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WCET TM JournalVolume 37 Number 3 July/September 2017

Official Journal of The World Council of Enterostomal Therapists

a world of exper t professional nursing care for people with ostomy, wound or continence needs

In this issuePresident’s message: A very productive congress and meeting season

Editorial: Worldwide concerns

WhatsApp as a tool for extending nursing care after recovery

Delving into skin and soft tissue infections (SSTI) Part II: Focus on superficial infections

Relevance of a new flexible convex stoma appliance

Location, creation and emotion: Three critical components for managing a complex case

WCET™ board nominations

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World Council of Enterostomal Therapists JournalVolume 37 Number 3 July/September 2017

Contents

President’s message: A very productive congress and meeting season 3

Susan Stelton

Editorial: Worldwide concerns 6

Karen Zulkowski

WhatsApp as a tool for extending nursing care after recovery 8

Danila Maculotti, Stefano Bonometti & Daniela Vazzoli

Delving into skin and soft tissue infections (SSTI)

Part II: Focus on superficial infections 20

Caley Shukalek, Laurie Parsons & Ranjani Somayaji

Relevance of a new flexible convex stoma appliance 26

Danièle Chaumier & Corinne Gadrat

Location, creation and emotion:

Three critical components for managing a complex case 32

Melanie Perez

WCET™ board nominations 34

The World Council of Enterostomal Therapists Journal is indexed in the Cumulative Index to Nursing and Allied Health Literature.

Disclaimer Opinions expressed in the WCET ™ Journal are those of the authors and not necessarily those of the World Council of Enterostomal Therapists, the Editor or the Editorial Board.

The World Council of Enterostomal Therapists Journal

ISSN 0819-4610 Published quarterlyCopyright ©2017 by the World Council of Enterostomal Therapists Printed in Australia

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WCET ™: a world of expert professional nursing care for people with ostomy, wound or continence needs.

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WCET Journal Volume 37 Number 3 – July/September 2017

World Council of Enterostomal TherapistsAn Association of Nurses Registered Charity 1057749

The WCET ™ mission is to lead the global advancement of specialised professional nursing care for people with ostomy, wound or continence needs

PresidentSusan Stelton MSN, RN, ACNS-BC, CWOCNClinical Nurse SpecialistSt Joseph Regional Medical Center, 5215 Holy Cross Parkway, Mishawaka, Indiana 46545, USAEmail [email protected] wcet_susannah1

Vice-PresidentElizabeth A Ayello PhD, RN, ACNS-BC, CWON, ETN, MAPWCA, FAANFaculty, Excelsior College School of Nursing209–14 82 Avenue, Hollis Hills New York 11427, USAEmail [email protected] elizabethayello

TreasurerAlison CrawshawRGN, BSc, ENB216Independent Clinical Nurse Specialist, 92 Lasswade Road, Edinburgh EH16 6SU, ScotlandEmail [email protected] alison.crawshaw

EXECUTIVE OFFICERS

CHAIRPERSONS OF STANDING COMMITTEES

JOURNAL EDITORIAL BOARD MEMBERS

EducationDenise HibbertClinical Specialist Director Colorectal Therapy Program King Faisal Specialist Hospital & Research Center Riyadh, Saudi Arabia Mobile 966 502 920315 Email [email protected] denise.hibbert1

Norma N Gill FoundationArum Ratna PratiwiHead Dept of Nursing Development, Wound Care Coordinator, Siloam Hospitals Surabaya Surabaya, Indonesia Email [email protected] arapratiwi

Elizabeth Ayello, USASharon Baranoski, USACarmel Boylen, AustraliaEva Carlsson, SwedenPankaj Choudvary, India

Jill Cox, USALori Henderson, USAChi Keung Peter Lai, Hong KongDiane Maydick, USADaniel O’Neill, USA

R Gary Sibbald, CanadaHiske Smart, South AfricaSandra Smits, The NetherlandsErica Thibault, USAMichelle Lee Wai-Kuen, Hong Kong

JOURNAL EXECUTIVE EDITORKaren ZulkowskiDNS, RN83-5782 Rd, Captain Cook, HI 96704, USAEmail [email protected] Skype drkarenz

Elizabeth A Ayello, USA, Executive Editor Emeritus

Barbara Delmore, USA, Assistant Editor, WoundsJudy Hanley, UK Assistant Editor, Ostomy

Sarah Lebovits, USA, Assistant Editor, OstomyKevin Woo, Canada, Assistant Editor, IncontinenceJo Sica, Assistant Editor, UK content

Publications and CommunicationsLaurent ChabalCentre of Stomatherapie, Ensemble hospitalier de la CôteEmail [email protected] laurentchabal

Congress and Meeting CoordinatorDee Waugh RN, RM, ETPO Box 44598, Claremont 7735, South AfricaMobile +27 83 600 9521Email [email protected] Skype dee.waugh1

TranslatorsLupita Lobo Cordero, MexicoSandra Guerrero Gomboa, ColumbiaAyisa Karadog, TurkeySvatava Nova’kova’, Czech Republic

Ingunn Aamot, NorwaySupun Prageeth Samarakoon, Sri LankaJune Zhang, China

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President’s message

A very productive congress and meeting season

Susan SteltonMSN, RN, ACNS-BC, CWOCN Clinical Nurse Specialist St Joseph Regional Medical Center Mishawaka, Indiana, USA Email [email protected]

Every year, or every other year, as is the case with WCET™, professional organisations meet to provide education, introduce new products and conduct their organisation’s business. Part of the WCET™ Executive Board duties includes attending congresses to represent the WCET™, meeting the other organisation’s leaders and, when possible, making presentations on topics of interest. ‘Congress season’ tends to occur spanning the months from March to December.

This year the WCET™ is having a very busy ‘congress season’. In March, whilst visiting family in Switzerland, I had the opportunity to meet with the Swiss National Stomatherapy Organisation at its meeting in Notwil, Switzerland. Chairperson of the WCET™ Publications and Communications (P & C) Committee Laurent Chabal helped to coordinate this meeting, which was presented in both French and German. I presented a brief ‘Update on WCET™ Activities’ to the attendees.

The Asia-Pacific Enterostomal Therapy Nursing Association (APETNA) met in March in Bogor, Indonesia. I presented talks as an invited speaker about ‘WCET™ Support of ET Nursing in Asia’ and on ‘ET Practice in the USA’.

WCET™ Vice-President Elizabeth Ayello attended the Wound Ostomy and Continence Nurses Society (WOCN) meeting in May in Salt Lake City, Utah, USA.

I had the opportunity to attend, and be an invited speaker, for the Turkish Colorectal Surgeons and Nurses Meeting in May in Antalya, Turkey. There I taught courses and seminars on ‘Management of Complicate Stomas’, ‘High-output Stoma and Fistula Management’, ‘Stoma Site Selection and Marking for Fecal and Urinary Stomas’ and ‘Fecal Incontinence Management’.

At the end of May Elizabeth Ayello and I had the opportunity to attend the Canadian Association for Enterostomal Therapy (CAET) Congress in London, Ontario, Canada. While there, we attended the WCET™-Canada meeting and made a

presentation about ‘The WCET™ and its Current Activities.’

Laurent Chabal, Congress and Meeting Coordinator Dee Waugh and I attended the European Council of Enterostomal Therapy (ECET) Congress held in June in Berlin, Germany. There I gave two talks: ‘Challenging Stoma Site Selection and Marking’ and ‘Medical Device-related Pressure Injuries.’

Treasurer Alison Crawshaw and P & C Chairperson, Laurent Chabal will attend the Association of Stoma Care Nurses – UK (ASCN-UK) in October.

At each of the above mentioned meetings, WCET™ board members received a free registration and WCET™ was given a free stand to promote the WCET™ Congresse and other activities. Through the combined efforts of Elizabeth Ayello, Laurent Chabal, Arum Pratiwi, Dee Waugh and me, nearly 100 new or renewed memberships were completed over the course of these 2017 meetings.

The WCET™ Executive Board Meeting was held in April in Kuala Lumpur, Malaysia, the site of Congress 2018, with all board members present. This was a productive meeting where we reviewed the strategic plan, revised the budget, made plans for obtaining new sponsorship for our activities, planned new educational products and discussed other topics of interest.

As you can see, this has been indeed a very busy year so far!

Mensaje del PresidenteCongreso y Temporada de Reuniones muy ProductivasCada año o cada dos años, como es el caso de WCET ™, las organizaciones profesionales se reúnen para proporcionar educación, introducir nuevos productos y examinar los intereses de sus organizaciones. Parte de los deberes del Consejo Ejecutivo del WCET incluye asistir a congresos para representar el WCET ™, reunirse con los líderes de las otras organizaciones y, cuando sea posible, hacer presentaciones sobre temas de interés. La “temporada de Congresos” tiende a ocurrir durante los meses de marzo a diciembre.

Este año el WCET ™ está teniendo una temporada de congresos muy ocupada. En marzo, mientras visitaba a familiares en Suiza, tuve la oportunidad de reunirme con la Organización Nacional Suiza de Estomaterapia en su reunión en Notwil, Suiza. El Presidente del Comité de Publicaciones

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y Comunicaciones de WCET™, Laurent Chabal, ayudó a coordinar esta reunión que fue presentada tanto en francés como en alemán. He presentado un breve “Informe sobre las Actividades del WCET™ “ a los asistentes. La Asociación de Enfermería de Terapia Enterostomal de Asia Pacífico (APETNA) se reunió en marzo en Bogor, Indonesia. Allí estuve como orador invitado con la conferencia “Apoyo del ‘WCET™ a las enfermeras ET en Asia” y sobre ‘La práctica de la ET en EE.UU.”. La Vicepresidenta de WCET™, Elizabeth Ayello, asistió a la Conferencia Anual de la Sociedad de Enfermería de Ostomías y Continencia (WOCN) en mayo de Salt Lake City, Utah, EE.UU. Tuve la oportunidad de asistir y ser orador invitado en el Congreso Turco de Cirujanos de Colorrectales y Enfermeras en mayo en Antalya, Turquía. Allí dicté cursos y seminarios sobre “Manejo de Estomas complicados”, “Estomas de Alto Gasto y Manejo de Fístulas”, “Selección y Marcado de Estomas Fecales y Urinarios” y “Manejo de la Incontinencia Fecal”. A finales de mayo, la vicepresidenta de WCET™, Elizabeth Ayello, y yo tuvimos la oportunidad de asistir al Congreso de la Asociación Canadiense de Terapia Enterostomal (CAET) en Londres, Ontario, Canadá. Allí, donde nos reunimos con WCET™ Canadá e hicimos una presentación sobre “El WCET™ y sus actividades actuales”. El presidente de P & C, Laurent Chabal y el coordinador de Congresos y Reuniones, Dee Waugh, asistieron al Consejo Europeo de Estomaterapia (ECET) celebrado en junio en Berlín, Alemania. La tesorera, Alison Crawshaw, y el presidente de P & C, Laurent Chabal, asistirán a la Conferencia Anual de la Asociación de Enfermeras de Cuidado de Estoma -UK (ASCN- Reino Unido) en octubre.

En cada una de las reuniones antes mencionadas, los miembros del Consejo de WCET™ recibieron registro y stand gratuito para promover el congreso del WCET™ y otras actividades. A través de los esfuerzos combinados de Elizabeth Ayello, Laurent Chabal, Arum Pratiwi, Dee Waugh y yo, casi 100 nuevos miembros o renovaciones se han realizado durante estas reuniones del 2017.

La reunión de la Junta Ejecutiva del WCET™ se celebró en abril en Kuala Lumpur, Malasia, sede del Congreso 2018, con la presencia de todos los miembros del Consejo. Esta fue una reunión productiva en la que revisamos el plan estratégico, el presupuesto, hicimos planes para obtener nuevos patrocinios para nuestras actividades, planeamos nuevos productos educativos y discutimos otros temas de interés.

Como puede ver, este ha sido, de hecho, un año muy ocupado hasta ahora!

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Editorial

Worldwide concerns

Karen ZulkowskiDNS, RN Editor - WCET Journal Email [email protected]

As I sit and write my editorial, the Houston, Texas area is experiencing massive flooding from Hurricane Harvey. Hundreds of thousands of people are without power and/or water. This is a major disaster here in the US, but worldwide it is estimated that 783 million people do not have access to clean water on a regular basis. Unsafe water kills approximately 5,000 children a day. Two million children die each year from a lack of clean water and proper sanitation.

The World Health Organisation (WHO) estimates that globally at least two billion people use a drinking water source that may be contaminated with faeces. Using faeces-contaminated water can transmit diseases such as cholera, dysentery, typhoid, polio and other diarrhea-related illness. In fact, contaminated water is thought to contribute to over 500,000 diarrhea-related deaths per year. The WHO goes on to estimate that by 2025, half of the world’s population will be living in water-stressed areas. Currently in low- and middle-income countries, 38% of health care facilities lack an improved water source, 19% do not have improved sanitation and 35% lack water and soap for handwashing (http://www.who.int/mediacentre/factsheets/fs391/en/).

Yet people without clean water either from a natural disaster or lack of access, have wounds, incontinence and ostomy needs. It is imperative that there are people available to help meet their health care issues and teach proper care.

For over two decades, the WCETTM has provided scholarships for nurses in developing countries to further their education and help establish local educational programmes. There are general scholarships (to provide assistance to educators for on-site training in developing countries), educational material scholarships (to provide assistance obtaining teaching materials for Enterostomal Therapy (ET) training), membership scholarships (to provide registered nurses with a one-year WCETTM membership), ETNEP scholarships (to assist nurses in attending a WCETTM recognised ETNEP/REP programme), and Congress travel scholarships (to enable

nurses from emerging and developed countries to attend the biennial WCETTM Congress).

In addition, the WCETTM has international twinning projects. Twinning projects were established in 1999 to establish and foster links between ET nurses in developed countries and nurses in emerging countries. The goal of the NNGF Twinning Project is to promote and develop the specialty of ET Nursing. These projects help by bringing information, educational support and product availability to underserved areas of the world.

In 2014 the WCETTM published its International Ostomy Guideline. The goal of this guideline was to provide evidence for practice that could be applied to any patient population in resource scarce or resource abundant areas of the world. The guideline included an emphasis on cultural diversity and cultural considerations for everyone. Starting in September 2018, we will begin working on a 2020 updated edition of the guideline. We will need people to be readers and give feedback, article reviewers and, most importantly, contributors.

The 2014 edition asked all the country international delegates to either submit information about their culture or ask others in their country to contribute. We will also ask for volunteer translators. So please start thinking about how you can help. I will see many of you at the 2018 Congress and would love to talk with you. Help us help people worldwide.

Supported byOrganised by

www.wcet2018.com [email protected]

Keynote Speakers

Rohani ArshadKuala Lumpur, Malaysia

Associate Professor, MAHSA University and Director, Nursing Professional Group

Meheshinder SinghKuala Lumpur, Malaysia

President, Malaysian Society of Colorectal Surgeons

Vicki Patton Sydney, Australia

Clinical Nurse Consultant, Pelvic Floor Unit, St George Public Hospital

Elizabeth English Adelaide, Australia

SRN ET

Gulnaz TariqAbu Dhabi, United Arab Emirates

Wound Care Specialist, Sheikh Khalifa

Medical City, Abu Dhabi IIWCC Course

Coordinator

Hiromi SanadaTokyo, Japan

Department of Gerontological Nursing/Wound Care Management, Graduate School of

Medicine, The University of Tokyo

Carmen George Melbourne, Australia

SRN ET

Michelle Lee Hong Kong

Nurse Consultant,

Queen Mary Hospital

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ABSTRACT

Aim: New technologies, in particular social networking technologies, have changed our society. The widespread availability and use of social media make the hypothesis that they can be used in healthcare.

Methods: Some volunteers, including patients and caregivers, created a “WhatsApp” group on their smartphone. In order to evaluate expectations and results from this experience, two questionnaires were used to examine three areas of nursing care: relational, linguistic, and technical-professional.

Results: From analysis of the questionnaires, the WhatsApp was found to be a valid tool to give continuity of care after discharge. Participants recognised the importance of sharing similar experiences coming from having a disease. Nursing answers were evaluated as complete. The quantitative, qualitative and explorative survey allowed analysis of the relationship between social media's

Danila Maculotti*Enterostomal Nurse, Wound Care Specialist Fondazione Ospedaliero Poliambulanza, Brescia, Italy Email [email protected]

Stefano BonomettiAssociate Professor of Education Department of Biotechnology and Life Sciences University of Insubria, Varese, Italy Email [email protected]

Daniela VazzoliNursing Student Università cattolica del Sacro Cuore di Roma, sede Brescia, Italy Email [email protected]

* Corresponding author

WhatsApp as a tool for extending nursing care after recovery

widespread availability and the healthcare environment. Using social networks to support nursing care is possible if an expert nurse, thanks to his/her skills and knowledge, moderates the interactions inside the group; and evaluates and solves issues in the rehabilitation centre and online.

Conclusions: Patients and caregivers evaluated this experience in a positive way and sharing experiences underlined the group solidarity within the WhatsApp group. The app activated a small online community, where posts and needs were shared. The accuracy of therapeutic answers, confidence in the nurse and the resultant safety perception, confirm the opportunity to match continuity of nursing care with new communication technologies.

INTRODUCTION

A recurring behaviour among those suffering from illness is the necessity to find a cause for the undesired event that has unexpectedly intruded upon their lives. People look for a reason, a cause that can explain the unexpected occurrence of the illness, going through different moods: from the assignation of blame to a situation or environment, to a relentless sense of guilt with regard to certain failures and behaviours, even as far as fatalistic justification1. People try to give meaning to situations of uncertainty, anxiety and doubt. This research considers various mechanisms for managing uncertainty and anxiety, focusing the attention, in many cases, on the present. We may risk making a comparison with the situation in which modern man lives, as indicated by Baumann2, focused entirely on today. We are immersed in a liquid society that leads us to a vision of poor anticipation and prediction capacity; we find it hard to rebuild a precise linearity that justifies our condition and even harder to identify a precise path for the future. In the case of the post-modern man, as with those who have suffered illness, the fundamental point is to recover the capacity to establish relations with others, to build genuine relationships even in weak bonds3.

This circularity between action, relationship and reflectiveness placed within the context of the world today is fully interwoven with new digital technologies that have changed our way of communicating and building social relationships. In the light of these considerations, the research team, made up of a doctor, a specialist nurse, a professor of education and a nursing student, set the objective of understanding whether the new relational spaces developed on social networks and in online chats are able to offer opportunities to reflect on a situation of uncertainty, illness and suffering, in order to transform the individual view of a personal situation and reshape new pathways in life.

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This field cannot overlook the learning dimension, setting the further objective of understanding even informal learning experiences4 within an online setting5. Starting with these questions, a path of qualitative investigation was planned, with the aim of exploring these dynamics within an active online group in WhatsApp. The group was composed of ostomy patients after recovery at a non-profit hospital in the Lombardy region.

FRAMEWORK THEORY

In order to understand the possible effectiveness in terms of care, relations and education of an online interactive setting, such as a group chat on the social network WhatsApp, it is important to establish what is meant by the nurse–patient relationship and the suitable connotation to be given to the current online communication experience, within social networks. This establishment highlights the scientific and technological progresses that permeate nursing and information and communication technology (ICT) worlds.

The founding aspects of nursing already emerged from the work of Henderson and Nightingale, in which nursing is expressed as a care activity aimed at undertaking all actions, with the purpose of maintaining health or healing, supporting the patient towards a possible reacquisition of autonomy. One definition can be found in the International Council of Nurses Code6, which is also expressed by the Royal College of Nursing using the following words: “The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.”7 An exploration of specialist literature of the past two decades undertaken by Scott, Matthews and Kirwan8, alongside an empirical investigation, highlights the fact that nursing today is a key factor in the development and continuity of a human and efficient care system. Care must provide both a technical and professional service and a “human and compassionate treatment, including psychological and emotional support for the patient, where necessary”8, p. 31. From this emerges directly a form of nursing training that promotes technical/professional and psychological/social/educational skills, with the aim of understanding the patient’s full experience of his/her illness. This conceptualisation of the nursing practice must necessarily become an organisational culture and common practice, without which there would be a negative impact on both the patient care and also on the motivation and commitment of the nursing team.

The ICT society has radically changed the way people conduct interpersonal relations, as well as the methods of diagnosis, treatment and care in the case of illness9. This transformation of professional practice has permeated organisational contexts with considerable resistance on the part of healthcare staff. In order to have an idea of the social media networks spread within social contexts, we just need to

think that the global number of internet users in 2016 reached 3 billion, of which 2 billion are accounts activated via social media, with an average annual increase of 332 million over the past year10. In Italy, in 2016, 24 million active users of social networks via mobile devices were recorded. A unique aspect of all this is that the social network phenomenon has become increasingly intergenerational: whilst users were initially mostly of the youngest generation, this has now changed demographically, with users now represented to a great extent by adults. To understand this change in ways of communication, four fundamental aspects can be highlighted: 1. multi-directionality — the distributive structure of online information evolves towards a heterogeneous system, in which each network node is both source and container at the same time, as described by Negroponte; in this scenario, the precise distinction between sender and recipient is blurred and the information flows become multi-polar (many-to-many); 2. self-propulsion — the majority of content available is generated directly by the users (user-generated content, UGC), both via original input in text or multimedia format, and via the recombination of contributions by others; 3. aggregation — generally, users create individual online profiles voluntarily and, at the same time, they are encouraged to create user groups or communities, capable of satisfying the need for individual affirmation or instances of a social and supportive nature, amongst which the predominant motivation is the preservation/development of friendships, as well as to share common interests an passions; 4. sharing — there is a very widespread use of exchange of opinions, experiences and individual knowledge, with the aim of creating a base of collective know-how, available for use and/or contribution by everyone.

Despite the fact that there is still widespread use of hard copy material for communication within hospitals, many operators, particularly doctors, have started using their smartphones and social media to facilitate exchanges within the field of informal professional communication11,12 and even within the educational field13,14. The use of social networks, especially WhatsApp, even in the professional field, is becoming a widespread practice, although its use is mostly informal. This is possible because WhatsApp is a messaging tool that does not require any particular superstructure, is easy to use and allows the exchange of text, images, emoticons, photographs, videos and, more recently, video calls. For these reasons, it is an application of very widespread use, used both via smartphone app and via internet using a laptop computer. Its potentiality is expressed by the use of emoticons, which reinforce the non-verbal and paraverbal function of communication, offering interlocutors the possibility of adding paraverbal emphasis to written information, thus enriching the exchange and promoting the correct interpretation of meaning.

As part of these technological developments, the nursing profession can identify possibilities of improving primary

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and continuity of care, reshaping the relationship between hospital and community. New communication technologies can provide nursing with new spaces and new methods of self-expression, overcoming sectorial and disciplinary boundaries, as well as promoting informal and interactive communication and educational spaces.

METHODOLOGY OF RESEARCH

The aim of this research is to investigate, by using explorative methods, if a group chat in WhatsApp can extend nursing care relationships also after a patient’s discharge.

The research team identified a sample of ostomy patients and other patients with indistinct pathology and final prognosis in the abdominal surgery unit and under treatment at the nursing setting called “Hole Oasis”, from January to July 2016. The sample group comprised volunteers (n=15) including the patients themselves or, in the case of those patients who do not have technological skills, their caregivers. The patients and research team signed an agreement about respect of privacy and good clinical practice, approved by the department head.

There were 15 active patients in the WhatsApp group, whereof 11 provided information by completing the entry questionnaire (t0) and nine responded to the final questionnaire (t1). During the project a person died whereas a patient did not answer the questions.

The choice to use the WhatsApp system, through the creation of an ad hoc group, came from: the appreciation of certain informal and occasional experiences in use at the Hole Oasis nursing care facility; the ease of use of the system; the chance to create a communicative/relational context (including a moderator), from the use of different codes of communication (written, verbal, images, emoticons); as well as ease of accessibility, privacy and the cost-free use guarantee.

The research process features two methods of data collection: a qualitative and a quantitative method, based on a conceptual diagram created by using a literature analysis. In particular, the online nursing care relationship has been investigated according to three dimensions:

a) The relational level — this dimension involved finding out about the patients’ personal experiences of illness and treatment, following five indicators: 1. The spontaneous sharing of personal experiences; 2. Reducing anxiety through the recognition of the same problems in others; 3. Increasing personal strength and abilities; 4. The comparison between equals in interwoven life stories; and 5. Moral support.

b) Technical/professional support — this dimension is described by indicators that underline: 1. Customisation of care meeting expectations; 2. Early assessment of post-surgery complications; 3. Stoma management; 4. Learning new precautions even in the prevention stage; and 5. Follow-up visits.

c) The communicative/linguistic level — this third section investigated the progress of communication methods and the speech register, focusing on four aspects: 1. Informality and immediacy of exchanges; 2. Freedom of expression and level of confidentiality; 3. Use of different codes to express emotions and feelings; and 4. Type of vocabulary.

A series of investigation categories have been created for the analysis of text written in the messages, which have subsequently been divided into items for the creation of a questionnaire, submitted in two stages — upon entry and six months after the start of the research. During the collection of quantitative data, the degree of correspondence between expectations and satisfaction in relation to the patients' experience have also been measured (Figure 1).

Data analysis has developed through the reading and classification of messages, based on the identified dimensions, expanding where necessary to include new references. In terms of quantitative research, analysis has been undertaken of the frequency of replies, with related graphic elaboration.

The results of the investigation highlighted significant elements to be used in the configuration of what we could call expanded nursing, that is to say, through cross-border care procedures15,16, a horizontal broadening of the interaction that is activated during the recovery, and that continues even by means of online environments, extending the nurse–patient relationship beyond the confines of the hospital (Figure 1 a and b).

RESULTS

Qualitative analysis

The data collected as part of the qualitative analysis was analysed through reading written text and observing emoticons and posts with images. It revealed a greater number of posts related to the relational level of the patient, instead of technical/professional setting. From the point of view of the “sentimental relationship” category, the experience gained by the chat participants displays a strong sense of solidarity. This dimension must highlighted, insofar as the experiment sample did not include any participants who were previously acquainted; instead, upon creation of the chat, mutual presentation was initiated, which was initially brief but went on to become increasingly in-depth. On this level, the group demonstrated increasing autonomy, even though intervention by the nurse, expert in the pathology and with the role of mediator, played a fundamental, yet never pervasive, role. Many posts expressed fear for the uncertain situation the patients were experiencing, anxiety over treatment, in many cases chemotherapy, and its side effects. Around 60% of messages involved themes tied to the relational/sentimental dimension, expressing both aspects of worry, sadness and despondency and interventions of support, sharing good

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Entry questionnaire (t0)

1 Do you think that the use of WhatsApp could help for extending the care relationship?

◦ No, I doubt it can◦ I think it is hard, but possible◦ Yes, it could help◦ I don't know

2 What do you think about the proposal of using WhatsApp for nursing and care purposes?

◦ I never considered it before◦ I have heard about it, but not for these purposes◦ I have used it for these purposes, but informally

3 Do you think that the support given by the other members of this WhatsApp group could be helpful with anxieties and worries?

◦ Very helpful◦ Quite helpful◦ A little helpful◦ Not at all helpful

4 Have you experienced WhatsApp before to share moments of personal difficulty with other people?

◦ No, I didn't◦ Yes, just once◦ Yes, more than once

5 Do you think that being part of this WhatsApp group will improve your social relationships?

◦ Yes, I think so◦ I think it will be hard, but possible◦ No, I doubt it◦ I don't know

Figure 1a

news, joy with regard to the outcome of treatment or of tests. In these cases, the use of emoticons strengthened the meaning of the message, with a central function in creating a team spirit.

In the messages relating to the “technical/professional support” category, the nurse’s role comes into play, as moderator of relations and expert within the group. The nurse’s interventions within the group have been appreciated by the participants. The interventions as moderator/expert always display rapidity of reply with regard to the request, the overlooking of the time constraints of his/her shift, full appreciation on the part of the patients for the resolution of problems posted. In this regard, the requests by patients are distributed among problems tied to the operational management of wafers (supply, application, removal), the management of peristomal lesion/irritation complications, therapy type and method of administration, precautions to adopt in everyday life.

In the case of technical/professional support, it was observed that, in the initial stages, the dialogue developed between patient and nurse, but, over time, participants brought their experiences and successful good practices to the chat table. This demonstrates that the group was not just a space for personal and emergency requests, or for sharing emotional, personal or relational problems, but that it became a space for dialogue on the treatment practices and a source of possible new solutions in stoma management.

Text analysis underlined the dynamics typical of group communication; from the creation of strong bonds between group members, to the recollection of previous experiences as opportunities for consolidating mutual knowledge. In certain moments, the solidarity dimension emerges strongly to provide hope and energy; in other moments, there is simply understanding expressed through listening and sharing. In particular:

• the consideration given to life stories, even prior to illness;

• the emotional support in moments of despondency;

• the light-hearted sharing of certain treatment experiences;

• mutual recognition as self-reinforcement.

Quantitative analysis

Quantitative analysis undertaken using two questionnaires at t0 and t1 after six months, the trend in answers confirms the effectiveness of the research. After six months, patients expressed the hope that a similar practice should be extended to the daily practice of treatment processes. The online dialogue space within a group chat was evaluated as a positive experience by all patients and WhatsApp results as a valid tool to give continuity of care after the discharge.

All participants evaluated this experience as positive and recommended it to the other patients. They also judged the

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1 On the basis of your experience in this group, do you consider that the use of WhatsApp for nursing and care purposes will be desirable?

◦ It will not be desirable at all◦ It will be a little desirable◦ It will be partially desirable◦ It will be quite desirable◦ It will be very desirable

2 Do you think that support given by the other members of the WhatsApp group was helpful to you in order to face worries and anxieties?

◦ Not at all◦ Very little◦ Quite helpful◦ Very helpful

3 Do you think that using WhatsApp — like you did in this group — has extended the nursing and care relationship, even beyond the hospital stay period?

◦ Yes, sure◦ Only partially◦ No, I don't think so◦ I don't know

4 Could the answers given by the expert in the WhatsApp group solve your doubts and problems?

◦ Never◦ A little◦ Quite good◦ Always

5 Was it important for you to be in contact/relationship with other people experiencing the same disease?

◦ Not at all◦ Very little◦ Quite important◦ Very important

6 Have you read again previous WhatsApp chat which you had days or months ago, in order to reflect on problems or replies?

◦ No, I didn't◦ Sometimes◦ Often

7 Have stoma management tips proven to be effective?◦ Rarely◦ Sometimes yes, sometimes not◦ In most cases

8 What was the most important thing in this experience of the WhatsApp group?

◦ Please write down your reply

9 Would you recommend another patient to join the group?◦ Yes◦ No

Figure 1b

interventions of the expert nurse to be more than positive and relevant.

In the first questionnaire, there was a general indifference towards the use of WhatsApp as a possible tool in nurse–patient relationships — almost 90% had never considered the use of a social network for this function (n=10). Just under half had never considered this social network as a tool for sharing personal or difficult moments with someone and almost 30% believed, at the initial stage, that it was not possible to improve social relations through this.

In the second questionnaire, after six months, perceptions changed. All participants (n=9) evaluated the experience as

positive, considering it as a real and possible form of help and care. As has already been highlighted by the qualitative data, the role of the nurse emerges strongly, both as preferred interlocutor for the resolution of problems and as mediator in relations, capable of sensing and supporting the mood of the group. The 90% of participants considered the online relationships completely positive, confirming the possibility of implementing an effective care relationship even within an online environment.

CONCLUSION

This research was conducted with the aim of understanding if an online group such as WhatsApp could be a valid support

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in nursing care after recovery. Results show that it is not only possible, but also wished for by patients.

The study presents some limitations regarding the explorative research paths, coming from mainly the limited number of cases analysed, the identification of dimensions and categories of analysis in progress and at a reduced level of formalisation.

In the meantime, analysed elements highlight certain necessary conditions. Among these, a key factor should be the presence of an expert moderator, both in terms of nursing experience and online communication skills, as well as being an expert in group relationships; he/she must also be able to read the clinical complexity of the requests and thus provide an adequate response. As far as the group is concerned, the strengthening of self-confidence of the patients must be favoured in order to activate a full and authentic sharing of experiences, which enables the implementation of a process of informal therapeutic education.

ACKNOWLEDGEMENTS

We would like to thank all the patients who participated in this study.

AVAILABILITY OF DATA AND MATERIALS

The datasets during and/or analysed during the current study are available from the corresponding author on reasonable request.

AUTHORS’ CONTRIBUTIONS

SB and DV defined the research theme and designed the study. DM was expert nursing and mediator in WhatsApp. SB, DM and DV analysed and interpreted the data and drafted the manuscript; in particular SB the framework theory and methodology of research, DM the discussion and conclusion, DV the introduction and discussion. All authors helped to revise the manuscript critically. All authors read and approved the final manuscript.

COMPETING INTERESTS

The authors declare that they have no competing interests.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethics approval was sought with the Department at Surgery of Fondazione Ospedaliera Poliambulanza. All patients provided written informed consent.

REFERENCES

1. Robert A & Aronowitz MD. Make Sense of Illness. Science, Society, and Disease. New York: Cambridge University Press, 1998

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3. Granovetter M. The strength of weak ties. Am J Sociol 1973;

78:1360-80. Transl in It. Granovetter M. La forza dei legami

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INTRODUZIONE

Un atteggiamento ricorrente nei vissuti di malattia è rappresentato dalla necessità di rintracciare una causa riguardo all’evento spiacevole, che in modo inatteso invade la propria vita. Le persone cercano una ragione, una causa che possa spiegare l’accadimento inatteso della malattia, passando attraverso stati d’animo differenti: dall’attribuzione di responsabilità al contesto o all’ambiente, ad un inesorabile senso di colpa rispetto ad alcune mancanze e comportamenti, fino ad arrivare a giustificazioni anche fatalistiche1. Le persone cercano di dare un senso alla situazione di incertezza, di ansia e di dubbio. Questa ricerca mette in campo vari meccanismi per governare l’incertezza e l’ansia, focalizzando l’attenzione in molti casi sul presente. Si può azzardare un paragone con la condizione in cui vive l’uomo contemporaneo come indica Bauman2 ripiegato sull’oggi. Siamo immersi in una società liquida che ci porta a una visione a bassa capacità di anticipazione e previsione, difficilmente riusciamo a ricostruire una linearità precisa che giustifica il nostro stato e ancor meno si riesce ad identificare un percorso preciso nel futuro. Nel caso dell’uomo post moderno come per il vissuto di malattia il punto fondamentale è recuperare una capacità di relazione con gli altri, di costruire anche nei legami deboli3 rapporti autentici. Ciò rafforza il nostro pensiero critico sul proprio agire, relativizza un certo egocentrismo e favorisce un nuovo sguardo sulla realtà.

Questa circolarità tra azione, relazione e riflessività contestualizzata nel mondo di oggi si intreccia a pieno con le nuove tecnologie digitali che hanno cambiato il nostro modo di comunicare e costruire relazioni sociali. Alla luce di queste riflessioni, il team di ricerca, composto da un medico, un’infermiera specializzata, un docente dell’area pedagogica e una laureanda in infermieristica, si è posto l’obiettivo di comprendere se i nuovi spazi relazionali sviluppati nei social network e nelle chat online possano offrire opportunità per riflettere sulla situazione di incertezza, di malattia, di sofferenza per trasformare il proprio sguardo sulla propria situazione e ridisegnare nuove traiettorie di vita.

Questo ambito non può tralasciare la dimensione dell’apprendimento ponendosi anche l’obiettivo di comprendere esperienze di apprendimento anche informale4 in un setting online5.

A partire da queste domande si è pianificato un percorso di indagine di natura qualitativa al fine esplorare tali dinamiche

WhatsApp come strumento per proseguire il nursing oltre la degenza

all’interno di un gruppo online attivo in WhatsApp, composto da pazienti post degenti, portatori di stomia in cura presso un Istituto Ospedaliero no profit della Lombardia.

FRAMEWORK THEORY

Per comprendere la possibile efficacia assistenziale, relazionale ed educativa di uno setting d’interazione online, come una chat di gruppo nel social network WhatsApp, è importante posizionare cosa si intende per relazione infermieristica e quale connotazione è opportuno dare all’attuale esperienza comunicativa online, all’interno dei social network. Questo posizionamento mette in luce i progressi scientifici e tecnologici che pervadono i mondi professionali, fra questi quello infermieristico e quell’Information and Communication Technology.

Gli aspetti fondativi del nursing emergono già dai lavori di Henderson e Nightingale nei quali l’infermieristica si esprime come un’attività assistenziale finalizzata a compiere tutti quegli atti tendenti al mantenimento della salute o alla guarigione, favorendo il paziente ad una riconquista possibile della propria autonomia. Una definizione che possiamo ritrovare nell’International Council of Nurses Code6 espressa anche dal Royal College of Nursing con le parole « The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.»7 Una ricognizione nella letteratura specialistica delle ultime due decadi svolta da Scott, Matthews e Kirwan8 affiancata da un’indagine empirica, mette in luce come il nursing attuale sia un fattore chiave per lo sviluppo e la continuità di un sistema di cura umano ed efficiente. L’attività assistenziale deve fornire sia un servizio tecnico-professionale sia un «trattamento umano e compassionevole, incluso il supporto psicologico ed emozionale al paziente ove necessario»8,p. 31. Da qui emerge direttamente una formazione per il profilo infermieristico che promuova competenze tecnico-professionali e psico-socio-educative al fine di comprendere l’intero vissuto di malattia del paziente. Questa concettualizzazione della pratica del nursing è necessario che diventi cultura organizzativa e pratica condivisa pena un impatto negativo non solo verso la cura del paziente ma anche sulla motivazione e l’impegno dell’équipe infermieristica.

La società dell’informazione e della comunicazione tecnologica (ICT) ha radicalmente cambiamo le modalità

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relazioni fra le persone, nonché le modalità di diagnosi, di trattamento e di assistenza all’interno dei contesti di cura9. Una trasformazione delle pratiche professionali che ha pervaso i contesti organizzativi attraversando non poche resistenze da parte del personale sanitario. Per avere un dato riguardo al grado di pervasività dei social media nei contesti sociali basti pensare che gli utenti di internet nel mondo nel 2016 hanno toccato la soglia dei 3 miliardi di cui 2 sono account attivati attraverso social media, con incremento medio nell’ultimo anno di 332 mln di utenti10. In Italia, nel 2016 si sono contati 24 mln di utenti attivi nei social attraverso devise mobile. Un aspetto singolare è dato dal fatto che il fenomeno dei Social Network abbia assunto sempre più caratteristiche inter-generazionali: la platea dei loro utenti, inizialmente circoscritta ai più giovani, ha modificato la sua composizione dal punto di vista demografico, essendo attualmente rappresentata in larga misura da utenti adulti. Alla luce di questa trasformazione della modalità comunicative si possono evidenziare quattro aspetti fondamentali: multi-direzionalità, la struttura distributiva delle informazioni in rete, evolve verso una struttura eterogenea nella quale ogni nodo della rete è al tempo stesso sorgente e contenitore come indicava Negroponte; in tale scenario, sfuma quindi la distinzione precisa tra mittenti e destinatari e i flussi informativi diventano multipolari (many-to-many); auto-propulsione: larga parte dei contenuti disponibili viene generata direttamente dagli utenti (user-generated content, UGC), sia attraverso apporti originali, in formato testuale o multimediale, sia mediante ricombinazione di contributi altrui; aggregazione: è generalmente effettuata la messa in rete, su base volontaria, di profili individuali e viene al contempo stimolata la creazione di gruppi o comunità di utenti, tra i quali prevale il desiderio di conservare/sviluppare relazioni di tipo amicale nonché di condividere interessi e passioni comuni, in grado di soddisfare esigenze di affermazione individuale ovvero istanze di tipo sociale e solidale; condivisione: risulta molto diffuso lo scambio di opinioni, esperienze e conoscenze personali, finalizzato alla creazione di una base di saperi collettiva, alla quale ciascuno può attingere e/o fornire un proprio contributo.

Nonostante vi sia ancora ampio uso di materiale cartaceo per le comunicazione all’interno dei contesti ospedalieri molti operatori, in particolar medici, hanno iniziato ad utilizzare il proprio smartphone e i social media per facilitare gli scambi nell’ambito della comunicazione professionale informale11,12 e anche in ambito formativo13,14. L’utilizzo di social network, in particolare WhatsApp anche in ambito professionale sta divenendo una pratica diffuso anche se il più delle volte informale. Ciò è possibile perché WhatsApp è uno strumento per lo scambio di messaggi che non richiede particolari sovrastrutture, semplicità d’uso e che permette lo scambio di testo, immagini, emoticon, fotografie, video, nonché recentemente anche videotelefonate. È un’applicazione per questo molto diffusa, utilizzata sia tramite l’app su

smartphone o via web con il browser di un laptop. La sua potenzialità è espressa dall’uso di emoticon che rafforzano la funzione non verbale e para verbale della comunicazione offrendo agli interlocutori la possibilità di caratterizzare l’informazione scritta con un’enfasi paraverbale, arricchendo di conseguenza lo scambio comunicativo e la correttezza dell’interpretazione dei significati.

La professione infermieristica all’interno di questo orizzonte tecnologico può connotarsi per una rinnovata assistenza primaria, nonché nella continuità di cura rimodulando anche il rapporto tra realtà ospedaliera e territorio. Le nuove tecnologie della comunicazione possono fornire al nursing nuovi spazi e nuove modalità di esprimersi, vengono superati confini settoriali e disciplinari, nonché valorizzati spazi comunicativi ed educativi informali e interattivi.

METHODOLOGY OF RESEARCH

La ricerca in oggetto ha valuto indagare, secondo modalità esplorative, se una chat di gruppo in WhatsApp possa prolungare la relazione assistenziale infermieristica anche dopo la dimissione dei pazienti.

Il team di ricerca ha individuato un campione di pazienti afferenti all’Unità Operativa di Chirurgia addominale e in cura presso il servizio di assistenza infermieristica per pazienti portatori di stomia e di indistinta patologia e prognosi finale, denominato “Hole Oasis”, dal gennaio a luglio 2016. Il campione ha visto la partecipazione di pazienti ad adesione volontaria e qualora non avessero avuto le competenze tecnologiche sufficienti, dei loro caregivers.

Il paziente e il team di ricerca hanno firmato un accordo riguardo al rispetto della privacy e del corretto lavoro clinico, approvato dal direttore del dipartimento ospedaliero. I pazienti attivi nel gruppo di WhatsApp erano 15 dei questi 11 hanno risposto al questionario di ingresso (t0) e 9 hanno risposto al questionario finale (t1). Un paziente è deceduto durante il progetto di ricerca e un paziente non ha risposto.

La scelta di optare per la piattaforma WhatsApp, con la creazione di un gruppo ad hoc, emerge dalla valorizzazione di alcune esperienze informali e occasionali in uso presso il servizio infermieristico Hole Hoasis, dalla facilità di utilizzo dell’applicazione, dalla possibilità di creare un contesto comunicativo-relazionale in grado di avere anche una figura moderatrice, utilizzare codici comunicativi diversi (dallo scritto, al verbale, dalle immagini alle emoticon), nonché dalla facile accessibilità, garanzia di privacy e gratuità.

Il percorso di ricerca è caratterizzato da due modalità di rilevazione dei dati, una di natura qualitativa, l’altra di natura quantitativa a partire da uno schema concettuale frutto dell’analisi della letteratura. In particolare, la relazione assistenziale infermieristica online è stata indagata secondo tre dimensioni:

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a) il piano relazionale, con questa dimensione di è voluto rilevare l’emersione dei vissuti soggettivi rispetto all’esperienza della malattia e del trattamento di cura secondo cinque indicatori: 1. Il racconto spontaneo dei propri vissuti; 2. il contenimento dell’ansia attraverso il riconoscimento nell’altro dei medesimi problemi; 3. Il rafforzamento del sé e delle proprie capacità; 4. Il confronto fra pari nell’intreccio delle storie di vita; 5. Il sostegno morale.

b) il supporto tecnico-professionale, questa dimensione è descr i t ta dagl i indicatori che evidenziano: 1 . Personalizzazione della risposta di cura rispondete alle attese; 2. Precoce valutazione di insorgenze post intervento; 3. Indicazioni operativa per una gestione ordinaria della stomia; 4. Acquisizione di nuovi accorgimenti anche in fase preventiva; 5. Immediata gestione di visite in presenza presso l’ambulatorio.

c) il piano comunicativo-linguistico, la terza dimensione ha indagato l’andamento delle modalità comunicative e del registro linguistico, si è posto l’attenzione su quattro aspetti: 1. Informalità e immediatezza negli scambi; 2. Libertà di espressione e livello di confidenza; 3. Utilizzo di codici differente per esprimere emozioni e sentimenti; 4. Tipologia di lessico.

Alla luce delle dimensioni descritte sono state articolate una serie di categorie di indagine per l’analisi dei testi scritti nei messaggi e declinate successivamente in items per configurare un questionario, somministrato in due fasi, in ingresso e dopo 6 mesi dall’avvio della sperimentazione. Durante la rilevazione quantitativa si è misurato inoltre il livello di corrispondenza rispetto alle attese e il gradimento riguardo l’esperienza condotta (vedi Figure 1).

Per quanto concerne la parte qualitativa della ricerca, l’analisi dei dati si è sviluppata attraverso la lettura e la categorizzazione dei messaggi, a partire dalle dimensioni individuate, espandendo ove necessario con nuovi riferimenti. Per la parte quantitativa, si è proceduto con l’analisi delle frequenze delle risposte e la rispettiva elaborazione grafica.

I risultati dell’indagine hanno messo in evidenza elementi significativi per configurare un’attività di nursing che potremmo dire ‘espansa’, ovvero attraverso processi di cura travalicano i confini15,16, un allargamento orizzontale dell’interazione che prende avvio durante la degenza, e che prosegue anche attraverso ambienti online, prolungando la relazione infermieristica oltre lo spazio dell’ospedale (Figure 1 a and b).

DISCUSSIONE

I dati raccolti dall’analisi qualitativa attraverso la lettura del testo scritto e l’osservazione degli emoticon e dei post con immagini, evidenziano in primis una numerosità maggiore di post attribuibili alla categoria relativa alla dimensione

affettiva nel vissuto di malattia rispetto a quella relativa al contributo tecnico professionale. Dal punto di vista della categoria “relazione affettiva” l’esperienza maturata nella chat dai partecipanti mostra un forte senso solidaristico. Questa è una dimensione da sottolineare, in quanto il campione della sperimentazione non presentava conoscenze reciproche in presenza, ma all’apertura della chat si è attivata una presentazione reciproca, inizialmente sintetica, e via via sempre più approfondita. A questo livello, il gruppo ha dimostrato sempre più autonomia, anche se gli interventi dell’infermiera, esperta nella patologia e con ruolo di mediatore, hanno avuto un ruolo fondamentale anche se mai pervasivo. Molti post hanno espresso la paura per la situazione incerta che stavano vivendo, l’ansia rispetto alla cura, in molti casi chemioterapia, e ai suoi effetti collaterali. Circa un 60% dei messaggi hanno espresso tematiche connesse con la dimensione relazionale-affettiva esprimendo sia aspetti di preoccupazione, tristezza e sconforto sia interventi di supporto, di condivisione di buone notizie, di gioia rispetto all’esito della cura o di qualche esame. In questi casi, l’utilizzo di emoticon ha rafforzato il significato del messaggio, con una funzione centrale nel costruire un clima di gruppo.

Nei messaggi relativi alla categoria “contributo tecnico-professionale” emerge il ruolo dell’infermiera, quale moderatrice delle relazioni ed esperta all’interno del gruppo. I suoi interventi nel gruppo sono stati percepiti con apprezzamento da parte dei partecipanti. Gli interventi della moderatrice/esperta mostrano sempre tempestività rispetto alla richiesta, superamento dei vincoli d’orario del proprio servizio, pieno apprezzamento da parte dei malati per la risoluzione dei problemi posti. Al riguardo, le richieste da parte dei pazienti si sono distribuite fra problemi legati alla gestione operativa delle placche (fornitura, applicazione, rimozione), gestione di complicanze lesivo/irritative della zona peristomale, tipologia e modalità di somministrazione del farmaco, accorgimenti da adottare nel proprio stile di vita. All’interno di questo spazio relazionale specifico i pazienti hanno avuto la possibilità di un confronto diretto e informale per valutare la necessità di una visita specialistica oppure una semplice visita presso l’ambulatorio, nonché una medicazione a livello domiciliare.

Negli scambi relativi alle necessità di supporto tecnico-professionale, si è potuto osservare inoltre come il dialogo in fase iniziale si sia sviluppato tra il paziente e l’infermiera, ma nel procedere del tempo, i partecipanti hanno portato sul tavolo della chat la loro esperienza e le buone prassi realizzate. Ciò evidenzia come il gruppo non sia stato solo uno spazio di richiesta personalizzata e emergenziale o una condivisione delle problematiche emotive, personali o relazionali, ma è divenuto nel tempo uno spazio di confronto sulle pratiche di cura e luogo generativo di possibili nuove soluzioni nella gestione delle stomie.

L’analisi del testo ha portato alla luce tipiche dinamiche relative la comunicazione all’interno dei gruppi, dalla

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configurazione di un legame forte tra chi è parte del gruppo, al recupero di esperienze precedenti come occasioni per consolidare la conoscenza reciproca, in alcuni momenti emerge con forza la dimensione solidaristica per dare energie e speranza, in altri momenti la semplice comprensione espressa con l’ascolto e la condivisione. In particolare, si possono riportare come evidenti:

• le considerazioni relative alle storie di vita, anche precedenti la malattia;

• il supporto emotivo nel momento dello sconforto;

• la condivisione ironica di alcune esperienze di cura;

• il riconoscimento reciproco come rafforzamento del sé.

Per quanto concerne l’analisi quantitativa avvenuta attraverso la somministrazione di due questionari a t0 e t1 dopo 6 mesi, la linea di tendenza delle risposte afferma l’efficacia della sperimentazione. I pazienti hanno espresso a distanza di 6 mesi l’auspicio che una pratica simile possa esser estesa nella pratica quotidiana dei processi di cura. Lo spazio di confronto online all’interno di una chat di gruppo nel social network WhatsApp è stata ritenuta per la totalità dei partecipanti positiva e in grado di prolungare la relazione infermieristica oltre il periodo della degenza.

La totalità dei partecipanti alla sperimentazione ha espresso un giudizio positivo sulla opzione di consigliare la partecipazione ad un altro paziente e ha ritenuto più che positivi e centrati gli interventi dell’infermiera esperta.

In fase di ingresso, il questionario ha rilevato una generale distacco riguardo a WhatsApp come strumento possibile per la relazione infermieristica, quasi il 90% dei rispondenti non aveva mai preso in considerazione un social network per questa funzione. Poco meno della metà non aveva mai preso in considerazione questo social come strumento per condividere momenti personali di difficoltà con qualcuno e circa un 30% riteneva in fase di ingresso che non fosse possibile attraverso questo social migliorare le relazioni sociali.

Nella rilevazione nella seconda fase a distanza di 6 mesi, le percezioni sono cambiate, la totalità ha ritenuto positiva l’esperienza, considerando questo momento come una reale e possibile attività assistenziale e di cura. Emerge con forza, come già è stato evidenziato dai dati qualitativi il ruolo dell’infermiera sia come interlocutore privilegiato per la risoluzione dei problemi sia come mediatore delle relazioni, in grado di cogliere e sostenere il clima del gruppo.

CONCLUSION

L’esperienza condotta, con l’intenzione di comprendere la reale efficacia di un gruppo online attivato nell’ambiente per prolungare la relazione infermieristica, indica che ciò è possibile e, nelle condizioni sperimentate, è anche auspicato dai pazienti.

Lo studio presenta limiti connessi ai percorsi di ricerca esplorativa, emergenti principalmente dal ridotto numero di casi analizzati, dall’identificazione di dimensioni e categorie di analisi in progress e a un ridotto livello di formalizzazione.


1 Do you think that the use of WhatsApp could help for extending the care relationship?

◦ No, I doubt it can◦ I think it is hard, but possible◦ Yes, it could help◦ I don't know

2 What do you think about the proposal of using WhatsApp for nursing and care purposes?

◦ I never considered it before◦ I have heard about it, but not for these purposes◦ I have used it for these purposes, but informally

3 Do you think that the support given by the other members of this WhatsApp group could be helpful with anxieties and worries?

◦ Very helpful◦ Quite helpful◦ A little helpful◦ Not at all helpful

4 Have you experienced WhatsApp before to share moments of personal difficulty with other people?

◦ No, I didn't◦ Yes, just once◦ Yes, more than once

5 Do you think that being part of this WhatsApp group will improve your social relationships?

◦ Yes, I think so◦ I think it will be hard, but possible◦ No, I doubt it◦ I don't know

Figure 1a

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Gli elementi emersi dall’analisi, al tempo stesso, mettono in luce alcune condizioni necessarie. Fra queste si ritiene un fattore chiave la presenza di una figura di moderatore esperto sia sul piano infermieristico sia sul piano della comunicazione online, nonché competente riguardo le relazioni di gruppo, deve inoltre possedere la capacità di discernere la complessità clinica delle richieste e quindi di produrre una risposta adeguata. Per quanto riguardo il gruppo è necessario che sia favorito un rafforzamento dell’autostima nei pazienti per attivare uno scambio esperienziale pieno e autentico, che permetta l’attivazione di un processo di educazione terapeutica informale.

ACKNOWLEDGEMENTS

We would like to thank all the patients who participated in this study.

AVAILABILITY OF DATA AND MATERIALS

The datasets during and/or analysed during the current study are available from the corresponding author on reasonable request.

AUTHORS’ CONTRIBUTIONS

SB and DV defined the research theme and designed the study. DM was expert nursing and mediator in WhatsApp.


1 On the basis of your experience in this group, do you consider that the use of WhatsApp for nursing and care purposes will be desirable?

◦ It will not be desirable at all◦ It will be a little desirable◦ It will be partially desirable◦ It will be quite desirable◦ It will be very desirable

2 Do you think that support given by the other members of the WhatsApp group was helpful to you in order to face worries and anxieties?

◦ Not at all◦ Very little◦ Quite helpful◦ Very helpful

3 Do you think that using WhatsApp — like you did in this group — has extended the nursing and care relationship, even beyond the hospital stay period?

◦ Yes, sure◦ Only partially◦ No, I don't think so◦ I don't know

4 Could the answers given by the expert in the WhatsApp group solve your doubts and problems?

◦ Never◦ Little◦ Quite good◦ Always

5 Was it important for you to be in contact/relationship with other people experiencing the same disease?

◦ Not at all◦ Very little◦ Quite important◦ Very important

6 Have you read again previous WhatsApp chat which you had days or months ago, in order to reflect on problems or replies?

◦ No, I didn't◦ Sometimes◦ Often

7 Have stoma management tips proven to be effective?◦ Rarely◦ Sometimes yes, sometimes not◦ In most cases

8 What was the most important thing in this experience of the WhatsApp group?

◦ Please write down your reply

9 Would you recommend another patient to join the group?◦ Yes◦ No

Figure 1b

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SB, DM and DV analysed and interpreted the data and drafted the manuscript, in particular SB framework theory and methodology of research, DM discussion and conclusion, DV introduction e discussion. All authors helped to revise the manuscript critically. All authors read and approved the final manuscript.

COMPETING INTERESTS

The authors declare that they have no competing interests.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethics approval was sought with the department at Surgery of Fondazione Ospedaliera Poliambulanza. All patients provided written informed consent.

BIBLIOGRAFIA

1. Robert A & Aronowitz MD. Make Sense of Illness. Science, Society, and Disease. New York: Cambridge University Press, 1998.

2. Bauman Z. Vite di corsa. Come salvarsi dalla tirannia dell’effimero. Bologna: Il Mulino, 2009.

3. Granovetter M. The strength of weak ties. Am J Sociol 1973; 78:1360-80. Trad in It. Granovetter M. La forza dei legami deboli. Napoli: Liguori, 1998.

4. Eraut, M. Informal learning in the workplace. Studies in Continuing Education 2009; 26(2) :247–273. DOI: 10.1080/158037042000225245

5. Downes S. New Technology Supporting Informal Learning. Journal of Emerging Technologies in Web Intelligence 2010; 2(1):27–33. DOI: 10.4304/jetwi.2.1.27-33

6. International Council of Nurses (ICN). Code of Ethics for Nurses. Geneva: ICN, 2006.

7. Royal College of Nursing. Definition nursing. https://www.rcn.org.uk/professional-development/publications/pub-004768. Accessed 9 gennaio 2017.

8. Scott PA, Matthews A & Kirwan M. What is nursing in the 21st century and what does the 21st century health system require of nursing? Nurs Philos 2014; 15:23–34. DOI: 10.1111/nup.12032

9. Powell-Cope G, Nelson AL & Patterson ES. Patient care technology and safety. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research & Quality (AHRQ), 2008.

10. Kemp, Report Digital in 2016. 2016. http://wearesocial.com/it/blog/2016/01/report-digital-social-mobile-in-2016. Accessed 9 gennaio 2017.

11. Johnston MJ, King D, Arora S, Behar N, Athanasiou T & Sevdalis S. Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. Am J Surg 2015; 209(1):45–51. DOI: 10.1016/j.amjsurg.2014.08.030

12. Payne KB, Wharrad H & Watts K. Smartphone and medical related app use among medical students and junior doctors in the United Kingdom (UK): a regional survey. BMC Med Inform Decis Mak 2012; 12:121. DOI: 10.1186/1472-6947-12-121

13. Raiman L, Antbring R & Mahmood A. WhatsApp messenger as a tool to supplement medical education for medical students on clinical attachment. BMC Med Educ 2017; 17:7. DOI 10.1186/s12909-017-0855-x

14. Franko OI & Tirrell TF. Smartphone app use among medical providers in ACGME training programs. J Med Syst 2012; 36(3):135–9. DOI: 10.1007/s10916-011-9798-7

15. Bonometti S. I contesti dell’educare. In Perla L, Riva MG, eds. L’agire educativo. Manuale per educatori e operatori socio-assistenziali. Brescia: La Scuola, 2016, pp. 95-107.

16. Bonometti S. A cross-media environment for teacher training. In Fardun HM, Gallud JA. IDEE '14 Proceedings of the 2014 Workshop on Interaction Design in Educational Environments. New York: Association for Computing Machinery (ACM), International Conference Proceedings Series.

Norma N Gill FoundationThe aim of the Norma N Gill Foundation is to facilitate education in esterostomal therapy (ET) nursing worldwide. This aim can only be realised with the support of our members and colleagues in industry.

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ABSTRACT

In this second part of a series of articles on skin and soft tissue infections (SSTI), the entities of impetigo, folliculitis and erysipelas are explored. A case-based approach to the diagnosis and management of these infections for clinicians is provided.

Keywords: Soft tissue infection, SSTI, erysipelas, impetigo.

INTRODUCTION

Skin and soft tissue infections (SSTI) are a common clinical entity resulting from minor local trauma, or less frequently from haematogenous seeding. SSTI may be characterised by depth of infection, location and aetiologic pathogen. Superficial SSTIs include the primary pyoderma entities of impetigo, folliculitis and erysipelas and involve the epidermis and/or superficial dermis (Figure 1). In this second article of the series, a case-based overview with diagnostic and management considerations to these three infectious entities will be provided. For a broader overview of SSTI, readers are referred to the previous article in the series1.

Caley ShukalekMD, MSc Department of Medicine, University of Calgary, Calgary, AB, Canada

Laurie ParsonsMD Department of Medicine, University of Calgary, Calgary, AB, Canada

Ranjani Somayaji*BScPT, MD, MPH, FRCPC Clinical Lecturer — Division of Infectious Diseases Department of Medicine University of Calgary Calgary, Canada Email [email protected]


Delving into skin and soft tissue infections (SSTI)

Part II: Focus on superficial infections

CASE 1:

HP is a 17-year-old girl presenting to her primary care physician with a new rash which developed five days ago on the anterior shin area of her right leg. HP reports that it began with just a few lesions on the lower shin, but it quickly spread to involve most of the right leg with 20-30 small white pimples. Yesterday she noted a few lesions on the left leg and this morning a new lesion on the left side of her cheek. The eruption is mildly pruritic but she is otherwise well with no reports of fever or pain. She has tried squeezing a few lesions and was able to express a small amount of white purulent material from each lesion. Current grooming practice includes removing leg hair with a disposable razor which she changes every 2-3 weeks and application of a moisturising lotion.

On presentation, the lesions consisted of 1-2 mm white pustules on an erythematous base (example depicted in Figure 2). Lesions were often centred around a hair follicle. There were approximately 20 lesion on the right leg, three on the left and another isolated lesion on the left cheek. Some of the older lesions on the right leg were beginning to crust. She was found to be afebrile and there was no evidence of lymphadenopathy.

Given the spreading nature of the lesions and the suspicion that spread was the result of a contaminated razor blade plus lesion manipulation, conservative therapy was recommended. HP was advised to refrain from hair removal until the infection resolved and to replace the razor.

FOLLICULITIS

Folliculitis is a common SSTI in otherwise healthy young adults and children. Despite the reported frequency of folliculitis and other SSTIs there is, surprisingly, limited data on prevalence and incidence rates of these common skin infections2. Folliculitis in particular is the most common SSTI and Staphylococcus aureus is, for the most part, the most common causative agent3. In some individuals recurrent episodes of folliculitis have been documented (chronic folliculitis)2 and there is good evidence that nasal carriage of S. aureus is a precursor condition4.

Pathogenesis: The usual pattern of skin microflora distribution is in the axilla, groin and intertriginous skin where increased moisture provides a suitable environment. The upper stratum corneum and upper hair follicle is where these bacteria are usually found. The microflora of the skin is part of the local defence system which prevents invasion by other pathogenic bacteria. For other SSTIs, invasion of

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the skin usually occurs through a break in the integument which may also be the mechanism for follicular invasion5. Methicillin-resistant S. aureus have been implicated in 40% of hospital5 and 72% of community-acquired6 SSTI cases in Canadian and US studies respectively6.

Clinical presentation: Clinically, folliculitis appears on the skin as small pustules pierced by a terminal hair on an erythematous base. These pustules are often pruritic; however, they are occasionally tender to light touch. There is usually no associated fever or lymphadenopathy but severe and extensive involvement can result in lymph node enlargement7.

Any hair-bearing area can be affected but folliculitis is most commonly found on parts of the body where terminal hair growth is seen, such as the scalp, upper and lower extremities, axilla, groin, beard and trunk5.

Differential diagnosis: The differential diagnosis of folliculitis includes other bacterial agents and non-infectious aetiologies. Gram-negative folliculitis is most often due to Pseudomonas aeruginosa (hot tub folliculitis)7 or Proteus species. Rarely folliculitis can be non-bacterial. Viruses such as Herpes simplex or Varicella zoster virus have been cultured from follicular pustules as well as dermatophytes and yeasts7.

The differential diagnosis also includes non-infectious aetiologies such as eosinophilic folliculitis, acne vulgaris, rosacea, pseudo-folliculitis barbae, prickly heat rash (militaria

pustulosa) or as a side effect of medication3. Sterile folliculitis can also a result of irritant contact dermatitis from topically applied medications such as tar or anthralin8.

Treatment: Pustules of superficial bacterial folliculitis usually develop in crops and heal without treatment within seven to 10 days4. Treatment can be conservative except when folliculitis is chronic.

CASE 2:

Ms Smith is a 50-year-old woman with a history of eczema, who presented with a two-day history of crusting over her ears bilaterally. She had developed a pruritic rash around her ears bilaterally one week ago and thought she may have had an allergic reaction. She had been using topical, non-prescription steroid creams, and noted that she developed some sores with mild itching. The sores began on her right ear and later spread to her left ear one to two days later. She did not report any specific injuries, history of similar illness, or contact with others including children with similar symptoms. She denied any fever, but had mild pain and pruritus at the affected areas. Due to the location and her symptoms, Ms Smith had been absent from work for a few days. On presentation, her external ears were inflamed, with a small amount of serous discharge, and honey-coloured crusting. No pustules or blisters were present. No rash or lesions were noted elsewhere on physical examination. Inner ear exam was normal (Figure 3).

Following the assessment, Ms Smith was diagnosed with secondary impetigo following a likely contact dermatitis. Based on the location of the lesions, and the patient’s concerns, she was treated with a short course of oral cephalexin 500 mg four times daily for five days. On follow-up assessment at two weeks, Ms Smith had complete resolution without scarring.

Figure 1: Diagram depicting depth of involvement with superficial skin and soft tissue infections (© RS 2017)

Figure 2: A characteristic lesion in folliculitis (source: https://en.wikipedia.org/wiki/Folliculitis#/media/File:Isolated_folliculitis.jpg)

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IMPETIGO

Impetigo is a superficial infection of the skin characterised by an initially vesicular, and later crusted appearance. Impetigo has an annual incidence of 1–2% with epidemics occurring in summer months9. The majority of impetigo cases occur in children. Historically group A streptococcus (GAS) was the principal agent of impetigo and isolated in approximately 80% of cases either in isolation or mixed with S. aureus10. More recently, S. aureus (including methicillin-resistant strains) dominates cases of impetigo as GAS is found only in 20–30% of cases9-13. However, it is possible that the role of staphylococci in impetigo is not fully understood and certain virulence factors produced by S. aureus impairs the ability to recover GAS isolates from infection sites14.

Pathogenesis: Impetigo consists of superficial intraepidermal vesicles and vesico-pustules. Studies suggest that GAS acquisition on normal skin precedes the onset of impetigo by approximately 10 days10. Primary dermatoses or trauma leading to breach of the skin barrier then leads to the development of impetigo. As previously noted, impetigo occurs most commonly in summer months with heat and humidity. If impetigo is associated with S. aureus, this is thought to be preceded by nasal staphylococcal colonisation15. In returning travelers presenting with impetigo, onset is associated with insect bite history16.

In GAS, non-bullous impetigo, the corneal layer of the epidermis is disrupted, and bacteria can bind to the sub-corneal keratinocytes17. This is mediated by the S. pyogenes M protein18. They also bind along the basal layer of the epidermis through action of protein F. Similarly in S. aureus, a number of virulence factors enhance adhesion to the epithelium and matrix protein structures19. Exfoliative toxins may also be implicated in the non-bullous and bullous forms of impetigo14. Notably, impetigo is highly communicable, especially amongst children, and spread is enhanced due to poor hygiene and crowded conditions.

Clinical manifestations: Streptococcal impetigo begins as small vesicles which may have surrounding halos on exposed areas14. These lesions become pustular and rupture readily with a discharge that dries and forms the characteristic "honey-coloured" crusts. Lesions may be pruritic, and scratching of lesions may further spread infection. Impetigo lesions tend to be painless and patients have minimal systemic symptoms of infection (that is to say, fever). The lesions of impetigo are superficial and do not ulcerate. There may be mild associated lymphadenopathy. Due to the superficial location of infection, healing usually occurs without scarring.

Microbiology: Group A streptococcus and S. aureus are the most common aetiologic agents of impetigo. Other streptococci such as Group B, C, and G may rarely cause impetigo. As MRSA incidence rises, both community and hospital-acquired strains have been implicated in cases of impetigo13.

Differential diagnosis: Other infectious aetiologies to consider include the herpesviridae, and fungal infections. The impetigo lesions may resemble varicella (chickenpox) in early stages but the crusting in impetigo is harder and darker in colour14. The thick crusts seen in impetigo are also not characteristic of fungal infections such as tinea circinata. Herpes simplex vesicular lesions may also resemble impetigo and this is important to distinguish as topical therapies for impetigo may irritate HSV lesions. HSV lesions tend to have characteristic distributions (oral or genital classically), and are painful. Other entities on the differential include acute palmoplantar pustulosis20, atopic or contact dermatitis, discoid lupus, and infestations such as scabies21.

Therapy: Historically, penicillin was the drug of choice for impetigo, both for the treatment and the prevention of acute glomerulonephritis as GAS was the primary pathogen. However, with increased prevalence of S. aureus and mixed infections, primary therapy must have anti-staphylococcal

Figure 3: Secondary impetigo (© RS 2017) Figure 4: Facial erysipelas (© RS 2017)

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activity. Both penicillinase-resistant oral penicillins and cephalosporins are effective for the treatment of impetigo. The incidence of MRSA in impetigo remains to be established but should be considered based on patient risk factors, and response to initial therapy. Local wound care includes crust removal, which may be done by soaking with soap and water. If there is extensive disease with wounds, wound culture may be considered following initial therapy and assessment of response. Topical agents may be used when there is a limited area of impetigo including when MRSA is implicated.

Topical agents include mupirocin ointment in a polyethylene glycol base, fusidic acid cream, and retapumulin ointment. Mupirocin has been demonstrated to be as effective as oral erythromycin for impetigo but the incidence of mupirocin resistance in S. aureus isolates has been steadily rising over the past decade14,22. Retapumulin ointment is the first agent in a novel class of antibiotics called pleuromutilins, and acts by inhibiting protein synthesis23. It is effective against S. aureus and GAS, and has been approved for impetigo. Fusidic acid cream is effective for childhood impetigo and especially for S. aureus but, again, due to rising antimicrobial resistance, use has been limited11. All topical agents should be applied gently to minimise tissue trauma, maceration and infection spread. If impetigo is widespread, systemic agents are recommended, and close follow-up of patients on topical therapies is required due to rising antimicrobial resistance rates14.

CASE 3:

Ms Cavanaugh is a 72-year-old woman with a history of hypertension, who presented to the emergency department with a 36-hour history of fevers followed by onset of redness, pain and swelling of both sides of her face. She had two pet cats but did not recall any specific scratches or bites, and had no other history of trauma. She also did not report any new medications or facial products, and did not have a history of atopy or eczema. The fever was accompanied by chills and anorexia, with the redness beginning 24 hours later and spreading rapidly. She noted that it was quite warm and very tender to touch. On exam, she was febrile with a temperature of 38.7C, and had an elevated heart rate at 110 beats per minute. Facial exam revealed well-demarcated areas of redness and swelling over her cheeks and nose bilaterally [Figure 4]. The area was painful to light palpation. No blistering was present. Oropharyngeal, otic and ocular (throat/ear/eye) exams were normal.

Based on the assessment, Ms Cavanaugh was diagnosed with facial erysipelas. Given her systemic symptoms, she was initiated on intravenous (IV) cefazolin 2 g every eight hours with no specific empiric MRSA coverage given based on community epidemiology and absence of MRSA risk factors or history. She was reviewed in 24 hours and noted to be mildly improved with decreased fevers. IV antibiotics were continued for a total of 72 hours at which time she had approximately 40% improvement with resolution of fevers. Antibiotics were stepped down to oral cephalexin 500 mg four times daily (based on weight <80 kg) for seven days further. At the end of

therapy, the infection had resolved and she had apparent healing of her skin structures at the expected rate.

ERYSIPELAS

Erysipelas is a rapidly progressive superficial cellulitis of the skin with notable involvement of the superficial lymphatics. Although other organisms can be implicated, erysipelas is generally attributed to GAS infection24, but the causative organism is often difficult to identify in the absence of bacteremia.

Clinical manifestations: Erysipelas cases occur more frequently in infants or young children, as well as older adults14. Of cases, up to 80% involve the lower extremities and the remainder involve the face though, historically, facial erysipelas was the most common presentation25. Similar to other SSTIs, minor local trauma, skin lesions, or other infections (that is to say, fungal) may act as the portals of entry, but a cause may not be identified in many cases. Risk factors for erysipelas include diabetes mellitus, venous stasis, lymphoedema, alcohol abuse and others. Recurrence rates for erysipelas are approximately 30%26, especially in the context of venous stasis and/or lymphoedema, and infections can recur at the site of a prior infection.

Erysipelas presents as a bright-red, painful lesion with associated oedema and induration ("peau d’orange" appearance)14. The lesion has a sharply demarcated and raised border that advances with progression of the infection. Persons may have systemic signs of illness including fever that precedes the skin manifestations. In approximately 5% of cases, erysipelas can have be complicated by bullae (large blisters) and is termed bullous erysipelas; alternatively, the infection can extend to include deeper skin and soft tissue structures14.

Microbiology: GAS is the most commonly associated bacterial organism, though S. aureus or other streptococcal species (for example, Group C streptococci, Group G streptococci) may also be implicated. As is common in SSTI, GAS is not typically cultured from erysipelas skin lesions including with bacteremia, and only occasionally can be identified in lesion biopsies or aspirates. In complicated erysipelas with ulcers, GAS isolation is increased to ~30% of cases14. In cases of bullous erysipelas, the blister fluid is most commonly sterile though bacteria may sometimes be cultured27. A systematic review of patients with erysipelas and bacteremia found that bacterial organisms were isolated in only 5% of cases and 50% of these were GAS, ~33% were other streptococcal species, and ~10% were due to S. aureus or other Gram-negative bacteria25.

Differential diagnosis: The characteristic presentation and appearance of the lesion is used to establish the diagnosis of erysipelas. However, a number of other infectious and non-infectious conditions must be considered. Herpes zoster virus (HZV) infection involving the 5th cranial nerve (second

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division) can resemble erysipelas, affecting one side of the face, but HZV also causes pain and increased skin sensitivity (hyperesthesia) prior to the onset of skin lesions14. Contact dermatitis or urticaria (hives) may also be confused with erysipelas, but these patients are systemically well and also have pruritus (itching). Other entities include inflammatory cancers of the breast, lesions of familial Mediterranean fever, and erythema chronicum migrans, as may occur in Lyme disease14.

Therapy: For mild cases of erysipelas, oral penicillins or macrolides (for example, erythromycin, clarithromycin), or clindamycin (if macrolide resistance) may be used. When more extensive, IV antibiotics such as Penicillin G, or first-generation cephalosporins can be used with step-down to oral therapy based on clinical improvement. As erysipelas and cellulitis cannot always be readily differentiated, therapy to cover both GAS and S. aureus can be initiated (that is to say, first-generation cephalosporin or anti-staphylococcal penicillin such as naficillin or oxacillin)14. In cases of severe or complicated bullous erysipelas, empiric therapy can include MRSA coverage such as vancomycin while awaiting culture results27. For individuals with recurrent erysipelas, chronic suppression with oral or IV penicillin can be considered in select cases28.

CONCLUSION

Impetigo, folliculitis and erysipelas represent infections of the superficial skin and soft tissues and can occur following minor local trauma. GAS and S. aureus are the most common bacterial organisms implicated and treatment differs based on the presentation and clinical severity. A detailed history and examination are necessary to accurately diagnose and manage these infections.

DISCLOSURES

The authors declare no conflicts of interest.

REFERENCES

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3. Tognetti L, Martinelli C, Berti S et al. Bacterial skin and soft tissue infections: review of the epidemiology, microbiology, aetiopathogenesis and treatment. J Eur Acad Dermatol Venereol 2012; 26:931–941.

4. Laureano AC, Schwartz RA & Cohen PJ. Facial bacterial infections: Folliculitis. Clin Dermatol 2014; 32:711–714.

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10. Ferrieri P, Dajani AS, Wannamaker LW et al. Natural history of impetigo, I. Site sequence of acquisition and familial patterns of spread of cutaneous streptococci. J Clin Invest 1972; 51:2851–2862.

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14. Pasternack M & Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, PA: Churchill Livingstone, 2010, pp. 1577–1601.

15. Dajani A, Ferrieri P & Wannamaker LW. Natural history of impetigo, II. Etiologic agents and bacterial interactions. J Clin Invest 1972; 51:2863–2871.

16. Hochedez P, Canestri A, Lecso M et al. Skin and soft tissue infections in returning travelers. Am J Trop Med Hyg 2009; 80:431–434.

17. Darmstadt G, Fleckman P, Jonas M et al. Differentiation of cultured keratinocytes promotes the adherence of Streptococcus pyogenes. J Clin Invest 1998; 101:128–136.

18. Okada N, Pentland AP, Falk P et al. M protein and protein F act as important determinations of cell-specific tropism of Streptococcus pyogenes in skin tissue. J Clin Invest 1994; 94:965–977.

19. Zetola N, Francis JS, Nuermberger EL et al. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis 2005; 5:275–286.

20. Burge S & Ryan TJ. Acute palmoplantar pustulosis. Br J Dermatol 1985; 113:77–83.

21. Brown J, Shriner DL, Schwartz RA et al. Impetigo: an update. Int J Dermatol 2003; 42:251–255.

22. Stevens D, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: Update by the Infectious Diseases Society of America. CID 2014.

23. Koning S, van der Wouden JC, Chosidow O et al. Efficacy and safety of retapamulin ointment as treatment of impetigo: randomized double-blind multicentre placebo-controlled trial. Br J Dermatol 2008; 158:1077–1082.

24. Bernard P, Bedame C, Mounier M et al. Streptococcal cause of erysipelas and cellulitis in adults. Arch Dermatol 1989; 125:779–782.

25. Gunderson C & Martinello RA. A systematic review of bacteremias in cellulitis and erysipela. J Infect 2012; 64:148–155.

26. Jorup-Ronstrom C. Epidemiological, bacteriological and complicating features of erysipela. Scand J Infect Dis 1986; 18:519–524.

27. Krasagakis K, Samonis G, Maniatakis P et al. Bullous erysipelas: clinical presentation, staphylococcal involvement and methicillin resistance. Dermatology 2006; 212:31–35.

28. Leclerc S, Teixeira A, Mahé E et al. Recurrent erysipelas: 47 cases. Dermatology 2007; 214:52–57.

The Kuala Lumpur Convention Centre (Malay: Pusat Konvensyen Kuala Lumpur) is a convention and exhibition centre in Kuala Lumpur, Malaysia, and part of the Kuala Lumpur City Centre precinct, known as KLCC.

Designed to be a "city within a city" the 40-hectare (99-acre) City Centre site includes the 50-acre (20 ha) KLCC Park and the PETRONAS Twin Towers. KLCC is accessible through KLCC LRT station on the Kelana Jaya Line.

About the Venue

WORKSHOP 1: WOUND Diabetic Foot Management: Assessment & Care including Preventive Measures

WORKSHOP 2: OSTOMY Peristomal Skin Complications and its Management

WORKSHOP 3: CONTINENCE Urinary & Faecal Incontinence: History, Evaluation & Management

WORKSHOP 4: COMMUNICATION Challenges in Ethnocentric Community

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Abstract NowLogin to

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Date: Sunday, 15 April 2018 Time: 1300 - 1430 hrs

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ABSTRACT

Peristomal skin complications or leakages underneath the appliance are common in ostomy individuals. The relevance of convex stoma systems to prevent leakages has been demonstrated in cases of an invaginated stoma or uneven peristomal areas. However, these convex devices, due to their usual rigidity, can cause discomfort. A multicentre, transverse survey was conducted among 93 healthcare professionals and 219 ostomy patients in order to document the real-life experience of a new stoma device, the SenSura® Mio Convex Fit. The majority (77.7%) of stoma care nurses were far more/more satisfied with this new, flexible, convex appliance than with the convex solutions currently available and 96.6% wished to continue using it in patients requiring a convex appliance. The majority of patients were also satisfied, including those frequently presenting with leakages (n=126). In this survey, 60.3% of patients often had initial leakages, but the use of a new appliance provided a feeling of safety to 8 out of 10 patients (79.3%), which was an essential element of patient satisfaction. This flexible convex baseplate, capable of allowing the stoma to protrude and to adapt to the movements of the body, is an interesting option to prevent the occurrence of leakages and to help resolve peristomal skin complications without compromising patient comfort. Seeking the advice of a stoma care nurse is recommended if the choice of an appliance proves difficult.

Keywords: Stoma, satisfaction, convexity, flexibility, leakage.

Danièle Chaumier*Stoma Care Nurse Tenon Hospital, Paris, France Email [email protected]=

Relevance of a new flexible convex stoma appliance

Corinne GadratHead Stoma Care Nurse Pellegrin Hospital Group Bordeaux, France Email [email protected]


INTRODUCTION

Today, it is commonly admitted that leakages underneath the appliance are one of the main causes of a reduced quality of life for individuals with an incontinent stoma (collection of effluent or urine in a stoma bag). Three out of four ostomy patients present with leakages underneath the device and nine out of 10 patients worry about them occurring1. Due to the variations in morphology of the peristomal area, the choice of a good appliance can be a veritable challenge.

The intention of convex appliances to prevent leakages is well established: in the case of invaginated or flush stomas, the convexity allows the stoma to protrude. In addition, it helps to smooth out the uneven or hollow peristomal areas. These baseplates therefore help to guide the effluent away from the skin, to improve the adhesive capability of the baseplate and to prevent leakages. They may prove interesting, particularly in the presence of liquid and abundant effluent2. However, these convex devices can cause discomfort due to their usual rigidity. Cases of skin lesions due to pressure on the peristomal area have also been reported2. The new, flexible, semi-convex appliance, SenSura® Mio Convex Fit, fitted with the unique Flexlines (or flexibility lines) concept, allows the stoma to protrude and prevents leakages without compromising flexibility, with the aim of improving the patient’s physical comfort and psychological well-being.

A survey was conducted to assess the satisfaction of healthcare professionals and patients with this new appliance in real-life conditions.

METHODOLOGY

This multicentre transverse study was conducted in real-life conditions among stoma care nurses and their ostomy patients seen in consultation or hospitalisation and requiring a semi-convex system. Consent collection was not required. The questionnaires were anonymised. Overall satisfaction with the use of the two-piece SenSura® Mio Convex Fit (Flex, Figure 1; or Click, Figure 2) was assessed, particularly in terms of wearing comfort (flexibility of the baseplate, capacity to fit to a real body, to follow the movements of the body), ease of use (coupling, cleaning) and feeling of safety, as well as the wish to continue using the product.

PARTICIPANTS

Ninety-three stoma care nurses answered the questionnaire, as did 219 patients, 158 for the Click system and 61 for the Flex system. The participants were mainly individuals with a digestive stoma (98 ileostomies, 82 colostomies and 30

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urostomies). The majority presented with an invaginated (34%) or flush (44%) stoma. In addition, 59.2% of patients had a hollow peristomal area and 69.1% had superficial or deep folds. In the main, the need for resorting to a convex appliance was to allow the stoma to protrude (68.4%) and the presence of frequent leakages (60.3%). This justified the use of accessories in 85.2% of patients, mainly protective skin paste or rings, belt or tapes.

RESULTS

Health professionals’ questionnaire

Overall, about 9 out of 10 nurses (88.7%) were very satisfied/satisfied with the new flexible convex appliance (Table 1), whether the coupling was mechanical (89.8%) or adhesive (86.7%). Satisfaction level was particularly high, especially in terms of safety of the appliance (94.4%), adaptability (90%) and flexibility of the baseplate (93.5%). It is interesting to note the unanimous (100%) satisfaction of healthcare professionals with the various characteristics of the SenSura® Mio bag (water-repellent textile, invisible under clothes, 360° filter, et cetera).

The majority (77.7%) of participating stoma care nurses were far more/more satisfied with the SenSura® Mio Convex Fit system than with the convex solutions currently available and 96.6% wished to continue using it in patients requiring a convex appliance.

Patients’ questionnaire

Overall, about 8 out of 10 patients (79.6%) were very satisfied/satisfied with the SenSura® Mio Convex Fit system, whether the coupling was mechanical or adhesive, particularly for the feeling of safety it provided (79.3% very satisfied/satisfied), the flexibility of the baseplate (88.9% very

satisfied/satisfied) which fits to real bodies and follows the movements of the body (84.9% very satisfied/satisfied) and for the ease of cleaning the baseplate (91.1% very satisfied/satisfied).

In the 126 patients often reporting leakages with their usual appliance, 76.4% were very satisfied/satisfied concerning the feeling of safety when wearing the new system and 38.1% (43 patients) stated they used fewer accessories than with their usual appliance.

In the 96 patients using a convex baseplate initially, 66.3% wished to continue using the new, flexible convex appliance, and 27.8% stated they used fewer accessories than before.

DISCUSSION

The results of this survey on the real life use of a new SenSura® Mio Convex Fit appliance confirm the high level of satisfaction among healthcare professionals and patients, concerning the technical characteristics of the SenSura® Mio range, convex or standard: flexibility of the baseplate that fits to a real body and follows the movements of the body; bag in water-repellent textile, invisible under clothes and fitted with a 360° filter.

In this survey, 6 out of 10 patients often had leakages initially. The use of a new appliance provided a feeling of safety to 8 out of 10 patients (79.3%), which was an essential element of patient satisfaction. Indeed, the concern over leakages is a major worry that gives rise to a lack of safety, impacting quality of life and not only affecting their social activities but also the quality of their sleep1. In addition, the Dialogue Study3 showed that leakages were the main factor in the development of peristomal lesions (48% due to irritation, 21% due to mechanical trauma and 7% due to allergy).

Figure 1: SenSura® Mio Convex Fit Flex (with adhesive coupling)

Figure 2: SenSura® Mio Convex Fit Click (with mechanical coupling)

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It should be noted that there are two convexity levels in France (deep and semi-convex). Therefore, it is essential to determine the degree of convexity that best suits the stoma and to choose the most appropriate appliance by considering the peristomal contour. Some manufacturers offer a guide for choosing the appliance, such as the Convexity Wheel from Coloplast.

CONCLUSION

The choice of stoma appliance is sometimes truly challenging. In this survey, 60.3% of patients often presented with leakages to their usual appliance and the majority had a stoma that was difficult to fit (invaginated stoma, hollow peristomal area, deep folds, et cetera). The use of the flexible convex appliance SenSura® Mio Convex Fit, capable of allowing the stoma to protrude and to follow the movements of the

body, is an interesting option for preventing the occurrence of leakages and helping to resolve peristomal skin complications. Seeking the advice of a stoma care nurse is recommended if the choice of an appliance proves difficult. A list of stoma care nurses is available on the AFET (Association Française d'Entérostoma-Thérapeutes – French Association of Stoma Care Nurses) website.

REFERENCES

1. Claessens I et al. The Ostomy Life Study: the everyday challenges faced by people living with a stoma in a snapshot. Gastrointestinal Nursing 2015; 13(5):18–25.

2. Boyd K, Thompson MJ, Boyd-Carson W & Trainor B. Use of convex appliances. Nurs Stand 2004; 18(20):37–38.

3. Martins L et al. Maintaining healthy skin around an ostomy: peristomal skin disorders and self-assessment. Gastrointestinal Nursing 2011; 9(2 Suppl):9–13.

Table 1: Satisfaction of stoma care nurses with SenSura® Mio Convex Fit Click and Flex (n=93)

Satisfaction with SenSura Mio Convex Fit

MD

Very satisfied

Satisfied

Moderately satisfied

Slightly satisfied

Not at all satisfied

Total

N N % N % N % N % N % N %

Overall satisfaction 4 23 25.8 56 62.9 10 11.2 0 0.0 0 0.0 89 100.0

Safety of appliance 4 33 37.1 51 57.3 5 5.6 0 0.0 0 0.0 89 100.0

Flexibility of baseplate 1 40 43.5 46 50.0 6 6.5 0 0.0 0 0.0 92 100.0

Capacity to fit to real body 3 32 35.6 49 54.4 9 10.0 0 0.0 0 0.0 90 100.0

Capacity to follow movements of body

5 25 28.4 54 61.4 9 10.2 0 0.0 0 0.0 88 100.0

Capacity to allow stoma to protrude and fit securely

4 33 37.1 47 52.8 9 10.1 0 0.0 0 0.0 89 100.0

Capacity to allow stoma to protrude, while being flexible

5 28 31.8 52 59.1 8 9.1 0 0.0 0 0.0 88 100.0

Ease of use of coupling 4 31 34.8 35 39.3 17 19.1 5 5.6 1 1.1 89 100.0

Ease of cleaning the baseplate

5 41 46.6 42 47.7 4 4.5 1 1.1 0 0.0 88 100.0

The SenSura® Mio bag: water-repellent textile, invisible under clothes, 360° filter, et cetera

4 61 68.5 28 31.5 0 0.0 0 0.0 0 0.0 89 100.0

MD: missing data

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RESUME

Les problèmes de peau péristomiale ou de fuites sous l’appareillage sont fréquents chez les personnes stomisées. L’intérêt des appareillages de stomies convexes pour prévenir les fuites est démontré en cas de stomies invaginées ou de zones irrégulières. Cependant, ces dispositifs convexes, du fait de leur habituelle rigidité, peuvent être à l’origine d’inconfort. Une enquête transversale multicentrique a été menée auprès de 93 professionnels de santé et 219 patients stomisés, afin de documenter l'expérience en situation réelle de vie, d'un nouvel appareillage de stomie, SenSura® Mio Convex Fit. La majorité (77,7%) des stomathérapeutes étaient beaucoup plus/plus satisfaites avec ce nouvel appareillage convexe flexible qu’avec les solutions convexes actuellement disponibles et 96,6% souhaitaient poursuivre son utilisation chez les patients nécessitant un appareillage convexe. La majorité des patients étaient également satisfaits, y compris ceux présentant fréquemment des fuites (n=126). Dans cette enquête, 60,3% des patients avaient souvent des fuites initialement, cependant l’utilisation du nouvel appareillage a procuré un sentiment de sécurité à 8 patients sur 10 (79,3%), élément essentiel de la satisfaction du patient. Ce support convexe flexible, capable de faire ressortir la stomie et de suivre les mouvements du corps, est une option intéressante pour prévenir la survenue des fuites et aider à résoudre des problèmes de peau péristomiale, sans compromettre le confort du patient. Il est recommandé de prendre l’avis d’une infirmière stomathérapeute en cas de difficultés quant au choix de l’appareillage.

Mots cles: Stomie, satisfaction, convexité, flexibilité, fuites.

INTRODUCTION

Il est aujourd’hui communément admis que les fuites sous l’appareillage représentent une des principales causes d’altération de la qualité de vie des personnes porteuses d’une stomie incontinente (recueil des effluents ou de l’urine dans une poche de stomie). Trois patients stomisés sur quatre présentent des fuites sous l’appareillage et neuf patients sur 10 craignent leur survenue1. En raison des variations de la morphologie de la zone péristomiale, le choix du bon appareillage peut être un véritable défi.

L’intérêt des appareillages convexes pour prévenir les fuites est bien établi: en cas de stomies invaginées ou affleurantes, la convexité permet de faire ressortir la stomie. De plus, elle permet d’aplanir les zones péristomiales irrégulières ou creuses. Ces supports permettent donc de diriger les effluents loin de la peau, d’améliorer l’adhésivité du support et de prévenir les fuites. Ils peuvent s’avérer intéressants notamment en présence d’effluents liquides et abondants2.

Intérêt d’un nouvel appareillage de stomie convexe flexible

Cependant ces dispositifs convexes du fait de leur habituelle rigidité peuvent être à l’origine d’inconfort. Des cas de lésions cutanées par pression sur la zone péristomiale ont de même été rapportés2. Le nouvel appareillage semi-convexe flexible, SenSura® Mio Convex Fit, équipé du concept unique de Flexlines (ou lignes de flexibilité), permet de faire ressortir la stomie et de prévenir les fuites sans compromettre la flexibilité, dans le but d’améliorer le confort physique et psychique du patient.

Une enquête a été réalisée afin d’évaluer la satisfaction des professionnels de santé et des patients avec ce nouvel appareillage en situation réelle de vie.

METHODOLOGIE

Cette enquête transversale multicentrique a été menée, dans les conditions de vie réelle, auprès d’infirmières stomathérapeutes et de leurs patients stomisés vus en consultation ou en hospitalisation et nécessitant un appareillage semi-convexe. Le recueil du consentement n’était pas requis. Les questionnaires étaient anonymisés. La satisfaction globale avec l’utilisation du nouvel appareillage 2-pièces, SenSura® Mio Convex Fit (Flex, Figure 1; ou Click, Figure 2) a été évaluée, notamment en termes de confort au port (flexibilité du support, capacité à s’adapter à la morphologie, à suivre les mouvements du corps), facilité d’utilisation (couplage, nettoyage) et sentiment de sécurité; ainsi que le souhait de poursuivre l’utilisation du produit.

PARTICIPANTS

Quatre-vingt-treize infirmières stomathérapeutes ont répondu au questionnaire et 219 patients, 158 pour le système Click et 61 pour le système Flex. Les participants étaient principalement des stomisés digestifs (98 iléo, 82 colostomisés et 30 urostomisés). La majorité présentait une stomie invaginée (34%) ou affleurante (44%). Par ailleurs, 59,2% des patients avaient une zone péristomiale creuse et 69,1% des plis superficiels ou profonds. Le recours à un appareillage convexe était principalement la nécessité de faire ressortir la stomie (68,4%) et la présence de fuites fréquentes (60,3%). Cela justifiait l’usage des accessoires chez 85,2% des patients, principalement pâte ou anneau de protection cutanée, ceinture ou renforts adhésifs.

RESULTATS

Questionnaire professionnels de santé

Au global, près de 9 infirmières sur 10 (88,7%) étaient très satisfaites/satisfaites du nouvel appareillage convexe

30


flexible (Tableau 1), que le couplage soit mécanique (89,8%) ou adhésif (86,7%). Le niveau de satisfaction était particulièrement élevé notamment en termes de sécurité de l’appareillage (94,4%), d’adaptabilité (90%) et de flexibilité du support (93,5%). Il est intéressant de noter la satisfaction unanime (100%) des professionnels de santé avec les caractéristiques distinctives de la poche SenSura® Mio (textile déperlant, invisible sous le vêtement, filtre 360°, ...).

La majorité (77,7%) des stomathérapeutes participantes étaient beaucoup plus/plus satisfaites avec le système SenSura® Mio Convex Fit qu’avec les solutions convexes actuellement disponibles et 96,6% souhaitaient poursuivre son utilisation chez les patients nécessitant un appareillage convexe.

Questionnaire patients

Au global, près de 8 patients sur 10 (79,6%) étaient très satisfaits/satisfaits du système SenSura® Mio Convex Fit, que le couplage soit mécanique ou adhésif, notamment pour le sentiment de sécurité qu’il procure (79,3% très satisfaits/satisfaits), la flexibilité du support (88,9% très satisfaits/satisfaits) qui s’adapte à la morphologie et suit les mouvements du corps (84,9% très satisfaits/satisfaits) et pour la facilité de nettoyage du support (91.1% très satisfaits/satisfaits).

Chez les 126 patients rapportant souvent des fuites avec leur appareillage habituel, 76,4% étaient très satisfaits/satisfaits quant au sentiment de sécurité lors du port du nouveau système et 38,1% (43 patients) ont déclaré utiliser moins d’accessoires qu’avec leur appareillage habituel.

Chez les 96 patients utilisant un support convexe initialement, 66,3% souhaitaient continuer à utiliser le nouvel

appareillage convexe flexible, de plus, 27,8% ont déclaré utiliser moins d’accessoires qu’avant.

DISCUSSION

Les résultats de cette enquête d’utilisation en situation réelle du nouvel appareillage SenSura® Mio Convex Fit confirment le niveau de satisfaction élevé des professionnels de santé et des patients, concernant les caractéristiques techniques de la gamme SenSura® Mio, convexe ou standard: flexibilité du support qui s’adapte à la morphologie et suit les mouvements du corps; poche en textile déperlant, invisible sous le vêtement et munie d’un filtre à 360°.

Dans cette enquête, 6 patients sur 10 avaient souvent des fuites initialement. L’utilisation du nouvel appareillage a procuré un sentiment de sécurité à 8 patients sur 10 (79,3%), élément essentiel de la satisfaction du patient. En effet, la crainte des fuites reste une préoccupation majeure qui fait naître un sentiment d'insécurité, impactant la qualité de vie et affectant non seulement leurs activités sociales mais également la qualité de leur sommeil1. De plus, l'étude Dialogue Study3 a démontré que les fuites étaient le facteur principal de développement des lésions péristomiales (48% d’origine irritative, 21% par traumatisme mécanique et 7% d’origine allergique).

Il est à noter qu’il existe en France deux niveaux de convexité (profonde et semi-convexe). Il est par conséquent essentiel de déterminer le degré de convexité qui convient le mieux à la stomie et de choisir l’appareillage le plus adapté en tenant compte de la morphologie péristomiale. Certains fabricants fournissent un guide de choix de l’appareillage, tel que la roue de la convexité des Laboratoires Coloplast.

Figure 1: SenSura® Mio Convex Fit Flex (avec couplage adhésif)

Figure 2: SenSura® Mio Convex Fit Click (avec couplage mécanique)

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CONCLUSION

Le choix de l’appareillage de stomie représente parfois un véritable challenge. Dans cette enquête, 60,3% présentaient souvent des fuites avec leur appareillage habituel et la majorité avait une stomie difficile à appareiller (stomie invaginée, zone péristomiale creuse, plis profonds…). L’utilisation de l’appareillage convexe flexible SenSura® Mio Convex Fit, capable de faire ressortir la stomie et de suivre les mouvements du corps, est une option intéressante pour prévenir la survenue des fuites et aider à résoudre des problèmes de peau péristomiale. Il est recommandé de prendre l’avis d’une infirmière stomathérapeute en cas

de difficultés quant au choix de l’appareillage. Une liste des stomathérapeutes est fournie sur le site de l’AFET (Association Française d'Entérostoma-Thérapeutes).

BIBLIOGRAPHIE

1. Claessens I et al. The Ostomy Life Study: the everyday challenges faced by people living with a stoma in a snapshot. Gastrointestinal Nursing 2015; 13(5):18–25.

2. Boyd K, Thompson MJ, Boyd-Carson W & Trainor B. Use of convex appliances. Nurs Stand 2004; 18(20):37–38.

3. Martins L et al. Maintaining healthy skin around an ostomy: peristomal skin disorders and self-assessment. Gastrointestinal Nursing 2011; 9(2 Suppl):9–13.

Tableau 1: Satisfaction des stomathérapeutes avec SenSura® Mio Convex Fit Click et Flex (n=93)

Satisfaction avec SenSura Mio Convex Fit

DM

Très satisfait

Satisfait

Moyennement satisfait

Peu satisfait

Pas du tout satisfait

Total

N N % N % N % N % N % N %

Satisfaction globale 4 23 25.8 56 62.9 10 11.2 0 0.0 0 0.0 89 100.0

Sécurité de l'appareillage

4 33 37.1 51 57.3 5 5.6 0 0.0 0 0.0 89 100.0

Flexibilité du support

1 40 43.5 46 50.0 6 6.5 0 0.0 0 0.0 92 100.0

Capacité à s'adapter à la morphologie

3 32 35.6 49 54.4 9 10.0 0 0.0 0 0.0 90 100.0

Capacité à suivre les mouvements du corps

5 25 28.4 54 61.4 9 10.2 0 0.0 0 0.0 88 100.0

Capacité à faire ressortir la stomie et à la maintenir

4 33 37.1 47 52.8 9 10.1 0 0.0 0 0.0 89 100.0

Capacité à faire ressortir la stomie, tout en étant flexible

5 28 31.8 52 59.1 8 9.1 0 0.0 0 0.0 88 100.0

Facilité d'utilisation du couplage

4 31 34.8 35 39.3 17 19.1 5 5.6 1 1.1 89 100.0

Facilité de nettoyage du support

5 41 46.6 42 47.7 4 4.5 1 1.1 0 0.0 88 100.0

La poche SenSura® Mio: textile déperlant, invisible sous le vêtement, filtre 360°,...

4 61 68.5 28 31.5 0 0.0 0 0.0 0 0.0 89 100.0

DM données manquantes

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BACKGROUND

Mr RS was a 69-year-old male admitted for elective surgery for colorectal cancer with peritoneal metastasis. He underwent a peritonectomy with hyperthermic intra-peritoneal chemotherapy (HIPEC), bilateral diaphragm stripping with a large piece of his right diaphragm removed, left diaphragm stripping, splenectomy, hilar dissection, total colectomy, diaphragm repair, and formation of end ileostomy.

He was seen for pre-operative counselling, education and siting by the stomal therapy nurse (STN). At the time of his abdominal assessment it became apparent that siting would be very problematic. The length of his abdomen was relatively short with multiple creases and skin irregularities noted. Two experienced STNs deemed that only a very small portion of abdomen could be an appropriate location. Mr RS was quite interactive during the pre-operative counselling and his stoma siting. It is important that the patient is involved in the final choice of stoma position as they can be more accepting of its final location and more actively participate in their own care1.

While post-operatively his stoma had been assessed to be the most suitable location identifiable, his recovery was heavily impacted with complications such as an intra-abdominal collection, mid-abdominal wound dehiscence, high stoma output, and poor oral intake. A multidisciplinary team methodology was implemented to develop a holistic approach to his care and subsequent recovery. This case study examines the usage of a new skin barrier and stomal therapy nursing creativity in managing this complex case.

CHALLENGES

As discussed, Mr RS faced numerous challenges after surgery. Notably his poor oral intake led to weight loss and malnutrition, leading to altered abdominal contours. Despite his reduced oral intake, he suffered from high stoma output — ranging from two to three litres of watery and erosive stool

Melanie PerezRN — Stomal Therapy St George Public Hospital Kogarah, NSW, Australia Email [email protected]

Location, creation and emotion: Three critical components for managing a complex case

per day. The weight loss and high stoma output caused his abdomen to further sink (almost concave), leading to deep lateral creases at 3 o’clock and 9 o’clock (Figure 1). The stoma was created with the lumen facing the 6 o’clock position so when the stoma discharged it would often lift the skin barrier of the pouching system from the peristomal skin. These multiple factors contributed to repeated leakages and peristomal moisture-associated skin damage (PMASD) which became cyclic in nature with his worsening skin condition. Compounding these issues, his midline wound dehiscence limited the skin barrier footprint that we were able to apply. The proximity of a surgical drain so close to the peristomal area also made adhesion even more difficult. Multiple pouching systems were assessed with varying accessories but with limited to no success. The patient became highly anxious and less keen to try different stoma products with these continued failures.

To create modifications and to adjust to their new lifestyle, stoma patients need appropriate support2. The experience of stoma formation can be discouraging and in some extreme cases, completely debilitating without proper care, support and rehabilitation2. Extensive counselling regarding his stoma care was provided to both Mr RS and his wife. Multidisciplinary team involvement was highly utilised, but despite all the support, constant reassurance and multiple products evaluated, his case had been somewhat ‘hit and miss.’ Patients with ill-fitting pouching systems are noted to have psychological morbidity leading to prolong adaptation3.

Figure 1: Stoma creases and irregularities

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MANAGEMENT AND INTERVENTIONS

During this readmission, his abdomen was extensively assessed and reassessed in the lying and sitting positions. Multiple factors were given consideration and we advised Mr RS that we would implement a new pouching system and adhere to this plan for a defined period to assess its impact. He was placed into a new Dansac two-piece GX+ convex skin barrier, corresponding high-output stoma pouch, and skin barrier accessories (one large and one small flat barrier ring/seal) (Figure 2).

The high flexibility of the barrier allowed for secure conformation to the peristomal skin irregularities and its high erosion-resistance was ideal for addressing the nature of his output. The option to connect it to another collection system to reduce the weight on the skin barrier adhesive has kept the pouch empty when required — resulting in no leakages. Adding an ostomy belt to the belt tabs helps keep the pouch in place while promoting his independence and mobility. Utilising this barrier formulation has also given us an option to change it every second day to allow the peristomal skin recovery time from stripping (Figure 3).

Mr RS was given the option of re-fashioning the stoma but has now declined given the great success since using this barrier formulation. He has verbalised he just wants to go home, recuperate and heal completely, while waiting for his reversal when the time is right. A secure and well-fitted stoma pouch is crucial and plays a vital role on the patient’s journey towards adjusting to their stoma3.

OUTCOME

Mr RS was discharged with a renewed sense of hope and inspiration to live a full life in the country while awaiting his reversal. His ability to enjoy activities now affords him a good quality of life4. Mr RS just wanted to be able to return home without worrying about his pouching system and his skin care issues. He now changes his pouch every Monday, Wednesday and Friday as per his preference. This management method has given back the life in his eyes and the smile on his face.

NOTE

Dansac & GX+ are registered Trademarks of Dansac A/S Fredensborg, Denmark.

REFERENCES

1. Cronin E. Stoma siting: why and how to mark the abdomen in preparation for surgery. Gastrointestinal Nursing 2014; 12(3):12–19.

2. Taylor C, Lopes de Azevedo-Gilbert R & Gabe S. Rehabilitation needs following stoma formation: a patient survey. Br J Commun Nurs 2012; 17(3):102–107.

3. Williams J. The importance of choosing the correct stoma appliance to meet patient needs. Br J Commun Nurs 2017; 22(2):58–59. CINAHL Complete, EBSCOhost, viewed 26 February 2017.

4. Burch J. Exploring quality of life for stoma patients living in the community. Br J Commun Nurs 2016; 21(8):378–382.

Figure 2: Pouching system and accessories

Ongoing attempts at finding the best product suitable for this patient were curtailed after his request to be transferred to a hospital closer to his own home that he had been away from for some months. He was handed over to a local STN and was on a soft convex skin barrier with seals (barrier rings) at the time he was transferred.

After three weeks, he returned to our facility with no change in his oral intake and continued weight loss. On assessment, his peristomal skin was significantly worse with mild bleeding. He had been using a pouching system with a flat skin barrier and a large skin barrier seal. He verbalised they had been having the same ongoing leakage issues, PMASD and product failures.

Figure 3: PMASD

34


PRESIDENT

Candidate:

Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, ETN, MAPWCA, FAAN (New York, USA)

Present employment:

Faculty, Excelsior College School of Nursing, New York, University of Toronto, IIWCC Faculty, Toronto, Abu Dhabi and IIWCC NYU Course Director, Clinical Editor, Advances in Skin and Wound Care journal, WoundPedia Course Director — Philippines and New York, President, Ayello Harris and Associates, Inc. New York, NY, USA

Professional qualifications:

I have been an active member of the WCET™ since 2002. For 10 years, I served as Executive Editor of the WCET™ Journal, was bestowed the title of Executive Journal Editor Emeritus in 2014 and still continue to serve on the WCET™ Journal Editorial Board. In that capacity, I perform peer review of various manuscripts, mentor new authors, seek out authors to write manuscripts that might have potential for publication in the journal, and also submit manuscripts that along with my professional colleagues we have written.

Since my election as WCET™ Vice-President in 2014, for over the past three years I have worked with the WCET™ President, members of the WCET™ Executive Board and the WCET™ Management Company to operationalise the WCET™ strategic plan and attend to the organisational processes and logistics necessary to help lead the WCET™. I have used the skills and experiences gained from my previous WCET™ positions as well as from other national and international organisations (Past Board of Director and President of the National Pressure Ulcer Advisory Panel (NPUAP), Chairperson of the WOCN© Accreditation Committee, and Board of Director of the American Professional Wound Care Association (APWCA)).

Some of my WCET™ achievements are:

• Worked with the President to reorganise and improve the operations of the WCET™.

• For each issue of the WCET™ BullETin, I have worked with the Chairperson of WCET™ Publications and Communications on the WCET™ BullETin regarding ideas, proofing and writing a VP message.

WCET™ board nominations

• Served as the board liaison to the International Delegates (ID). Created a Certificate of Appreciation and sent it to IDs who completed their volunteer service in 2014, 2015 and 2016. Revised and distributed to all the IDs the updated the WCET™ ID handbook. Sent welcome email to new IDs. Have increased the number of IDs that have posted welcome letters in their own language to their country members when they log onto the WCET™ website.

• Have coordinated the newly created WCET™ Wound Wise Column in the American Journal of Nursing (AJN) which began in 2016. The AJN is the oldest general nursing journal in the USA. It also has a large international readership. Having this column in the AJN has increased our visibility for our specialty to the general nurse as well as introduced them to the WCET™.

• Reviewed, revised and worked with Jen (Bank) Wood from our management company regarding the 2015 and the 2017 Membership Survey. Thanks to WCET™ members who volunteered, both surveys were translated into multiple languages. For 2017, the survey is now in five languages other than English. In 2015 for the first time, there were more survey respondents in languages other than English. Results from the 2015 survey were presented at the general business meeting in Cape Town and published in issue 1 2017 of the WCET™ Journal.

• Served as a liaison to the WCET™ Constitution Advisory Panel. The WCET™ Constitution was successfully revised in 2016.

• Worked with the President to regularly communicate together and separately with WCET™ members via email.

• Helped to advertise and promote the 2018™ WCET Congress in Kuala Lumpur and the 2016 Congress in Cape Town.

• Responded to the Executive Editor’s requests to peer review articles, solicit articles for the WCET™ Journal and promote new advisements and/or supplements in the journal.

• Helped create and edited the WCET™ Ostomy Pocket Guide.

• Solicited speakers and assisted in reviewing slides for some of the WCET™ webinars.

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www.wcetn.org

• Work to develop leadership skills for WCET™ members with the important goal of educating the next generation of the WCET™ Executive Board, Committee and Panel members.

• Continue to support existing educational projects as well as develop new educational projects to promote WCET™ nursing worldwide.

• Work to increase WCET™ membership worldwide.

• Be an advocate and represent the WCET™ at professional meetings.

• Explore new opportunities to continue to contribute to the WCET™ finances.

• Communicate with the WCET™ membership through the President’s message in the WCET™ Journal.

• Promote the WCET™ in all of my other professional work, contacts and educational presentations.

It would be an honour and privilege to have the opportunity to continue to serve the WCET™ by being elected to serve as your 2018–2020 President. Please consider my professional qualifications and past achievements as you consider my candidacy for this vital office for our organisation.

VICE-PRESIDENT

Name:

Laurent Chabal (Morges, and Geneva, Switzerland)

Present employment:

Ensemble Hôpitalier de la Côte — Morges, HES-SO University of Applied

Sciences and Arts Western Switzerland, School of Health Sciences, Geneva; HES-SO Haute Ecole Spécialisée de Suisse occidentale, Haute école de Santé, Genève


RN, Specialised Nurse, University of Applied Sciences Lecturer

Professional activities:

ET in Ostomy and Incontinence care (50% time job), Teacher, University Conference Model Coordinator (40% time job)

Objectives if elected to nominated position:

If I am elected as your Vice-President, I:

• Will work with the WCET™ President, our Management Company and the members of the Executive Board (EB), in order to assist with the necessary logistical operation.

• Will make the link with/between the members, the International Delegates (ID) and the EB.

• Will do my best to serve, support and help as needed or requested.

• Networked with colleagues to benefit the WCET™ including having the WCET™ as one of the organisations to issue the Cape Town Declarations on Diabetes and Diabetic foot care.


• Board-certified wound and ostomy nurse.

• Writer/editor author of over 200 peer-reviewed journal articles and book chapters. Co-author/co-editor of two wound care books, the WCET™ International Ostomy Guideline, WCET™ Ostomy Pocket Guide, WCET™ NNG Festschrift Book.

o Researcher and member of interprofessional teams. Most recent published study is on education of nurses in the USA on pressure injuries. Advances in Skin and Wound Care 2017, 30(2).

• Educator — For over 15 years, have taught with interprofessional teams with special focus on providing education in emerging countries. Created and continue to teach a basic and intermediate WoundPedia course in USA and the Philippines. Have partnered with the military in the Philippines to enhance their knowledge of wound and ostomy care.

• Mentor — Role model and mentor to health care professionals in USA and worldwide on education, research, practice and nursing/organisational leadership.


If I am elected as your President, I will:

• Bring my energy, enthusiasm, and international network connections to perform the duties and responsibilities as the lead officer of the WCET™.

• Continue to work vigorously to implement the vision and mission to further enhance the WCET™.

• Work with the Executive Board, WCET™ Management Company, IDs, Industry partners, and Professional Organisations to implement the WCET™ action plan derived from the strategic plan.

• Continue to communicate regularly with WCET™ members via email and other media and respond to your needs and feedback to enhance our organisation.

• Network with health care professionals, societies and others on behalf of the WCET™.

• Seek new and creative initiatives for the WCET™.

• Help plan the celebration in 2020 which will recognise the 100th anniversary of the birth of Norma N. Gill.

• Increase the visibility of the WCET™ and seek new opportunities to achieve its mission throughout the world.

36


• Will work with the incoming WCET™ Publications and Communications Chairperson in order to ensure a smooth transition.

• Will send (probably with some help) the written VP message on time for the BullETin.

• Wish to learn more about WCET™ business and keep this incredible luck to take part of this amazing adventure.

TREASURER

No nominations

EDUCATION CHAIRPERSON

Name:

Denise Hibbert (Riyadh, Saudi Arabia)

Present employment:

Clinical Specialist Director Colorectal Therapy Program, King Faisal Specialist Hospital & Research Centre


RGN, DipHE, BSc (hons), ONC, STN, FSSCRS, MSc (wound healing and tissue repair)


World Council of Enterostomal Therapists (WCET) Education Committee Chairperson (2016–2018), Saudi Society Colon and Rectal Surgery (SSCRS) — Executive Board Member, Saudi Enterostomal Therapy Chapter of the SSCRS — Founder & Chair, International Council of Nurses/Advanced Practice Nurses — Education Committee Chair, SSCRS —Education Committee Member, KFSH&RC Research Council Member, KFSH&RC Nursing Affairs Council Member, KFSH&RC Nursing Credentialing and Privileging Committee, KFSH&RC Program Directors Operational Committee, Organising Committee annual International Saudi Colorectal Disease Forum, Organising Committee annual Colorectal Disease Public Awareness Day, Chair Nursing Day: SWC: International Saudi Colorectal Disease Forum


• To strengthen and broaden the Education Committee membership.

• To increase networking between WCET ETNEP/REP directors and educators.

• To increase number of certified stoma therapists in Middle Eastern countries.

• To advocate for continence services in the Middle East, especially in Saudi Arabia.

NNGF CHAIRPERSON

Name:

Arum Ratna Pratiwi (Surabaya, Indonesia)

Present employment:

Head Dept of Nursing Development,

Wound Care Coordinator, Siloam Hospitals

Surabaya


• Enterostomal Therapist

Indonesian ETNEP, 2007

• Nurse

Sekolah Tinggi Ilmu Kesehatan (STIKES) St Vincentius A

Paulo Surabaya-Indonesia, September 2010.

D3 of Nursing — Malang Nursing Academy —

Indonesia, 1998.


• Nurse at Maternity ward, 1998–2001

• Nurse at Medical Surgical ward, 2002–2005

• Wound Care Nurse, 2005–2008

• Wound Care Coordinator, 2008 – present

• Wound Care Coordinator Siloam Hospitals Group-

Indonesia, 2011 – present

• Head Dept of Nursing Development Siloam Hospitals

Surabaya, 2013 – present

Organisational experience:

• Committee Member of NNGF Committee 2012 – present

• Indonesian International Delegate for WCET, 2012 –

present

• Education Committee Chairperson for Indonesian

Enterostomal Therapy Association (InETNA), 2010–2012


I would like to maximise the role of NNGF by:

• Working closely with the NNGF committee and WCET

board to ensure the mission of the NNGF is foremost.

• Creating easier ways for members or others to donate to

NNGF, thus maximising NNGF funding.

• Setting priority for the distribution of scholarships.

37

www.wcetn.org

PUBLICATIONS AND COMMUNICATIONS CHAIRPERSON

Name:

Karen Bruton, RN, BScN, MCISc-WH CETN(C) (British Columbia, Canada)

Present employment:

Outpost Nursing on First Nations Reserves in Northern Ontario and Community Health Nurse including Public Health and

Immunisations (Bayshore Nursing); Outpost Nursing on First Nations Reserves in Northern BC and Community Health Nurse (Solutions Agency)


RN, BScN, MCISc-WH, CETN(C)


Non-Profit Association Member and Postitions Held

Registered Nurses Association of Ontario (2006 – 2014)

Workplace Liaison

Association for The Advancement for Wound Care (2010 – present)

Research Committee

World Council of Enterostomal Therapists (2008 – present)

International Delegate 2012–2016; Publications and Communications Committee

Canadian Association of Enterostomal Therapists (2008 – present)

President 2010-2012; National Conference Planning Chair

Canadian Association for Wound Care (2002 – present)

Research Committee; Education Committee

Ontario Nurses’ Association (1998 – 2011)

ONA Grievance; Bargaining Unit President; Local 105 Coordinator

Four County Wound Care Committee (1998 – 2012)

Vendor Liaison; Conference Planning Chair

Professional practice leader – past responsibilities

• Online eLearning Centre (Medworxx) — program development and system management

• Clinical needs — one on one, bedside education, short in-services and full day education — available immediately for staff when requested or booked

• Orientation of new RNs and RPNs; follow up on new staff

• Special needs — nurses

• SharePoint Internet Platform for Educational Services

• Meditech — teach Order Entry and or Online Documentation

• Ontario Televideo Network System support help

• Trials & evaluation of new products

• Project Charter and Briefing Notes submissions

• New grad follow-up — support system

• Bring in vendors — offer in services for new products — sometimes include free meals

• Wound and Ostomy Care Consults

• Ostomy education — new ostomy patients and nurses; problem solving for difficult stomas

• West High School — health careers — usually spring — 4 Wednesdays 45 minutes

• Co-Op high school student rotation

• I have organised five large conferences and multiple small educational events. The attendance for the large conferences have been anywhere from 110 to 240. Income raised for each event on an average is approximate $10,000.

Committees

• HealthPro (GPO) — member of the national Clinical Advisory Committee

• Interprofessional Practice Committee

• Nursing Advisory Committee

• Falls Committee

• Occupational Health and Safety Committee

• Skin Ulcer Prevention and Wound Healing — Chair

• Safe Medication Committee

• Four Counties Wound Committee

• Registered Nurses Association of Ontario Workplace Liaison; Northumberland County Rep

Liaisons

• Four County Wound Care Committee — vendor liaison.

• Chair of four past conferences — net profit from each conference $8,000–14,000

• Canadian Association of Enterostomal Therapists

• President Elect 2008–2010

• President 2010–2012

38


• 2010 — Conference Chair — Record attendance (426 attendees);

• Abstract Review Panel — 2014, 2015, 2016 (with WOCN joint Conference)

• World Council of Enterostomal Therapists—– International Delegate — 2012–2016

• M e m b e r o f t h e W C E T P u b l i c a t i o n s a n d Communications Committee

• Abstract Review Panel — 2014, 2016

• Research Committee with Laura Bolton — 2012 to present

Ontario Nurses’ Association

• ONA Grievance and Bargaining Unit President of 160 members 1998–2006

• Local 105 Coordinator (14 facilities — 604 members) 2002–2012

• Chair: 4 yearly meetings — 17 executive

• Accountable and responsible for managing our yearly budget of $110,000.00

Roll of Honour Industry 2016

Norma N Gill Foundation

The following companies have generously given donations towards the NNGF scholarships

• Booking and organising nursing functions (i.e. Nursing Week) approximately 30 to 150 attendees

Projects/presentations

• 2012 participated on the development panels for the Registered Nurses Association of Ontario’s Best Practice Guideline Assessment and Management of Foot Ulcers for People with Diabetes and in 2008 Ostomy Care.

• Presented at many national (CAET, CAWC, local events and for industry) and international conferences (Australia, Sweden, South Africa, USA)

• Wound Care educational workshops (1 to 2 days) private and industry. Various topics including Conservative Sharp Wound Debridement Volunteered one week at a Haiti Hospital — 2014


I will promote WCET Core Values which consists: respect, integrity, communication, holistic care and scientific approach. As a Chairperson Publications/Communications Committee I will encourage and motivate member participation which includes: sharing experiences; getting involved with WCET work; writing articles; et cetera. I will be responsible to efficiently complete the activities of the Chairperson Publications Communications Committee.

39

www.wcetn.org

Product news

NEW Aurum® Profile with Manuka Honey

Soft and mouldable, conforms to anybody profile.

Provides a secure seal around complex body contours where a flat flange is not suitable.

Ideal for:

• Parastomal hernias

• Peristomal irregularities

For more information visit: wellandmedical.com/aurum-profile-ostomy-range

Roll of Honour Members 2017The following persons have very generously given financial support to help promote

enterostomal therapy (ET) nursing and to assist nurses to become members of WCET.

Norma N Gill Foundation

Sponsored a memberGreg Paull – Australia

Deidre Anne Wough – South AfricaPaula Erwin Toth – USA

Karen Kennedy-Evan – USARoxanne Elling – USA

Dorothy Doughty – USAMamdouh Taha – Abu Dhabi

Karen Hill – USAJanet Stoia Davis - USAOther member donationsHong Yang Hu – China

Wang Qing Hua – ChinaIrma Puspita Arisanty – Indonesia

Nguyen Thi Lam – VietnamSue Delanty – AustraliaGeeta Kumari – India

Frances Geschimsky – USADinusha Peiris – Colombo

Endang Saptarini – IndonesiaGenevieve Cahir – Australia

Areej Alqatifi – Saudi ArabiaSusan Stelton – USA

Julie Elizabeth Cannoly – AustraliaHileni Samuel – Namibia

Jane Fellows – USAKathryn Froiland – USA

Wen-pei Huang – TaiwanDiane Krasner – USAJing Hua Mei – China

Huei-chun Wu – TaiwanAdriane Pereira – Brazil

Lu Gan – ChinaXiao Di Hu – China

Quihong Xiang – ChinaHanzhang Tian – China

Cuie Zhang –ChinaYuhong Zhang – China

Dan Ren – ChinaEuodia Kristiani – Indonesia

Qing Li – ChinaLiu Chun – China

Analyn Abordo – PhilippinesKaren Kennedy-Evan – USA

Mary Brennan – USAJudea Tan – USA

Mamdouh Taha – Abu DhabiRong Mei Tan – Malaysia

Ying Zhang – ChinaNobuko Murphy – Australia

Locadie Hamadi – FranceShirley Hewerdine – Australia

Tarik Alam – CanadaDana Balassa – USA

Tina Beckerton – CanadaLinda Benskin – USA

Launa Dahm – CanadaBree Goodman– Canada

Richard Gustavson - USALeslie Heath - Canada

Corey Heerscaap - CanadaResemary Hill – CanadaKelly Jaswarowski – USA

Monica Koch – USATerri Labate - Canada

Ann Le Mesurier - CanadaElizabeth McElroy - USA

Vicky Polak - CanadaElizabeth Savage - USA

R. Gary Sibbald - CanadaPatrycja Skotniczna - Canada

Misty Stephens - CanadaAnna Tumchewics – Canada

Ling Yiu - China

40


WCET™ International DelegatesALGERIAID needed

AUSTRALIASharon BoxallEmail [email protected]

AUSTRIAID needed

BAHRAIN, KINGDOM OFEman Al JahmiEmail [email protected]

BELGIUMBrigitte CrispinEmail [email protected]

BOTSWANAChabo MbangiwaEmail [email protected]

BRAZILSee Hee Park KimEmail [email protected]

CANADAKimberly LeBlancEmail [email protected]

CHILEHeidi Marie Hevia CamposEmail [email protected]

CHINAZheng Mei ChunEmail [email protected]

COLOMBIASandra GamboaEmail [email protected]

COSTA RICAAndrés Campos VargasEmail [email protected]

CROATIAMarija Hegedus MateticEmail [email protected]

CZECH REPUBLICIva OtradovcovaEmail [email protected]

DENMARKJette KundalEmail [email protected]

ESTONIAJanne KukkEmail [email protected]

FINLANDAnn-Cristin Smidslund-RastasEmail [email protected]

Kingdom of Bahrian

Hiske Smart

Wound Healing and Hyperbaric Unit

King Hamad University Hospital

Shaikh Isa Bin Salman Causeway

Al Sayh, Kingdom of Bahrain

Tel. +973 1744 4444

[email protected]

FRANCEMartine PagesEmail [email protected]

GERMANYHans-Juergen MarkusEmail [email protected]

HONG KONGSiu Ming (Susan) LawEmail [email protected]

HUNGARYTimea CsiszarEmail [email protected]

INDIAHemlata GupteEmail [email protected]

INDONESIASaldy YusufEmail [email protected]

IRANSetareh Azizi ElizeEmail [email protected]

IRELANDMarianne DoranEmail [email protected]

ISRAELRuthy EfarganEmail [email protected]

ITALYGian Carlo CaneseEmail [email protected]

JAPANHitomi KataokaEmail [email protected]

KENYAPatrick Mutuma KiambiEmail [email protected]

KOREA, SOUTHHae Ok LeeEmail [email protected]

MACAUKit Weng HoEmail [email protected]

MALAYSIAYeng Lai NgEmail [email protected]

MEXICOGuadalupe Maria Lobo CorderoEmail [email protected]

NAMIBIALaura ObbesEmail [email protected]

NEPALShanti BajracharyaEmail [email protected]

NETHERLANDSKitty PeetenEmail [email protected]

NEW ZEALANDFrancesca MartinEmail [email protected]

NIGERIAOgbonna Martina NwadinkpaEmail [email protected]

NORWAYGrethe Foelstad LundEmail [email protected]

OMANID needed

PHILIPPINESPaula Cristina QuiambaoEmail [email protected]

POLANDMagdalena LeykEmail [email protected]

PORTUGALIsabel Morais SantosEmail [email protected]

PUERTO RICOElsa SantiagoEmail [email protected]

ROMANIACristina GhiranEmail [email protected]

RUSSIAMaria GolubevaEmail [email protected]

SAUDI ARABIALouise RaffertyEmail [email protected]

SERBIAŽivka MadzicEmail [email protected]

SINGAPOREChoo Eng OngEmail [email protected]

SLOVENIAID needed

SOUTH AFRICAMonica FranckEmail [email protected]

SPAINID needed

SRI LANKADammalage Udena Athua KumaraEmail [email protected]

SWEDENEva BengtssonEmail [email protected]

SWITZERLANDKaren ReisenEmail [email protected]

TAIWANKai-Li LeeEmail [email protected]

THAILANDYuwadee KestsumpunEmail [email protected]

TOGOVincent Kokou KouamiEmail [email protected]

TURKEYAyise KaradagEmail [email protected]

UNITED ARAB EMIRATESGulnaz TariqEmail [email protected]

UNITED KINGDOMMaddie WhiteEmail [email protected]

UNITED STATESShelly Burdette-TaylorEmail [email protected]

VIETNAMLam (K. Ngoai Tieu hoa) Nguyen Email Thi [email protected]

ZIMBABWERudo MutekedzaEmail [email protected]

Is your ID missing?If you are not receiving emails from WCET™ or your ID, please check your email address on the database as many emails are bouncing back!

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WCET Journal - World Council of Enterostomal Therapists september 2017.pdf · a world of expert...

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Transcript of WCET Journal - World Council of Enterostomal Therapists september 2017.pdf · a world of expert...