INTRODUCTION

Incontinence-associated dermatitis (IAD) is a common and underrecognized painful skin condition that is caused by erosion of the skin from chronic exposure to urine, stool, or both because of incontinence.1 In the pathophysiology of IAD, mechanical factors such as changes in skin pH because of irritants in urine and stool, frequent skin cleaning with microorganisms, an airless environment created by incontinence pads, and friction also play a significant role.2,3 Due to this influence of myriad factors, it was thought that IAD should be differentiated from diaper dermatitis. However, moisture-associated skin damage (MASD) is an umbrella term, with IAD being one specific form of MASD. To further understand the International Classification of Diseases (ICD) codes, the World Health Organization classifies MASD as irritant contact dermatitis, whereas IAD describes the skin damage associated with exposure to urine, stool, or a combination of these in adults (ICD-11 EK02.22).4

Hemodynamic instability, poor tissue perfusion and oxygenation, the presence of medical devices, restricted mobility, medication use (eg, tranquilizers, vasoactive drugs, corticosteroids), malnutrition, and urinary and fecal incontinence increase the risk of developing IAD in intensive care patients. In ICUs, the benefits of preventing IAD may be ignored because of nurses’ excessive workload,5 inadequate or inconsistent evaluation of at-risk patients,6 and the ICU’s prioritization of addressing the patient’s primary health problem.1,7,8

The incidence of IAD varies in ICUs, where many risk factors are present. Causative factors such as exposure to urine and/or feces, along with general risk factors such as type and frequency of incontinence episodes, poor skin condition, medications, nutrition status, critical illness, diarrhea, enteral tube feeding, immobility or compromised mobility, hypoxia, hyperthermia, infection, and pharmacologic use (inotropes, vasopressors, aperients, steroids), pose threats to skin integrity.8 A comprehensive literature review indicated that the prevalence of IAD in intensive care varies between 61.5% and 95%, whereas its incidence varies between 23% and 50%.7 Another study reported an incidence ranging between 15% and 36%.9

No researchers have investigated the prevalence of IAD in Turkey. According to the literature, the prevalence of urinary incontinence in women living in the community ranged from 16.4% to 49.5%, and the prevalence of fecal incontinence in all individuals living in the community was 8.9%.10–12 Kara et al13 reported that of 1,532 dermatologic cases in an ICU between 2008 and 2013, 25% of patients experienced IAD and stasis dermatitis. Skin care and evaluation are basic elements of nursing care.14

Previous studies have measured nurses’ level of knowledge about IAD prevention and management, and one evaluated the knowledge of the healthcare team.15–17 Qiang et al18 conducted a single-center study that included intensive care nurses. Three studies were conducted in Turkey.19–22 The objectives in these studies included scale adaptation and validation, determining nurses’ knowledge level, and evaluating nurses’ ability to distinguish between IAD and pressure injuries (PIs).19–22

Across these studies, nurses had an insufficient level of knowledge regarding IAD.15–19 This may lead to underreporting of IAD, prolonged treatment and care processes, and PI development.23 Nursing care should be based on evidence-based practice, not unsystematic clinical experience. Nurses should use the best available clinical evidence for decision-making to reduce the risk of complications and improve the level of nursing care that is provided.14

Ensuring that nurses have adequate knowledge of IAD and use evidence-based guidelines for IAD treatment is essential for the prevention and management of IAD. Understanding nurses’ knowledge level of IAD can identify knowledge gaps and ultimately provide information for translating evidence-based IAD guidelines into clinical practice. In this study, the authors aimed to determine the knowledge level of nurses working in intensive care settings where IAD rates are high.

METHODS Study Design and Setting

This descriptive, cross-sectional, multicenter study was carried out in the adult ICU of two private and three state hospitals located in the central districts of a province in Turkey.

Participants

Hospitals in the central districts were stratified as state, private, and training research hospitals using a simple random sampling method in the selection of the sample. Of the 400 nurses working in the adult ICUs of the specified hospitals, 296 nurses agreed to participate and were included in the study.

The authors conducted post hoc analysis on the required sample size for the study using the rate of IAD knowledge in Barakat-Johnson et al16 as a reference value. With an effect size of 0.26, α of .05, and a sample size of 296, the power was calculated to be 100.0%.

Data Collection

A researcher collected data during the day shift (outside of the intensive care nurses’ shift hours) from September to June 2021. Two forms were used for data collection: the Nurse Descriptive Characteristics Form and the IAD Knowledge Test. The forms were self-completed by the nurses and took approximately 15 minutes to complete.

Nurse Descriptive Characteristics Form

This form was prepared by the researchers within the framework of the literature.15,19,24 The comprehensibility of the form was confirmed by a preliminary application to five nurses. The form includes eight questions related to nurses’ demographic characteristics: age, sex, education level, type of intensive care, intensive care level, career length, intensive care experience, and IAD training.

IAD Knowledge Test

The researchers used similar studies and guidelines to create this questionnaire evaluating nurses’ IAD knowledge.3,4,19,22–25 The form consists of 40 true/false test items that include information about the definition, prevention, and treatment of IAD. It covers the following topics: structure and functions of skin (3 questions), etiology of IAD (11 questions), definition of IAD (13 questions), classification and evaluation of IAD (4 questions), and IAD prevention and treatment interventions (9 questions). After the questions were prepared, a statistics department lecturer, a nursing department lecturer, and a specialist intensive care nurse reviewed and finalized them. The Cronbach α coefficient of the items was .94. Researchers evaluated the answers by number and percentage correct and mean score.

Data Analysis

Researchers used SPSS 24 software (IBM Corp) for data analysis. Descriptive statistics (eg, mean, SD) were used to evaluate continuous variables, whereas frequency and percentage were used for qualitative variables. The researchers checked the data for anormal distribution, as well as skewness and kurtosis values. They used Mann-Whitney U and Kruskal-Wallis tests to compare the qualitative variables. The relationship between the variables specified in the measurement and the IAD knowledge level was evaluated with the Spearman correlation test. P < .05 was considered significant.

Ethical Approval

The researchers conducted this study within the framework of the Declaration of Helsinki. It was approved by the university’s noninterventional ethics committee (no. 2021/5, dated May 5, 2021). All participants provided informed consent to participte in the study.

RESULTS

Table 1 shows the proportions of nurses’ responses to IAD statements. Nurses provided the highest number of correct responses to the following three statements: “Excess moisture and fluid can disrupt the skin’s barrier function.” (79.1%, n = 234), “IAD is a painful and unsettling skin problem” (69.6%, n = 206), and “Exposure to urine/feces or both is the most important risk factor for the development of IAD.” (67.9%, n = 201). Nurses provided the lowest number of correct responses to the following three statements: “Viable tissue loss develops first in IAD” (6.7%, n = 37), “The presence of redness that does not fade by pressing on the incontinence-exposed area is defined as stage 1 IAD” (16.6%, n = 49), and “IAD should be evaluated in the category of pressure injuries” (21.3%, n = 63).

Table 1. - NURSES’ RESPONSES TO THE IAD KNOWLEDGE TEST Test Items Correct Response Rate, n (%) Structure and function of the skin Excess moisture and fluid can disrupt the skin’s barrier function. 234 (79.1)a Normal skin flora is acidic. 111 (37.5) The pH of healthy skin is between 4 and 6. 145 (49.2) Definition and etiology of IAD IAD develops only due to urinary incontinence. 150 (50.7) IAD is a type of moisture-related skin damage. 192 (64.9) Mechanical factors such as friction, skin pH, and natural skin flora do not impact the development of IAD. 179 (60.5) Proteases, lipases, and drug metabolites in the feces impact the development of IAD due to fecal incontinence. 168 (56.9) Exposure to urine/feces or both is the most important risk factor for the development of IAD. 201 (67.9)a Low oxygen saturation, diabetes, and insufficient fluid intake are risk factors for the development of IAD. 66 (22.3) Age is not a risk factor for the development of IAD. 168 (56.8) IAD is not a health problem in infants. 165 (55.7) IAD is a general term that refers to skin damage due to urine or feces contact. 193 (65.2) Malnutrition, lack of personal hygiene, and inactivity are risk factors for IAD. 167 (56.4) Incontinence type does not affect the risk of IAD. 138 (46.6) Diagnosing IAD IAD is a painful and unsettling skin problem. 206 (69.6)a IAD should be evaluated in the category of pressure injuries. 63 (21.3)b Viable tissue loss develops first in IAD. 37 (6.7)b IAD develops in parts of the body where bones are prominent. 73 (24.7) IAD manifests with symptoms of pain, itching, tingling, and burning. 183 (61.8) In IAD, skin damage occurs from the bottom layer to the upper layer. 183 (61.8) IAD areas where skin integrity is not impaired are warmer and harder than the surrounding skin. 172 (58.1) IAD develops in a large area around the perianal and perigenital regions. 171 (57.8) It may be difficult to distinguish IAD from stage 1 and stage 2 pressure injuries. 130 (43.9) The presence of redness that does not fade by pressing on the incontinence-exposed area is defined as stage 1 IAD. 49 (16.6)b Vesicles and bullae are not findings of IAD. 126 (42.6) Superficial skin infections are not seen in patients with IAD. 191 (64.5) Redness and discoloration of the skin decrease with a change of position in patients with IAD. 82 (27.7) Classification and evaluation of IAD Skin assessment of patients with incontinence should be performed at least once a day. 195 (66.3) IAD and pressure injury can occur simultaneously. 69 (23.3) In IAD, a color change with definite borders is observed in the skin. 73 (24.7) It is recommended to use an instrument/scale in the classification and evaluation of IAD. 159 (53.7) Prevention and treatment of IAD Because the use of barrier cream prevents liquid from contacting the skin, it is recommended for patients with incontinence. 188 (63.5) Water and soap should be used to clean the skin of patients with incontinence. 120 (40.5) Frequent product replacement (eg, diapers, pads) does not affect the development of IAD. 105 (35.5) It is recommended to use products that require rinsing for cleaning the skin of individuals with incontinence. 178 (60.1) It is recommended to use moisturizing creams with barrier properties to prevent IAD in dry and rough skin. 166 (56.1) In patients with erythema, skin integrity should be preserved until the etiology is clarified. 173 (58.4) The pH of skin cleansers should be close to normal skin pH. 163 (55.1) Skin protective barrier products such as petroleum jelly, zinc oxide, dimethicone, and acrylate terpolymer contain barrier components. 157 (53.0) It is recommended to routinely use creams in the antibiotic group in patients with incontinence. 111 (37.5)

Abbreviation: IAD, incontinence-associated dermatitis.

aThree items with the highest number of correct answers.

bThree items with the lowest number of correct answers.

Table 2 presents the nurses’ demographic characteristics and comparisons with the IAD total knowledge score. The mean age of the nurses was 26.55 ± 3.87 years (range, 20-47 years). Of them, 60.51% (n = 178) were women, 81.4% (n = 241) had a bachelor’s degree, 61.8% (n = 183) were in general intensive care, 88.9% (n = 263) were working at a tertiary-level ICU, and 76.7% (n = 227) had not received any training on IAD. The mean duration of working in the profession was 4.13 ± 3.61 years (range, 1-25 years), and the duration of working in the ICU was 2.67 ± 2.56 years (range, 1-22 years).

Table 2. - NURSES’ RESPONSES TO THE IAD KNOWLEDGE TEST BY DEMOGRAPHIC VARIABLES Variable n (%) IAD Knowledge Test Total Score Test Statistic P Mean ± SD Median Range Age, y Z = −0.653 .514 ≤25 141 (47.6) 18.89 ± 7.01 21 0-32 >25 155 (52.4) 17.89 ± 8.24 21 0-34 Sex Z = −1.225 .222 Male 118 (39.9) 18.07 ± 8.08 20 0-34 Woman 178 (60.51) 19.25 ± 7.87 22 0-32 Education level KW = 0.145 .930 High school 30 (10.1) 19.50 ± 7.30 22 4-31 Associate’s degree 25 (8.4) 19.45 ± 6.71 20 7-30 Bachelor’s degree 241 (81.4) 18.62 ± 8.17 21 0-34 Type of intensive care F = 5.806 .003; C > Ba Internal (A) 80 (28) 17.65 ± 6.40 19 1-32 Surgery (B) 33 (11.1) 15.28 ± 8.93 17 0-31 General (C) 183 (61.8) 19.88 ± 8.18 22 0-34 Intensive care level Z = −1.986 .047 Level 1 - - - - Level 2 33 (11.1) 16.42 ± 7.36 16 0-31 Level 3 263 (88.9) 19.08 ± 8.00 21 0-34 IAD training t = −0.436 .663 Yes 69 (23.3) 18.48 ± 7.94 20 0-32 No 227 (76.7) 18.87 ± 7.98 21 0-34

Abbreviations: IAD, incontinence-associated dermatitis; KW, Kruskal-Wallis.

aPairwise comparison results with Mann-Whitney U test.

Comparisons of nurses’ demographic characteristics and IAD total knowledge scores revealed that nurses working in tertiary level care and general ICUs had higher IAD total knowledge scores (Ps = .003 and .047, respectively). Total IAD knowledge scores did not differ by sex, age, education, or IAD training.

Table 3 shows the correlation of nurses’ age, occupation, ICU, and work duration in the institution with the level of IAD knowledge. Researchers found no relationships among age, time in the profession, institution, or ICU with IAD knowledge level.

Table 3. - CORRELATION OF NURSES’ EMPLOYMENT VARIABLES WITH IAD KNOWLEDGE TEST SCORE Variable IAD Knowledge Test Score Test Statistic Mean ± SD Range r P Years of work in the profession 4.18 ± 3.63 1-25 0.066 .255 Years of employment in the institution 3.11 ± 2.64 1-25 0.077 .184 Years of work in the ICU 2.71 ± 2.55 1-22 0.060 .305 Age, y 26.55 ± 3.89 20-47 −0.063 .282

Abbreviation: IAD, incontinence-associated dermatitis.

The Figure shows nurses’ correct response rates to the IAD knowledge test. As shown, the correct response rate for the knowledge test was 49.80%. The highest correct response rate (55.27%) was obtained from the “structure and function of the skin” subdimension, and the lowest correct response rate (41.45%) was obtained from the “IAD diagnosis” subdimension.

Figure.:

IAD KNOWLEDGE TEST CORRECT RESPONSE CHARTAbbreviation: IAD, incontinence-associated dermatitis.

DISCUSSION

Incontinence-associated dermatitis is a serious health condition that reduces quality of life and predisposes patients to developing PIs.1,26 With proper care and preventive measures, IAD is preventable.1 Nurses must know how to determine IAD risk factors, apply preventive care, and accurately evaluate and diagnose IAD.27

In the current study, nurses’ correct response rate on the IAD knowledge test was low (49.80%; Table 1). The total correct response rates obtained from this study are also low compared with those of similar research.16,18,19,24 This result may be related to the low number of nurses who reported receiving IAD training. Because IAD is a new topic in Turkey, there is limited literature in this field. In particular, descriptive and epidemiologic studies are needed to draw attention to IAD. In addition, the data were collected during COVID-19. During this period, nurses faced excessive working hours that triggered problems such as physical fatigue and psychological stress, which may have affected their recall of IAD-related knowledge.

Approximately half of the nurses in this study (49.2%) knew the normal pH range of the skin (Table 1). Knowing the normal limits of skin pH is especially important for choosing the correct cleansing products to be applied to the skin.3,26 The rate of IAD decreases when patients use a skin care product suitable for their skin pH.28,29 In this study, a minority of nurses correctly answered whether soap and water should be used to clean the skin in patients with IAD (40.5% correct). The results obtained from similar studies indicate that nurses have a low level of knowledge on this subject.16,19 According to the results of a scoping study evaluating knowledge gaps in the etiology and pathophysiology of IAD, the role of urine and its natural pH on skin integrity should be investigated.30

Recent studies highlight that urine and/or fecal exposure distinguishes IAD from other types of irritant contact dermatitis.9 This distinguishing factor is used in the diagnosis of IAD by the Wound, Ostomy and Continence Nurses Association and was included in the ICD framework; a separate code was created for each irritant contact dermatitis type.31 Concerning the definition and etiology of IAD, more than half of the participating nurses (67.9%) correctly answered that urine and stool exposure are important risk factors. However, the question about whether incontinence type affects IAD risk received fewer correct answers (46.6%). Barakat-Johnson et al16 stated that IAD is a condition related only to liquid. Accurate documentation of these diagnostic features enables colleagues or a coder reviewing notes in the electronic health record to easily identify and accurately code these clinically relevant forms of irritant contact dermatitis. Accurate labeling of the various forms of irritant contact dermatitis is equally important, not only for advanced practice providers such as GPs and clinical nurse specialists but also for any WOC nurse caring for patients with irritant contact dermatitis.9

Incontinence type is an important factor in the development of IAD. Generally, urinary catheter application is preferred to prevent skin irritation from urinary incontinence. However, IAD develops mainly due to stool incontinence.3,8 Because stool contains lipolytic (lipid-digesting) and proteolytic (protein-digesting) enzymes that can damage the stratum corneum, it affects the barrier function of the skin more than urine.1,3,4 This may be overlooked, particularly in intensive care patients.3,7

Fewer than half of nurses (42.45%) correctly answered questions about the diagnosis of IAD (Table 1). The researchers noted that nurses had difficulty distinguishing between IAD and PIs, which aligns with previous findings.16,19 Difficulty distinguishing between IAD and PI may prevent nurses from proving adequate care for patients with IAD, jeopardize healing, prolong the hospital stay, and increase healthcare costs.17 Although there are common risk factors among both types of injury, specific features such as the affected area, etiology, assessment and presentation, and clinical findings distinguish IAD from PI. Pressure injuries show discoloration that does not fade with pressure and are usually located on bony prominences.23 Accurate evaluation and diagnosis of IAD are important for the patient to receive appropriate preventive care and treatment and for the healthcare system to have correct documentation and reimbursement.2

The fact that IAD is a risk factor for PIs and that stage 1 of IAD and stage 1 of PI are very similar in appearance may contribute to the confusion in diagnosis.23 An objective, standardized assessment tool is needed to distinguish IAD from other forms of perineal skin injury and to differentiate stage 1 and stage 2 PIs from IAD. In this regard, it is critical to make appropriate interventions and evaluate their effectiveness.23,28 Although misclassification has important impacts on the prevention, treatment, and quality of care for patients with IAD, there is not enough evidence for the measurement tools used to improve clinical decision-making and care.

A validated tool is needed to determine the presence and severity of IAD and standardize the assessment.3,4,23,28 A recent systematic review by Tezcan et al32 evaluated the following scales used to diagnose incontinence and assess risk: Michigan Incontinence Symptom Index, Incontinence Associated Dermatitis Assessment Scale, Incontinence-Associated Skin Damage Severity Instrument, Incontinence-Associated Dermatitis Intervention Tool-D, Ghent Global IAD Categorization Tool, Ghent Global IAD Monitoring Tool, and the Minimum Data Set for Incontinence-Associated Dermatitis. The review resolves the uncertainty regarding the use of IAD assessment tools in the literature.32 In particular, the Michigan Incontinence Symptom Index is a tool with proven usability in the Turkish population, and its use is recommended.33 Using these tools in clinics and sharing the results will contribute to the literature. Skin care and evaluation are among the basic elements of care in all areas of nursing.14

In the present study, nearly half of the nurses correctly answered the test items about IAD prevention and treatment. However, nurses evidenced low correct response rates to the suggestions of “changing products frequently,” “antibiotics should be used when needed in treatment,” and “cleaning the skin with soap and water after incontinence” (Table 1). Barakat-Johnson et al16 also found that knowledge regarding cleaning the skin with soap and water in cases of incontinence was low. Qiang et al18 evaluated the practices of intensive care nurses and found that they used alcohol wipes, paper towels, and warm water to cleanse the perianal region of patients with IAD. However, standard soap attacks corneocytes, potentially altering skin’s pH and disrupting its barrier function because of its alkalinity.34 A skin cleanser with a pH range similar to normal skin pH (ie, pH 4-6) is preferable to conventional alkaline soap. In cases where pH-balanced cleaners are not available, mild soap and water are recommended as a minimum standard for cleaning, or products that do not require rinsing and drying (eg, Cavilon No-Rinse Skin Cleanser; 3M).4,7,34

Hospitals that provide tertiary care and general ICUs treat critically ill patients who require special care and treatment. Skin assessment and care may be overlooked in critically ill patients, even though they are fundamental nursing concepts.35 In this study, nurses working in the general ICU and tertiary intensive care level had significantly higher knowledge levels about IAD (Table 2). The prevalence of IAD is high in general ICUs and tertiary care services,8 increasing the probability that those nurses have encountered patients with IAD.

In the present study, nurses’ knowledge of IAD did not vary by level of IAD training (P > .05; Table 2). In contrast, Lee et al36 found that nurses who received wound care training had higher levels of IAD knowledge. This discrepancy may be related to the low number of nurses trained in IAD in the present study. Education in IAD prevention and management is a high priority: Advanced knowledge is key to implementing protocols for the prevention and management of IAD, including the correct and differential diagnosis of IAD and the appropriate use of available products. Therefore, it is important to determine nurses’ current knowledge levels about IAD and the obstacles to IAD care to develop appropriate education content and determine effective care strategies.23 According to the literature, quality improvement studies on IAD prevention and management increase nurses’ knowledge and positive attitudes and behaviors toward IAD36 and reduce the incidence of IAD.37,38

No correlations were found between nurses’ years of work in the profession, institution, or ICU type and their total IAD knowledge score (Table 3). The literature on this topic is mixed, with some studies finding no relationship between professional experience and knowledge of IAD16,18,24 and others finding that professional experience has a positive effect on IAD knowledge.16,18 In the present study, the majority of the nurse participants had low professional experience, which may have impacted the results.

Limitations

The results of the study cannot be generalized beyond the units at two private and three public hospitals where the study was conducted. Further, data collection coincided with the COVID-19 pandemic, and nurses may not have given the necessary to the questionnaires because of their workload.

CONCLUSIONS

The nurses in this study had insufficient knowledge about IAD etiology, prevention, evaluation, and treatment. Although nurses generally knew that IAD is MASD and that the use of barrier-acting products is beneficial in removing moisture, they confused the diagnosis criteria between IAD and PI.

Education in the prevention and management of IAD is a high priority. Advanced knowledge is key to implementing protocols for the prevention and management of IAD, including the correct and differential diagnosis of IAD and the appropriate use of available products. It is important to determine nurses’ knowledge and education levels regarding IAD care to determine what education content is needed. Hospitals should develop comprehensive in-service programs for nurses and ensure their regular participation in these programs. Future research should evaluate the IAD knowledge of nurses and other health personnel working in different clinical units, hospitals, and care settings.

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