of patient safety management activities. There was a significant negative correlation between job stress and patient safety nursing activities (r=-.19), indicating that higher job stress leads to lower patient safety nursing activities (Table 4 )

Factors in patient safety management activities

Factors affecting patient safety nursing activities of the participants were found in Table 5 . To identify the factors influencing patient safety nursing activities of the study participants, with patient safety nursing activities as the dependent variable, independent variables such as comprehensive nursing care service unit experience, income, COVID-19 nursing anxiety, institutional evaluation experience, sense of calling, organizational commitment, job stress, and nursing work environment were selected from the general characteristics with significant differences in patient safety nursing activities. Before conducting the regression analysis, multicollinearity diagnosis was performed, and the VIF (Variance Inflation Factor) ranged from 1.064 to 2.579, all of which were less than 10, and the tolerance limits ranged from .39 to .94, all of which were between 0.1 and 1.0, indicating that there was no problem of multicollinearity in the data. The Durbin-Watson test result was 1.961, indicating that there was no multicollinearity and that the residual distribution satisfied the normality assumption. In the results of residual analysis, all assumptions of linearity, normality of errors, and homoscedasticity were satisfied. There were no outliers.

In Model 1, since most demographic variables among the general characteristics have a relationship with social phenomena, age and education were used as control variables to minimize bias in the regression coefficient estimates. When comprehensive nursing care service unit experience and income, which showed statistically significant differences in the difference analysis, were entered, the regression model was statistically significant (F=5.243, p <.001). In Model 2, when COVID-19 nursing anxiety and patient safety-related characteristics were additionally included, the regression model was statistically significant (F=4.874, p <.001), and comprehensive nursing care service unit experience (β=-.235, p =.002), income (β=.224, p =.003), COVID-19 nursing anxiety (β=-.182, p =.01), and institutional evaluation experience (β=.182, p =.008) were significant influencing factors, and the explanatory power of the model increased by 17.7%.

In Model 3, when sense of calling, organizational commitment, job stress, and nursing work environment were additionally included, the regression model was statistically significant (F=6.098, p <.001), and the comprehensive nursing care service unit experience (β=.209, p =.004), income (β=.241, p =.001), COVID-19 nursing anxiety (β=-.134, p =.048), sense of calling (β=.383, p <.001), and job stress (β=-.187, p =.029) were significant influencing factors, and the explanatory power was 30% (R 2 =.30, adjusted R 2 =.26, p <.001).

This study aims to investigate the sense of calling, organizational commitment, job stress, nursing work environment, and patient safety nursing activities of nurses working in the comprehensive nursing care service units during the COVID-19 pandemic, and to identify factors influencing patient safety nursing activities, to provide basic data for improving patient safety nursing activities of nurses in comprehensive nursing care service units. This paper focuses on discussing the major results of the study. It was found that nurses in comprehensive nursing care service units during the prolonged COVID-19 situation had increased workload and job stress, which was related to the pandemic situation, and the overworked state of the frontline nurses underscores the need for social support systems for them, even if it is necessary for patient safety, as suggested in a previous study. The average score for patient safety nursing activities was 4.77, which supports the results of previous studies, but there have been no studies on the comprehensive nursing care service units using the same measure. The high average score for patient safety nursing activities found in this study and previous studies can be interpreted as indicating that there was greater emphasis on patient safety and that nurses in comprehensive nursing care service units are actively practicing patient safety in the context of the COVID-19 pandemic.

The subcategories of patient safety nursing activities were rated highest in falls prevention (4.77 ± 0.42), followed by infection prevention (4.66 ± 0.46), and the lowest was high-risk medication management (4.01 ± 0.76). This is consistent with previous studies that showed a high level of falls and infection prevention activities among nurses in comprehensive nursing care service units [ 27 ]. As the use of comprehensive nursing care service units increases with age, with the elderly over 65 years old and over 70 years old being at high risk for falls, and with orthopedics, neurosurgery, and internal medicine being the main departments in hospitals operating comprehensive nursing care service units, which mainly admit patients with reduced mobility [ 28 ], it is important for nurses to actively engage in fall prevention activities in order to prevent falls in hospitalized patients who may not have a primary caregiver. Therefore, it is necessary to provide education on fall prevention knowledge for nurses in comprehensive nursing care service units, develop fall prevention programs that consider ward characteristics, and improve the atmosphere by holding nurses responsible in case of fall accidents.

The next highest subcategory of patient safety nursing activities was infection control, which was rated highly because of the strong transmission of COVID-19 infection, resulting in the strengthening of infection control guidelines in medical institutions and emphasis on infection control by medical staff. Nurses in comprehensive nursing care service units are aware of the importance of infection control for the prevention of COVID-19 infection and perform thorough infection control activities, especially because of the characteristics of the ward that require close contact with hospitalized patients. They also closely monitor any small changes in patients while actively sharing information on infection control guidelines with medical staff, patients, and primary caregivers. Therefore, in the context of COVID-19, an environment for discussing changes in infection control guidelines while performing infection control activities, including hand hygiene, should be created, and collaboration is essential to prevent infection control activities from becoming a source of work-related stress. Patient safety nursing activities are an important indicator in the operation of comprehensive nursing care service units, and insufficient support and personnel shortage, as well as improving the organizational atmosphere related to safety reporting, should be addressed to improve the practical abilities of nurses.

Differences in patient safety nursing activities based on general characteristics showed statistically significant differences in comprehensive nursing care service unit work experience, income, COVID-19 nursing anxiety, and institutional evaluation experience. Regarding comprehensive nursing care service unit work experience, the average score for patient safety nursing activities was higher for those with less than one year of experience and one to two years of experience. This is contrary to a study suggesting that patient safety nursing activities improve with increasing experience due to greater clinical experience and responsibility. However, there is a need for repeated studies as a previous study conducted on nurses in university hospitals and small hospitals showed that those with less than one year of work experience had higher awareness of patient safety culture than those with more experience.

In this study, 36% of nurses working in the comprehensive nursing care service unit had less than three years of experience. This finding reflects the ongoing expansion of the comprehensive nursing service system. It was noted that relatively inexperienced nurses performed patient safety nursing activities while conducting regular patient rounds.

As for income, the results of this study differed from a previous study, which showed that nurses with income levels below 2 million won had higher patient safety nursing activity scores than those with income levels between 2.01 and 2.5 million won. On the other hand, it could also be due to the different characteristics of working hours in the comprehensive nursing care service unit, as there are nurses who work in three shifts, day or night shift in the same unit, which results in different allowances and salaries. Regarding COVID-19 anxiety, a group of nurses who did not experience anxiety symptoms when thinking about COVID-19 patients performed better patient safety nursing activities, indicating that job insecurity has a negative impact on safe behavior. In addition, a study conducted during the COVID-19 pandemic showed that nurses' anxiety about COVID-19 had negative effects on physical activity.

As for institutional evaluation experience, since the certification evaluation system for medical institutions emphasizes the importance of patient safety, nurses with institutional evaluation experience have increased knowledge and attitudes about patient safety and are making efforts to comply with institutional patient safety regulations to prepare for evaluations. Therefore, in order to enhance patient safety management activities of nurses in small and medium-sized hospitals' comprehensive nursing care service units, it is necessary to establish patient safety departments and standardize guidelines and expand the scope of certification evaluations within small and medium-sized hospitals, as the number of safety management departments in these hospitals is relatively low compared to larger medical institutions.

There was a positive correlation between patient safety nursing activities, sense of calling, organizational commitment, and nursing work environment among the study participants, while job stress showed a negative correlation. Emotional organizational commitment influences safe behavior and is supported by research that shows a correlation between emotional r [ 29 , 30 ]. To secure nursing personnel for patient safety, it is necessary to establish a fair compensation system for existing nurses and prevent the loss of personnel, creating a cooperative atmosphere among hospital members.

Factors influencing patient safety among nurses in comprehensive nursing care service units were analyzed using hierarchical multiple regression analysis. According to Model 3, the significant influencing factors were the length of experience in comprehensive nursing care service, income, anxiety on COVID-19, institutional evaluation experience, sense of calling and job stress. However, considering the high turnover rate among nurses with 3 to 5 years of experience in comprehensive nursing care service units [ 31 ], it is necessary to establish an appropriate compensation and welfare system for experienced nurses to enhance their patient safety performance. To reduce COVID-19 anxiety among nurses, hospital-level programs to develop and implement anxiety reduction strategies, such as psychological therapy, should be considered [ 32 ].

While sense of calling has been identified as the most significant variable in patient safety in the nursing field, there are limitations to discussing the influence of sense of calling and patient safety nursing activities due to the scarcity of previous studies that have applied research from other fields [ 33 ]. However, examining similar studies shows that nurses perform their duties to the best of their ability for the sake of patients during disasters, and in the case of the COVID-19, it is inferred that they exhibit a higher sense of professional responsibility for patient safety. Sense of calling is an important factor in nursing workforce management, as it enhances the organizational competitiveness of nurses and serves as a catalyst for achieving organizational performance [ 34 , 35 ]. Nursing is a profession where a sense of calling is more important than any other profession, and because of the high employment rate for nurses, practical motivations outweigh sociocultural aspects such as volunteering and sacrifice. Therefore, it is necessary to reflect educational curricula on sense of calling, which involves doing socially meaningful work from undergraduate education, and mentoring programsfor nurses [ 36 , 37 ].

The job stress investigated in this study refers to effort-reward imbalance (ERI), which is characterized by an imbalance between the effort invested and the rewards received within an organization. This situation creates an atmosphere where members are not fully appreciated, promotion prospects are poor, and job positions and income levels are inadequate for their education and career levels. In small- and medium-sized hospitals, opportunities to enhance expertise are limited, and there are insufficient opportunities for capacity development [ 38 ]. Inappropriate treatment and compensation can lead to job stress among nurses; therefore, career management systems for nurses in small- and medium-sized hospitals should be implemented, and opportunities for skills development should be provided. There is a correlation between job stress and increased workload before and after the COVID-19 outbreak. Due to the recent spread of COVID-19 infection, nurses have been required to make additional efforts in tasks such as working at screening clinics, managing treatment centers, and monitoring home care patients, in addition to their regular duties [ 39 ]. Therefore, it is necessary to examine whether there are discrepancies in salary due to COVID-19-related work between medical institutions and whether nurses are under excessive pressure from social pressure.

Additionally, a study [ 40 ] targeting nurses in the comprehensive nursing care service units reported that some nurses tried to hide infection exposure due to reprimands. This indicates a lack of protective measures for nurses in handling exposure to infections that may occur while caring for COVID-19 patients. Inappropriate treatment is a factor that hinders infection prevention nursing intervention related to patient safety; therefore, it is necessary to improve the organizational culture to prevent individual mistakes when reporting safety concerns.

In contrast, organizational commitment, and nursing work environment, which were found to have significant correlations in previous studies [ 41 ] as factors influencing patient safety nursing activities, did not emerge as significant factors in this study. Regarding organizational commitment, a regression analysis was conducted again with the inclusion of the highly correlated emotional organizational commitment sub-factor, but the results remained non-significant. In previous studies, the proportion of organizational commitment among those over 30 years old was 39% and 34.2%, respectively, but in this study, those in their 20s accounted for the highest percentage at 44.2%, indicating different results. Therefore, further research is needed to investigate the factors influencing organizational commitment and patient safety management behavior. As for the nursing work environment, the lack of patient safety manuals and the subjectivity of the tool measurement concept suggest the need for repeated studies using direct variables.

Nursing implications

This study aimed to measure the sense of calling and identify factors affecting patient safety activities among comprehensive nursing care service unit nurses during the COVID-19 pandemic and contribute to developing basic data that can be used in developing safety nursing activity indicators. Additionally, as a strategy to enhance patient safety nursing activities among comprehensive nursing care service unit nurses, it is suggested that a mentoring relationship should be developed and applied to increase their sense of calling and to reduce job stress.

Moreover, an intervention study should be conducted to examine whether the imbalance between the efforts and rewards of comprehensive nursing care service unit nurses affects patient safety nursing activities. To improve patient safety nursing activities among comprehensive nursing care service unit nurses, it is recommended to establish a reward system for nurses, measure excessive effort related to intertwined nursing duties, and verify the effects of reducing job stress through medical institution support systems.

Limitations

First, the study was limited in scope to nurses working in integrated nursing and care service wards in small and medium-sized hospitals in Seoul and some areas of the Gyeongin region with at least one year of clinical experience, and the survey was conducted online during a period when the number of COVID-19 confirmed cases was increasing. Therefore, caution is needed in generalizing the results even within the selected sample of nurses who responded faithfully to the online survey. Secondly, the instruments used in this study were created before the COVID-19 situation, so there may be differences in content from the sense of mission, organizational commitment, job stress, and nursing work environment of nurses in integrated nursing and care service wards during the current situation. Finally, since the infection control measures for COVID-19 vary by institution among nurses working in integrated nursing and care service, there may be differences in the COVID-19 nursing experiences of the subjects.

This descriptive survey aimed to gather fundamental information about the factors that affect patient safety nursing activities among nurses in comprehensive nursing care service units, including sense of calling, organizational commitment, job stress, and nursing work environment. The study focused on identifying the factors that contribute to patient safety nursing activities among nurses in comprehensive nursing care service units during the COVID-19 pandemic. The study employed the job demands-resources model as a conceptual framework. Among the general characteristics, factors such as work experience in comprehensive nursing care service unit, income, anxiety levels in caring for COVID-19 patients, sense of calling, and job stress were identified as influencing patient safety management activities. Higher levels of education, income, and sense of calling were associated with increased engagement in patient safety management activities. Conversely, lower experience in comprehensive nursing care service unit, lower anxiety levels in caring for COVID-19 patients, and reduced job stress were also linked to higher levels of patient safety nursing activities. To enhance patient safety management activities, it is necessary to develop a sense of calling education program, improve nursing work systems tailored to the demands of the COVID-19 situation, and establish a fair compensation system.

Implications for future research and practice

First, future research could explore innovative approaches that can strengthen nurses' sense of calling, through mentorship and institutional recognition. Second, a mediation study should be conducted to determine if there is an imbalance between the efforts and rewards of nurses in comprehensive nursing care service units that affects patient safety nursing services. Additionally, by quantifying the extent of excessive effort and its implications for patient safety, measuring excessive effort in interconnected nursing tasks requires the development of reliable metrics and tools that accurately capture the workload and stressors experienced by nurses in comprehensive care settings. Third, further research should be conducted with a broader range of participants from various medical institutions as the study only included nurses working in small and medium-sized hospitals in some regions. Finally, subsequent research should be conducted to identify new variables related to patient safety management activities that may have an impact beyond the sense of calling and job stress among nurses in comprehensive nursing care service units.

Availability of data and materials

The data that support the findings of this study are available from the authors Korea, upon reasonable request.

Park JY. Nursing heroes under social pressure: An review of the refusal to care. Korean J Med Ethics. 2021;24(1):89–95. https://doi.org/10.35301/ksme.2021.24.1.89 .

Article   Google Scholar  

Kim J, Kim S, Park E, Jeong S, Lee E. Policy issues and new direction for comprehensive nursing service in the national health insurance. J Korean Acad Nurs. 2017;23(3):312–22. https://doi.org/10.11111/jkana.2017.23.3.312 .

Kim HW, Yoo JE, Woo CH. Effect of calling, meaning of work, job stress, and stress coping on organizational commitment among career soldiers. Korean J Stress Res. 2017;25(1):30–6. https://doi.org/10.17547/kjsr.2017.25.1.30 .

Duffy RD, Allan BA, Bott EM, Dik BJ. Does the source of a calling matter? External summons, destiny, and perfect fit. J Career Assess. 2014;22(4):562–74. https://doi.org/10.1177/1069072713514812 .

An JS. Analysis of image of nurses on articles in Korean daily newspapers after Corona pandemic. J Converg Cult Tech. 2021;7(1):66–74. https://doi.org/10.17703/JCCT.2021.7.1.66 .

Ha BY, Bae YS, Ryu HS, Jeon MK. Experience of nurses in charge of COVID-19 screening at general hospitals in Korea. J Korean Acad Nurs. 2022;52(1):66–79. https://doi.org/10.4040/jkan.21166 .

Article   PubMed   Google Scholar  

Kim YM, Kang YS. Effects of self-efficacy, career plateau, job embeddedness, and organizational commitment on the turnover intention of nurses. J Korean Acad Nurs. 2015;21(5):530–41. https://doi.org/10.11111/jkana.2015.21.5.530 .

Jeong EK. Public health emergency preparedness and response in Korea. J Korean Med Assoc. 2017;60(4):296–9. https://doi.org/10.5124/jkma.2017.60.4.296 .

Lee JS, Lee JW. A comparison of factors affecting hospital revisit intention in comprehensive nursing care unit and general care unit. J Korea Acad-Ind Cooperation Soc. 2020;21(4):73–81. https://doi.org/10.5762/KAIS.2020.21.4.73 .

Choi HN, Lee MH. Comparing the Emotional Labor, Job Stress, and Nursing Performance of Nurses in the Comprehensive Nursing Care Ward and the General Ward. J Korean Acad Soc Home Health Care Nurs. 2018;25(2):139–46. https://doi.org/10.22705/jkashcn.2018 .

Lee SS, Yu SU. Comparison Analysis between Comprehensive nursing care service and Non-Comprehensive nursing care service through Electronic Nursing Documentation. J Health Inform Statistics. 2017;42(2):170–6. https://doi.org/10.21032/jhis.2017.42.2.170 .

Shubayr MA, Mashyakhy M, Al Agili DE, Albar N, Quadri MF. Factors Associated with Infection-Control Behavior of Dental Health-Care Workers During the COVID-19 Pandemic: A Cross-Sectional Study Applying the Theory of Planned Behavior. J Multidiscip Healthcare. 2020;13:1527–35. https://doi.org/10.2147/JMDH.S278078 .

Estabrooks CA, Midodzi WK, Cummings GG, Ricker KL, Giovannetti P. Measuring the hospital practice environment: a Canadian context. Res Nurs Health. 2002;25(4):256–68.

Hong JY, Chae JM, Song MR, Kim EM. A Utilization Strategy of Nursing Staff by Types of Medical Institutions - nurse staffing level of medium and small-sized hospitals. J Korea Academia-Ind Cooperation Soc. 2017;18(8):162–70. https://doi.org/10.5762/KAIS.2017.18.8.162 .

Cha BK, Choi J. A Comparative Study on Perception of Patient Safety Culture and Safety Care Activities: Comparing University Hospital Nurses and Small Hospital Nurse. J Korean Acad Nurs Admin. 2015;21(4):405–16. https://doi.org/10.11111/jkana.2015.21.4.405 .

Bakker AB, Hakanen JJ, Demerouti E, Xanthopoulou D. Job resources boost work engagement, particularly when job demands are high. J Educ Psychol. 2007;99(2):274.

Hu H, Wang C, Lan Y et al. Nurses’ turnover intention, hope and career identity: the mediating role of job satisfaction. BMC Nurs. 2022;21:43. https://doi.org/10.1186/s12912-022-00821-5 .

Park HH, Kim S. A structural equation model of nurses' patient safety management activities. Journal of Korean Academy of Nursing Administration. 2019;25(2):63–72.

Hagmaier T, Abele AE. The multidimensionality of calling: conceptualization, measurement, and a bicultural perspective. Journal of Vocational Behavior. 2012;81(1): 39-51. https://doi.org/10.1016/j.jvb.2012.04.006 .

Ha YJ, Choi YE, Eun HY, Sohn YW. Validation of the Korean version of Multidimensional Calling Measure (MCM-K). Korean Journal of Industrial and Organizational Psychology. 2014;27(1):191–220. https://doi.org/10.24230/ksiop.27.1.201402.191 .

Allen NJ, Meyer JP. The measurement and antecedents of affective, continuance and normative commitment to the organization. Journal of Occupational Psychology. 1990;63(1):1–8. https://doi.org/10.1111/j.2044-8325.1990.tb00506.x .

Lee K, Allen NJ, Meyer JP, Rhee KY. The three-component model of organizational commitment: an application to South Korea. Applied Psychology. 2001;50(4):596-614. https://doi.org/10.1111/1464-0597.00072 .

Siegrist J, Starke D, Chandola T, Godin I, Marmot M, Niedhammer I, et al. The measurement of effort-reward imbalance at work: European comparisons. Social Science & Medicine. 2004;58(8):1483–1499. https://doi.org/10.1016/S0277-9536(03)00351-4 .

Eum KD, Li J, Lee HE, Kim SS, Paek D, Siegrist J, et al. Psychometric properties of the Korean version of the effort-reward imbalance questionnaire: A study in a petrochemical company. International Archives of Occupational and Environmental Health. 2007;80:653–661. https://doi.org/10.1007/s00420-007-0174-3 .

Lake E. T. Development of the practice environment scale of the nursing work index. Research in Nursing & Health. 2002;25(3):176-188. https://doi.org/10.1002/nur.10032 .

Cho EH, Choi MN, Kim EY, Yoo IY, Lee NJ. Construct validity and reliability of the Korean version of the practice environment scale of nursing work index for Korean nurses. Journal of Korean Academy of Nursing. 2011;41(3):325–332. https://doi.org/10.4040/jkan.2011.41.3.325 .

Cheon GU, Kim JY. The Relationships among awareness of patient safety culture, critical thinking disposition and patient safety nursing activities of nurses among comprehensive nursing care service unit. Journal of Korea Academia-Industrial cooperation Society. 2018;19(6):345–354. https://doi.org/10.5762/KAIS.2018.19.6.345 .

Bu EH, et al. A Study on the Improvement of Comprehensive Nursing Care Adoption. Ilsan Hospital Institute of Health Insurance & Clinical Research. 2015:20–029.

Seo JG, Kwon HG. A Study on The Effect of Organizational Commitment on The Worker's Safety Behavior: Focused on The Moderating Effect of Job Insecurity. Journal of the Korea Industrial Information Systems Research. 2017;22(1):127–128. https://doi.org/10.9723/jksiis.2017.22.1.127 .

Lee SH, Kwon TS, Baek YS, Choi YS, Kim SG. Effects on Organizational Commitment and Safety Behavior of Employment Anxiety for PSD Maintenance Workers. Journal of the Korean Society for Railway. 2018;21(4):413–423. https://doi.org/10.7782/JKSR.2018.21.4.413 .

Park SY. The Effects of Role Conflict and Interpersonal Relations on Turnover Intention of Total Care Service Unit Nurses [Master's thesis, Hanyang University]. 2019. https://sspace.snu.ac.kr/bitstream/10371/149242/1/000000160160.pdf .

Park JM. An Exploratory Study on Anxiety and Depression of Corona Virus 19 among Hospital Nurses. Journal of Convergence for Information Technology. 2021;11(10):53–59. https://doi.org/10.22156/CS4SMB.2021.11.10.053 .

Kim YJ, Lee NY. Factors Affecting Posttraumatic Growth of Nurses Caring for Patients with COVID-19. Journal of Korean Clinical Nursing Research. 2021;27(1):1–11. https://doi.org/10.22650/JKCNR.2021.27.1.1 .

Kim HW, Han SJ. Mediating Effects of Self-efficacy between Calling and Nursing Professionalism for Nurses in General Hospitals. Journal of Korean Academy of Nursing Administration. 2019;25(3):22–238. https://doi.org/10.11111/jkana.2019.25.3.220 .

Hong SN, Choi JK. A Study on the Impact of Safety Culture Perceptions of Flight Attendants on the Psychological Organizational Effectiveness: Moderating Effect of Vocational Calling. Korean Journal of Hospitality and Tourism. 2021;30(4):103–122. https://doi.org/10.24992/KJHT.2021.6.30.04.103 .

Kim MJ, Kim SH. Influences of Calling, Work Value, and Organizational Commitment on Turnover Intention in Nurses Employed at University Hospitals in a Region. The Korean Journal of Health Service Management. 2016;10(1):67–77. https://doi.org/10.12811/kshsm.2016.10.1.067 .

Ehrhardt K, Ensher E. Perceiving a calling, living a calling, and calling outcomes: How mentoring matters. Journal of Counseling Psychology. 2021;68(2):168.

Park JY, Woo CH. The Effect of Job Stress, Meaning of Work, and Calling on Job Embeddedness of Nurses in General Hospitals. Journal of the Korea Convergence Society. 2018;9(7):105–115. https://doi.org/10.15207/JKCS.2018.9.7.105 .

Han YH, Kim HY, Ko JA, Kim EJ. Relationship between Expectations of Clinical Ladder System, Career Commitment and Turnover Intention of Nurses in Small and Medium Sized Hospitals. Journal of Korean Academy of Nursing. 2018;24(5):466–478. https://doi.org/10.22650/JKCNR.2018.24.1.67 .

Kwon MJ, Yi YJ. Factors influencing on performance for infection control of nurses working in comprehensive nursing care service unit under COVID-19 pandemic. Journal of Korean Academy of Nursing Administration. 2022;28(2):121–130. https://doi.org/10.11111/jkana.2022.28.2.121 .

Kang H, Choi SK, Kim IS. Factors influencing on patient safety management activities in operating room nurses. Journal of the Korea Academia-Industrial Cooperation Society. 2016;17(9):329–339. https://doi.org/10.5762/KAIS.2016.17.9.329 .

Download references

This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT Future Planning (No. RS-2023-00245180) and by Korea Health Industry Development Institute (grant number: HI18C1317). The funding agencies had no role in the study design; in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

Author information

Authors and affiliations.

College of Nursing Science, Kyung Hee University, Seoul, South Korea

YeJi Lee & Won Ju Hwang

College of Nursing Science, Kyung Hee University, East-west Nursing Research Institute, Seoul, South Korea

Won Ju Hwang

You can also search for this author in PubMed   Google Scholar

Contributions

YeJi Lee conceived the study. Won Ju Hwang were involved in writing the manuscript. YeJi Lee and Won Ju Hwang were responsible for data collection. All authors reviewed the manuscript and contributed to and approved the final submitted version.

Corresponding author

Correspondence to Won Ju Hwang .

Ethics declarations

Ethics approval and consent to participate.

We informed all the participants that this study is only used by academic research and not used for any other purposes. All included participants gave their written informed consent. This study was performed after receiving approval from the research ethics committee of Kyung Hee University (KHSIRB-21-583(RA)).

Consent for publication

Not applicable.

Competing of interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Lee, Y., Hwang, W.J. The impact of nurse’s sense of calling, organizational commitment, job stress, and nursing work environment on patient safety management activities in comprehensive nursing care service units during the covid-19 pandemic. BMC Nurs 23 , 311 (2024). https://doi.org/10.1186/s12912-024-01929-6

Download citation

Received : 30 September 2023

Accepted : 10 April 2024

Published : 07 May 2024

DOI : https://doi.org/10.1186/s12912-024-01929-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Patient safety

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]