The Effect of Action Research on Neobladder Function Training in Patients with Orthotopic Ileal Neobladders: A Prospective Cohort Study Chun-Xiu Xiao1#, Wei Zhang2#, Bing-Xin Lin2* Purpose: This study aims to evaluate the effects of action research on neobladder function training in patients with orthotopic ileal neobladders. Methods: A total of 68 patients with orthotopic ileal neobladders were randomly divided into two groups: a con- trol group (31 patients) and an experimental group (37 patients). Patients in the control group received neobladder function training, while patients in the experimental group received neobladder function training based on the ac- tion research method. The effects of neobladder function training in all patients were evaluated after three months. Results: (1) The differences between the two groups in the micturition time interval, urine volume per time, num- ber of incidences of nocturia, and urinary continence rate (day time and night time) were statistically significant (P < 0.05). (2) Compared to the control group (241.6 ± 42.3 mL, 15.1 ± 4.9 mL/s, 23.1 ± 9.9 cmH 2 O, 63.6 ± 22.3 mL), the bladder capacity (292.6 ± 66.9 mL), maximum urinary flow rate (19.2 ± 6.5 mL/s), and bladder detrusor pressure (31.2 ± 11.4 cmH 2 O) of the experimental group increased, while the residual urine volume (47.2 ± 21.1 mL) decreased (P < 0.05). Conclusion: Neobladder function training based on the action research method can improve the neobladder func- tion of patients with orthotopic ileal neobladders. Keywords: action research; orthotopic ileal neobladder; neobladder function INTRODUCTION Bladder cancer is the ninth most common cancer and the second most common urologic malignan- cy worldwide (1). Currently, the most effective method for the treatment of invasive bladder cancer is radical cystectomy with an orthotopic ileal neobladder(2). This method of bladder replacement is closest to the normal physiological state of the human body and has grad- ually become the recommended approach for urine diversion(2). However, as the intestine—which is a re- placement for the new bladder—does not have senso- ry function and active contraction ability, it is prone to complications, such as urinary incontinence, urinary re- tention, hydronephrosis, and renal damage(3). To enable patients to adapt to the new urination mode and improve their urination function, urine storage, and urine con- trol, postoperative training of the function of the new bladder is particularly important. However, after the training, patients often continue to have problems, such as night dysuria and urinary incontinence(1). Therefore, it is particularly important to improve the effectiveness of new bladder function training. Action research is also known as a problem-solving ap- proach. It is a research method that closely combines work with problem solving and carries out a spiral cycle of planning, action, observation, and reflection(4). It has 1Department of Nursing, Fujian Medical University Union Hospital, Fuzhou 350001, China. 2Department of Urinary Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China. *Correspondence: Department of Urinary Surgery, Fujian Medical University Union Hospital, No. 29 of Xin Quan Road, Gulou District, Fuzhou 350001, China. Tel: +86-0591-86218417. E-mail: linbingxin1344@163.com Received April 2020 & Accepted April 2021 been increasingly applied in nursing research: Tong et al.(5) for example, applied the method to hemophiliac patients with total knee arthroplasty, finding that it led to a significant reduction in the incidence of bleeding and a significant increase in the range of movements (ROM). Li et al.(6) used the method in the feeding of patients with senile dementia, bringing the diet nursing of the patients closer to clinical practice. Tian et al.(7) provided nursing interventions based on action research to patients with cerebral infarction, finding that it could significantly improve a patient’s neurological function and ability to carry out everyday tasks. As the effectiveness of action research in the training of orthotopic ileum neobladders has not yet been reported, the present study aims to explore the application val- ue of action research in neobladder function training in these patients. PATIENTS AND METHODS Patients A total of 68 male patients who underwent radical cys- tectomy between January 2014 and June 2018 in the urology departments of the top three hospitals were en- rolled in this study. Inclusion criteria: (1) invasive bladder urothelial carci- noma confirmed by pathological examination; (2) pa- Urology Journal/Vol 18 No. 5/ September-October 2021/ pp. 525-529. [DOI: 10.22037/uj.v18i.6167] UROLOGICAL ONCOLOGY tients were able to communicate; (3) informed consent was obtained from the patient and their family. Exclusion criteria: (1) distant metastases of cancer; (2) other serious diseases. The patients were split into two groups—a control group (31 patients) and an experimental group (37 pa- tients)—using assignments by a random number table and grouping of the assigned numbers by a special per- son. The study used a single blind design: the follow-up specialist and the statistics specialist were blinded, but the nurse in charge of the health research was not. Ethics approval The institutional review board of the hospital approved the study protocol. All enrolled patients or their fami- ly members provided signed informed consent prior to participation. Study design The study aimed to investigate the effect of action re- search on new bladder function training. First, the prob- lems that exist in new bladder function training in pa- tients with orthotopic ileal neobladders were identified. Three spiral circulation processes (cycles) of action re- search were then used to solve each problem. All the nurses who participated in the study had worked as nurses for more than five years and attended a train- ing course on the action research method. Problem identification Patients with orthotopic ileal neobladders are prone to urinary incontinence and other complications after sur- gery(8). Therefore, it is necessary to identify an effec- tive bladder training mode to improve bladder urina- tion function after surgery. However, there is currently no uniform method for urination function exercise in patients with orthotopic ileal neobladders after rad- ical resection of bladder cancer. In the present study, a self-developed questionnaire was used to investigate the problems of neobladder function training in 68 pa- tients with orthotopic ileal neobladders. The results re- vealed that 70.7% of patients considered the teaching of new bladder training methods by nurses difficult to understand and easy to forget. It was also found that 77.6% of the patients continued to lack knowledge of the importance of new bladder function training, and 91.4% believed it necessary to improve the training methods. These results provide a reference for improv- ing neobladder training. Planning Both groups received routine new bladder function training, including pelvic floor muscle training and levator ani muscle training, according to clinical uro- logical disease treatment guidelines(9). The day before surgery, each patient was evaluated by a urological specialist nurse and guided through routine bladder function training(10), which consisted of (1) pelvic floor muscle exercises and(2) levator ani muscle training ex- ercises. After surgery, the patients were given (3) urine storage function training and (4) urine control mode training. (1) Pelvic floor muscle exercises: the patient should be in a supine position, a sitting position, or a walking position, breathe deeply, and contract the pelvic floor muscles for 10–15 seconds, then relax for 10 seconds, and repeat 30 times, 3 times a day. (2) Levator ani muscle training exercises: the patient should breathe in quietly and contract his abdominal muscle, gluteus muscle, anal sphincter muscle, and pu- dendal muscle simultaneously for 15–18 seconds, then breathe out and relax, and repeat 30 times, 3 times a day. (3) Urine storage function training: a regular clamp- ing catheter and an appropriate clamping catheter were used. Initially, urine was released once every 30 min- utes, which was gradually increased to once every hour. The urine storage capacity of the new bladder was ob- served. (4) Urine control mode training: in the process of uri- nation the patient should consciously contract the per- ineum, stop urination, and then relax the muscles of the perineum to continue urination, repeating until his bladder is empty. This should be repeated two or three times a day. In addition to this training, the experimental group was given intervention using the action research method. Action The members of the research team undertook a three- day training course, which included (1) the concepts of a new bladder, pelvic floor muscles, the levator ani muscle, and other anatomical positions; (2) the surgi- cal methods, indications, and possible postoperative complications of radical cystectomy for orthotopic ileal neobladders; (3) the purpose and significance of new bladder function training; (4) the methods of new blad- der function training. Figure 1. Action research spiral Action research in training of neobladder-Xiao et al. Urological Oncology 526 The day before surgery, members of the research team gave one-on-one lectures to each patient and their fam- ily, instructing patients on how to perform the function- al exercises and giving them demonstrations. Patients were followed up after discharge to survey the status of the training. Observation, reflection, revision, and implementation Cycle 1 (1) Observation and reflection: Regarding the timing of the training and education materials, it was found that, prior to surgery, patients were worried about the effects, complications, and prognosis of the surgery; as such, they were absent-minded or inattentive during the training. After the operation, they were weak and uncomfortable due to multiple drainage tubes, so they could not attentively listen and understand the training. Regarding the content of the training and education ma- terials, it was found that most patients felt it was diffi- cult to master the pelvic floor muscle training. (2) Revision of intervention plans and measures: The timing of the training and distribution of education ma- terials was adjusted. In this revised approach, the train- ing and education materials were given to each patient three days before surgery to ensure they fully under- stood the importance of the training. The day before the operation, patients in the same department shared their experience of bladder function training to help eliminate their concerns. Three to five days after sur- gery, the researchers gave instructions to each partici- pant one-on-one and emphasized the importance of the training. Patients were able to ask questions at any time during the process to ensure that they understood the training. The education materials were also altered us- ing cartoons to make them easier to understand. These materials focused on the new bladder, the pelvic floor muscle, the characteristics of the post-operative urina- tion method, and possible complications. Cycle 2 (1) Observation and reflection: During the follow-up af- ter discharge, it was found that the new bladder function training of patients was relatively casual and that the patients could not recall the recent conditions of their urination. This made it difficult to make a clinical diag- nosis with the bladder training method. (2) Revision of intervention plans and measures: Pa- tients were taught to set alarm clocks to remind them to do their training exercises and were instructed to main- tain a urination diary. The main contents of the diary included the number of urinations within 24 hours and any nocturnal urination, the interval between urinations, the volume of each urination, the number of urinary incontinences, and whether there were any accompa- nying symptoms (such as intermittent urination, sense of urine insufficiency, and dysuria). After discharge, a clinical nurse was responsible for a weekly telephone follow-up, which focused on three things: investigating compliance with the new bladder function training, ask- ing for information from the urination diary, and timely correction of bad behaviors and habits. Cycle 3 (1) Observation and reflection: The patients indicated that maintaining a urination diary was too complicated and that they often forgot to use it. (2) Revision of intervention plans and measures: A tab- ular urination diary was established, in which patients only needed to mark √ or × under the corresponding content. As the urination diary initially contained too many pages, which was not conducive to use, the updat- ed diary had one table for each month. For easy storage, patients could also maintain a one-page urine diary a day. Evaluating indicators Three months after surgery, the urinary control indexes, including the interval time between two urinations, the volume of each urination, number of incidences of noc- turia, rate of urine control during the day (the number of daytime controllability/the total number of daytime uri- nations), and rate of urine control at night (the number of night-time controllability/the total number of night- time urinations) were measured for both groups. This was the primary clinical outcome. The secondary clinical outcome was measuring the uri- nary flow mechanics indexes, including bladder volume (the volume of urine stored when the bladder is full), residual urine volume (the amount of urine left in the bladder after urination), maximum urine flow rate (the maximum volume of urine discharged from the ure- thra per unit time), and pressure of the bladder detrusor muscle (pressure caused by contraction and relaxation of the bladder detrusor). The urinary flow mechanics were operated by a qualified medical technician using a urodynamic analyzer from Beijing Leiborui Medical Technology Co., Ltd. Statistical analysis The measurement data were expressed as `x ± standard deviation (SD), and a t test was used for comparison between the two groups. Count data were expressed in ratio or rate, and a chi-squared test was used for com- parison between the two groups. All statistical analyses were carried out using IBM SPSS 17.0 for Windows (IBM Corp., New York, NY, USA). P < 0.05 was con- sidered statistically significant. RESULTS Table 1 shows the results of the comparisons between Table 1. Comparison of general data between the two groups Group n Age /Year Education Tumor Staging Pathologic Type Middle School School T2 T3 Epithelioma Squamous Cell Gland Cell Education Education Carcinoma Carcinoma Control Group 31 50.1 ± 12.8 21 10 14 17 29 1 1 Experimental Group 37 51.5 ± 13.9 23 14 16 21 34 2 1 t/χ2 1.85 0.23 0.025 1.3 P 0.17 0.632 0.874 0.522 Action research in training of neobladder-Xiao et al. Vol 18 No 5 September-October 2021 527 the two groups in terms of micturition time interval, volume of urine per time, number of incidences of noc- turia, and urinary continence rate in the daytime and night-time. Compared with the control group, the micturition time interval and volume of urine per time increased (P < 0.05), the number of nocturia decreased (P < 0.05), and the rate of urine control in the daytime and night-time increased (P < 0.05) in the experimental group. Table 2 shows the results of the comparisons between the two groups in terms of bladder capacity, maximum urinary flow rate, bladder detrusor pressure, and resid- ual urine volume. The bladder capacity, maximum uri- nary flow rate, and bladder detrusor pressure were high- er in the experimental group than in the control group (P < 0.05), while the residual urine volume was lower in the experimental group than in the control group (P < 0.05). DISCUSSION Action research(11) aims to develop a research process that allows researchers to discovers problems, formu- late plans to solve the problems, implement the plans, observe the implementation process, analyze the re- sults of the implementation, and re-plan where neces- sary, thereby solving problems in clinical practice (see Figure 1). Experience suggests that an action research approach is particularly relevant when treating patients with chronic diseases and complex care needs(4). In the present study, the action research method was ap- plied in the training of neobladder function in patients with orthotopic ileal neobladders. No significant differ- ences were found in the ages, education levels, tumor staging, and pathologic types of the patients in the two groups, which provided a justification for the study. The results of the urination and the urinary control indexes revealed that the micturition time interval and urine volume per time increased, the number of incidences of nocturia decreased, and the urinary continence rate in the daytime and night-time increased in the exper- imental group compared with the control group. The results of the urinary flow mechanics indexes revealed that bladder volume, maximum urine flow rate, and pressure of the bladder detrusor muscle were higher in the experimental group than in the control group, while the residual urine volume was lower in the experimental group than in the control group. Conventional new bladder function training mainly consists of health education given during hospitaliza- tion combined with follow-up after discharge, and the impact of the training is not effectively monitored. Fur- thermore, the timing of the pre-operative health educa- tion is not appropriate and the educational materials are not focused, so patients cannot fully grasp the content. In the present study, patients in the experimental group received training with the action research method ap- plied, allowing appropriate measures to be implement- ed to improve the effectiveness of the training. Throughout the research process, the four steps of plan- ning, action, observation, and reflection were carried out in three spiral cycles to develop a more effective new bladder function training program(12-13). The pro- cess emphasized each patient’s feelings and sought solutions when problems were encountered. As a result, the education materials and standardized teaching pro- cess were formulated in a more targeted manner, and the patients were given the details of the practical prob- lems encountered in new bladder function training to help them understand why the training was required. Through the step-by-step training of bladder filling and regular emptying, the pelvic floor muscles were repeat- edly contracted and relaxed to improve the storage, uri- nation, and urine control of the new bladder. A voiding diary is a commonly used diagnostic tool to aid clinicians in treatment planning for patients with urinary incontinence(14). In the present study, a tabular urination diary was developed and made into a book, in which patients only needed to mark √ or × under the corresponding content. This was a simpler and easier approach to the diary, allowing the patients to become active managers instead of passive participants, thereby increasing their enthusiasm for the new bladder func- tion training. The present study found that it is also important to ex- plain the purpose and method of the new bladder func- tion training and of maintaining a urination diary to the patient’s family members, as it enables the patient to obtain their support and encouragement. Telephone fol- low-up acts as another form of social support(15-16), mak- ing patients feel valued and encouraging them to con- tinue with the training. During a telephone follow-up, patients can actively consult relevant knowledge, there- Table2. Results of urination and urinary control indexes (`x±s). Group n Micturition time Urine volume (mL) Number of nocturia Urinary continence Urinary continence rate interval (h) rate in day-time (%) in night-time (%) Control group 31 2.3 ± 0.8 218 ± 58.1 3.4 ± 1.5 77.4 71.0 Experimental group 37 3.5 ± 1.1 265 ± 69.1 2.5 ± 1.0 94.6 91.9 t/χ2 4.37 8.92 1.93 4.33 5.08 P 0.02 < 0.01 0.03 0.04 0.03 Group n Bladder Residual urine Maximum urinary Bladder detrusor capacity (mL) volume (mL) flow rate (mL/s) pressure (cmH 2 O) Control group 31 241.6 ± 42.3 63.6 ± 22.3 15.1 ± 4.9 23.1 ± 9.9 Experimental group 37 292.6 ± 66.9 47.2 ± 21.1 19.2 ± 6.5 31.2 ± 11.4 t/χ2 9.83 8.61 9.52 11.86 P < 0.01 < 0.01 0.02 < 0.01 Table 3. Results of urinary flow mechanics indexes (`x±s). Action research in training of neobladder-Xiao et al. Urological Oncology 528 by further strengthening the importance of the training. The results of the present study are limited by the small sample size and short evaluation period. Therefore, these results may not apply to all patients with ortho- topic ileum neobladders in different areas of China or in other populations. The patients were also from a single institution, which may cause site bias. Although the present results suggest that the application of the action research method to neobladder function training in patients with orthotopic ileum neobladders would improve the effect of the training, larger prospective multicenter studies with longer application periods are needed to confirm the results. 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