In recognition of the 40th anniversary of the Journal of Wound, Ostomy and Continence Nursing (Journal), I reviewed the evolution of continence-related articles. The Journal began in 1974 as the ET Journal, becoming the Journal of Enterostomal Therapy in 1981, the Journal of Enterostomal Therapy Nursing in 1991, and Journal of Wound, Ostomy and Continence Nursing in 1994. In 1986, the Society, then the International Association of Enterostomal Therapy, voted to expanded the ET nurses' scope of practice to include continence care.1 This review focuses on the early publications in the Journal related to incontinence, focusing on articles published between 1986, when the scope of practice was expanded to include continence care, and the 1996, 10 years after the scope of practice was expanded.

The Journal of Enterostomal Therapy

Twenty-two published articles or editorials related to incontinence were identified in the Journal of Enterostomal Therapy. The first, published in 1984,2 focused on fecal incontinence and its management, particularly the use of a perianal pouch to contain the stool. Consistent with most publications in the nursing literature of the time, it is a how-to article describing pouch application and care of the patient with a pouch. While a variety of products have been developed to contain stool in patients with fecal incontinence, pouches continue to be an option for managing these patients.3 Between 1986 and 1989, several general overview articles were published about urinary incontinence (UI), its basic evaluation, and treatment options.4-9 These articles provided readers with basic knowledge about UI. In 1988, the Society's Standards Committee published Standards of Care: Urinary Incontinence to assist ET nurses define and evaluate their practice relative to the care of individuals with UI.10 Most of the interventions listed continue to be relevant to WOC nurse practice today. In 1990, the Journal of Enterostomal Therapy published an issue that exclusively focused on UI. In the introduction to the issue, Guest Editor, Katherine Jeter urged ET nurses to gain the knowledge needed to assess and plan appropriate interventions for individuals with UI, focusing on treating rather than simply managing this common problem.11 Kristy Wright, the then Society President, urged ET nurses to embrace continence as part of their practice and to assume the role of the specialist in incontinence care.12 In addition to providing a general overview of lower urinary tract function and the types of UI, the articles in this special issue focused on the assessment and management of UI in specialized populations including children,13 women,14 persons with Alzheimer disease,15 and nursing home residents.16 In the same issue, Tries17 published a classic article that introduced readers to biofeedback as a method for teaching pelvic floor muscle exercises. In this comprehensive article, she reviewed the rationale for utilizing biofeedback as a teaching modality, discussed the historical development of this intervention, reviewed existing literature to support its use, and discussed its use in specific patient populations. While the Journal of Enterostomal Therapy published a number of articles on UI and its evaluation and management, no research studies were identified and there were few articles focusing on fecal incontinence.

The Journal of Enterostomal Therapy Nursing

The Journal of Enterostomal Therapy Nursing continued to publish integrative review articles about the types, evaluation, and treatment of UI,18,19 along with articles reporting original data. For example, Wyman20 published a single-case study on the management of mixed urge and stress UI with bladder training. This intervention continues to be used for management of UI. During this time period, 3 small studies focusing on the evaluation or management of UI were published. Moore and colleagues21 reported the results of a study examining whether 24-hour monitoring of UI, in the absence of urodynamic testing, could provide adequate information to recommend treatment. The study setting was a small community hospital where most of the patients were long-term care patients awaiting placement. The probable diagnosis (incontinence, urge UI, stress UI, or overflow UI) was based on findings of every 2-hour pad changes, uroflow, and a record of fluid intake. Based the probable diagnosis, treatment recommendations were made to nursing and medical staff. The investigators concluded that the 24-hour monitoring was a feasible alternative to conventional urodynamics in similar settings. Two-hour pad changes continue to be used commonly in the evaluation of UI in long-term care settings. Pieper and Cleland22 published the results of a small laboratory study examining the effect of an external urine-collection device on urine containment, vulvar skin integrity, comfort, and microbiologic changes in urine and periurethral and vaginal tissue in 6 healthy women who wore the device for 8 to 9 hours per day for 5 days. In this healthy population with limited use of the device, it did direct urine away from the skin and there were no adverse effects. While the generalizability of these findings is limited, the problem studied, the absence of reliable external urine collection devices for women continues today. The third study published on incontinence examined the impact of a structured skin care routine in preventing perineal dermatitis.23 While the intervention was no more effective than the unstructured comparison routine, the authors noted the rapid development of perineal dermatitis, now called incontinence-associated dermatitis, in patients with combined urine and fecal incontinence. Incontinence-associated dermatitis continues to be a common problem and WOC nurses are leaders in its identification, prevention, and management. This is evidenced by the approximately 15 articles published in the Journal on incontinence-associated dermatitis during the past 2 years.

The Journal of Wound, Ostomy and Continence Nursing

After the Journal of Enterostomal Therapy Nursing evolved into the Journal of Wound, Ostomy and Continence Nursing in 1994, there was a gradual increase in the number of articles focusing on incontinence-related issues. In the first few years of the Journal, there continued to be a number of pieces talking about the role of the ET nurse in continence care. In 1994, Fiers24 published a guest editorial describing the activities the 1993 American Nurses Association discussion group that was convened to respond to the Agency for Health Care and Policy's Guidelines for Urinary Incontinence in Adults. She represented WOC nurses at the meeting. Factors that impacted or limited the availability of nursing services to individuals with incontinence were discussed and 4 task forces were identified, focusing on education (to identify competencies for nurses who deliver continence care), research (to improve the understanding of roles nurses play in the delivery of continence care), reimbursement (focusing on reimbursement issues related to nursing services for continence care), and legislative (how nurses could positively influence legislature related to nursing continence care). That same year, Bryant published a President's Message focusing on continence care and ET nursing practice and highlighting the Society's commitment to positively impact the care of individuals with incontinence.25

Urinary Incontinence

In 1995, the Journal dedicated a second issue to continence care. In addition to 5 articles focusing on UI and advanced topics related to its evaluation, in an editorial Gray argued for the progression of WOC nursing into the management of UI. He pointed out that WOC nurses had long managed extraurethral incontinence (eg, ileal conduit diversions) and that transitioning to the management of UI in an intact urinary system was a logical expansion in their practice. He also opined that by offering a certification examination for specialty nurses who manage urinary and fecal incontinence, the WOCN Certification Board (WOCNCB) increased its recognition of continence nursing both as a specialty and as part of the scope of practice for WOC nurses.26 The Journal promoted the importance of continence care as part of the WOC nurses' scope of practice by not only devoting an issue to advance concepts in continence assessment and management, but by adding a "Continence Care" section to the Journal along with sections focusing on Wound Care, Ostomy Care, and Profession Practice and by appointing Dr. Mary Palmer as the first Continence Care Section Editor. After Johnson and Gary27 provided an overview of the impact of UI, as well as its pathophysiology, types, and treatment, 4 articles in this issue focused on role of urodynamics, videourodyamics, and uroflowmetry in the evaluation of UI including indications, patient preparation, techniques, and interpretation of test findings.26,29-31

Over the next 2 years, a number of classic articles published in the Journal provided a basis for providing continence care to special populations. In a 1994 article, Rayome and colleagues32 discussed a case of a man with significant postradical prostatectomy stress UI. The discussion identified the challenges of managing UI in this patient population and discussed a number of treatment options. In a 1996 article, Fasing33 discussed the issue of UI in hospitalized adults and reviewed acute and chronic UI in this patient population, assessment of UI in the hospitalized patient, and the management of both acute and chronic UI in this setting. Urinary incontinence remains a prevalent and often-neglected problem in acute care settings. In a 1996 article, Colling34 reviewed UI and its assessment and management in care-dependent nursing home residents. Management of UI remains a common and challenging problem in this patient population and the management techniques described by Colling remain a cornerstone of treatment in long-term care settings.

Fecal Incontinence

Most of the continence-related articles appearing the early years of the Journal focused on UI. There were many fewer articles on fecal incontinence and its management. Nevertheless, WOC nurse authors contributed multiple clinically relevant observations such as diarrhea as a major risk factor for fecal incontinence in the hospitalized patient. Fruto,35 in an article in 1994, reviewed the management of diarrhea in acute care settings. She reviewed the most prevalent types of diarrhea seen in the acute care setting, including diarrhea related to motility disturbances, secretory, osmotic, and malabsorptive diarrhea. Major risk factors for diarrhea in the acute care setting, medications, enteral feedings, and infections were discussed, and nursing assessment and management were summarized. Given the rise of C difficile-associated diarrhea, the information presented in this review remains relevant to nursing practice today.

In 1996, Dougherty36 published a classic article on bowel training. She reviewed normal defecation, assessment of the patient with fecal incontinence or other bowel dysfunctions, and the indications for bowel training. She provides a detailed description of bowel management programs including a step-by-step approach to reestablish normal defecation patterns and specific management options with their indications and limitations. Managing patients with disruptions in normal defecation remains a major challenge for nursing working in a variety of health care settings and this article provides an excellent overview of this problem and its management.

Future Directions

As evidenced by this brief review, the role of the WOC nurse in continence management continues to evolve. Interventions such as selection of absorptive pads and containment devices, once criticized as "mopping and sopping" have retaken their rightful place as essential for many patients with chronic urinary or fecal incontinence. In addition, management of the indwelling catheter and prevention of catheter-associated urinary tract infection have emerged as major "never-events" and WOC nurses comprise an essential component of care in both acute- and long-term care settings. The evolution of fecal containment devices has risen as a key component of stool containment in the critical care setting. Finally, the rise in evidence and increasing recognition of incontinence-associated dermatitis serve to tie together the holistic approach to continence management-associated characteristic of our heritage.

Conclusions

Continence care was the most recent addition to the scope of practice for WOC nursing, added in 1986. This editorial reviewed how this expansion in the scope of practice was reflected in articles published in the Journal, focusing on the first 10 years after the Society voted to add continence care to the scope of practice. During this time period, most of the published articles focused on UI with many fewer focusing on fecal incontinence. There were frequent editorials addressing the change in scope of practice and encouraging ET nurses to embrace the care of persons with incontinence. Although there were some small research studies among the early continence-focused articles published in the Journal during this time period, most of the articles focused on how to evaluate and treat patients with incontinence. Early articles were more general with later articles tending to focus more of the care of specific patient populations and more advanced evaluation and management techniques. Given where the majority of Society members were developmentally in relation to continence care during this timeframe, this early focus on clinical practice seems appropriate.

References