Authors

  1. Gray, Mikel

Article Content

In This Issue of JWOCN

Jan Colwell once noted that while special focus issues focusing on wounds or continence issues tended to be comparatively specific (past examples include larval debridement therapy, moisture-associated skin damage, bowel and bladder dysfunction), special focus issues pertaining to ostomies tended to be general. This trend reflects the overall small number of articles published in the area of ostomy nursing care, and the even smaller evidence base underpinning this care. Therefore, I am especially pleased to announce that the special focus for this issue is "Quality of Life With an Intestinal Ostomy." The luxury of such a specific focus reflects the growing number of manuscripts focusing on ostomy care received by the Journal and the growing body of evidence supporting our care. While I am proud of this evidence of growth in the field of ostomy care research, I am equally pleased to see that the issue also addresses the wide spectrum of issues pertinent to multiple aspects of your clinical and professional practice as a WOC nurse, including state of the science articles in both wound and continence management.

 

The special focus comprises 3 articles. Joy Pittman, Kathy Kozell, and others pose 3 questions in this issue's Evidence-Based Report Card: Does ostomy produce a clinically relevant impact on quality of life, do nursing interventions ameliorate this effect, and should WOC nurses routinely measure quality of life in the clinical setting? Read this feature to find out more; some of the answers may surprise you. Andrea Altschuler, Michelle Ramirez, Marcia Grant, Christopher Wendel, Mark Hornbrook, Lisa Herrinton, and Robert Krouse examine the influence of male partner's support on ostomy creation in women. Based to no small extent on the strength of the VA Ostomy Health-Related Quality of Life Study, we have a growing knowledge of health-related quality of life in adult men with intestinal ostomies. However, our knowledge of quality of life and psychosocial issues affecting women is less robust. You will want to read this study to gain insight into the influence of the male partner on women's quality of life and adjustment to an intestinal ostomy. Because most patients undergoing ostomy surgery tend to be older, our knowledge of young adults' quality of life and psychosocial adjustment to an ostomy is also limited. Therefore, you will want to carefully review Lorraine Sinclair's study of the experiences of young adults during the first 4 years following creation of a permanent ileostomy. This interesting and valuable study is one of the first qualitative studies focusing exclusively on young adults published in the Journal since Toth's classic study appeared in 1999.1

 

In addition to the special focus on quality of life, the Ostomy Section features 2 more articles that contain essential information to your practice. The WOCN and American Urological Association have released a joint position statement on stoma site marking in patients with urostomies. This document both complements and completes the statement coauthored with the American Society of Colon and Rectal Surgeons (ASCRS) about stoma site marking and also provides you with additional documentation of this essential component of WOC practice. Also, you will want to carefully review Chia-Chun Li's article on sexuality among patients with a colostomy and complete the attached continuing education opportunity. As our society becomes more and more complex, knowledge of transcultural nursing is rapidly evolving from a specialty study to a measure of basic clinical competence. This article is another must-read feature because it combines a challenging issue (sexual function following ostomy surgery) with knowledge about 2 seldom-studied groups, Asian American women and gay and lesbian patients.

 

This issue's Wound Care section features an innovative research article from Barbara Bates-Jensen, Heather McCreath, and Voranan Pongquan, who report on measurement of subepithelial moisture for predicting Stage I and Stage II pressure ulcers in nursing home patients with darker skin tones. You will want to read this innovative study to form your opinion of the potential clinical utility of subepidermal moisture as a physiologic measure enhancing our ability to differentiate moisture-associated from pressure (ischemic)-induced skin damage.

 

This issue's Continence Care section presents yet another article demonstrating the interface between wound and continence care. K. Pinar, Katherine Moore, E. Smits, K. Murphy, and D. Schopflocher evaluate urinary leg bags, focusing on the effect of various designs on skin health, comfort, and patient satisfaction. Whether your practice focuses mainly on continence or wound care you will want to read this article to determine the features of the optimal leg bag for urinary drainage.

 

The View From Here feature deals with a professional practice issue literally ripped from the highlights of an ongoing debate. Bridget Mejza speculates about an issue that I have felt strongly about for many years. In an insightful and visionary discussion, she questions whether the WOC nurse of the future should hold a Doctor of Nursing Practice degree. Her thesis is based on 2 fascinating and important questions: Will the WOC specialty ultimately define itself as an advanced practice and will advanced practice evolve from a postbaccalaureate master's-based model to a postbaccalaureate doctoral model? Read her feature and decide for yourself about this imminently plausible and potentially preferable future for our specialty practice.

 

Eileen Harwood continues the ongoing Spotlight on Research feature about data collection, using questionnaires or interviews. This article, which is third in a series of 6, focuses on developing protocols for collecting data. As with previous articles, it is based on studies previously published in the Journal, rendering it readily translatable to the novice as well as expert clinical investigator.

 

Amy Schaffner continues our feature focusing on Getting Ready for Certification. This feature provides 3 questions similar to those appearing on the certification examination. Not only do the questions demonstrate the 3 levels of questions you will face on certification examinations, they also provide rationales for the correct answer and related distractors.

 

This issue's Clinical Challenges summarizes 3 cases of Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN). Karen Edwards, Hattie Stokes, Kelly Suttle, and Catrice Potts describe their institution's approach to managing these challenging and often devastating disorders. The information in this article will be of interest to any WOC nurse who practices in the acute or critical care setting. You will want to read this feature to see how a university-based health system improved clinical outcomes by establishing a facility-wide protocol.

 

Evidence From Other Publications

WOUND CARE

The protocol reported by Edwards, Stoker, Suttle, Potts, and Coles describes the involvement of their facility's wound care team for the management of exfoliating disorders including TEN and Stevens-Johnson syndrome. Because these interdisciplinary teams are experienced with burn-induced skin loss, their expertise is ideally suited to the management of any disorder associated with widespread skin loss. In a recent issue of the Journal of Burn Care & Research, Endorf and colleagues2 outline clinical practice guidelines for managing patients with TEN in a burn unit. The guideline includes useful evidence-based recommendations for the use of systemic antimicrobials, the controversial role of systemic treatments for TEN, options for topical wound therapy, nutritional support, ophthalmic consultation, and the use of clinical scoring tools. Many WOC nurses will find the information about the controversy surrounding systemic treatments and ocular management especially useful. Some may find information about topical therapy less detailed than they would wish, but this may be viewed as an opportunity to add WOC expertise to an optimal interdisciplinary protocol for managing these often devastating and always challenging disorders.

 

OSTOMY CARE

From the time of their creation, some ostomies are classified as permanent (such as those created to treat certain colorectal malignancies) and some are classified as temporary (eg, some ostomies created to manage trauma or as part of a staged procedure for creating an ileal pouch anal anastomosis). However, advances in surgical techniques for reconstructing the gastrointestinal tract have created options for closure in a growing number of patients with ostomies, even among selected patients who underwent ostomy surgery for colorectal cancer or inflammatory bowel disease. Daluvoy and coworkers3 retrospectively reviewed 96 persons (49 women and 47 men) who underwent ostomy surgery at a single institution over a 6-year period. Thirty-five patients (36%) underwent ostomy closure, an average of 5.6 months after their initial procedure. The authors identified 3 factors associated with an increased likelihood of ostomy reversal: age, race, and ostomy type. Specifically, the mean age for patients undergoing surgery was 49.9 years as compared to a mean age of 60.5 years for those who did not undergo reversal (P = .01). Nevertheless, neither age, gender, nor body mass index emerged as predictive of ostomy reversal on logistic regression analysis. Logistic regression analysis revealed that African American patients were 4 times less likely to undergo reversal surgery than Caucasian Americans. Multivariate analysis also revealed that persons with loop ileostomies were 5 times more likely to undergo reversal surgery than those with a sigmoid colostomy. As with all retrospective analyses, the finding of this study leaves many pertinent questions unanswered, such as the influence of underlying diagnosis, complication frequency and severity, impact on quality of life, and psychosocial adjustment to an ostomy. Nevertheless, study findings identify 2 factors influencing the likelihood of ostomy reversal, age and race, that deserve further investigation and possible intervention. The authors' findings also illustrate gaps in our knowledge about what comprises a permanent ostomy and what constitutes a temporary stoma.

 

CONTINENCE CARE

Knowledge of the performance of the various commercially available adult-containment briefs is important for WOC nurses and for continence specialists. Multiple considerations are clinically relevant, including selected performance factors and cost. Wet back describes the ability of an incontinence pad to absorb fluid during an incontinent episode and retain that moisture within the pad. Failure to contain the leakage episode leads to wetness against the skin, thus the label "wet back." Standardized techniques for testing this property were described by Cottenden and colleagues.4 Readers will recognize Cottenden as part of a London-based research group who has significantly contributed to our knowledge of absorptive continence products and associated skin issues. Erekson and associates5 used this technique to evaluate 10 different absorptive products commercially available in the United States. They found that brand names tended to perform better than generic products, but they also tended to cost more. They also found that incontinence pads tended to perform better than undergarments for women. A careful review of these results is worthwhile for continence specialists practicing in the ambulatory care setting and for WOC nurses practicing in acute- or long-term care settings, particularly when called upon to provide recommendations for institutional purchases of absorptive incontinence products.

 

References

 

1. Erwin-Toth P. The effect of ostomy surgery between the ages of 6 and 12 years on psychosocial development during childhood, adolescence, and young adulthood. J Wound, Ostomy Continence Nurs. 1999;26(2):77-85. [Context Link]

 

2. Endorf FW, Cancio LC, Gibran NS. Toxic epidermal necrolysis clinical guidelines. J Burn Care Res. 2008;29(5):706-712. [Context Link]

 

3. Daluvoy S, Gonzalez F, Vaziri K, Sabnis A, Brody F. Factors associated with ostomy reversal. Surg Endosc. 2008;22(10):2168-2170. [Context Link]

 

4. Cottenden AE, Dean GE, Brooks RJ. Predicting the leakage performance of small body-worn disposable incontinence pads using laboratory tests. Med Eng Phys. 1997;19(6):556-571. [Context Link]

 

5. Erekson EA, Meyer SA, Milick C, McLennan MT. Incontinence pads: recommending the best product-based wetback performance and price. Int Urogynecol J. 2008;19:1411-1414. [Context Link]

Philosophy of the Wound, Ostomy and Continence Nurses Society

 

The WOCN believes that nursing as a profession enhances healthcare services to a multifaceted society and includes prevention, health maintenance, therapeutic intervention, and rehabilitation. Wound, ostomy, and continence care are areas of specialty practice within the framework of nursing that strive to advance the healthcare and quality of life of all affected individuals.

 

The WOCN believes that continuing education and research provide the basis for current comprehensive nursing practice for patients with wounds, ostomies, and incontinence. Learning may occur on a basic, advanced, or continuing educational level and combines the acquisition of theoretical knowledge and clinical expertise. The WOCN provides and approves quality continuing education for its members and for other healthcare professionals to enhance and improve wound, ostomy, and incontinence nursing practice.

 

By a process of accreditation, the WOCN promotes high standards of education and requires a baccalaureate degree with a nursing major or an equivalent as the entry level for educational programs and for specialty courses in wound, ostomy, or continence management.