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PURPOSE: To describe results of study evaluating a Projected Augmented Reality P-AR system for its potential to enhance nursing education about pressure injuries. DESIGN: Pilot evaluation survey. SUBJECTS AND SETTING: The sample comprised nursing students and faculty at a school of nursing in a large, Midwestern public university. METHODS: The P-AR system was prototyped using commercial-off-the-shelf components and software algorithms, applied to pressure injury nursing education content. After interaction with the P-AR system, participants completed a survey evaluating the following features of the P-AR system for potential: engagement, effectiveness, usefulness, user-friendliness, and realism, users’ overall impression and satisfaction with system features. Evaluation statements used a 5-level Likert-scale; open-ended questions about what was liked, disliked or anything else offered opportunity for comments. RESULTS: A total of 32 participants, which included 27 students (30% BSN, 44% MN, and 26% DNP students, 81% female) and 5 faculty (80% female) participated. Student and faculty median evaluation scores were 5 (strongly agree or very satisfied) and 4 (agree or satisfied) for nearly all evaluation and satisfaction statements. Students’ satisfaction with “realism” received a median score of 3 (neutral). The P-AR system was refined to include realistic still and animated images. CONCLUSION: P-AR, an innovative technology using three-dimensional, dynamic images, was applied to nursing education content about pressure injury and was evaluated as having potential to enhance pressure injury teaching and learning. Education about complex processes of pressure injury development and management may benefit from using cutting-edge simulation technologies such as P-AR.

Moisture-associated skin damage (MASD) occurs when skin is repeatedly exposed to various sources of bodily secretions or effluents, often leading to irritant contact dermatitis, characterized by inflammation with or without denudation of affected skin. In 2020, the Wound, Ostomy and Continence Nurses Society commissioned an initiative that led to the addition of multiple International Classification of Diseases, Tenth Revision, Clinical Modification codes (ICD-10-CM) for irritant contact dermatitis caused by various forms of MASD for use in the United States. In a recent issue of the Journal of Wound, Ostomy and Continence Nursing, a clinical practice alert identifying the various new codes was published that summarized each of the new codes and provided highlights of the descriptions for each of these codes. This is the second in a series of 2 follow-up articles providing a more detailed description of the MASD conditions to which the newest irritant contact dermatitis ICD-10-CM codes apply. Specifically, this article reviews the clinical manifestations and assessment, pathophysiology, epidemiology, prevention, and management of irritant contact dermatitis associated with digestive secretions from a stoma or fistula, and fecal or urinary effluent from an abdominal stoma or enterocutaneous fistula.

Moisture-associated skin damage (MASD) occurs when skin is repeatedly exposed to various sources of bodily secretions or effluents, often leading to irritant contact dermatitis with inflammation, with or without denudation of affected skin. In 2020, the Wound, Ostomy and Continence Nurses Society took an initiative that led to the addition of multiple International Classification for Diseases codes for irritant contract dermatitis caused by various forms of MASD for use in the United States (ICD-10-CM). In the last issue of the Journal of Wound, Ostomy and Continence Nursing, a clinical practice alert identifying the various new codes was published that summarized each of the new codes and provided highlights of the descriptions of each of the these codes. This is the first in a series of 2 articles providing a more detailed description of the newest irritant contact dermatitis codes linked to MASD. Specifically, this article reviews the clinical manifestations and assessment, pathophysiology, epidemiology, prevention, and management of irritant contact dermatitis due to saliva, respiratory secretions, and fecal or urinary incontinence.

ObjectiveThis rapid priority setting exercise aimed to identify, expand, prioritise and explore stakeholder (patients, carers and healthcare practitioners) topic uncertainties on faecal incontinence (FI).DesignAn evidence gap map (EGM) was produced to give a visual overview of emerging trial evidence; existing systematic review-level evidence and FI stakeholder topic uncertainties derived from a survey. This EGM was used in a knowledge exchange workshop that promoted group discussions leading to the prioritisation and exploration of FI stakeholder identified topic uncertainties.ResultsOverall, a mismatch between the existing and emerging evidence and key FI stakeholder topic uncertainties was found. The prioritised topic uncertainties identified in the workshop were as follows: psychological support; lifestyle interventions; long-term effects of living with FI; education; constipation and the cultural impact of FI. When these six prioritised topic uncertainties were explored in more depth, the following themes were identified: education; impact and burden of living with FI; psychological support; healthcare service improvements and inconsistencies; the stigma of FI; treatments and management; culturally appropriate management and technology and its accessibility.ConclusionsTopic uncertainties identified were broad and wide ranging even after prioritisation. More research is required to unpick the themes emerging from the in-depth discussion and explore these further to achieve a consensus on deliverable research questions.

Purpose The purpose of this study was to identify factors associated with healthcare-acquired catheter-associated urinary tract infections (HA-CAUTIs) using multiple data sources and data mining techniques. Subjects and setting Three data sets were integrated for analysis: electronic health record data from a university hospital in the Midwestern United States was combined with staffing and environmental data from the hospital's National Database of Nursing Quality Indicators and a list of patients with HA-CAUTIs. Methods Three data mining techniques were used for identification of factors associated with HA-CAUTI: decision trees, logistic regression, and support vector machines. Results Fewer total nursing hours per patient-day, lower percentage of direct care RNs with specialty nursing certification, higher percentage of direct care RNs with associate's degree in nursing, and higher percentage of direct care RNs with BSN, MSN, or doctoral degree are associated with HA-CAUTI occurrence. The results also support the association of the following factors with HA-CAUTI identified by previous studies: female gender; older age (>50 years); longer length of stay; severe underlying disease; glucose lab results (>200 mg/dL); longer use of the catheter; and RN staffing. Conclusions Additional findings from this study demonstrated that the presence of more nurses with specialty nursing certifications can reduce HA-CAUTI occurrence. While there may be valid reasons for leaving in a urinary catheter, findings show that having a catheter in for more than 48 hours contributes to HA-CAUTI occurrence. Finally, the findings suggest that more nursing hours per patient-day are related to better patient outcomes.

Pressure ulcers increase the risk of costly hospitalization and mortality of nursing home residents, so timely healing is important. Disparities in healthcare have been identified in the nursing home population but little is known about disparities in the healing of pressure ulcers.To assess racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Multi-levels predictors, at the individual resident, nursing home, and community/Census tract level, were examined in three large data sets.Minimum Data Set records of older individuals admitted to one of 439 nursing homes of a national, for-profit chain over three years with a stages 2-4 pressure ulcer (n=10,861) were searched to the 90-day assessment for the first record showing pressure ulcer healing. Predictors of pressure ulcer healing were analyzed for White admissions first using logistic regression. The Peters-Belson method was used to assess racial or ethnic disparities among minority group admissions.A significantly smaller proportion of Black nursing home admissions had their pressure ulcer heal than expected had they been part of the White group. There were no disparities in pressure ulcer healing disadvantaging other minority groups. Significant predictors of a nonhealing of pressure ulcer were greater deficits in activities of daily living and pressure ulcer severity.Reducing disparities in pressure ulcer healing is needed for Blacks admitted to nursing homes. Knowledge of disparities in pressure ulcer healing can direct interventions aiming to achieve equity in healthcare for a growing number of minority nursing home admissions.

PURPOSE The study's purpose was to assess the pH of the skin of older (aged ≥75 years) incontinent nursing home residents after exposure to an incontinence brief containing spiral-shaped fiber wet with an alkaline solution mimicking urine or fecal pH and compared to skin pH after exposure to an industry standard brief wet with the same solution and various controls. DESIGN The design was experimental, as conditions were applied to skin and skin pH was measured in random order, and subjects served as their own controls. SETTING AND SUBJECTS The setting was a Midwestern nonprofit nursing home. The sample was 26 nursing home residents; their mean age was 87 years (SD = 6 years); 77% were female. Most (69%) had urinary incontinence alone, and 31% had dual urinary and fecal incontinence. METHODS Skin pH was measured in duplicate on 6 areas of the inner thighs and 6 areas of the volar surface of the forearms. Each area was exposed to 1 of 6 conditions applied in random order: an incontinence brief containing spiral-shaped fiber wet with an alkaline solution and one that was dry; a standard incontinence brief (without spiral-shaped fiber) wet with the same alkaline solution and one that was dry; the alkaline solution alone; and normal skin. RESULTS On both the thighs and the forearms, skin pH was significantly lower (more acidic) after exposure to the incontinence brief containing spiral-shaped fiber wet with an alkaline solution compared to the wet standard brief and all other control conditions (P < .001). On thighs, the mean skin pH was 5.7 (SD = 0.5) after exposure to the wet brief with spiral-shaped fiber versus 6.4 (SD = 0.5) after exposure to the wet standard brief. On forearms, the mean skin pH was 5.3 (SD = 0.4) after exposure to the wet brief with spiral-shaped fiber versus 6.0 (SD = 0.4) after exposure to the wet standard brief. CONCLUSIONS Incontinence briefs containing a spiral-shaped fiber significantly acidify the pH of the skin exposed to an alkaline solution, while industry standard briefs do not. Since alkaline skin pH is a risk factor for incontinence-associated dermatitis (IAD), results suggest that briefs with spiral-shaped fiber may help prevent IAD. Findings encourage further research.

Purpose The purpose of this study was to determine the incidence and predictors of incontinence-associated dermatitis (IAD) in nursing home residents. Methods Records of a cohort of 10,713 elderly (≥65 years) newly incontinent nursing home residents in 448 nursing homes in 28 states free of IAD were followed up for IAD development. Potential multilevel predictors of IAD were identified in 4 national datasets containing information about the characteristics of individual nursing home residents, nursing home care environment, and communities in which the nursing homes were located. A unique set of health practitioner orders provided information about IAD and the predictors of IAD prevention and pressure injuries in the extended perineal area. Analysis was based on hierarchical logistical regression. Results The incidence of IAD was 5.5%. Significant predictors of IAD were not receiving preventive interventions for IAD, presence of a perineal pressure injury, having greater functional limitations in activities of daily living, more perfusion problems, and lesser cognitive deficits. Conclusion Findings highlight the importance of prevention of IAD and treatment/prevention of pressure injuries. A WOC nurse offers expertise in these interventions and can educate staff about IAD predictors, which can improve resident outcomes. Other recommendations include implementing plans of care to improve functional status, treat perfusion problems, and provide assistance with incontinence and skin care to residents with milder as well as greater cognitive deficits.

INTRODUCTION: Self-management with clinician guidance is a cornerstone of successful conservative treatment for accidental bowel leakage (ABL). There are currently few resources to assist patients with that essential self-management. The purpose of this study was to describe self-management of ABL and explore interest in a mobile health application (mHealth app) for supporting ABL self-management among community-living women. METHODS: Using an observational/descriptive design, women (18+ years) previously seen in a urogynecology clinic for ABL were mailed a survey containing 8 multiple-choice questions and an open-ended prompt for comments. RESULTS: Survey responses were received from 161 women (18% response rate). The highest percentage of participants were aged 61-70 years (39%). Nearly half of the participants (47%) “did not know anything,” about ABL self-management before visiting a clinician. Only 4% “knew a lot.” Of those who have been trying to self-manage their ABL (n=132), 37% reported that it was not effective, and only 5% thought their self-management was “very effective”. Half (50%) of the participants had “a lot of” interest in an mHealth app to support managing ABL, and 30% had “some” interest.” The vast majority (89%) thought that it was “very important” to have ongoing guidance and support for self-managing ABL. CONCLUSIONS: Before visiting a clinician, most women with ABL lacked knowledge about ABL self-management and their self-management was not very effective. Women thought having guidance to self-manage ABL was important. There is good interest among women in an mHealth app supporting self-management of ABL if one were created..

Availability of public toilets in parklands and open spaces is a community resource for all persons and may support self-management of incontinence. The purpose of this study was to describe and map the availability of public toilets in parklands and open spaces in major international cities by city population and area. Observational/descriptive design. Twelve cities in nine countries with available data about toilets in parklands (Minneapolis-St. Paul (MSP), New York City, Philadelphia, Toronto, and Osaka) or open spaces (Greater London, Greater Sydney, Paris, Berlin, Brussels, and Seoul) were included in the analysis. Data were from online open/free data sets. Availability of publicly owned and/or operated permanent toilet facilities was measured/analyzed as number, density (calculated by population and area (km2)), and distribution (visualized using Geographic Information Systems). Density of public toilets/area (km2) in parklands was highest in Osaka. MSP had the most toilets per 100,000 residents. In open spaces, the density of public toilets/area (km2) was highest in Paris. Sydney had the most toilets in open spaces per 100,000 residents. The distribution of public toilets across parklands was fairly even in MSP, Philadelphia, and Toronto. The distribution of public toilets in open spaces was highly concentrated in one area in Brussels. Sydney has a low population density but a high toilet density in open spaces. Availability of public toilets in parklands or open spaces varies among international cities. Toilet availability should be considered in urban planning and community healthcare programs to promote continence, health, and quality of life.

PURPOSE The principal aim of this study was to map and describe the availability of parkland public toilets in major US cities per population and area. DESIGN Observational and descriptive. SUBJECTS AND SETTING Data were collected from the following cities: Austin, Texas; Minneapolis-St Paul (MSP), Minnesota; Nashville, Tennessee; New York City (NYC), New York; Philadelphia, Pennsylvania; San Francisco, California (SFC); Seattle, Washington; and Tampa, Florida. These cities are located throughout the United States. METHODS Data from the US Census and cities' parks/recreation departments about publicly owned and operated permanent toilet facilities were analyzed and then mapped using geographic information systems. Toilet density by population and residential area (mi) was calculated, and toilet distribution was visualized. RESULTS When calculated per 100,000 residents, MSP had the most parkland public toilets with 24; Tampa, Seattle, and Philadelphia had 17 to 22; and Nashville, NYC, and SFC had the fewest, around 7 toilets. Parkland public toilet density per residential area was highest in NYC and Philadelphia (>2/mi), followed by MSP, Seattle, and SFC (1/mi), then Tampa, Austin, and Nashville (

No systematic review has examined the collective randomized and nonrandomized evidence for fecal incontinence treatment effectiveness across the range of surgical treatments.The purpose of this study was to assess the efficacy, comparative effectiveness, and harms of surgical treatments for fecal incontinence in adults.Ovid MEDLINE, EMBASE, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and the Cochrane Central Register of Controlled Trials, as well as hand searches of systematic reviews, were used as data sources.Two investigators screened abstracts for eligibility (surgical treatment of fecal incontinence in adults, published 1980-2015, randomized controlled trial or observational study with comparator; case series were included for adverse effects). Full-text articles were reviewed for patient-reported outcomes. We extracted data, assessed study risk of bias, and evaluated strength of evidence for each treatment-outcome combination.Surgical treatments for fecal incontinence were included interventions.Fecal incontinence episodes/severity, quality of life, urgency, and pain were measured.Twenty-two studies met inclusion criteria (13 randomized trials and 9 observational trials); 53 case series were included for harms. Most patients were middle-aged women with mixed FI etiologies. Intervention and outcome heterogeneity precluded meta-analysis. Evidence was insufficient for all of the surgical comparisons. Few studies examined the same comparisons; no studies were high quality. Functional improvements varied; some authors excluded those patients with complications or lost to follow-up from analyses. Complications ranged from minor to major (infection, bowel obstruction, perforation, and fistula) and were most frequent after the artificial bowel sphincter (22%-100%). Major surgical complications often required reoperation; few required permanent colostomy.Most evidence is intermediate term, with small patient samples and substantial methodologic limitations.Evidence was insufficient to support clinical or policy decisions for any surgical treatments for fecal incontinence in adults. More invasive surgical procedures had substantial complications. The lack of compliance with study reporting standards is a modifiable impediment in the field. Future studies should focus on longer-term outcomes and attempt to identify subgroups of adults who might benefit from specific procedures.

PURPOSE The purpose of this study was to evaluate a revised version of the Incontinence-Associated Skin Damage Severity instrument (IASD.D.2) using 3 different groups of nursing staff. Revisions to the instrument included renumbering 1 body area where incontinence-associated dermatitis (IAD) occurs into 2 areas (right and left), which raised the total possible score from 52 to 56, and defining the borders of the body areas. DESIGN Observational, evaluative design. SAMPLE AND SETTING Five clinical experts certified in wound, ostomy, and/or continence (WOC) nursing evaluated content validity. Evaluators were attendees at the WOC Nurses (WOCN) Society 2014 conference, hospital nurses, and nursing staff at a nursing home. Evaluators were attendees at the WOCN Society's 2014 National Conference, hospital nurses at a community hospital with Magnet designation, and nursing staff at a skilled nursing home in the Midwestern United States. The evaluator group comprised 198 conference attendees (all nurses; age 53 ± 8.2 years, mean ± SD), 67 hospital nurses (age 37 ± 11 years), and 34 nursing home nursing staff (age 45 ±13.8 years). The majority of evaluators (>75%) in each of the groups were female. METHODS Clinical experts evaluated the content validity of the revised instrument. Evaluators scored 5 to 9 photographic cases using the revised instrument. Four of the cases were scored by all evaluators. The agreement of case scores among all evaluators was analyzed to assess interrater reliability. The scores of evaluators grouped by evaluators' self-identified skin color or nursing experience (

Older adults admitted to nursing homes (NHs) are at risk for low social engagement, which has associations with medical, psychological, and social well-being. Minorities may be at a disadvantage for social engagement because of their racial or ethnic group identity. This study assessed whether there were racial/ethnic disparities in social engagement among older adults ( N = 15,927) at 1 year after their NH admission using multi-level predictors. No racial or ethnic-based disparities in social engagement were found; hence, an analysis of risk factors at NH admission that predicted low social engagement at 1 year for all residents was conducted. Significant risk factors for low social engagement were low social engagement at admission, deficits in activities in daily living and cognition, problems with vision and communication, and residing in an NH in an urban community. Results highlight the importance of initiating interventions to increase social engagement at the time of NH admission.

PURPOSE Little is known about the incidence and characteristics of incontinence-associated dermatitis (IAD) in community-living individuals with fecal incontinence. The primary aim of this study was to describe the incidence and characteristics of self-reported IAD among community-living individuals with fecal incontinence. The study also examined whether IAD was associated with older age, sex, presence of urinary incontinence, or fecal incontinence severity. DESIGN Secondary data analysis was performed using a prospective cohort design. SUBJECTS AND SETTING Data were drawn from community-living adults (n = 98) with fecal incontinence (76% female, 34% aged ≥65 years, 90% white) who participated in a study about dietary fiber supplementation and were free of IAD at the start. Thirty five percent also had urinary incontinence. METHODS Subjects assessed their skin for IAD daily for 52 days, reporting types of IAD damage (redness, rash/fungal infection, and skin loss), location of IAD, and symptoms. They reported fecal incontinence on a diary for the first and last 14 study days. RESULTS The incidence of IAD was 41% (40 of the 98). The fecal incontinence severity score for subjects developing IAD was 1.2 higher than those who never had IAD (P < .001). There was no significant association of IAD with age, sex, or dual fecal and urinary incontinence. Incontinence-associated dermatitis developed within 2 weeks and healed in approximately 1 week. The most common sign and symptom were redness (60% patients) and soreness (78% patients), respectively. Most subjects (85%) had IAD in one location. CONCLUSIONS Assessing for IAD in community-living patients with fecal incontinence is important as IAD is common and causes discomfort. The relatively mild severity of IAD offers WOC nurses the opportunity for improving patient outcomes by preventing and managing this problem.

Little is known about the prevalence of pressure ulcers (PUs) among racial and ethnic groups of older individuals admitted to nursing homes (NHs). NHs admitting higher percentages of minority individuals may face resource challenges for groups with more PUs or ones of greater severity. This study examined the prevalence of PUs (Stages 2 to 4) among older adults admitted to NHs by race and ethnicity at the individual, NH, and regional levels. Results show that the prevalence of PUs in Black older adults admitted to NHs was greater than that in Hispanic older adults, which were both greater than in White older adults. The PU rate among admissions of Black individuals was 1.7 times higher than White individuals. A higher prevalence of PUs was observed among NHs with a lower percentage of admissions of White individuals. [ Journal of Gerontological Nursing, 40 (3), 20–26.]

Overview: Widely used by patients to control symptoms of chronic conditions such as diabetes, asthma, and arthritis, self-management can also help patients with urinary or fecal incontinence. The authors discuss the principles of self-management, the behaviors and skills self-managing patients need to acquire, and the nurse's role in reinforcing their use. They then describe strategies that can be incorporated within the framework of self-management to control urinary, fecal, or dual incontinence.

Although clinical benefits of dietary fiber supplementation seem to depend partially on the extent of fiber degradation and fermentation by colonic bacteria, little is known about the effect of supplemental fiber type on bacterial metabolism. In an experiment using a nonadapted human bacterial population from three normal subjects, the extent of in vitro fermentation was greater for gum arabic (GA) than for psyllium (PSY), which was greater than that for carboxymethylcellulose (CMC). In a separate experiment, in vitro incubation with feces from 52 subjects with fecal incontinence, before and after random assignment to and consumption of one of three fiber (GA, PSY, or CMC) supplements or a placebo for 20-21 days, indicated that prior consumption of a specific fiber source did not increase its degradation by fecal bacteria. Results suggest that the colonic microbial community enriched on a particular fiber substrate can rapidly adapt to the presentation of a new fiber substrate. Clinical implications of the findings are that intake of a fiber source by humans is not expected to result in bacterial adaptation that would require continually larger and eventually intolerable amounts of fiber to achieve therapeutic benefits.

Purpose The objective of this study was to examine the attitudes of baccalaureate nursing students toward their role in pressure injury prevention (PIP) and describe how clinical experiences influence their attitudes. Understanding students' attitudes and experiences related to PIP may facilitate development of evidence-based interventions for PIP by nurses. Design Qualitative exploratory descriptive design. Setting and subjects Participants were 16 senior nursing students enrolled in a prelicensure baccalaureate nursing program in an accredited school of nursing. Half of the participants had completed their first 2 years of the nursing major in the baccalaureate program. The remaining participants completed their first 2 years in a community college associate degree nursing program. Method Semistructured, in-depth, open-ended interviews were conducted. Interviews were digitally recorded and transcribed verbatim; data were analyzed for key themes using content analysis. Results Four categories of attitudes about PIP were identified: (1) ambivalence, (2) emerging awareness, (3) committed, and (4) passionate. Diverse clinical experiences in pediatrics, the operating room, trauma units, and long-term care facilities enhanced nursing students' learning related to PIP. Experiences observing WOC nurses and other staff role models engaged in PIP were associated with student commitment and passion for PIP. Conclusions Findings from this study can be used to guide interventions to enhance attitudes of commitment to PIP. WOC nurses, clinical preceptors, and clinical staff can involve nursing students in intentional PIP learning activities to improve clinical practice and patient outcomes. Intentionally incorporating key learning activities about PIP in the nursing curriculum is recommended.

Purpose The purpose of this study was to describe the prevalence, incidence, and effectiveness of home health care (HHC) agencies' services with and without a WOC nurse related to wounds, incontinence, and urinary tract infection (UTI) patient outcomes. Subjects and setting There were 449,243 episodes of care from a national convenience sample of 785 HHC agencies representing nonmaternity patients who were aged 18 years or older and receiving skilled home health services between October 1, 2008, and December 31, 2009. Design This study employed descriptive and comparative designs for data collection and analysis. We analyzed data from HHC agencies' electronic health records and conducted an Internet-based survey of HHC agencies. Instruments Data for this study were documented by HHC clinicians using the Outcome and Assessment Information Set. An Internet survey identified if a WOC nurse provided care or consultations within an HHC agency. Results The majority of HHC agencies (88.5%) had some influence of a WOC nurse. The incidence of wounds, incontinence, and UTIs was higher for agencies with no WOC nurse. Home health care agencies with WOC nurses had significantly better improvement outcomes for pressure ulcers, lower extremity ulcers, surgical wounds, urinary incontinence, bowel incontinence, and UTIs as well as significantly better stabilization outcomes for these outcomes except lower extremity ulcers. Virtually all patients in HHC agencies with and without a WOC nurse had stabilization of their lower extremity ulcers. Conclusions Findings of this study suggest that influence of a WOC nurse is effective in achieving several important positive outcomes of HHC agencies' services for wounds, incontinence, and UTIs.

AIMS There are few studies of nursing home residents that have investigated the development of dual incontinence, perhaps the most severe type of incontinence as both urinary and fecal incontinence occur. To determine the time to and predictors of dual incontinence in older nursing home residents. METHODS Using a cohort design, records of older nursing home admissions who were continent or had only urinary or only fecal incontinence (n = 39,181) were followed forward for report of dual incontinence. Four national US datasets containing potential predictors at multiple levels describing characteristics of nursing home residents, nursing homes (n = 445), and socioeconomic and sociodemographic status of the community surrounding nursing homes were analyzed. A Cox proportional hazard regression with nursing home-specific random effect was used. RESULTS At 6 months after admission, 28% of nursing home residents developed dual incontinence, at 1 year 42% did so, and at 2 years, 61% had dual incontinence. Significant predictors for time to developing dual incontinence were having urinary incontinence, greater functional or cognitive deficits, more comorbidities, older age, and lesser quality of nursing home care. CONCLUSIONS The development of dual incontinence is a major problem among nursing home residents. Predictors in this study offer guidance in developing interventions to prevent and reduce the time to developing this problem which may improve the quality of life of nursing residents.

PURPOSE The purpose of this study was to examine barriers to communicating with healthcare professionals and health literacy about incontinence among different types of informal caregivers of individuals with Alzheimer disease (AD). DESIGN Descriptive secondary analysis. SUBJECTS AND SETTING The sample included 48 family/friend adult caregivers of individuals who had AD. Seventy-five percent were female; their mean age was 64 ± 14 years (mean ± SD). Caregivers were spouses (44%), daughters (31%), or extended family members/friends (25%). Nearly half (48%) of caregivers had a racially or ethnically diverse background; 58% of their care recipients had incontinence. METHODS Data were collected via focus groups, interviews, and written surveys. Verbal responses were audiotaped, transcribed, and analyzed for themes by caregiver type using content analysis. RESULTS Caregivers of persons with AD described role-related barriers to improving health literacy about incontinence and its management. Main themes of barriers emerged for each type of role that were emotive in nature for daughters, experiential for both spouse caregivers, system related for husbands, and relational (being perceived as an outsider) for extended family/friends. CONCLUSIONS Nurse continence specialists have an important role in raising health literacy about incontinence and its management for informal caregivers of individual with AD. Results inform the development of interventions that are tailored to the type of caregiver as recommended by national health literacy initiatives with the aim of improving outcomes such as incontinence of care recipients.

Racial/ethnic disparities in preventing health problems have been reported in nursing homes. Incontinence is common among nursing home residents and can result in inflammatory-type skin damage, referred to as incontinence-associated skin damage (IASD). Little is known about the prevention of IASD and whether there are racial/ethnic disparities in its prevention. This study assessed the proportion of older nursing home residents receiving IASD prevention after developing incontinence after admission ( n = 10,713) and whether there were racial/ethnic disparities in IASD prevention. Predictors of preventing IASD were also examined. Four national data sets provided potential predictors at multiple levels. Disparities were analyzed using the Peters-Belson method; predictors of preventing IASD were assessed using hierarchical logistic regression. Prevention of IASD was received by 0.12 of residents and no racial/ethnic disparities were found. Predictors of preventing IASD were primarily resident-level factors including limitations in activities of daily living, poor nutrition, and more oxygenation problems.

Maintaining continence of nursing home (NH) residents promotes dignity and well-being and may reduce morbidity and healthcare treatment costs. To determine the prevalence of older continent adults who received primary prevention of incontinence at NH admission, assess whether there were racial or ethnic disparities in incontinence prevention, and describe factors associated with any disparities.The design was an observational cross-sectional study of a nation-wide cohort of older adults free of incontinence at NH admission (n = 42,693). Four US datasets describing NH and NH resident characteristics, practitioner orders for NH treatment/care, and socioeconomic and sociodemographic status of the community surrounding the NHs were analyzed. Disparities were analyzed for four minority groups identified on the minimum data set using the Peters-Belson method and covariates at multiple levels.Twelve percent of NH admissions received incontinence prevention. There was a significant disparity (2%) in incontinence prevention for Blacks (P 0.05): Fewer Black admissions (8.6%) were observed to receive incontinence prevention than was expected had they been part of the White group (10.6%). The percentage of White admissions receiving incontinence prevention was 10.6%. Significant factors associated with disparity in receiving incontinence prevention were having greater deficits in ADL function and cognition and more comorbidities. No disparity disadvantaging the other minority groups was found.Greater efforts for instituting incontinence prevention at the time of NH admission are needed. Eliminating racial disparities in incontinence prevention seems an attainable goal. Appropriate staff training, organizational commitment, and monitoring progress toward equitable outcomes can help achieve this goal. Neurourol. Urodynam. 36:1124-1130, 2017. © 2016 Wiley Periodicals, Inc.

Moisture-associated skin damage (MASD) occurs when excessive moisture in urine, stool, and wound exudate leads to inflammation of the skin, with or without erosion or secondary cutaneous infection. This article, produced by a panel of clinical experts who met to discuss moisture as an etiologic factor in skin damage, focuses on peristomal moisture-associated dermatitis and periwound moisture-associated dermatitis. The principles outlined here address assessment, prevention, and treatment of MASD affecting the peristomal or periwound skin.

Purpose The purpose of this study was to determine the time to development, severity, and risk factors of incontinence-associated dermatitis (IAD) among critically ill patients with fecal incontinence. Subjects and setting Forty-five patients with a mean age of 49.4 ± 18.5 years (mean ± SD) in the surgical/trauma critical care unit (ICU) of 1 of 3 urban hospitals who were free of any perineal skin damage at study start participated in the study. The majority (76%) were male. Methods Surveillance of skin for IAD and chart review of data initially and daily. Results Incontinence-associated dermatitis developed in 36% of patients. The median time to onset of IAD was 4 days (range, 1-6). Eighty-one percent of patients still had IAD at discharge from the ICU and at the end of their surveillance (median time = 7 days, range, 1-19 days). The severity of erythema associated with IAD was mild, moderate, or severe for 13%, 11%, or 4% (means) of the time patients were observed. Denudement occurred 9% of the observed time. Frequent incontinence of loose or liquid stools and diminished cognitive awareness were significant independent risk factors for development of IAD sooner. Conclusion Incontinence-associated dermatitis develops in critically ill patients with fecal incontinence relatively quickly and does not resolve in most before their discharge from the ICU. Early monitoring and prevention of IAD, especially in patients with diminished cognition or with frequent leakage of loose or liquid feces, are recommended to promote skin health.

Dry skin is a common problem in the older individual due to physiological changes of the aging process as well as chronic health conditions. Dry skin can worsen if management is inappropriate or lacking. Nursing management of dry skin in the elderly is comprehensive including applying topical products to replenish lipids and reduce water loss, maintaining or increasing fluid intake, limiting sun exposure, and reducing symptoms of chronic illnesses.

b Background: Knowledge about adverse symptoms over time from fiber supplementation is lacking. b Purpose: The aim of this study was to compare the severity of adverse gastrointestinal (GI) symptoms during supplementation with dietary fiber or placebo over time in adults with fecal incontinence. A secondary aim was to determine the relationship between symptom severity and emotional upset and their association with study attrition and reducing fiber dose. b Methods: Participants(N = 189; 77% female; 92% White; age, M =5 8 years,SD = 14 years) with fecal incontinence were randomly assigned to a placebo or a supplement of 16 g total dietary fiber per day from 1 of 3 sources: gum arabic, psyllium, or carboxymethylcellulose. They reported GI symptoms daily during baseline (14 days), incremental fiber dosing (6 days), and 2 segments of steady full fiber dose (32 days total). b Results: Severity of symptoms in all groups was minimal. Adjusting for study segment and day, a greater feeling of fullness in the psyllium group was the only symptom that differed from symptoms in the placebo group. The odds of having greater severity of flatus, belching, fullness, and bloating were 1.2Y2.0 times greater in the steady dose segment compared with baseline. There was a positive association between symptom severity and emotional upset. Participants with a greater feeling of fullness or bloating or higher scores for total symptom severity or emotional upset were more likely to withdraw from the study sooner or reduce fiber dose. b Conclusions: Persons with fecal incontinence experience a variety of GI symptoms over time. Symptom severity and emotional upset appear to influence fiber tolerance and study attrition. Supplements seemed well tolerated.

PURPOSE: The purpose of the study was to discover which patient and support system characteristics and interventions documented by home health clinicians were associated with improvement in urinary and bowel incontinence contrasting logistic regression and data mining approaches. SUBJECTS AND SETTING: Seventeen hundred ninety-three patients in this study experienced 2072 episodes of care. The study sample comprised all nonmaternity patients aged 18 years or older receiving skilled home health services in 2004. Subjects were drawn from a convenience sample of 15 home health agencies. DESIGN: We completed a secondary analysis of data from 15 home health agencies' electronic health records. Data for this study were documented by home care clinicians using the Outcome and Assessment Information Set (OASIS) structured assessment form and the Omaha System interventions, which is a standardized terminology. RESULTS: There were 684 patients with urinary incontinence and 187 with bowel incontinence. By discharge 38% improved in urinary incontinence and 45% improved their bowel incontinence. Using logistic regression, no patient or support system characteristics were identified that associated with improvement in either urinary or bowel incontinence, only a limited number of interventions were significant. A data mining decision tree was producible only for bowel incontinence, demonstrating a combination of patient and support system factors as well as selected interventions were important in determining whether patients would improve in bowel incontinence. CONCLUSIONS: Home health patients have complex comorbid conditions requiring home care nurses to have broad, generalized knowledge. Future research is needed to determine if the inclusion of a certified WOC nurse would improve outcomes.

Although many successful treatments for incontinence exist they are not effective or suitable for all people. Inconspicuous and dependable management with continence products and devices plays a crucial part in maintaining quality of life. We aim to briefly review what is known and not known in the field of continence products and devices and set out suggested priorities for research and development. The field of continence product research encompasses techniques and designs from basic laboratory science, through to clinical trials of products and to evaluations of service delivery models. Priorities for research include determining prevalence and costs of product use, development of patient reported outcomes, and development of methods for measuring skin health and for quantifying urine/faecal leakage. Product development priorities include better washable pads for women, absorbent products for fecal incontinence and flatus filters. Clinical trials of different product categories (e.g., devices for men) are needed, as are qualitative studies of patient experiences of product use. Neurourol. Urodynam

Purpose The primary purpose of this study was to examine continence literacy of individuals with fecal incontinence (FI) by identifying terms they used to refer to FI and to explore their emotional responses to FI. A secondary aim was to compare differences based on gender and age in younger ( 65 years) with FI. Design Secondary analysis of data collected prospectively in a clinical trial of fiber supplementation for FI. Methods Content analysis of participants' statements reported in field notes of data collectors and their responses to data forms and questions. Results Only one participant used the term fecal incontinence to describe FI. Alternate terms described stool characteristics, named other gastrointestinal problems, or respondents referred to FI, using a term that seemed to depersonalize the problem. Emotional responses to FI focused on the influence of bothersome symptoms, interference with social activities, and need for control. Some participants used humor to cope with FI and reported emotional benefits gained through participation in a study. Women were impacted by the social limitations of having FI more than men. Younger people were more likely to express feelings of emotional upset than were older respondents. Conclusion There is a need to increase health literacy about FI. WOC nurses are well qualified to educate patients about FI and to evaluate if higher continence literacy increases reporting of FI. Understanding the various emotional responses to FI may guide the optimal support that WOC nurses can provide and facilitate better management of FI.

This article summarises the findings from the Conservative Management of Faecal Incontinence in Adults Committee of the International Consultation on Incontinence. We conducted comprehensive literature searches using the following keywords combined with the relevant intervention: "anal, anorectal, bowel, faecal, fecal, rectal, stool" and "continent$ or incontinent$," Prevalence etimates for faecal or anal incontinence vary widely, from 2.2% to 2.5%. Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification, but the evidence base is small. Unlike urinary incontinence, few "lifestyle" associations have been identified with FI and little is known about whether interventions designed to reduce potential risk factors might improve FI. The article summarises the evidence and recommendations from the committee for clinical practice and future research.

PURPOSE Fecal incontinence (FI) severity is determined by self-report, and most tools rely on recall of symptoms. This study examined whether recall of FI severity differed from daily reports on a diary and the factors influencing any difference. INSTRUMENTS AND DESIGN: Data of 96 participants (mean age 59 years, 78% female) reported on 3 data collection forms (a demographics form, a bowel history, and a stool diary) were analyzed. Data collected during an initial bowel history when participants reported FI severity using recall were compared to similar data participants recorded on a 14-day daily stool diary during a baseline period of a study investigating the effects of different types of dietary fiber on FI. RESULTS The total FI severity score from the daily stool diary (median 5.0, range 1.2-15.5; P = .04) was significantly higher (worse FI) than the recalled bowel history (median 3.0, range 0.36-27.5). A higher, more positive difference in scores between recall and daily diary reporting indicated greater underreporting on recall. Caregivers underreported FI severity on recall compared to noncaregivers (P = .003). CONCLUSIONS Reasons for underreporting FI are probably multifactorial; findings suggest that being a caregiver and having double incontinence are contributing factors. Clinicians should inquire about FI with a discerning yet sensitive approach. Use of a daily stool diary is recommended in research and may be useful in practice.

Although many women suffer from fecal incontinence (FI), little is known about their day-to-day experiences. The aims of this phenomenological study were to understand the experience of women living with FI from their perspective and to elicit women's self-care and management strategies for FI. Ten women participated in audiotaped, unstructured interviews that were transcribed into a written text. The text was analyzed using Van Manen's approach for deriving themes. The findings display the women's experience of lived time, lived space, lived relationships, and lived body and the essential theme of “controlling the body out of control.” The findings demonstrate that FI is a problem that affects women in all dimensions of their lifeworld experience and describes the continual attention and self-management FI requires.

Title. Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients. Aim. This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea. Background. Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause. Method. This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance. Findings. The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea. Conclusion. As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.

Incontinence-associated dermatitis (IAD) is an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin. Little research has focused on IAD, resulting in significant gaps in our understanding of its epidemiology, natural history, etiology, and pathophysiology. A growing number of studies have examined clinical and economic outcomes associated with prevention strategies, but less research exists concerning the efficacy of various treatments. In the clinical and research settings, IAD is often combined with skin damage caused by pressure and shear or related factors, sometimes leading to confusion among clinicians concerning its etiology and diagnosis. This article reviews existing literature related to IAD, outlines strategies for assessing, preventing, and treating IAD, and provides suggestions for additional research needed to enhance our understanding and management of this common but under-reported and understudied skin disorder.

Incontinence is a common health problem among nursing home (NH) residents. Differences between black and white NH residents in incontinence prevalence have been reported. Although reducing health disparities is a principal objective of the national health care agenda, little is known about disparities in incidence of new incontinence in NHs. The purpose of this study was to assess whether there were racial/ethnic disparities in the time to development of incontinence in adults over age 65 who had been continent on NH admission. If no racial or ethnic disparities in time to incontinence were found, other predictors of time to incontinence would be explored. Three national databases were sources of data on 42,693 adults over 65 admitted to 446 for-profit NHs in a national chain. Multi-level predictors of time to any type of incontinence were analyzed, using Cox proportional hazards regression for white Non-Hispanic NH admissions and the Peters-Belson method for minority NH admissions: American Indians/Alaskan Natives, Asians/Pacific Islanders, Black non-Hispanics, and Hispanics. No racial/ethnic disparities in time to incontinence were found. Approximately 30% of all racial/ethnic groups had developed incontinence by 6 months. Those who developed incontinence sooner were older and had greater deficits in activities of daily living (ADL) and cognition. Results were consistent with past evidence and suggest that interventions to maintain continence from the time of admission should be applied across racial/ethnic groups.

Determining whether racial and ethnic disparities exist for a health-related outcome requires first specifying how outcomes will be measured and disparities calculated. We explain and contrast two common approaches for quantifying racial/ethnic disparities in health, with an applied example from nursing research. Data from a national for-profit chain of nursing homes in the US were analyzed to estimate racial/ethnic disparities in incidence of pressure ulcer within 90 days of nursing home admission. Two approaches were used and then compared: logistic regression and Peters-Belson. Advantages and disadvantages of each approach are given. Logistic regression can be used to quantify disparities as the odds of the outcome for one group relative to another. Peters-Belson can be used to quantify an overall disparity between groups as a risk difference and also provides the proportion of that disparity that is explained by available risk factors. Extensions to continuous outcomes, to survival outcomes, and to clustered data are outlined. Both logistic regression and Peters-Belson are easily implementable and interpretable and provide information on the predictors associated with the outcome. These disparity estimation methods have different interpretations, assumptions, strengths, and weaknesses, of which the researcher should be aware when planning an analytic approach.

PURPOSE We sought to identify perioperative factors associated with long-term adjustment to an incontinent ostomy. METHODOLOGY The Ostomy Adjustment Scale (OAS), a demographic form, and a $5 gift certificate were mailed to 200 ostomates. Associations between items from the Survey of Perioperative Factors of Ostomy Adjustment, demographic forms, and total OAS scores were assessed using bivariate and multiple linear regression analysis. RESULTS The survey response rate was 74%. About half (70/146, 49%) of the respondents were women, 99% (144/145) were Caucasian, and 74% (109/146) were married. Their mean age was 65+/-14 years. Fifty-six percent (79/141) of the respondents had an ileostomy, 28% (39/141) had a colostomy, and 15% (21/141) had a urostomy. The mean OAS score for all the respondents was 159.5+/-26.2, indicating a good overall adjustment to an incontinent ostomy. In bivariate analyses, the factor associated with a lower OAS score indicating poorer adjustment was distress related to affording and obtaining ostomy supplies. The more helpful the ostomates found the preoperative education provided by a wound, ostomy, and continence specialist nurse, the better was their adjustment as indicated by a higher OAS score. Having ongoing/recurrent illness and having an ostomy created by a specialty surgeon were also associated with better adjustment. When multiple factors were considered in a stepwise regression analysis, adjustment was lowered by distress about obtaining ostomy supplies. Adjustment was improved when preoperative education provided by a wound, ostomy, and continence specialist nurse was considered helpful for the ongoing/ recurrent illness. CONCLUSION Many ostomates have a good long-term adjustment to ostomy surgery and value education provided by a wound, ostomy, and continence nurse. Perioperative patient education and addressing patient distress over obtaining supplies are areas that can benefit from wound, ostomy, and continence nurse intervention.

Background Perineal dermatitis is an adverse outcome of incontinence, which is common in older nursing home residents; yet knowledge about perineal dermatitis in this population is sorely lacking. Objectives To determine the prevalence and significant correlates of perineal dermatitis in older nursing home residents. Methods Assessment data from 59,558 records in the Minimum Data Set (MDS) were linked with 2,883,049 orders in the medical record which enabled definition of variables related to perineal dermatitis, identification of cases, and determination of the prevalence of perineal dermatitis. Data from two subsamples, each with the records of 10,215 older nursing home residents, were analyzed using logistic regression to identify the significant correlates of perineal dermatitis. Results Perineal dermatitis was found in 5.7% (n = 3,405) of residents and 73% of these were incontinent. Having perineal dermatitis was significantly associated with (a) impairments in tissue tolerance (i.e., more health problems, presence of a fever, requiring nutrition support, and having more problems of diminished perfusion or oxygenation); (b)problems of the perineal environment (i.e., having fecal incontinence only, double incontinence, and more items associated with mechanical chafing); and (c) altered toileting ability from daily use of restraints. Discussion Several correlates of perineal dermatitis (mechanical chafing, fecal and double incontinence, and use of restraints) appear modifiable through nursing intervention. Clinical interventions should consider the complex health status of this population.

Background: As knowledge of the prevalence and impact of fecal incontinence increases, additional research is needed to improve patient outcomes and support the practice of nurses in this area. Objectives: To outline needs for future nursing research on fecal incontinence in aging adults. Methods: Existing literature about fecal incontinence was analyzed to generate a plan for future research. Results: Recommendations for investigation were proposed in the following areas: mechanisms underlying fecal incontinence and common to fecal incontinence and urinary incontinence; assessment of fecal incontinence; management strategies; and tracking a patient's response to fecal incontinence therapies across the healthcare system. Other areas of study identified as priorities included lessening the psychological burden of fecal incontinence, preventing perineal skin problems with appropriate skin care protocols and products, and developing efficacious nursing home routines and environments. Conclusions: Increasing the capacity of nursing research focused on fecal incontinence through funding support and recruitment incentives for new investigators is essential to achieve the proposed agenda.

Background: Millions of Americans with incontinence use some type of device or product to manage or collect urine or feces. However, research on their clinical uses, problems requiring nursing care, and patient satisfaction is lacking. Objectives: To review the various products and devices used for incontinence, identify directions for research and development on technology, and outline the ways nurses can influence and participate in those investigations. Methods: Existing literature on incontinence technology, devices, and products was analyzed to generate a plan for future research. Results: Gaps in knowledge exist about the uses, best practices, quality of life factors, and problems associated with catheters, absorbent products, other internal and external devices, and skin care products. Conclusions: Collaboration among public and private sectors would result in greater likelihood of high quality clinical research that has sufficient power and integrity, more efficient use of resources special to each setting, and expedited application of technologies for patient use.

Developing and testing the quality of a research instrument, including its ability to be used by culturally diverse persons, is an important methodological objective. The present study determined the content validity and feasibility of culturally diverse persons to use an instrument to classify stool consistency that has been employed in research on fecal incontinence. Five multidisciplinary clinicians experienced in assessing stool consistency determined the tool to possess content validity. Twenty-four foreign nationals of diverse cultures who spoke English as a second language (ESL) classified the consistency of nine stools using word only or word plus diagram descriptions. The agreement of the ratings of the participants were compared with the those of an experienced investigator. There was no significant difference between the ratings of participants using either type of description. There was good agreement between the classifications of the participants and those of the investigator. The findings of this study contribute to the quality of our instrument and support its use by culturally diverse persons.

In 2001, the Journal began publishing a special feature the Evidence-Based Report Card. These articles were designed to systematically identify and review evidence pertaining to wound, ostomy and continence specialty practice and summarize recommendations for clinical practice. Based on feedback from WOCN members and Society leadership, the Journal will relaunch this popular and valuable special feature. This article describes methods used to generate Evidence-Based Report Cards, a taxonomy of levels of evidence, and criteria for ranking the strength of recommendations for treatment.

Objective: The objective of this study was to assess whether there are racial and ethnic disparities in the time to development of a pressure ulcer and number of pressure ulcer treatments in individuals aged 65 and older after nursing home admission. Method: Multi-level predictors of time to a pressure ulcer from three national surveys were analyzed using Cox proportional hazards regression for White Non-Hispanic residents. Using the Peters–Belson method to assess for disparities, estimates from the regression models were applied to American Indians/Alaskan Natives, Asians/Pacific Islanders, Blacks, and Hispanics separately resulting in estimates of expected outcomes as if they were White Non-Hispanic, and were then compared with their observed outcomes. Results: More Blacks developed pressure ulcers sooner than expected. No disparities in time to a pressure ulcer disadvantaging other racial/ethnic groups were found. There were no disparities in pressure ulcer treatment for any group. Discussion: Reducing disparities in pressure ulcer development offers a strategy to improve the quality of nursing home care.