The authors observed several recurrent themes during the group interventions. Fear of finding cancer and the perception of the procedure’s invasiveness were raised and addressed. Also misconceptions about CRC were debunked, such as the belief that a lack of bowel symptoms indicated no chance of having CRC or that only a family history indicated a risk factor. Patients discussed how much they learned about CRC, colon anatomy, and the importance of the bowel preparation. A multifaceted teaching approach was used to convey teaching points, such as flip charts, colonoscopy equipment, tours of procedure rooms, and visuals of various bowel preparation qualities. Throughout the educational intervention, humor, active listening, and reflection were woven into discussions to create a comfortable and relaxed learning environment.
Discussion and Limitations
The study results were unexpected. The authors had hypothesized that the group preprocedure educational intervention would have made a statistically significant difference in preparation quality, but it did not. In addition, the authors’ observations during the intervention led them to believe that the subjects had gained knowledge about how to correctly administer the bowel preparation.
Related: Do Age and Gender Matter in Colorectal Cancer?
A significant limitation of this pilot study was the difficulty in extrapolating meaningful data within the intervention group and between the intervention and control groups. After closely examining the raw data, the authors identified some key issues: There were only 28 subjects in each group who had bowel preparation quality described. This small sample size makes it difficult to draw meaningful conclusions. However, the education session in and of itself was clearly a positive experience for subjects, and the authors would recommend a future study with a larger sample size.
A prior power analysis would have helped this study determine a sufficient number of subjects that would be needed to determine whether the intervention had an effect. Furthermore, instead of tossing a coin to randomize the study groups, other types of randomization could have been used.
Other study limitations that came to light were:
- Variable preparation quality documentation by endoscopists;
- Limited availability of days to schedule group intervention classes;
- Some subjects did not attend the group session but still had the procedure done;
- The study invitation letter was long, and there were no financial incentives to participate;
- If pre- and postintervention testing had been conducted, effective and ineffective teaching strategies could have been identified; and
- The principal investigator also performed some of the procedures during the study, introducing potential bias.
Since the study, the authors have learned more about changes in national standards for bowel preparation administration and polyp surveillance. Preparation instructions need to be updated to reflect current recommendations for split-dose preparation administration in which the bowel preparation is taken in spaced doses, leading to better compliance and outcomes.6 Informally, patients and family have told staff that preparation instructions are difficult to understand. Following a Plan-Do-Study-Act cycle, feedback from patients should be obtained before revising and printing preparation instructions.7 This feedback could ensure that preparation instructions are written in patient-friendly, easily understood language.
Conclusion
Nursing professionals are likely to be effective in helping veterans achieve improved bowel preparation quality, because nurses have an established record as patient educators and advocates. Good bowel preparation quality is an important, achievable objective for veterans. As Mangnall reported, bowel preparation quality data are a strong nurse-sensitive quality measure that can be used to devise more effective interventions to obtain better bowel preparation results.8 As clinicians working on the frontline, nurses are well positioned to assess, intervene, and evaluate whether or not the modifications they have made to bowel preparation instructions are effective as they measure bowel preparation quality status post colonoscopy.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
