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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.

The purpose of this study was to identify goals of fecal incontinence (FI) management and their importance to community-living adults if complete continence would not be possible. Participants expressed their goals of FI management in a semistructured interview, selected others from 12 investigator-identified goals, and rated their importance. Five thematic categories emerged from the 114 participant-identified goal statements: Fecal Incontinence/Bowel Pattern, Lifestyle, Emotional Responses, Adverse Effects of Fecal Incontinence, and Self-Care Practices. Participants selected a median of seven investigator-identified goals (range = 2 to 12). Goals selected by the most participants were decreased number of leaks of stool and greater confidence in controlling fecal incontinence. These goals also had the highest importance along with decreased leakage of loose or liquid stool. The type and number of management goals identified by participants offer a toolbox of options from which to focus therapy when cure is not possible and promote patient satisfaction.

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

There is a lack of awareness about fecal incontinence despite its prevalence and adverse impact on quality of life. Inadequate knowledge about fecal incontinence deters help-seeking, therapeutic consultation, and clinical research about effective prevention and management strategies. A systematic, evidenced-based approach to raise awareness of fecal incontinence is essential to forward progress and overcome multiple barriers. In this manuscript, strategies of this approach are prioritized and focus on increasing continence literacy and communication, emphasizing prevention and screening, disseminating evidenced-based management interventions, and promoting larger scale impact through effective partnerships. Neurourol. Urodynam. 29:612–615, 2010. Copyright © 2010 Wiley-Liss, Inc.

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.

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.

Purpose Reliability and validity are important measures of the quality of a research or clinical instrument. This research determined the inter-rater and test-retest reliability of a stool consistency classification system and the agreement between the subjects' and expert investigators' classifications. Methods Two studies were conducted with adult volunteers. Stool consistency was described by words only and words + diagrams. To determine inter-rater reliability, subjects in each of 3 groups (20 nurses, 20 nursing students, and 20 lay persons) classified the consistency of 12 stool specimens. To determine test-retest reliability, 43 additional subjects classified the consistency of 9 stool specimens in 2 sessions. Outcome measures Outcome measures were reported per individual stool specimen and for all stool specimens. The outcome measures were the consistency classifications by the 3 groups of raters when the 2 types of descriptors (word only and word + diagram) were used. Other outcomes were the consistency classifications of the subjects on the 2 days of stool evaluation and the classifications of the subjects compared with those of the investigators. Results No significant difference was found among the stool consistency classifications among nurses, nursing students, or lay persons. Classifications were similar for 11 of 12 stool specimens when either word-only or word + diagram descriptions were used. No significant difference was found among the classifications between days 1 and 2. At least 75% of the subjects' classifications of stool consistency in both studies agreed highly with those of the investigators. Conclusions The reliability and validity of the stool consistency classification system are good. The word-only descriptions of the consistency classifications appeared to be equally as effective as the word + diagram descriptions.

Success in competing for research funding, acceptance of an abstract, or publication of a manuscript depends in part on the ability to communicate in writing the essence of one's research. The research grant, abstract, and manuscript represent the three primary phases of formally communicating research from planning to dissemination of results. In this paper, perspectives on avoiding the common pitfalls of research writing in terms of content, style, and format are presented to facilitate a successful outcome.

BACKGROUND Information about fecal incontinence experienced by patients in acute-care settings is lacking. The relationship of fecal incontinence to several well-known nosocomial or iatrogenic causes of diarrhea has not been determined. OBJECTIVES To determine the cumulative incidence of fecal incontinence in hospitalized patients who are acutely ill, and to ascertain the relationship between fecal incontinence and stool consistency, and between diarrhea and two well-known nosocomial or iatrogenic etiologies of diarrhea: Clostridium difficile and tube feeding. The relationship of fecal incontinence and risk factors for diarrhea associated with C. difficile and tube feeding in hospitalized patients was examined. METHODS Fecal incontinence, stool frequency and consistency, administration of tube feeding and medications, severity of illness, and nutritional data were prospectively recorded in 152 patients on acute or critical care units of a university-affiliated Veterans' Affairs Medical Center. Rectal swabs and stool specimens from patients were obtained weekly for C. difficile culture. C. difficile culture and cytotoxin assay were performed on diarrheal stools. HindIII restriction endonuclease analysis (REA) was used for typing of C. difficile isolates. RESULTS In this study, 33% (50/152) of the patients had fecal incontinence. The proportion of total surveillance days with fecal incontinence in these patients was 0.50 +/- 0.06. A greater percentage of patients with diarrhea had fecal incontinence than patients without diarrhea (23/53 [43%] vs. 27/99 [27%]; p = 0.04). Incontinence was more frequent in patients with loose/liquid stool consistency than in patients with hard/soft stool consistency (48/50 [96%] vs. 71/100 [71%]; p < 0.001). The proportion of surveillance days with fecal incontinence was related to the proportion of surveillance days with diarrhea (r = 0.69; p < 0.001) and the proportion of surveillance days with loose/liquid stools (r = 0.64; p < 0.001). Multivariate risk factors for fecal incontinence were unformed/loose or liquid consistency of stool (RR = 11.1; 95% confidence interval [CI] = 2.2, 56.7), severity of illness (RR = 5.7; CI = 2.6, 12.3), and age (RR = 1.1; CI = 1, 1.1). CONCLUSIONS Fecal incontinence is common in hospitalized patients who are acutely ill, but the condition was not associated with any specific cause of diarrhea. Because loose or liquid stool consistency is a risk factor for fecal incontinence, use of treatments that result in a more formed stool may be beneficial in managing fecal incontinence. However, treatments that slow intestinal transit should be avoided in patients with C. difficile-associated diarrhea.

Purpose: In our clinical and research experience, persons with fecal incontinence anecdotally report altered diet intake to avoid incontinence. The purpose of this study was to compare the dietary intake of 39 persons with fecal incontinence living in the community with that of age- and gender-matched control subjects who had normal bowel function. The diets of both groups were compared with recommended dietary allowances (RDAs) for their constituent nutrients. Methods: Subjects prospectively recorded the type, amount, and method of preparing all foods and beverages ingested for 8 consecutive days. Diet records were analyzed using the Nutritionist IV software program. Main outcome measures: The main outcome measures were the amounts and percentage of the RDAs of macronutrients and micronutrients in the subjects' diets. Results: There were no significant differences in the intake of total kilocalories, protein, fat, dietary fiber, caffeine, or lactose by the fecal incontinence and control groups. The fecal incontinence group had a greater intake of carbohydrates, manganese, and vitamin B 1 compared with the control group. Diets of both groups exceeded 100% of the RDA for protein, phosphorus, iron, sodium, potassium, Vitamins B 1 , B 2 , B 3 , B 12 , and C and folate. Diets of both groups had less than 50% of the RDA for biotin, chromium, copper, and manganese but did not differ significantly. The percentages of the RDA for calcium and vitamin D were 84% ± 6% and 56% ± 8% for the fecal incontinence group and 90 ± 8 ( P = .6) and 69 ± 11 for the control group ( P = .4). Conclusions: The diets of persons with fecal incontinence were similar to those of control subjects with normal bowel function. Both the fecal incontinence and control groups may improve their nutritional patterns by lowering sodium and protein intake and increasing dietary fiber and monounsaturated fat intake. Calcium and vitamin D supplementation may improve dietary deficiencies and lower disease risks. Including a nutritional assessment and consultation in the care of persons with fecal incontinence to improve their general health and prevent disease is recommended, but consideration must be given to altered diet patterns perceived by the patient to prevent fecal incontinence.

PURPOSE: This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS: The Fecal Incontinence Quality of Life Scale is composed of a total of 29 items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS: Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha >0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS: The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement.

Needleless intravenous (IV) access devices have been introduced into many clinical settings for administering TPN and other IV fluids to decrease the risks of needle-stick injury and transmission of bloodborne pathogens. However, reports of outbreaks of bloodstream infections in patients receiving needleless devices illustrated a lack of infection-control guidelines for use of these devices, their components, and variable staff practices. Revised practice standards from the IV Nurses Society recommend rigorous infection-control practices. All components of the IV system used in administering TPN, including the needleless components, should be considered a closed system that is manipulated aseptically and changed daily.

Objective: The purpose of this study was to compare the stool consistency categorizations made by 39 adults with fecal incontinence and the percentage of water in their stools determined by lyophilization. Methods: Subjects collected all stools daily for 8 days during a baseline period and at the end of a fiber treatment period. Stool consistency was recorded as hard and formed, soft but formed, loose and unformed, or liquid, Aliquots of the stools were lyophilized to constant weight. Main Outcome Measures: The main outcome measures were the percentage of stool water among stools in each consistency category and the correlation between subjects' stool consistency categorizations and the percentage of stool water. Results: The subjects were 8 men and 21 women, ranging in age from 30 to 89 years, who were participating in a study of the effectiveness of dietary fiber for treating fecal incontinence. A total of 1023 stool samples were analyzed. Significant differences in the mean percentage of water were found among the 4 stool consistency categories (hard and formed = 68% ± 0.9%, soft but formed = 74% ± 0.3%, loose and unformed = 80% ± 0.4%, and liquid = 85% ± 0.3%; P < .001). Ninety-six percent of the stools had a percentage of water within 2 SDs of the mean percentage of water of other stools in their consistency category. Conclusion: This classification system of stool consistency is a valid and practical measure for clinical studies. It may be useful for clinicians and patients to evaluate outcomes of treatments directed at improving stool consistency.

Purpose To assess whether there was a significant improvement and stabilization (not worse at discharge) in pressure ulcers, lower extremity venous ulcers, surgical wounds, urinary incontinence, bowel incontinence, and urinary tract infections in home health care (HHC) patients cared for by a certified WOC nurse. Subjects and setting There were 449,170 episodes of care from a national convenience sample of 785 HHC agencies with 447,309 nonmaternity, adult patients between October 1, 2008, and December 31, 2009. Design Descriptive and comparative. Instruments and methods Data from the Outcome and Assessment Information Set documented by HHC clinicians were analyzed using mixed-effects logistic regression, propensity score analysis, and appropriate parametric and nonparametric tests. An Internet survey identified whether WOC nurses provided care to patients in an HHC agency. Home health care agencies identified records of patients receiving WOC nurse visits/consults. Results An HHC patient assigned to a WOC nurse had surgical wounds, pressure ulcers, and incontinence problems that were significantly worse than HHC patients not assigned to a WOC nurse. Patients cared for by a WOC nurse showed significant improvement and stabilization of the number of pressure ulcers and surgical wounds and the frequency of urinary and bowel incontinence, despite having problems that were more severe than other patients. Home health care patients not cared for by WOC nurses, with less-severe wound and incontinence problems, also got better. Conclusions WOC nurses are effective in achieving positive health outcomes for pressure ulcers, surgical wounds, and incontinence in HHC patients with severe health problems.

The Peters–Belson (PB) method was developed for quantifying and testing disparities between groups in an outcome by using linear regression to compute group-specific observed and expected outcomes. It has since been extended to generalized linear models for binary and other outcomes and to analyses with probability-based sample weighting. In this work, we extend the PB approach to right-censored survival analysis, including stratification if needed. The extension uses the theory and methods of expected survival on the basis of Cox regression in a reference population. Within the PB framework, among the groups to be compared, one group is chosen as the reference group, and outcomes in that group are modeled as a function of available predictors. By using this fitted model's estimated parameters, and the predictor values for a comparator group, the comparator group's expected outcomes are then calculated and compared, formally with testing and informally with graphics, with their observed outcomes. We derive the extension, show how we applied it in a study of incontinence in nursing home elderly, and discuss issues in implementing it. We used the ‘survival’ package in the R system to do computations. Copyright © 2013 John Wiley & Sons, Ltd.

PURPOSE To describe the occurrence and severity of incontinence-associated dermatitis among community-dwelling individuals with fecal incontinence. DESIGN Descriptive and comparative secondary data analysis. SUBJECTS AND SETTING One hundred eighty-nine community-dwelling individuals with fecal incontinence who participated in a study comparing the effects of dietary fiber on fecal incontinence. METHODS A survey on the use of absorbent products that contained questions about subjects' history of skin damage was administered at the start of the study. RESULTS Incontinence-associated dermatitis occurred in 52.5% of the community-living individuals with fecal incontinence. The severity of incontinence-associated dermatitis was mostly mild to moderate and occurred periodically. Redness without broken skin was the most common manifestation (68%). Most individuals (95%) reported the location of skin damage to be the anal/rectal area. Those with double incontinence also reported dermatitis around the vagina or penis. Individuals with a greater severity of fecal incontinence had a greater severity of incontinence-associated dermatitis (r = 0.27, P = .000). Both the frequency of incontinence (r = 0.23, P < .002) and the amount of feces leaked (r = 0.23, P < .002) had a significant correlation with incontinence-associated dermatitis severity. There were no significant differences in the occurrence or severity of incontinence-associated dermatitis by sex, age, or presence of double incontinence. CONCLUSION A high percentage of individuals in the community with fecal incontinence suffer from incontinence-associated dermatitis at times. This population may benefit from consultation with a WOC nurse about prevention and management of incontinence-associated dermatitis.

Objective While admissions of minorities to nursing homes (NHs) are increasing and prevalence of incontinence in NHs remains high, little is known about incontinence among racial-ethnic groups of NH admissions other than blacks. The purpose of this study was to describe the prevalence of incontinence among older adults admitted to NHs by race/ethnicity at three levels of measurement: individual resident, NH, and Census division. Design Cross-sectional and descriptive. Participants and Setting Admissions of persons age 65 or older to 1 of 457 NHs of a national, for-profit chain over 3 years 2000–2002 (n = 111,640 residents). Methods Data sources were the Minimum Data Set v. 2.0 and 2000 US Census. Prevalence of the following definitions of incontinence was analyzed: Only Urinary Incontinence (UI), Only Fecal Incontinence (FI), Dual Incontinence (DI; UI and FI), Any UI (UI with or without FI), Any FI (FI with or without UI), and Any Incontinence (UI and/or FI and/or DI). Results Asian patients, black patients, and Hispanic patients had a higher prevalence of Any Incontinence (67%, 66%, and 58%, respectively) compared to white patients (48%) and American Indian patients (46%). At the NH level, all prevalence measures of incontinence (except Only UI) appear to trend in the opposite direction from the percentage of NH admissions who were white. Among Asian and white patients, there was a higher prevalence of all types of incontinence in men compared with women except for Only UI. Among Census divisions, the prevalence of all types of incontinence, except Only UI, was lowest in the 2 divisions with the highest percentage of white admissions to their NHs. Conclusions NHs admitting more racial/ethnic minorities may be faced with managing more incontinence and needing additional staffing resources. The association of the prevalence of most types of incontinence with the race/ethnicity of NH admissions at all levels of measurement lend support to the growing evidence that contextual factors beyond individual resident characteristics may contribute to NH differences.

Purpose The purpose of this study was to investigate the lived experience of men managing fecal incontinence (FI). Method A phenomenological method was used to investigate the experience of FI. Eleven men participated in unstructured interviews. Van Manen's approach was used for data analysis. Results The findings display men's experiences of living with FI through space, relationships, time and body. The essential theme generated from the analysis was “secret resignation.” Resignation of having FI was the main coping strategy of the men in this study and was reflected in the limited approaches they used to manage their symptoms. The common reason of the resignation was considering FI normal for them and a consequence of aging. Discussion and Conclusion The findings provide guidance to rehabilitation nurses to first inquire about the presence of FI, education men about its etiologies, and develop plans of care that address men's main concerns.

In 2010, an international consensus conference was held to review current evidence regarding the pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of this literature review were published in a previous issue of this Journal. This article summarizes key consensus statements agreed upon by the panelists, evidence-based guidelines for prevention and management of IAD, and a discussion of the major challenges currently faced by clinicians caring for these patients. The panelists concur that IAD is clinically and pathologically distinct from pressure ulcers and intertriginous dermatitis, and that a consistently applied, structured, or defined skin care program is effective for prevention and management of IAD. They also agreed that differential assessment of IAD versus pressure ulceration versus intertriginous dermatitis remains a major challenge. Panel members also concur that evidence is lacking concerning which products and protocols provide the best outcomes for IAD prevention and treatment in individual patients. Issues related to differential assessment, product labeling and utilization, staff education, and cost of care are the primary focus of this article.

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Background Clostridium difficile infection is increasing in incidence and severity. The optimal treatment is unknown. Purpose To determine whether, among adults with C. difficile infection, treatment with certain antibiotics compared with others results in differences in initial cure, recurrence, and harms. Data sources MEDLINE, AMED, ClinicalTrials.gov, and Cochrane databases (search dates: inception through August 2011, limited to English-language reports); bibliography review. Study selection Randomized, controlled trials of adults with C. difficile infection, independent of outcomes, who were treated with medications available in the United States. Observational studies reporting strain were included. Data extraction Study design, inclusion and exclusion criteria, quality and strength of evidence as assessed by 2 reviewers, study definitions, and duration of treatment and follow-up. Outcomes included initial cure, recurrence, and treatment harms. Data synthesis 11 trials that included 1463 participants were identified. Three trials compared metronidazole with vancomycin; 8 compared metronidazole or vancomycin with another agent, combined agents, or placebo. Strain was analyzed in 1 trial and 2 cohort studies. No study comparing 2 antimicrobial agents demonstrated a statistically significant difference for initial cure; all comparisons were of low to moderate strength of evidence. Moderate-strength evidence from 1 study demonstrated that recurrence was decreased with fidaxomicin versus vancomycin (15% vs. 25%; difference, -10 percentage points [95% CI, -17 to -3 percentage points]; P=0.005). Subgroup analysis of a single study comparing metronidazole with vancomycin for patients who have severe C. difficile infection showed no difference by intention-to-treat analysis; this was rated as insufficient-strength evidence. Harms, when reported, did not differ between treatments in any study. Limitations Definitions of diarrhea, C. difficile infection, initial cure, and relapse varied. Some studies reported insufficient detail to allow assessment of all randomly assigned participants or of harms. Conclusion No antimicrobial agent is clearly superior for the initial cure of C. difficile infection. Recurrence is less frequent with fidaxomicin than with vancomycin. Primary funding source U.S. Department of Health and Human Services.

Background/Aims: Primary Care Providers (PCPs) are seeing more complex patients who were previously managed by specialists. PCPs may not have the time or expertise to fully elicit or evaluate all patient complaints, or apply the detailed evidence required to manage these conditions. We describe provider experience with eCVD, a web-based cardiovascular disease (CVD) management system for use in primary care. eCVD incorporated a shared-decision making (SDM) tool linked to a clinical decision support (CDS) tool that, together, were designed to promote the development of preference-sensitive and evidence-based care plans. Methods: Prior to a primary care encounter, patients completed a behavioral risk factor questionnaire to calculate their CVD risk. Patients at elevated risk used the eCVD system, which included an SDM tool that informed patients of their CVD risk, educated them on the types and benefits of risk factorspecific treatment options, and allowed them to select their preferred treatment options. Via an alert embedded in the electronic health record (EHR), the provider could access a CDS tool displaying both tailored, guideline-based recommendations and the patient’s chosen treatment preferences. We tracked use of the CDS and conducted structured interviews with providers to understand their experience with eCVD. Interview domains included: logistics/workflow, mode of presentation, content, patient preferences, and improving efficiency/effectiveness. Results: The CDS alert was presented for 118 patients; only 21.2% were opened by providers. Initial review of interview data showed that providers did not open the CDS alert due to time constraints or because it was indistinguishable from other EHR alerts. Providers stated that they believe discussing a patient’s preferences for care is important but difficult to do with complex patients because of the time needed to: 1) review all relevant data; 2) determine additional data needs (e.g., labs); 3) determine the appropriate clinical course of action; and 4) educate the patient. Conclusions: Models of technology adoption highlight the importance of usefulness and usability of a tool like eCVD. Our data suggest that, while the SDM/CDS content was useful, usability issues remain. Detailed thematic analysis of how the tool was accessed and the functionality it provided will be completed in December 2010.

A consensus panel was convened to review current knowledge of moisture-associated skin damage (MASD) and to provide recommendations for prevention and management. This article provides a summary of the discussion and the recommendations in regards to 2 types of MASD: incontinence-associated dermatitis (IAD) and intertriginous dermatitis (ITD). A focused history and physical assessment are essential for diagnosing IAD or ITD and distinguishing these forms of skin damage from other types of skin damage. Panel members recommend cleansing, moisturizing, and applying a skin protectant to skin affected by IAD and to the perineal skin of persons with urinary or fecal incontinence deemed at risk for IAD. Prevention and treatment of ITD includes measures to ensure that skin folds are dry and free from friction; however, panel members do not recommend use of bed linens, paper towels, or dressings for separating skin folds. Individuals with ITD are at risk for fungal and bacterial infections and these infections should be treated appropriately; for example, candidal infections should be treated with antifungal therapies.

Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are incontinence-associated dermatitis, intertriginous dermatitis, periwound moisture-associated dermatitis, and peristomal moisture-associated dermatitis. Although evidence is lacking, clinical experience suggests that MASD requires more than moisture alone. Instead, skin damage is attributable to multiple factors, including chemical irritants within the moisture source, its pH, mechanical factors such as friction, and associated microorganisms. To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown.

PURPOSE The use of disposable absorbent products by community-dwelling people with fecal incontinence (FI) was described. METHODS A survey was administered to 189 community-living individuals with FI at the start of a clinical trial about the effects of dietary fiber on FI. RESULTS Forty-five percent of respondents (86/189) used an absorbent product to manage FI. More women (88%, 76/86, P = .009) and persons aged 65 years and older (44%, 38/86, P = .001) wore an absorbent product. Participants who wore an absorbent product for FI had a higher (worse) FI severity score (median, 4.75; range, 1-27; P = .006). Sixty-three users wore pantiliners and they were the only ones who used more than 3 products per day. Feminine hygiene products were worn more than incontinence products. Half of users were satisfied with the product they used. Evaluations of product features differed by type of product; odor control had some of the lowest ratings. CONCLUSIONS Community-living individuals with FI, especially women and older individuals, tend to wear absorbent products. Perceptions of FI severity, preference, leakage of liquid stool, and presence of urinary incontinence influence the product type and pattern of wear. Participants report that modification of several features of absorbent products might make them more suitable for FI and increase satisfaction.

PURPOSE: The study aimed to describe modifications in diet and eating patterns made by community-living people to manage fecal incontinence (FI), and to compare these differences according to sex, age, and FI severity. SUBJECTS AND SETTINGS: Subjects were 188 community-living adults (77% female, 92% white, 34% aged 65 years or older) in the upper Midwest who participated in a study about managing FI with dietary fiber. METHODS: Subjects were interviewed about diet and eating pattern changes that they made to manage FI, and self-reported demographic data. FI severity was recorded daily. RESULTS: Fifty-five percent of participants perceived that some foods worsen their FI (eg, fatty or spicy foods and dairy products). More women than men (40% vs 18%, P = .008) reported avoiding foods to manage FI. A greater percentage of younger than older people believed that fatty/greasy foods (15% vs 4%) and alcohol (14% vs 3%) worsened their FI. Subjects with a higher FI severity score appeared to wait until FI was more severe before restricting caffeine than those with lower severity scores (22.2 ± 9.8 vs 11.69 ± 8.3, P = .034). One-third of subjects consumed foods rich in dietary fiber to prevent FI. Subjects also reported altered eating or cooking patterns, skipping meals, or eating at consistent times to manage FI. CONCLUSIONS: Diet modification for managing FI incorporates restriction of some foods, along with adding others foods to the diet. Nursing assessments of self-care practices for FI should include diet and eating pattern changes when developing a plan of care.

Purpose To develop and test the validity and interrater reliability of the Incontinence-Associated Dermatitis and its Severity Instrument, a novel tool describing incontinence-associated dermatitis and its severity. Methods Investigators consulted 2 certified WOC nurse experts to determine face validity of the instrument. Seven additional certified WOC nurses evaluated the tool for content validity. The instrument was tested for interrater reliability by attendees at the 2007 WOCN Society National Conference and employees at a health care system in Minnesota. Criterion validity was determined by comparing IAD severity scores of testers with those of the 2 WOC experts and PI. Results Consultants determined that the instrument had face and content validity. Two hundred forty-seven attendees at the WOCN Society's National Conference (mean nursing experience 25±9 years [mean±SD]), 100 nursing staff in Minnesota: 84 staff nurses (mean nursing experience 17±12 years), and 16 nursing assistants (mean nursing experience 7±7 years) determined that the instrument has content validity. There were no significant differences in scores of IAD severity for the 4 cases among the 3 types of testers (P>.05). Overall agreement between the 347 raters and the experts using intraclass correlation was 0.98 (P=.006). Conclusion The Incontinence-Associated Dermatitis and its Severity Instrument demonstrated good validity and interrater reliability and its development fulfills an unmet need in both research and clinical practice settings.

Although fecal incontinence can be both emotionally and socially debilitating, the embarrassment associated with it is so great that it often prevents patients from seeking much needed help from their health care providers. Nursing care begins with case finding and continues through conservative management, which has greatly improved over the past 15 years. This article summarizes the strategies that have proven most effective in uncovering and combating this prevalent yet seldom acknowledged condition.: defecation, diarrhea, fecal incontinence, feces, incontinence, incontinence of stool.

There is a lack of awareness about fecal incontinence despite its prevalence and adverse impact on quality of life. Inadequate knowledge about fecal incontinence deters help-seeking, therapeutic consultation, and clinical research about effective prevention and management strategies. A systematic, evidenced-based approach to raise awareness of fecal incontinence is essential to forward progress and overcome multiple barriers. In this manuscript, strategies of this approach are prioritized and focus on increasing continence literacy and communication, emphasizing prevention and screening, disseminating evidenced-based management interventions, and promoting larger scale impact through effective partnerships.

Fecal incontinence (FI) in community-dwelling men affects quality of life and increases the risk of institutionalization. Observational studies and randomized, controlled trials (RCTs) on epidemiology and prevention of FI published in English from 1990 to November 2007 were identified in several databases to abstract rates and adjusted odds ratios (ORs) of incontinence and to synthesize evidence with random effects models. Twenty-one observational studies and 4 RCTs were eligible for analysis. Pooled prevalence of FI in elderly men increased with age to 5% to 6%. Men over age 85 years (OR 2.5; 95% confidence interval [CI], 1.3-5) and with kidney diseases (OR 1.9; 95% CI, 1.2-3.3) had higher odds of incident FI. Significantly impaired cognitive status and general health were associated with FI. Men had increased risk of incontinence after radical prostatectomy or radiation for prostate cancer. Lower doses of radiation caused inconsistent reduction in FI across 2 RCTs. The prevalence of incontinence increased with age and functional dependency. Cognitive impairment, poor general health, surgery, and radiation for prostate cancer were associated with incontinence in community-dwelling men. No effective interventions are known at the present time.

PURPOSE Use of an absorbent product is a self-care strategy for managing fecal incontinence that protects against visible soiling. The purpose of this study was to examine use of a small surgical dressing that can be placed between the buttocks to absorb leaked feces. DESIGN Cross-sectional survey. SUBJECTS AND SETTING A survey was mailed to 75 randomly selected community-living people in 25 states and the District of Columbia, who ordered the dressing more than once within the past year. Thirty-six people (age = 55 ± 16 years mean ± SD), 57% men and 94% white responded. INSTRUMENT A 48-question survey that included questions asked about demographics and general health, emotional states (eg, anxiety and depression), bowel pattern and incontinence, quality of life, and use of an anorectal dressing was developed for this study. The survey also contained 2 tools, the Fecal Incontinence Severity Index and the Fecal Incontinence Quality of Life instrument. The Fecal Incontinence Severity Index is a tool that enables valid assessment of fecal incontinence severity using patient recall of symptoms of frequency and type of bowel leakage. The Fecal Incontinence Quality of Life instrument results in a valid and reliable evaluation of fecal incontinence–specific quality of life using 4 domains of lifestyle, coping/behavior, depression/self-perception, and embarrassment. RESULTS The fecal incontinence severity score was 28 ± 14 (mean ± SD); 79% leaked loose/liquid feces, 50% leaked daily, and leaked feces remained between the buttocks in 64%; 21% also leaked urine. Eighty-five percent experienced incontinence-associated dermatitis. Of those who used the dressing, 50% were men. The anorectal dressing was preferred to a pad by 92%, prevented soiling in 88%, and its ability to stay in place was rated very good or good by 76%. Eighty percent of respondents rated the dressing's comfort very good or good; 85% rated its overall effectiveness very good or good. Use of the dressing lessened anxiety about fecal soiling in 81% and was thought to improve quality of life in 76%. CONCLUSION An anorectal dressing offers an effective, comfortable alternative to a pad for absorbing leaked feces that seems acceptable to men.

Purpose To determine the cost and efficacy of 4 different regimens of incontinence-associated dermatitis (IAD) prevention in nursing home residents. Methods A multi-site open-label quasi-experimental study was conducted in 16 nursing homes stratified by location in 1 of 4 regions of the United States and randomly selected. In 3 of the 4 regimens, a moisture barrier ointment or cream of different compositions was applied after each episode of incontinence, and in 1 regimen, a polymer-based barrier film was applied 3 times per week. All regimens used a pH-balanced moisturizing cleanser. Time and motion measures were documented for the amount of skin care products used; the number, type, and time of caregivers performing IAD prevention care; and the number and type of supplies used. Rates of incontinence in each nursing home were determined during a 3-day surveillance period. Results A total of 1,918 nursing home residents were screened, and 51% (n = 981) qualified for prospective surveillance of incontinence dermatitis; the majority were female (80.1%) and elderly (96% > or = 65 years old). A total of 78.6% (771/981) of the participants were incontinent of both urine and feces. Compared to the 3 regimens in which a barrier was applied after each episode of incontinence, the use of a regimen in which a barrier film was applied 3 times weekly had significantly lower costs for the barrier product, labor associated with barrier application, and total cost, which included products, labor, and supplies. There were also savings in total product (cleanser and barrier) and total labor costs. Conclusions The use of a defined skin care regimen that includes a cleanser and a moisture barrier is associated with a low rate of IAD in nursing home residents who are incontinent. Use of a polymer skin barrier film 3 times weekly is effective for preventing incontinence-associated skin breakdown and can provide significant cost savings.

The recruitment of community-living participants for clinical trials of sensitive topics, when the population is largely hidden and reluctant to self-identify, and the study protocols and procedures intensive, creates significant challenges to researchers. The Fiber Study is an ongoing randomized controlled clinical trial conducted to compare the effectiveness of three dietary fibers with different levels of fermentability for symptom management in community-living adults with fecal incontinence. The researchers developed a staged approach to recruitment using three primary recruitment methods and a three-phase approach to the enrollment process. We have been successful in reaching, recruiting, and enrolling participants in a clinical trial, as well as in effectively managing study resources and staff time.