Abstract
Background:
The double-J (DJ) stent is an indispensable device in urology, a rudimentary part of numerous procedures and a management tool for patients with ureteric calculi. However, some issues connected to its usage still arise. The issues include patient discomfort, urinary symptoms (such as urgency and frequency), hematuria, infection, stent migration, and encrustation with prolonged indwelling time.
Aim:
The study aims to determine whether awhether a nursing instructional module has a positive effect on the acute side effects of DJ stent removal for ureterolithiasis patients.
Methods:
The study employed a quasi-experimental research design on 50 patients (25 in the study group, with a nursing instuctional model, and 25 in the control group, with support as usual). The patient’s knowledge about ureteral stones, the ureteral DJ stent assessment chart and the Ureteral Stent Discomfort tools were used to measure the patient’s knowledge about ureteral stones and appraise the ureteral stent discomfort and acute side effects after removal in the two groups.
Results:
Most studied patients were males (64.0, 56.0%) and married (80.0, 76.0%). There was a 100% satisfactory knowledge level for the study group and highly statistically significant differences in all domains of the ureteral stent discomfort test of urinary symptoms among ureterolithiasis patients after the nursing instructional module implementation for the studied patients.
Conclusion:
Implementing the nursing instructional module effectively refined patients’ knowledge and reduced ureteral stent discomfort and acute side effects.
Keywords: acute side effects, double-J stent, nursing instructional module, ureterolithiasis
Introduction
Double-J (DJ) stents are essential and commonly utilised in urology for various procedures. These stents play a crucial role in maintaining the patency of the ureter, preventing oedema and protecting against injury. As a result, they are considered an effective postoperative management approach for patients with conditions such as ureteric calculi, ureteric stricture, ureteropelvic junction obstruction or fibrosis, or iatrogenic ureteric damage. In cases of obstructive uropathy caused by urinary calculi, DJ stents are typically the preferred treatment option. The DJ ureteral stent is the most globally used indwelling stent and the first choice for managing obstruction symptoms in the upper urinary tract, consequential from urinary calculi (Mahmood et al., 2020).
DJ stents are temporarily placed in the ureter after ureterorenoscopy handling urinary stones, after open surgery or before extracorporeal shock wave lithotripsy to maintain ureteral patency and promote healing. It has a proximal curl placed in the renal pelvis and a distal curl located in the bladder to maintain the stent in place. Replacement or removal of a DJ stent is required within 6 weeks to 6 months, according to their production material or coating (Beshchasna et al., 2020). They are a simple and effective intervention to promote ureteral drainage to maintain renal function, relieve pain from ureteral obstruction and avoid needing external or noticeable devices (Betschart et al., 2017).
DJ ureteral stents are considered a valuable instrument in urology. Depending on the specific indication, these stents may be temporarily or permanently inserted (Geavlete et al., 2021). Insertion of a DJ stent is a less invasive procedure without an external wound for urinary internal drainage. It may provide a better quality of life and body image than percutaneous nephrostomy used for external drainage. It is now the most acknowledged and favoured procedure for maintaining a patent ureter (Lee et al., 2019). However, various complications are associated with the short-term or long-term use of DJ stents, which differ from minor side effects, including flank and suprapubic pain, discomfort, haematuria, irritation on voiding and frequency, to major complications such as vesicoureteric reflux, hydronephrosis, stent malposition, stent migration, stent dysfunction, encrustation, stent fracture, and significant urinary tract infections (Mahmood et al., 2020; Ray et al., 2015).
Removal of a DJ stent is a cause of patient morbidity. The majority of patients report reasonable to severe pain with stent removal, and some experience delayed significant pain after stent removal (Loh-Doyle et al., 2015). Cystoscopy is the standard procedure to eliminate ureteral double stents, which may cause discomfort and pain. Sedation and pain medication are mandatory to perform the procedure (Rassweiler et al., 2017). Previous studies have revealed that cystoscopy remains a possibly painful procedure, after which gross haematuria, urinary frequency and dysuria can arise more frequently than expected. The majority of patients experience ureteral stent-related symptoms (SRSs) which can include frequency, urgency, dysuria, incomplete voiding, flank and suprapubic pain, incontinence, sexual side effects, and emotional distress. SRSs have a negative effect on the functional capacity and quality of life in patients with ureteral stents (Van Besien et al., 2022; Wiesinger et al., 2019). Cystoscopic stent removal might compromise the patient’s quality of life and, in turn, impact the acceptance of re-ureteroscopic procedures in cases of stone relapse (Lu et al., 2020; Tae and Jeong, 2019).
Nurses provide care for patients with DJ stents. They should be fully aware of the potential side effects of DJ stents and report any untoward events to the urologist. Care coordination with an interprofessional team of nurses and physicians will result in improved patient outcomes (Leslie et al., 2022). Patient and family education before and after the procedure is very important in reducing DJ SRSs and complications (Kholis et al., 2021). Patients should be advised to comply with health education as much as possible and to change their life-style as complications may cause life-threatening issues. Therefore, this study will be conducted to identify the effect of a nursing instructional module on the acute side effects of DJ stent removal for ureterolithiasis patients (Geavlete et al., 2021).
Significance of the study
The DJ stent is crucial in urology and is a fundamental component of many urological procedures. However, certain issues associated with its use can still arise. Patients may experience stent-related discomfort and side effects including urinary symptoms, alterations in sexual function, work performance and quality of life related to having an indwelling ureteral stent. Following the removal of a DJ stent, patients require specialised nursing care, which includes continuous physical assessment, educating patients about the importance of increased fluid intake, avoiding strenuous physical activities, maintaining a healthy diet, self-monitoring urine colour, pain management, and follow-up. In light of this context, the present study assessed the impact of the nursing instructional module on the acute side effects experienced by ureterolithiasis patients during DJ stent removal.
Aim of the study
To identify the effect of a nursing instructional module on acute side effects of DJ stent removal for ureterolithiasis patients.
Research hypothesis
H1: Patients who receive the nursing instructional module will have decreased incidence and severity of acute side effects of DJ stent removal compared to those who do not receive it.
Methods
Research design
A quasi-experimental research design was utilised, adhering to the Consolidated Standards of Reporting Trials (CONSORT) guidelines to ensure adequate methodological quality and transparency in reporting the study.
Settings
The study was conducted at the Genitourinary Surgery Department, Alexandria Main University Hospital, Egypt.
Target participants
Adult patients diagnosed with ureterolithiasis and undergoing ureteroscopic lithotripsy were selected. Inclusion criteria were patients aged between 20 and 60 years old, with unilateral ureterolithiasis, where a ureteral DJ stent was to be inserted after flexible ureteroscopic lithotripsy, for whom this is the first time for a DJ stent and the stent remains less than or equal to 2 months, with no history of urinary tract surgery; with benign prostatic hyperplasia and chronic prostatitis, who were alert, could communicate and agreed to contribute in the current study. Exclusion criteria were patients with high-grade obstruction, needing a nephrostomy tube, with solitary kidneys, and with comorbid conditions such as chronic renal insufficiency or immune suppression.
A convenience sample of 50 adult patients diagnosed with ureterolithiasis and undergoing ureteroscopic lithotripsy admitted to the previously mentioned setting was selected and allocated to group one (control group) or two (study group), with 25 patients in each group.
Sample size calculation: With 92% power and a significance level of 0.05, the sample size needed to be 52 patients. Power was determined using Epi Info™ version 3.5 (Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA).
Out of the 70 patients eligible to participate in the trial, four did not fit the inclusion criteria, six declined, and five took part in the pilot study. These five were not included in the main study. Furthermore, five patients withdrew from the trial due to low participation in the sessions and there were challenges in getting in touch with them for an interview following the intervention. As a result, 50 clients total – 25 for the control group and 25 for the study group – were enrolled (see Figure 1). Power analysis was reassessed based on this final sample size. The recalculated power, with 50 participants, was approximately 92%. Assessments are carried out 1 week and 1 month following the deployment of the instructional programme.
Figure 1.
CONsolidated Standards of Reporting Trials (CONSORT Diagram).
Data collection tools
1. Patient’s structured interview schedule
This tool was based on a review of the recent related literature (Zhou et al., 2015) to identify patients’ socio-demographic and clinical data. It consisted of two parts:
Part I: Patients’ socio-demographic characteristics
It includes socio-demographic data of patients including name, age, sex, marital status, educational level, occupation, area of residence and telephone number.
Part II: Clinical data
It includes the duration of ureteral stones, associated chronic diseases, history of ureterolithiasis for the family, previous stone surgery or ureteroscopy, history of DJstents for the patient, history of urinary tract surgery, benign prostatic hyperplasia, chronic prostatitis; date of admission, date of discharge, date of surgery, and the due date for removal of the DJ stent.
2. Patient’s knowledge about ureteral stones and ureteral DJ stent assessment chart
This tool was also developed by the researcher based on reviewing the recent related literature (Lee et al., 2019; Ray et al., 2015; Zhou et al., 2015) to assess patients’ knowledge about ureterolithiasis and ureteral DJ stents, such as the anatomy of the urinary system, the definition of ureterolithiasis, causes of ureterolithiasis, signs and symptoms, complications, management, meaning and reasons for the use of a ureteral stent, indwelling time of ureteral stent, SRSs, contraindications and complications, acute side effects of stent removal, necessary modifications after indwelling and removal of DJ stent related to fluid intake, activity and diet.
The score for each question ranged from 1 to 2 grades – two grades for the correct answer and one grade for the incorrect answer. The total score is calculated and converted into percentages. The patients’ knowledge scores ⩾60% reflected a satisfactory level of knowledge, whereas the patients’ knowledge scores <60% reflected an unsatisfactory level.
III. Ureteral stent discomfort test
This tool was developed by Michel-Ramírez et al. (2019) to evaluate ureteral stent discomfort and acute side effects after removal. This was adopted and translated into the Arabic language. The questionnaire consists of 13 items and utilises a Likert scale model to assess six domains: urinary symptoms, pain, daily life, sexual life, medical care/use of analgesics, and quality of life. These domains are represented by 6, 2, 1, 1, 2 and 1 items, respectively. The frequency of symptom manifestation in each domain is used for evaluation. A verbal descriptive scale assesses the pain domain. The maximum score is 61 points, which rises in proportion to the severity of the symptoms. For the scoring system: each question ranges from 0 to 5 points in a Likert scale: (0) never, (1) very seldom, (2) seldom, (3) sometimes, (4) more than half the time and (5) almost always. The final score is considered by multiplying the sum of all the scores with a maximum score of 61 points. The more serious symptoms, the higher the score, according to the following scoring system: 13–<29 mild symptoms, 29–<45 moderate, and 45–61 severe symptoms.
Ethical consideration
Formal approval and permission to conduct the study were attained from the Research Ethics Committee of the Faculty of Nursing, Alexandria University, Egypt and the director of the Genitourinary Surgery Department. Each patient gave written informed consent before data collection, following an explanation of the study’s objectives. Participants in the study were assured privacy— and guaranteed confidentiality of the information gathered about each patient. The study participants received assurances that their involvement was entirely voluntary and that they could leave the study at any point.
Measures validity
The researcher established tools I and II, whereas tool III was adopted. Tools I, II and III were translated into Arabic. Five experts in the field of medical-surgical nursing tested the tools for content validity. Subsequent modifications were made.
Pilot study
A pilot study was conducted on 10% of the sample (five patients) to test the clarity and applicability of the study tools and appropriate modifications were made. Those patients were excluded from the actual study sample.
Data collection process
Participants meeting the inclusion criteria were selected from the Genitourinary Surgery Department in the hospital and divided into two equal groups (control and study groups). Participants were assigned to the control and study groups using a convenience sampling method. Initially, the control group was selected, followed by the study group. This sequential approach was implemented to minimise the potential for theoretical contamination between the groups. Specifically, by first gathering data from the control group, we ensured that their responses were not influenced by any prior exposure to the instructional material. Each group consisted of 25 patients, with the control group receiving standard care, whereas the study group received the nursing instructional module. This careful allocation process aimed to maintain the integrity of the study’s findings by ensuring that any observed differences in outcomes could be attributed to the intervention rather than external factors. Additionally, dedicated nursing and medical staff were assigned to each group. This approach not only provided consistent care but also helped reduce informal interactions that could lead to discussions about the instructional module. Staff members were trained to reinforce the importance of confidentiality and to avoid any conversations that might reveal information about the study. Upon enrolment, participants received thorough briefings about the study’s objectives and the importance of not discussing their experiences with other patients. This message was reiterated during follow-up visits, emphasising the necessity of adhering to confidentiality protocols. Moreover, during Outpatient Department visits, patients were scheduled in separate time slots, further minimising opportunities for interaction. By implementing these measures, the validity of the findings was safeguarded, ensuring that any observed differences in outcomes could be attributed solely to the intervention itself.
All patients were interviewed individually to identify their knowledge about ureterolithiasis, ureteral DJ stents, SRSs, and acute side effects of stent removal by utilising tool II the day before ureteroscopic lithotripsy. Patients’ instructional needs in the study group were identified after the initial evaluation of their knowledge. The instructional module is prepared using the following steps: Step I: An assessment step based on the results of tool II. The participants’ needs preceded the planning for developing the module. Step II: Formulating the module objectives according to participants’ needs. Step III: Selecting the module content. Step IV: Organise the module content according to a practicable learning sequence (from easy to difficult). After reviewing recent related literature, the researcher established the instructional module to provide information about ureterolithiasis and ureteral DJ stents (Chew et al., 2013; Hamed and Gaballah, 2021; Li et al., 2021; Loh-Doyle et al., 2015). The content of the instructional module included: the anatomy of the urinary system, the definition of ureterolithiasis, causes of ureterolithiasis, signs and symptoms, complications and management of ureterolithiasis, the definition of a DJ stent, reasons for an indwelling DJ stent, indwelling time of ureteral stent, SRSs, contraindications and complications, the process of stent removal, acute side effects of stent removal, necessary instructions after indwelling of DJ stent related to increase fluid intake, avoiding aggravating physical activities after insertion of a DJ stent, healthy diet, self-monitoring for urine colour, pain management, taking medication, and follow-up.
The instructional module was implemented in two consecutive sessions on the study group’s first and second postoperative days. In contrast, the control group received only routine hospital care, such as medication administration and monitoring of vital signs. The instructional module was delivered in a one-to-one format. This approach was chosen to ensure personalised interaction, allowing participants to ask questions and clarify their concerns about the DJ stent removal process and potential acute side effects. Each session lasted approximately 15–20 minutes according to the patient’s ability to concentrate. The teaching methods included a combination of verbal explanations, interactive discussion, visual aids (e.g. diagrams of the urinary system and stent placement), written materials (e.g. pamphlets with pre- and post-removal care instructions), and videos to address patient concerns. The instructional module was developed based on validated nursing guidelines and structured into a script format. This ensured consistency in the delivery of information across all participants. One researcher was responsible for delivering the module consistently for all patients in the study group, adhering strictly to the predefined script and instructional materials. Participants were encouraged to provide feedback immediately after the session. This helped confirm the uniformity and clarity of the intervention. Phone contact was made between the researcher and patients to ensure follow-up visits in outpatient clinics, module application, to answer queries, and remind patients of the due date for stent removal. Patients’ knowledge was re-evaluated 1 month after instructional module implementation using tool II. All patients were interviewed after the removal of a DJ stent to assess the effect of the instructional module on acute side effects of DJ stent removal for the study group who received the instructional module compared to the control group who did not receive the instructional module. This was through using tool III after a week and 1 month from removal of DJ stent after instructional module implementation.
Data analysis
IBM SPSS software package version 20.0 was used to analyse the data (IBM Corp., 2016). The qualitative data were displayed using numbers and percentages. The normality of the distribution was examined using the Shapiro–Wilk test. The terms range (minimum and maximum), average, standard deviation, and median were used to characterise quantitative data. The results were deemed significant at the 5% level. Chi-square analysis was used to categorise variables and facilitate group comparisons. When more than 20% of the cells had a count of fewer than 5, the chi-square was corrected using the Monte Carlo method. For numerical variables with a normal distribution, the Student t-test was used. The Mann–Whitney test was used to assess the quantitative variables with anomalous distributions when comparing the two groups under study. When comparing quantitative variables with aberrant distributions between more than two categories under study, the Kruskal–Wallis test was employed.
Results
Table 1 compares the two studied (study and control) groups according to patients’ socio-demographic characteristics. More than half of the patients (study and control groups) were males (64.0, 56.0%) and married (80.0, 76.0%). About 40.0% of both studied groups were in the age group from 50 to 60, and more than one-third were manual workers. None had previous educational programmes for ureteral stones.
Table 1.
Comparison between the two studied groups according to patients’ socio-demographic characteristics.
| Patients’ socio-demographic characteristics | Study (n = 25) | Control (n = 25) | χ2 | p | ||
|---|---|---|---|---|---|---|
| No. | % | No. | % | |||
| Age | ||||||
| 20–<30 | 4 | 16.0 | 1 | 4.0 | 2.393 | MCp = 0.539 |
| 30–<40 | 5 | 20.0 | 8 | 32.0 | ||
| 40–<50 | 6 | 24.0 | 6 | 24.0 | ||
| 50–60 | 10 | 40.0 | 10 | 40.0 | ||
| Sex | ||||||
| Male | 16 | 64.0 | 14 | 56.0 | 0.333 | 0.564 |
| Female | 9 | 36.0 | 11 | 44.0 | ||
| Marital status | ||||||
| Single | 4 | 16.0 | 3 | 12.0 | 1.570 | MCp = 1.000 |
| Married | 20 | 80.0 | 19 | 76.0 | ||
| Widow | 1 | 4.0 | 2 | 8.0 | ||
| Divorced | 0 | 0.0 | 1 | 4.0 | ||
| Level of education | ||||||
| Illiterate | 7 | 28.0 | 8 | 32.0 | 1.572 | MCp = 0.733 |
| Secondary | 11 | 44.0 | 7 | 28.0 | ||
| Primary | 4 | 16.0 | 6 | 24.0 | ||
| University | 3 | 12.0 | 4 | 16.0 | ||
| Place of residence | ||||||
| Rural | 15 | 60.0 | 10 | 40.0 | 2.000 | 0.157 |
| Urban | 10 | 40.0 | 15 | 60.0 | ||
| Occupation | ||||||
| Manual work | 12 | 48.0 | 9 | 36.0 | 0.781 | 0.677 |
| Office work | 6 | 24.0 | 8 | 32.0 | ||
| Not Working | 7 | 28.0 | 8 | 32.0 | ||
| Previous ureteral stones educational programmes | 0 | 0.0 | 0 | 0.0 | – | – |
χ2: Chi square test; MC: Monte Carlo; p: p-value for matching between two studied groups.
Table 2 compares the two groups according to clinical data. In relation to the duration of ureteral stones, it was more than 6 years for 44.0, 52% of both studied groups (study and control). There were no associated chronic diseases for 56% and 44% of both studied groups. Regarding a family history of ureteral stones, it was negative in more than half of both studied groups (56 and 68%), respectively. In relation to the duration of ureteral stent insertion, it was from 7 weeks to 2 months (52.0 and for consistency in reporting) for both studied groups.
Table 2.
Comparison between the two studied groups according to clinical data.
| Clinical data | Study (n = 25) | Control (n = 25) | χ2 | p | ||
|---|---|---|---|---|---|---|
| No. | % | No. | % | |||
| Duration of ureteral stones | ||||||
| <1 year | 7 | 28.0 | 4 | 16.0 | 1.652 | MCp = 0.699 |
| 1–<3 years | 3 | 12.0 | 2 | 8.0 | ||
| 3–<6 years | 4 | 16.0 | 6 | 24.0 | ||
| >6 years | 11 | 44.0 | 13 | 52.0 | ||
| Associated chronic diseases | ||||||
| Hypertension | 6 | 24.0 | 6 | 24.0 | 1.900 | MCp = 0.916 |
| Diabetes mellitus | 4 | 16.0 | 5 | 20.0 | ||
| Respiratory disease | 1 | 4.0 | 2 | 8.0 | ||
| Cardiac disease | 0 | 0.0 | 1 | 4.0 | ||
| No | 14 | 56.0 | 11 | 44.0 | ||
| Duration of chronic disease | (n = 11) | (n = 14) | ||||
| <1 year | 2 | 18.2 | 4 | 28.6 | 8.816* | MCp = 0.028* |
| 1–<3 years | 3 | 27.3 | 4 | 28.6 | ||
| 4–<6 years | 0 | 0.0 | 5 | 35.7 | ||
| >6 years | 6 | 54.5 | 1 | 7.1 | ||
| Family history of ureteral stones | ||||||
| Yes | 11 | 44.0 | 8 | 32.0 | 0.764 | 0.382 |
| No | 14 | 56.0 | 17 | 68.0 | ||
| History of ureteral stent | 0 | 0.0 | 0 | 0.0 | – | – |
| History of urinary tract surgery and/or ureteroscopy | 0 | 0.0 | 0 | 0.0 | – | – |
| History of Benign Prostatic Hyperplasia and Prostatitis | (n = 16) | (n = 14) | ||||
| No | 16 | 100.0 | 14 | 100.0 | – | – |
| Length of hospital stay | ||||||
| 1–3 days | 3 | 12.0 | 0 | 0.0 | 4.101 | MCp = 0.273 |
| 4–6 days | 9 | 36.0 | 8 | 32.0 | ||
| 7–10 days | 7 | 28.0 | 12 | 48.0 | ||
| 11–14 days | 6 | 24.0 | 5 | 20.0 | ||
| Duration of ureteral stent insertion | ||||||
| 2 weeks: <3 weeks | 0 | 0.0 | 1 | 4.0 | 3.994 | MCp = 0.774 |
| 3 weeks: <4 weeks | 1 | 4.0 | 0 | 0.0 | ||
| 4 weeks: <5 weeks | 3 | 12.0 | 3 | 12.0 | ||
| 5 weeks: <6 weeks | 3 | 12.0 | 1 | 4.0 | ||
| 6 weeks: <7 weeks | 5 | 20.0 | 6 | 24.0 | ||
| 7 weeks: 2 months | 13 | 52.0 | 14 | 56.0 | ||
χ2: Chi square; MC: Monte Carlo test; p: p value for matching between two studied groups.
Statistically significant at p ⩽ 0.05.
Table 3 denotes a comparison between the two studied groups according to overall patients’ knowledge about ureteral stones and ureteral DJ stents before and after 1 month of implementing the nursing instructional module. It was noticed that all studied groups’ patients had unsatisfactory (<60%) knowledge before instructional module implementation. In contrast, 1 month after the instructional module implementation, the percentage was 100% satisfactory knowledge level for the study group and 0% for the control group.
Table 3.
Comparison between the two studied groups (study and control) according to overall patients’ knowledge about ureteral stones and ureteral DJ stent before and after 1 month from implementation of the instructional module.
| Patient’s knowledge about ureteral stones and ureteral DJ stent |
Study (n = 25) | Control (n = 25) | Test of Sig. (p1) | Test of Sig. (p2) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Before | After 1 month | Before | After 1 month | |||||||
| No. | % | No. | % | No. | % | No. | % | |||
| Unsatisfactory (<60%) | 25 | 100.0 | 0 | 0.0 | 25 | 100.0 | 25 | 100.0 | – | χ2 = 50.00*
(>0.001*) |
| Satisfactory (⩾60%) | 0 | 0.0 | 25 | 100.0 | 0 | 0.0 | 0 | 0.0 | ||
| Total Score (20–40) | ||||||||||
| Min.–Max. | 23.0–31.0 | 35.0–40.0 | 22.0–28.0 | 24.0–30.0 |
t = 1.041 (0.303) |
t = 22.971*
(>0.001*) |
||||
| Mean ± SD. | 25.60 ± 1.83 | 37.60 ± 1.35 | 25.08 ± 1.71 | 27.08 ± 1.85 | ||||||
| % Score | ||||||||||
| Min.– Max. | 15.0–55.0 | 75.0–100.0 | 10.0–40.0 | 20.0–50.0 | ||||||
| Mean ± SD | 28.0 ± 9.13 | 88.0 ± 6.77 | 25.40 ± 8.53 | 35.40 ± 9.23 | ||||||
SD: Standard deviation; t: Student t-test; χ2: Chi square test MC: Monte Carlo.
Statistically significant at p ⩽ 0.05.
Table 4 shows a comparison between the two groups according to the score of the Ureteral Stent Discomfort Test (USDT) a week and a month after the removal of the DJ stent after the implementation of the instructional module. Statistically significant differences were found in all domains USDT of urinary symptoms: pain, daily life, sexual life, medical care/use of analgesics, quality of life total score, and overall score between both studied groups patients after a week and month from removal of DJ stent after implementation of the instructional module p = (>0.001*, <0.001*), (>0.001*, 0.012*), (>0.001*, <0.001*), (0.003*, 0.003*), (>0.001*, >0.001*), (>0.001*, <0.001*), (>0.001*, <0.001*).
Table 4.
Comparison between the two studied groups according to score of USDT after a week and month from removal of DJ stent after implementation of the instructional module.
| USDT | Study (n = 25) | Control (n = 25) | U (p1) | U (p2) | ||
|---|---|---|---|---|---|---|
| 1 Week | 1 Month | 1 Week | 1 Month | |||
| Urinary symptoms | ||||||
| Total score (0–30) | ||||||
| Median (Min.–Max.) | 7.0 (3.0–12.0) | 0.0 (0.0–3.0) | 16.0 (12.0–19.0) | 7.0 (4.0 –12.0) | 1.000* (>0.001*) | 0.000* (>0.001*) |
| Mean ± SD. | 7.20 ± 2.45 | 0.60 ± 1.0 | 15.52 ± 2.06 | 7.64 ± 2.04 | ||
| Pain | ||||||
| Total score (0–6) | ||||||
| Median (Min.–Max.) | 1.0 (0.0–3.0) | 0.0 (0.0–2.0) | 3.0 (1.0–5.0) | 0.0 (0.0–2.0) | 60.00* (>0.001*) | 226.00* (0.012*) |
| Mean ± SD. | 1.08 ± 0.95 | 0.08 ± 0.40 | 3.04 ± 1.06 | 0.56 ± 0.87 | ||
| Daily life | ||||||
| Total score (0–5) | ||||||
| Median (Min.–Max.) | 2.0 (0.0–3.0) | 0.0 (0.0–0.0) | 3.0 (2.0–4.0) | 1.0 (0.0–1.0) | 139.00* (>0.001*) | 100.00* (>0.001*) |
| Mean ± SD. | 1.56 ± 1.12 | 0.0 ± 0.0 | 2.68 ± 0.63 | 0.68 ± 0.48 | ||
| Sexual life | ||||||
| Total score (0–5) | ||||||
| Median (Min.–Max.) | 2.0 (0.0–3.0) | 0.0 (0.0–1.0) | 3.0 (0.0–4.0) | 1.0 (0.0–1.0) | 168.00* (0.003*) | 187.50* (0.003*) |
| Mean ± SD. | 1.32 ± 1.18 | 0.12 ± 0.33 | 2.28 ± 1.37 | 0.52 ± 0.51 | ||
| Medical care/use of analgesics | ||||||
| Total score (0–10) | ||||||
| Median (Min.–Max.) | 1.0 (0.0–3.0) | 0.0 (0.0–0.0) | 4.0 (2.0–6.0) | 0.0 (0.0–2.0) | 10.00* (>0.001*) | 200.00* (0.001*) |
| Mean ± SD. | 0.92 ± 0.91 | 0.0 ± 0.0 | 4.0±1.0 | 0.44±0.65 | ||
| Quality of life | ||||||
| Total score (0–5) | ||||||
| Median (Min.–Max.) | 2.0 (0.0–3.0) | 0.0 (0.0–2.0) | 3.0 (1.0–4.0) | 1.0 (1.0–2.0) | 102.00* (>0.001*) | 64.50* (>0.001*) |
| Mean ± SD. | 1.68 ± 0.95 | 0.36 ± 0.57 | 3.0 ± 0.91 | 1.48 ± 0.51 | ||
| Overall | ||||||
| Total score (0–61) | ||||||
| Median (Min.–Max.) | 13.0 (6.0–21.0) | 1.0 (0.0–5.0) | 31.0 (23.0–37.0) | 11.0 (7.0–17.0) | 0.000* (>0.001*) | 0.000* (>0.001*) |
| Mean ± SD. | 13.76 ± 4.55 | 1.16 ± 1.37 | 30.52 ± 3.39 | 11.32 ± 3.09 | ||
| % Score | 22.56 ± 7.46 | 1.90 ± 2.25 | 50.03 ± 5.56 | 18.56 ± 5.07 | ||
SD: Standard deviation; U: Mann–Whitney test; USDT: Ureteral Stent Discomfort Test.
Statistically significant at p ⩽ 0.05.
Table 5 illustrates the relation between the score for overall (USDT) and patients’ socio-demographic characteristics in the study group (n = 25) at 1 week. It was noted that there is no relation between the score for overall (USDT) and patients’ socio-demographic characteristics (p = 0.176, 0.388, 0.120, 0.174, 0.807, 0.848, 0.540, 0.756).
Table 5.
Relation between score for overall (USDT) and patients’ socio-demographic characteristics in study group (n = 25) in 1 week.
| Part I: Patients’ socio-demographic characteristics | No. | Score for overall (USDT) | Test of Sig. | p | |
|---|---|---|---|---|---|
| Mean ± SD. | Median (Min.–Max.) | ||||
| Age (years) | |||||
| 20–<30 | 4 | 9.75 ± 2.22 | 10.0 (7.0–12.0) | H = 4.944 | 0.176 |
| 30–<40 | 5 | 15.20 ± 3.42 | 15.0 (12.0–20.0) | ||
| 40–<50 | 6 | 15.33 ± 4.84 | 15.50 (8.0–21.0) | ||
| 50–60 | 10 | 13.70 ± 5.03 | 13.50 (6.0–21.0) | ||
| Sex | |||||
| Male | 16 | 13.06 ± 4.34 | 12.0 (6.0–21.0) | U = 56.000 | 0.388 |
| Female | 9 | 15.0 ± 4.90 | 17.0 (7.0–21.0) | ||
| Marital status | |||||
| Single | 4 | 9.75 ± 2.22 | 10.0 (7.0–12.0) | H = 4.235 | 0.120 |
| Married | 20 | 14.40 ± 4.58 | 14.0 (6.0–21.0) | ||
| Widow | 1 | 17.0 | |||
| Level of education | |||||
| Illiterate | 7 | 16.43 ± 2.82 | 17.0 (13.0–20.0) | H = 4.970 | 0.174 |
| Secondary | 11 | 12.27 ± 5.59 | 10.0 (6.0–21.0) | ||
| Primary | 4 | 14.75 ± 3.86 | 14.50 (11.0–19.0) | ||
| University | 3 | 11.67 ± 0.58 | 12.0 (11.0–12.0) | ||
| Place of residence | |||||
| Rural | 15 | 13.53 ± 4.26 | 13.0 (7.0–20.0) | U = 70.500 | 0.807 |
| Urban | 10 | 14.10 ± 5.17 | 13.50 (6.0–21.0) | ||
| Occupation | |||||
| Manual work | 12 | 13.08 ± 4.54 | 13.0 (7.0–21.0) | H = 0.331 | 0.848 |
| Office work | 6 | 14.50 ± 4.32 | 12.0 (11.0–21.0) | ||
| Not working | 7 | 14.29 ± 5.25 | 17.0 (6.0–20.0) | ||
| Length of hospital stay | |||||
| 1–3 days | 3 | 11.67 ± 0.58 | 12.0 (11.0–12.0) | H = 2.157 | 0.540 |
| 4–6 days | 9 | 15.0 ± 4.53 | 15.0 (6.0–21.0) | ||
| 7–10 days | 7 | 12.57 ± 4.89 | 11.0 (7.0–21.0) | ||
| 11–14 days | 6 | 14.33 ± 5.47 | 15.50 (8.0–20.0) | ||
| Duration of ureteral stent insertion | |||||
| 4 weeks: <5 weeks | 3 | 14.67 ± 5.51 | 12.0 (11.0–21.0) | H = 2.638 | 0.756 |
| 5 weeks: <6 weeks | 3 | 11.33 ± 4.04 | 12.0 (7.0–15.0) | ||
| 6 weeks: <7 weeks | 5 | 14.80 ± 5.54 | 17.0 (8.0–21.0) | ||
| 7 weeks: <8 weeks | 5 | 15.60 ± 3.29 | 15.0 (12.0–19.0) | ||
| 8 weeks: 2 months | 8 | 12.75 ± 5.12 | 12.0 (6.0–20.0) | ||
| 3 weeks: <4 weeks | 1 | 12.0 | |||
U: Mann–Whitney test; H: H for Kruskal–Wallis test; p: p-value for comparison between the studied categories.
Statistically significant at p ⩽ 0.05.
Discussion
The DJ stent is a fundamental component of numerous urological treatments, making it an indispensable instrument in urology. Nonetheless, certain problems remain with its use. Patients may experience stent-related discomfort. The ureteral stent can cause a range of urine symptoms as well as changes in sexual function, work performance, and overall quality of life. These symptoms are collectively referred to as urinary stent discomfort. There is no agreement on how to describe the syndrome. Urinary symptoms, including discomfort, nocturia, urgency, frequency, and impaired quality of life, are typically linked to it. After removal of a DJ stent patients require specialised nursing care, including ongoing physical assessment, teaching patients about increased fluid intake, avoiding aggravating physical activities after insertion of a DJ stent, healthy diet, self-monitoring for urine colour, pain management, taking medication, and follow-up. In this context, the present study was conducted to evaluate the effect of an instructional module on the acute side effects of DJ stent removal for ureterolithiasis patients.
The results of the current study verified that the age group was almost the same for Groups I and II. This may be linked to the selection criteria of patients’ age that fluctuated from 21 to 60 years old. Additionally, the current study demonstrated that a greater proportion of patients belonged to the age range of 50 to <60 years old. This finding was supported by Kholis, who noted that the most common age groups of patients complaining of ureteric stones ranged from 50 to 60 years old due to age-related changes (Kholis et al., 2021).
As regard sex, the present study showed that the majority of patients in both groups were male, which could be interpreted as males being at greater risk for developing ureteric stones than females. This result aligns with Abdelhamid et al. (2016), and Ülker et al. (2019), who found that the incidence of ureteric stones was higher in males than in females. In addition, Kholis verified that male patients compromised a majority of the study group and were complaining of ureteric stones. That was attributed to males having poor lifestyles, such as using over-the-counter medications and minimal water intake (Kholis et al., 2021).
Regarding marital status, the finding of this study indicated that the majority of patients were married; this could be related to the age group of the majority of patients, which ranged from 50< to 60 years old. A similar finding was revealed by Friedersdorff, who reported that most patients were married (Friedersdorff et al., 2020). A study conducted by Raja et al., (2020) linked with revealed contradictory results, where the majority of patients were single and divorced. They highlighted the detrimental effects of stone disease and therapies on patients’ health-related quality of life, impacting areas such as pain, physical symptoms, attitude to life, work/career, diet/life changes, social life, challenges with daily living, travel/holiday issues, relationships, and influence on family members (Raja et al., 2020). It was found that more than one-third of patients in our study were manual workers. This result was supported by a study by Patil et al., (2020), who found that ureteric stent patients were manual workers.
As for the duration of ureteral stones, it was more than 6 years. A similar finding was also found by Thongprayoon et al., (2020), who revealed that over a median follow-up of 4.7 years, 43% of patients who had regular follow-up assessments and had CT-detected asymptomatic kidney stones experienced symptomatic stone-passing episodes.
Regarding the overall patient knowledge about ureteral stones and ureteral DJ stents, it was found that all studied and control group patients had unsatisfactory knowledge before the instructional module implementation. In contrast, 1 month after the instructional module implementation, only the patients in the study group had a maximum knowledge score. Those results were supported by Malek et al., (2023), who found that following an instruction programme, there were statistically significant differences between the two groups concerning the degree of adherence that ureteric stone patients have to healthy lifestyle practices.
The current study illustrated that the majority of patients in both groups suffered from irritative urinary symptoms, pain, compromised daily and sexual life after a week, which was markedly decreased only in group I patients after the implementation of the instructional module. This is supported by Mostafa et al. (2022), who found that nursing management, including patients teaching about increased fluid intake, avoiding aggravating physical activities after insertion of a DJ stent, healthy diet, self-monitoring for urine colour, pain management, taking medication, and follow-up enhanced patients’ health outcomes (Mostafa et al., 2022). In addition, Badawy et al., (2019) showed that nursing care, including measures to improve immunity and eliminate infection, is critical to prevent exposure to signs of infection such as pain, hotness, redness, and impaired motor function.
Nursing competencies, particularly relational competencies, are pivotal in delivering effective patient education. Relational competencies, such as building trust, demonstrating empathy, and actively engaging patients in the educational process, contribute to patients’ better understanding of healthcare instructions and promote adherence to prescribed care. These skills also help alleviate patient anxiety, particularly in the context of procedures like DJ stent removal, where patients may experience significant apprehension. A recent study by Mancin et al., (2025) underscores the role of relational competencies in enhancing patient outcomes and satisfaction. Incorporating these competencies into the nursing instructional module likely contributed to the observed improvements in patient outcomes in this study.
Conclusion
Implementing a nursing instructional module for ureterolithiasis patients undergoing DJ stent removal showed promising results in reducing acute side effects and improving patient knowledge. The module significantly decreased urinary symptoms, pain, and disruptions in daily and sexual life. It also enhanced patients’ understanding of ureteral stones and DJ stents. Such increased understanding can reduce patient anxiety. These findings highlight the importance of patient education and specialised nursing care in optimising patient outcomes.
Recommendations
Developing a health education module for patients with urinary tract stones and DJ ureteral stents is crucial in urology and nephrology hospital departments. Collaboration between urologists, nurses, and other healthcare professionals is essential in providing holistic care to ureterolithiasis patients. By working together, healthcare teams can develop comprehensive care plans, implement educational support, and monitor patient outcomes effectively.
It is advised that comparable research be carried out on a bigger probability sample for generalisable results. Future studies could evaluate the long-term effects and patient satisfaction of implementing instructional modules for DJ stent removal. Additionally, investigating the impact of different educational interventions or instructional formats on patient outcomes would provide valuable insights into optimising patient care.
Furthermore, to optimise the benefits of this intervention, future research could adapt the instructional module for use in various healthcare settings. This includes investigating the feasibility of integrating the module into existing patient care protocols and tailoring the content to meet the specific needs of diverse patient populations.
Key points for policy, practice and/or research.
The study highlights the significant knowledge gap among patients regarding ureteral stones and DJ stents. Implementing routine health education for all patients can improve their understanding of the procedure, potential side effects, and self-management strategies.
The study demonstrates the effectiveness of health education in improving patient knowledge and reducing acute side effects. Nurses and healthcare providers should adopt this health education module as a standard practice for patients undergoing DJ stent removal.
The study emphasises the importance of patient education in managing symptoms and improving outcomes. Nurses should proactively engage patients in discussions about their condition, potential side effects, and self-care strategies.
The study focuses on the immediate impact of the module. Further research is needed to evaluate its long-term effectiveness in improving patient outcomes, reducing the recurrence of symptoms related to ureterolithiasis or stent-related discomfort, and reducing healthcare utilisation.
A future study is recommended to investigate patients’ adherence to self-care instructions taught during the intervention over several months or years.
The study suggests that technological interventions could be valuable for delivering patient education. Research can investigate the effectiveness and feasibility of using mobile apps or other digital platforms to deliver educational content.
Supplemental Material
Supplemental material, sj-doc-1-jrn-10.1177_17449871251328928 for Effect of a nursing instructional module on the acute side effects of double-J stent removal for ureterolithiasis patients: a quasi-experimental study by Rasha Fathy Dawood, Mahmoud Abdelwahab Khedr, Shadaid Alanezi and Emad Abdel Gawad Ali Rabie in Journal of Research in Nursing
Acknowledgments
The researchers are grateful to all participants in this study.
Biography
Rasha Fathy Dawood is an Assistant Professor of Medical-Surgical Nursing at Alexandria University, Egypt, specialising in patient care and nursing education to enhance clinical outcomes.
Mahmoud Abdelwahab Khedr is an Assistant Professor at Hafr Albatin University, Saudi Arabia, focusing on nursing practices and educational methodologies to improve healthcare delivery.
Shadaid Alanezi is an Assistant Professor at Hafr Albatin University, Saudi Arabia, specialising in Applied Medical sciences and public Health aimed at enhancing healthcare delivery.
Emad Abdel Gawad Ali Rabie is a Lecturer in Medical-Surgical Nursing at Alexandria University, Egypt, dedicated to advancing nursing education and research in clinical settings.
Footnotes
Author contributions: Rasha Fathy Dawood: Conceptualisation; Data curation; Formal analysis; Investigation; Methodology; Supervision; Validation; Writing – original draft.
Mahmoud Abdelwahab Khedr: Conceptualisation; Data curation; Formal analysis; Investigation; Methodology; Software; Supervision; Writing – review & editing.
Shadaid Alanezi: Visualisation; Writing – review & editing.
Emad Abdel Gawad Ali Rabie: Conceptualisation; Data curation; Formal analysis; Methodology; Project administration; Resources; Software; Validation. All authors actively contributed to and participated in approving the final manuscript.
Availability of data and materials: The datasets used or analysed in this study are available from the corresponding author upon request.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics approval and consent to participate: Before conducting the study, the Research Ethics Committee at Alexandria University’s Faculty of Nursing (IRB13620) approved it. A formal letter was then acquired from the Faculty of Nursing, Alexandria University, and sent to the relevant authorities at the selected location. The purpose of this letter was to seek their approval to collect data after providing a clear explanation of the study’s objectives. Official permission was obtained from the director of the Genitourinary Surgery Department after the description of the aim of the study. All procedures were conducted in accordance with the applicable guidelines and regulations outlined in the Declaration of Helsinki (October 2008 version). Each patient gave written informed consent before data collection, following a suitable explanation of the study’s objectives. Participants in the study claimed their privacy. Guaranteed confidentiality of the information gathered about each patient. The study participants received assurances that their involvement was entirely voluntary, and they could leave the study at any moment.
ORCID iDs: Mahmoud Abdelwahab Khedr 
https://orcid.org/0000-0003-3437-3764
Shadaid Alanezi
https://orcid.org/0009-0002-6667-5150
Supplemental material: Supplemental material for this article is available online at https://drive.google.com/drive/folders/1DKzButfJnrDgDh-pOnaykE3cJDAiw7jy?usp=sharing.
Contributor Information
Rasha Fathy Dawood, Assistant Professor of Medical-Surgical Nursing, Medical-Surgical Nursing Department, Faculty of Nursing, Alexandria University, Alexandria, Egypt.
Mahmoud Abdelwahab Khedr, Assistant Professor, College of Nursing, University of Hafr Albatin, Hafr Albatin, Saudi Arabia.
Shadaid Alanezi, Assistant Professor, College of Applied Medical Sciences, University of Hafr Albatin, Hafr Albatin, Saudi Arabia.
Emad Abdel Gawad Ali Rabie, Lecturer of Medical-Surgical Nursing, Medical-Surgical Nursing Department, Faculty of Nursing, Alexandria University, Alexandria, Egypt.
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Supplementary Materials
Supplemental material, sj-doc-1-jrn-10.1177_17449871251328928 for Effect of a nursing instructional module on the acute side effects of double-J stent removal for ureterolithiasis patients: a quasi-experimental study by Rasha Fathy Dawood, Mahmoud Abdelwahab Khedr, Shadaid Alanezi and Emad Abdel Gawad Ali Rabie in Journal of Research in Nursing