PERCEPTIONS OF COLOSTOMY PATIENTS ABOUT NURSING CARE IN ONCOLOGY INPATIENT UNITS

Objective: To analyze the perceptions of colorectal cancer patients using colostomy on the nursing care of the oncology inpatient units of a hospital in western Santa Catarina. Methods: Descriptive-exploratory study of qualitative approach carried out in the oncology inpatient units of the Hospital Regional do Oeste, in the period from January to August 2020, through a questionnaire containing sociodemographic data and semi-structured interview, applied to 20 patients with colorectal cancer using colostomy. The data were analyzed using Laurence Bardin’s Content Analysis. Results: The results indicated a prevalence of colostomy male patients, with a mean age of 60.25 years, married, retired, and with incomplete elementary education. From the qualitative analysis of the interviews emerged the category: patients’ perceptions of nursing care, which was subdivided into: nursing care with the bag and the stoma and nursing care during hospitalization. Conclusion: At the end of the survey, it is concluded that the colostomy patients perceive that the nursing staff performs the essential care of the bag and the stoma, including its exchange and hygiene during hospitalization, meeting the patients’ needs. In addition, they provide important guidance on the use of the devices, promoting health education.


INTRODUCTION
Bowel cancer is that which starts in the colon, rectum, or anus, also known as colorectal cancer. It is treatable and, in most cases, when detected early, curable. Most of these tumors originate from polyps, which are benign lesions inside the intestine¹. A colostomy is created when part of the large intestine is removed and another exteriorized. This results in a change in the body for the elimination of feces. When the colostomy is temporary, it can be reversed and bowel activity resumes its normal function. However, when the end portion of the colon or rectum becomes compromised, a permanent ostomy may be necessary 3 .
The individual living with cancer suffers daily the contradictory process between health and disease and needs to be the protagonist of this phase, creating life projects that express quality of life and contain within themselves the complexity that needs to be considered in the health-disease phenomenon 4 . Thus, as the representation of colorectal cancer patients about the quality of life after intestinal ostomy is known, it is possible that there will be improvements in the assistance, à bolsa e à estomia, incluindo sua troca e higiene durante a internação, atendendo às necessidades dos pacientes.

Estomaterapia.
Perceptions of colostomy patients about nursing care in oncology inpatient units as well as the awareness of the multidisciplinary health team, to understand the common sense, providing a rehabilitation and quality of life to these individuals 5 .
Systematic nursing intervention in enterostomal therapy, ranging from the preoperative period, continuing in the postoperative period and follow-up allows for the creation of adaptive strategies and new knowledge in the management of care for the ostomy, favoring psychosocial adaptation 6 . In addition, the need for the use of materials and other equipment for the care of the stoma and the skin is considered something new, different and so the provision of guidance is indispensable 7 .
Throughout the process, the colostomy patient experiences significant changes in his or her life, which affect not only the physiological, but also the psychological, physical, emotional, spiritual, and sexual aspects, which have repercussions on the quality of life. Thus, it needs attention in all its aspects during the rehabilitation process. Thus, nursing is very important in this phase, helping the individual and family members to choose the best equipment, informing them about the diets, and clarifying doubts related to the ostomy 5 .
Finally, the nurse acts as a mediator and facilitator of care, which enables the development of skills for care and the welcoming of doubts, fears, and anxieties presented by these people and their families. Thus, the communication process enables effective exchanges between nurse and client, which provides the minimization of difficulties arising from the ostomy 8 .
The research is justified because it is known how important nursing is in the lives of people with ostomies, and understanding how patients perceive nursing care allows these professionals to rethink and create strategies that provide

METHODS
This is a descriptive-exploratory study with a qualitative approach. The field of study was composed of the oncology inpatient units (Oncology I and II) of the Hospital Regional do Oeste, located in Chapecó -Santa Catarina. The institution has 319 beds, 275 of which are registered in the Cadastro Nacional de Estabelecimentos de Saúde (CNES) 9 .
Currently, based on information from the hospital in question, it is estimated that approximately 40 colorectal cancer patients using a colostomy are admitted for treatment in the oncology inpatient units per semester.
The sample was defined by saturation. Sample closure by theoretical saturation is operationally defined as the suspension of the inclusion of new participants when the data obtained begins to present, in the evaluation of the researcher, a certain redundancy or repetition, not being considered relevant to persist in data collection 10 . Thus, the sample was composed of 20 patients with colorectal cancer using a colostomy, admitted to the oncology inpatient units of the Hospital Regional do Oeste.
Were included: patients with colorectal cancer using a colostomy, aged between 25 and 75 years, admitted for treatment in the oncology inpatient units (Oncology I and II) of the Hospital Regional do Oeste, during the period established for data collection. Patients with cancer other than colorectal cancer or who do not have a colostomy were excluded.
For data collection, which occurred in the period from January to August 2020, a research instrument was employed consisting of a questionnaire identifying the patient, containing sociodemographic data and a semi-structured interview about the patient's perceptions of nursing care.
Participants were chosen based on disease staging and age, aiming for similarity in these criteria. For the approach to the patients, the researcher would go to the bed where they were and explain about the research, its objectives, risks and benefits. If they agreed to participate, they were invited to a reserved room, located in the oncology inpatient units, to facilitate data collection, so that there would be no interruptions. All those approached were able to move around without risk, and the room used for the interviews was defined on the day with the sector nurse, and most of the time the alternative therapy room was used.
After reading and filling out the Informed Consent Form and the Consent Form for the use of image and/or voice, the interviews were started. These were recorded (audio) to avoid the loss of speech details and had an average duration of 15 min.
Laurence Bardin's method was used to analyze the data, which organizes the phases of content analysis into three main chronological orders: pre-analysis; exploration of the material; and treatment of the results, inference and interpretation 11 . In the first phase, after collecting data through a semi-structured interview, the transcription of the speeches began. At this moment, it was possible to listen to the patients' speeches several times, being impregnated with them, which allowed the creation of notes to the research objectives and a brief notion of the perception of these individuals about the nursing care received in oncology inpatient units.
In the second phase a table was created divided into themes about the subject, which emerged from the first phase of the analysis. After that, the sub-themes were highlighted by various colors, i.e., what each patient reported about the themes that emerged, and then these statements were cut and pasted in the corresponding place in the table.
In the last phase, the clippings were read and then interpreted and described by the researchers. In addition, several categories emerged after the analysis of the results, but those that met the research objectives were chosen, and after the organization and description of the speeches, the discussion process began.
Regarding the risks of the research, which could be on the physical, moral, intellectual, social or cultural dimension.
Given this situation, data collection would only continue if the participants were emotionally able to continue, otherwise the interview would be discarded or rescheduled for a later time.
Considering the possibility of risks that could be aroused by the interview, the assistance team of the Hospital Regional do Oeste, especially psychology, would be requested to provide assistance to the patient if necessary, according to the agreement previously established between the research supervisor and the institution's staff. In addition, the necessary referrals would be made by the public health network, through the Unified Health System.
If it was necessary to provide support with medication or medical care, the support would be provided by the researcher, as long as these medications and medical care were effective for the psychological and physiological damage triggered by the interview.
The benefits obtained through the production of information consisted of: giving greater visibility to the theme, contributing to the improvement of nursing care to patients with colorectal cancer using a colostomy. To ensure confidentiality and anonymity, the research participants were asked to sign the Informed Consent Form (ICF). The document was signed in two copies of equal content, with one remaining with the researchers and the other with the interviewed patients. The data collection material will be stored by the researchers in a place of their exclusive access for a period of five years, and will be destroyed after the established period. The research was committed to the privacy and confidentiality of the data used, preserving the anonymity of the interviewees, who were identified by codenames referring to the letter P for patient, followed by the number of the interview (for example: P1, P2, etc.).
Perceptions of colostomy patients about nursing care in oncology inpatient units

RESULTS
A total of 20 patients were interviewed, with a mean age of 60.25 ± 8.41 years, with 75% being male and 25% female.
Regarding race, the majority (85%) declared themselves to be white. The prevalent age group was the elderly, with 55% of the sample studied. As to marital status, 75% were married. The number of children varied from 1 to 3 (80%) and from 4 to 8 (20%). Regarding the municipality of residence, 25% live in Chapecó and 75% in neighboring cities. Of those interviewed, 95% own their homes and 90% live with relatives. Regarding work occupation, the majority (55%) are retired. The education level most cited was incomplete elementary school (50%). Regarding the monthly income of the family, 50% receive from less than 1 minimum wage up to 3 minimum wages.
Regarding colorectal cancer, 80% of the interviewees have had the disease from 1 month to 2 years, and 20% over 2 years. The time of experience with the colostomy was represented by 85% of the interviewees who have had it from 20 days to 2 years. Most patients are in stage IV of the disease (70%), and regarding the number of hospitalizations, 40% have been hospitalized from 1 to 10 times, 40% from 11 to 20 times, 15% from 21 to 40 times, and 5% more than 40 times.
The qualitative data analysis allowed the construction of the following category: patients' perceptions of nursing care.
For didactic purposes, this category was subdivided into two subcategories: nursing care of the bag and the stoma and nursing care at hospitalization.

Patients' perceptions of nursing care
Nursing care for people with ostomies requires specific knowledge by the nurse. In addition, care should be in full, considering the client's needs at all stages of the process, from preoperative to rehabilitation 12 . Thus, it is necessary to put into practice humanized nursing care based on scientific evidence, encompassing all the people involved in the process, ensuring the success of the treatment 13 .
From the analysis of the interviewees' speeches, two subcategories about nursing care emerged, which are described below.

Nursing care of the bag and the stoma
The patients interviewed reported that the nurses and nursing staff performed care of the bag and the stoma, including hygiene, using water or even saline for cleaning, gauzes, forceps, and products for maintaining the ostomy. They also performed the exchange of the bag, including in situations where accidents occurred. As most of the interviewees reported, the nursing staff taught hygiene and changing the bag, and investigated colostomy complications, whether the colostomy was working properly, and whether the patient needed help changing the bag.

Nursing care during hospitalization
As for inpatient care, the interviewees commented on the care provided by the nursing staff, among which they listed: the affection, attention, concern for the patient, and the care received. From orientations, answering questions, solving problems, performing a physical exam, and even requesting care from the multiprofessional team. It is perceived that this assistance must be provided in all operative phases, enabling the adaptation of the person with the ostomy to the new lifestyle, besides providing the orientations related to the care with the stoma and the collecting bag, such as hygiene, acquisition of products, feeding, and actions to avoid complications 15 .
In the study by Paczek et al 16 , the main reasons people with stoma sought nursing care were evaluated. Among them are: the exchange of the bag, annual evaluation, first consultation, low durability of the bag, dermatitis, cauterization, orientation, and irrigation. These actions are of great relevance, since they stimulate self-care and help improve the user's quality of life.
Perceptions of colostomy patients about nursing care in oncology inpatient units This information is in line with the present research, as the nursing staff of the place studied performs the hygiene and exchange of the bag and teaches the user this activity, observing, also, if there are no complications related to the ostomy. Considering the fragility of the person with ostomy, after being submitted to the colostomy procedure, nursing becomes essential in the care of this client in all operative periods, and it is this interaction that will allow the development of self-care.
It is paramount that there is monitoring by an experienced nurse with knowledge of devices for ostomies, considering that the type of device used can also be a risk factor for the emergence of peristomal complications. Related to this is the fact that proper preoperative marking allows better adaptation to the devices, just as different types of stomata may require different types of devices 17 . In a research conducted by Ribeiro and Andrade 18 , it was evidenced that maintaining the cleanliness of the bag provides greater well-being to the patient. Thus, cleaning the peristomal skin, followed by a proper exchange is fundamental for health promotion, since it avoids complications. Furthermore, hygiene care is intrinsic to the science of nursing 19 .
Considering the speeches of the interviewed patients, it can be seen that the nurses and the nursing team are able to provide colostomy-oriented care. However, this care still presents some weaknesses, especially in the reports in which these professionals did not perform this hygiene and exchange. In the study by Anacleto, Cecchetto and Riegel 20 it was possible to identify the importance of humanized care and also the factors that influence humanized nursing care, related to the behavior of professionals. Moreover, when these are satisfied with their profession, they work more motivated 21 .
Considering this information, it can be seen that according to the participants of this study, nursing professionals provide humanized care. In this way, they attend to the patients' requests, being concerned with their well-being and effectively performing the actions that are within their competence.
Cancer patients need nursing care as they face many difficulties and side effects related to treatment 22  In caring for colostomy patients, the nurse is important for surgical recovery, teaching self-care, and social readaptation.
To this end, it is essential that it uses the Systematization of Nursing Care, promoting individualized, critical, reflective and integral care 24 .
In the research by Peiter et al²¹, respondents reported their frustrations and realizations regarding the effectiveness of the actions used in cancer patient care. Still, according to the researchers, the ideal care dreamed of by nurses will only be possible through teamwork.
Analyzing the statements of the interviewees of this research, it can be seen that nursing, for the most part, is concerned with providing care considering the life context of people with stoma. Thus, it guides them so that they are not left with doubts, besides involving professionals from other specialties, providing a multidisciplinary service.
Specialized care for cancer patients requires professionals to communicate adequately about the health situation, as well as to discuss the conduct adopted by the team. Thus, nursing care management is considered a strategy for targeted care, and implies the qualification of the assistance provided 21 .
Finally, nursing was described as helpful, supportive, and prudent. Moreover, its members proved to be willing and fulfilled their role, carrying out, whenever necessary, the appropriate care in the hospitalization. But on a day-to-day basis, some weaknesses are perceived, and often the patients' requests go unnoticed, mainly due to the great demand of activities.

CONCLUSION
It was possible to identify from this study that colorectal cancer patients using a colostomy perceive that the nursing staff of oncology inpatient units provide colostomy-related care. This care is focused on hygiene, product use, and bag change, as well as management of complications. In addition, it also performs care during hospitalization, which is fundamental for the quality of the treatment.
Despite the relevance of the data found, the research presents limitations, such as the fact that it was developed in only one hospital institution and did not glimpse the educational action of nursing and the preparation for self-care of people with stoma. Its results show how nursing care is provided in the units studied and contribute to learning in the nursing field about the topic, as well as serving as a basis for other studies that address and complement the research in question.
Still, they provide nurses with knowledge about the reality of care, and from this, they can improve it, with the intention of improving the quality of life of these individuals.
It is expected that this study may generate reflections in nurses, nursing staff, and managers, so as to enable continuing education activities for health professionals involved in the care of people with colostomy, besides providing subsidies for a humanized care, allowing a better quality of life for these individuals.