Cultivating Incontinence-associated Dermatitis Prevention Practices in an Australian Local Health District: A Quasi-experimental Study

Incontinence-associated dermatitis (IAD) is a painful skin condition that, according to a multisite epidemiologic analysis, an international pressure injury prevalence survey, the Global IAD Expert Panel, and a multicenter prevalence study,^1-4 is underreported, neglected, and difficult to treat in hospitalized patients. The condition is an irritant dermatitis characterized by erythema of the skin around the buttocks, perineum, gluteal clefts, and other areas where there is friction and moisture between the skin and clothing and bed linen.^5,6 IAD is caused by fecal or urinary incontinence or both and is included in a broader group of skin conditions referred to as moisture-associated skin damage (MASD).^5,7

IAD is a recognized risk factor for the development of pressure injuries (PIs).^1,2,8 A meta-analysis and systematic review of 58 studies by Beeckman et al⁸ established an association between IAD and the development of PIs. Gray and Giuliano¹ conducted a descriptive and correlational analysis of data on IAD and PIs in the sacral area involving 5342 patients in acute care facilities in 36 states in the United States. They found IAD significantly increased the likelihood of a patient developing a sacral PI. Furthermore, IAD is often incorrectly misdiagnosed as a PI.^9,10 Barakat-Johnson et al¹⁰ conducted a prospective, descriptive study in a large tertiary hospital in Australia of patients reported to have a PI. The authors found 176 out of 363 patients (48.5%) had various skin conditions that were not PIs. Moisture-associated skin conditions, namely IAD, accounted for 69 out of 176 (39.7%) of the skin conditions mistaken for PIs. Furthermore, IAD assessment, management, and prevention is not seen and discussed as a priority among clinicians, as found by the Global IAD Expert Panel.³ Prevention is the primary goal in the management of IAD and should comprise a number of evidence-based strategies aimed at maintaining skin integrity.³ In September 2014, the Global IAD Expert Panel met to review knowledge gaps in IAD and to advance best practice principles to address these gaps. They identified that preventing IAD can, in turn, prevent PIs and should be considered an essential component of PI prevention.³

The purpose of this study was to evaluate the impact of certain initiatives by examining the prevalence of IAD as well as incontinence practices. These initiatives comprised the formation of an IAD committee, review of existing IAD literature, education for nurses on the prevention and management of IAD and correct pad size, and the introduction of new skin cleansing and management products. These results were compared with the findings of the authors’ previous study.¹¹ Nurses’ overall perceptions about the use of a 3-in-1 barrier cream cloth also were assessed.

This study is 1 of 2 IAD initiatives¹¹ arising from a program of implementation science work to implement evidence-based IAD prevention and treatment in order to examine the effects of the program and address PIs in an urban Australian local health district (LHD). In 2015-2016, the authors conducted a cross-sectional, mixed-methods study across 12 wards in 4 hospitals in the LHD¹¹ to examine the prevalence of PIs and IAD as well as to determine evidence-into-practice gaps. Two (2) major practice gaps were identified: 1) IAD was misclassified as PI, and 2) existing incontinence nursing practice was inconsistent with contemporary evidence-based literature and guidelines and included use of antiseptic wash to cleanse skin after a soiled episode, slathering on zinc or ointment-based skin protectants that may impede pad absorbency, and incorrect sizing of containment devices. The consequences of these practice gaps are significant, with the potential to increase patients’ risk of developing a PI as well as IAD and increase patient discomfort and length of stay. Based on the results of previous research,^10,11 other cross-sectional and systematic review studies conducted in Australia and internationally,^8,12 and international guidelines,3 this LHD and the New South Wales State Pressure Injury Working Party¹³identified IAD as a clinical priority in acute care hospitals. These findings led to collaboration between this LHD, the New South Wales State Pressure Injury Working Party, and international leads¹² for conducting IAD prevalence audits and statewide PI point-prevalence audits.

To address the acknowledged practice gaps, an implementation science approach, guided by the Promoting Action on Research Implementation in Health (PARiHS) Framework,^14,15 was employed as part of the broader project addressing PIs. Implementation science is the study of how to design and evaluate methods that enable interventions to be effectively put into practice, taking into account the context and internal mechanisms.^14-17 The current study’s intervention involved evidence-based initiatives to address IAD and existing incontinence practices. Specifically, the initiatives included the formation of an IAD committee, review of existing IAD literature, education for nurses on the prevention and management of IAD and correct pad size, and introduction of new skin cleansing and management products.

Study phases. The pre-implementation data collection phase was undertaken between November 2015 and January 2016, the implementation phase from June 2016 to May 2017, and the post-implementation phase between June 2017 and October 2017. The terms and operational definitions used in this study are presented in Table 1.^3,5,14,18-22

Design. This study used a quasi-experimental, post-test study design to evaluate IAD prevalence and the nature of incontinence practices following the implementation of evidence-based strategies across a district of 4 hospitals in Australia. A single point collection of IAD prevalence was conducted at different time points across the 4 facilities. Patients were audited once; to accommodate workload, each facility had a different audit day. Bivariate statistics were used to compare the resulting data with pre-implementation data, which also were collected once.

Ethical considerations. Ethical approval was granted by the Sydney LHD Ethics Review Committee of the Royal Prince Alfred Hospital zone (ref: HREC/15/RPAH/482). Participant confidentiality was maintained by the deidentification of all participant identifying information at the point of data collection. To obtain patient consent, a nursing staff member approached the patient and explained the purpose of the study and obtained verbal consent. Once consent was obtained, auditors, who were senior nursing members of staff, provided a detailed explanation of the study. If a patient was unable to provide consent, a relative consented on his/her behalf. For the nurse focus groups (FGs), written consent was obtained from each nurse.

Setting. The study was undertaken in 12 wards in a LHD comprising 3 acute tertiary hospitals, 1 subacute rehabilitation hospital, and 5 community health centers. The LHD is in a large urban setting that provides primary, secondary, and tertiary care to a local population of 600 000 people. In order to make direct comparisons with the previous study, the same 12 wards as the previous study¹¹ were audited. These included acute and subacute aged care, rehabilitation, neurology, cardiovascular, intensive care, and palliative care. Each ward consisted of 13 to 30 beds, with a mean occupancy of 72.3%. Each ward was staffed with between 7 and 80 nurses.

Sample/Participants.
Audit patient sample. Patients were recruited on the day of the audit if they were admitted to 1 of the 12 wards and ≥18 years of age. Patients were excluded if they were unable to consent or if they were not present on the ward (eg, undergoing a procedure). Agreement from the nursing unit manager (NUM) and nurses on the relevant wards was obtained in order to approach the patient before data collection.

Focus group sample. All nurses (bedside nurses, nurse leaders, nurse educators, and student nurses) working on any of the 12 wards at the time of the study were invited to participate in the focus groups. Student nurses could attend only if their registered nurse preceptor was attending the focus group. The focus groups were held in the post-implementation phase, 3 to 5 months after the completion of the implementation phase and 12 months after the initial implementation that began June 2016.

Intervention: evidence-based initiatives. The intervention initiatives included: 1) formation of a committee consisting of senior nurses, skin integrity and infection control nurses, continence nurse educators, and nurse consultants; 2) changes to clinical practice, such as correct sizing of containment products, the proper use of bed protection products, and knowing the difference between IAD and PI; and 3) an education campaign on IAD prevention and incontinence nursing practices (see Table 2).^14-17,23,24 The intervention strategy to address cleaning, moisturizing, and protecting patients’ skin was a major practice change. A barrier cream cloth (see Table 1)^3,5,14,18-22 was used to cleanse, moisturize, and protect patient skin. Practice changes were documented using the same audit tool as in the authors’ previous study (see Figure).¹¹ This approach was universally implemented.

Outcome measures. Primary outcome measures were: 1) the prevalence of IAD and 2) changes in clinical practice (eg, use of barrier cream cloth, removal of unnecessary bed protection pads).

Data collection.
Patient audit. The prevalence audit included a head-to-toe skin assessment using the framework outlined by the National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Injury Alliance (NPUAP/EPUAP/PPPIA) guidelines,¹⁸ as well as observations of the incontinence practices. Researchers used the same audit tool as in their previous study (see Figure),¹¹ which was developed by the authors and conforms with IAD guidelines.³ The audit tool includes demographic data, continence and mobility status, IAD and PIs, incontinence products used, and nursing practice observations, which were documented by wound nurse leaders of each facility. IADs were classified as Category 1 or 2 (see Table 1),^3,5,14,18-22 and PIs were staged according to the NPUAP/EPUAP/PPPIA Pressure Ulcer Classification System.18 Data then were entered into Microsoft Excel. FGs. A discussion guide was developed by 2 senior wound clinicians and 2 researchers with expertise in qualitative research. The guide was pilot-tested on 5 nurses before use; no changes were deemed necessary. Questions included, What are your thoughts on the new 3-in-1 barrier cream cloth? and How has this assisted you in the care you provide your patients? Demographic information including gender, age, years of experience, and the role of each participant was collected. Interviews were digitally recorded and transcribed verbatim by an independent transcription company. A research officer conducted the focus groups which took 35 minutes on average. The NUM allocated time for staff to attend the focus groups.

Procedure. Steps involved in the development, roll out, and evaluation of the initiatives are outlined in Table 2.^14-17,23,24

Audit procedure. A senior nursing clinician at each site and the lead author were responsible for coordinating the post-implementation prevalence audit. NUMs and nursing staff were notified of the upcoming audit by email and at handover (change of shift) by senior clinicians. To ensure consistency, the same auditors from the authors’ previous study¹¹ collected the data. The auditors, who were senior nurses, were provided with a photographic chart of IAD grading. All auditors had the requisite knowledge to diagnose IAD. Interrater reliability was assessed to ensure consistency between auditors by undertaking a PI classification test for this study with the addition of IAD photos. This involved auditors correctly classifying PIs in line with the NPUAP/EPUAP/PPPIA Pressure Ulcer Classification System¹⁸and IADs as per the Global IAD Expert Panel.³ The pass rate set was at 85% as guided by a method outlined by Prentice et al²⁵ for conducting PI prevalence audits in Australia. The passing grade was achieved.

The auditors performed a head-to-toe skin inspection as per Prentice et al²⁵; patients were asked whether they were experiencing problems with incontinence. Patients in this study who had a urinary indwelling catheter were deemed continent.^19-21 If they were wearing an incontinence pad, it was assessed for correct sizing and application based on heavy, medium, or light incontinence/soiling. As per the authors’ previous study,¹¹ the correct incontinence pad was determined based on the type of incontinence, flow, the patient’s size (weight and height matched to the manufacturer pad size guide), mobility status, and the amount of urine or feces reported by the patient or nurse. Information on the nature of incontinence management was collected.³ This included skin care, correctly sized incontinence products (as per Cottenden et al²²), and the number of bed protection layers on each bed, such as disposable underpads (Blueys; Cello Paper Pty Ltd, Sydney, Australia) and washable underpads (Kylies; Ontex Healthcare, Sydney, Australia), plastic sheets, and draw sheets). Participating wards subsequently received a report with the main findings for their ward.

FG procedure. Flyers were distributed to the 12 wards, inviting nurses to participate in the FGs. Before distribution, permission was obtained from NUMs. FGs were held following afternoon handover on the ward. Each FG ran for 20 to 40 minutes and offered nurses an opportunity to share their views on their use of the newly introduced 3-in-1 barriercream cloth to reduce IADs.

Data analysis.
Prevalence audit. Data were collected via the paper-and-pencil audit tool and entered into and analyzed using IBM SPSS Statistics, version 22 (IBM Corp, Armonk, NY).²⁶ Entered data were cross-checked for accuracy and incomplete data were coded as missing. Prevalence rates of incontinence and IAD were analyzed descriptively as counts and percentages. Bivariate analysis was performed and statistical significance was set at P <.05. Results were compared with the pre-implementation audit (N = 250). Comparisons of the age of patients from the pre- and post-implementation patient cohorts were made using a t test. Chi-squared tests were used to compare gender, mobility status, IAD and hospital-acquired PI occurrence, and incontinent product use in both audits. Fisher’s exact test was used when cell counts were <5. No adjustment was made for multiple testing because all outcomes were prespecified.

FGs. The focus group transcripts were uploaded into NVivo 10 software (QSR International, Melbourne, Australia) for content analysis.²⁷ Transcripts were reviewed by 2 authors (MBJ, ML) individually and then together. Authors read, reread, and then coded the transcripts in NVivo and then met to compare coding and reach consensus. Distinct categories were identified from the analysis and assigned to a relevant theme with the assistance of co-authors.

Patients. In total, 259 patients (mean age 73.2 ± 17.0; 132 [51.6%] men, 124 women [48.4%]; gender missing for 3 patients) participated in the post-implementation audit. Additional characteristics of the patient sample can be found in Table 3. Characteristics of the post-implementation audit (N = 259) and the pre-implementation audit (N = 250)¹¹ are shown in Table 4. No significant difference was found between the mean ages of patients (P = .86) or the proportion of men and women (P = .81). Mobility status also did not differ between the pre- and post-implementation audits (P = .40). The patients within each audit were comparable in terms of basic demographics.

Comparison of incontinence. Of the 250 patients in the pre-implementation audit and the 252 patients in the post-implementation audit, 111 (44.4%) and 119 (47.2%), respectively, were incontinent; data on incontinence were missing for 7 patients in the post-implementation audit (P = .78). No statistically significant difference was noted in the proportion of patients with urinary incontinence between the pre- (58/111, 52.3%) and post-implementation audit (54/119, 45.4%) (P = .30) or in the proportion of patients with both fecal and urine incontinence in the pre-implementation (50/111, 45.0%) compared to post-implementation audit (46/119, 38.7%) (P = .33). However, the number of patients with fecal incontinence was lower in the pre-implementation audit (3/111, 2.7%) than in the post-implementation audit (19/119, 16%) (P = .001) and 139/250 (55.6%) patients were continent in the pre-implementation versus 133/252 patients (52.8%) in the post-implementation audit (P = .53). Thus, with the exception of fecal incontinence, the patients in each of the audits were comparable on continence measures. Overall, the patients in the pre- and post-implementation audit groups were similar enough to allow for an evaluation of the impact of the intervention.

Comparison of IAD and PI. The prevalence of IAD in the pre-implementation (23/250, 9.2%) and post-implementation audit (6/259, 2.3%) was significantly different (P = .015) (see Table 5). The prevalence of hospital-acquired PIs in the pre-implementation (9/250, 3.6%) and post-implementation audits (2/259, 0.8%) was significantly different (P = .034) (see Table 5).

Comparison of incontinent product use. Implementing evidence-based strategies resulted in a significant reduction in the use of bed protection between the pre-implementation (154/238, 64.7%, data missing for 12 patients) and 6/259 (2.3%) post-implementation audit (P <.01). Nurses did not use any plastics, washable underpads, or draw sheets as bed protection during the post implementation audit period (see Table 6), a significant improvement from the pre-implementation audit, which reported use of plastics in 67/242 patients (27.7%), washable underpads in 45/246 (18.3%), and draw sheets in 97/250 (38.8%). Only 6 disposable underpads (2.3% of patients) were found to be in use in this audit, which was an 87.5% decrease from the pre-implementation audit that noted use of 48 disposable underpads (19.2%) (P <.001) (see Table 5).

Another notable finding was the significant difference between the number of continent patients who were provided incontinent products: in the pre-implementation audit, 73/139 (52.5%) of continent patients had an incontinent product (either pad or bed protection), whereas 28/133 (21.1%) of continent patients had an incontinent product at the time of the post audit (P <.01) (see Table 5).

Nurse FGs. The demographic data for the 6 focus groups (31 nurse participants) is presented in Table 7. Nurses’ experiences with the barrier cream cloths and other issues with IAD were grouped into 4 categories: 1) benefits to the patient, 2) usability, 3) problems encountered, and 4) related factors.

Benefits to the patient. Participants provided positive feedback on the improved skin conditions of incontinent patients, particularly those with IAD, as a result of the barrier cream cloths.

There was one particular patient who was fecally incontinent and at high risk of developing IAD due to poor skin integrity from frequent loose bowels who did not develop any IAD due to the use of the cloths as a preventative measure. (FG1)

Participants stated that many patients felt a noticeable difference and improvement to their skin, including less tenderness and pain when they were cleaned.

I can especially think of one patient off the top of my head who was really badly excoriated and when you’d touch her she would just cry. And even after 2 days with the wipes she was like, “Oh, so much better.” (FG2)

In some cases, patients verbally requested the cloths, citing how comfortable they felt.

Some patients will ask us, “Can we use the wipes on the front, everything?” I say, “Yes.” And then say, “Okay, just put it on.” So we just put it on, it’s like “Oh, so comfortable.” (FG2)

Usability. The cloths also were used as a form of prevention and protection for patients who were incontinent to ensure that areas of the body were moisturized and that the condition did not escalate, potentially saving the use of products later on.

But if a patient’s starting to have loose bowels and you use them, well then you sort of prevent the problem to begin with and you don’t end up having to use them as much. (FG3)

Nurses found many uses for the cloths, which were used not only as a preventive intervention but also as a form of treatment for skin complaints such as “red and angry skin,” “excoriation,” “skin breakdown,” and “dry skin.” (FGs 1, 3, 5)

Participants also found the cloths to be effective at absorbing odor, making cleansing a more pleasant experience for both patient and nurse. Furthermore, nurses commended the hygienic nature of using disposable cloths, particularly compared with creams.

You’re not touching your gloves onto a tube that then is going to be touched again…and it absorbs the smell. (FG2)

Many participants reported the cloths were superior to conventionally used products such as barrier creams, particularly in terms of comfort, effectiveness, time efficiency, and ease of use. The moisturizing qualities of the cloth negated any need to use large amounts of barrier creams.

When you’re rubbing zinc on the patients they hate it, because it’s like this cold, horrible cream. It’s uncomfortable, it’s sticky. (FG3)

We cover our patients in zinc a lot and use a lot of zinc. And with those [cloths] you don’t need to. (FG4)

Conventional barrier creams, such as zinc creams, were deemed to be difficult to clean off without being rough and compromising the skin integrity, as well as being difficult to see through. Some participants stopped using barrier creams in favor of the cloths. Furthermore, several participants cited issues with how barrier creams were being used inappropriately. For example, too much cream was being applied, causing build up and time-consuming cleaning or improper cleaning. However, some nurses mentioned they were lathered thickly due to the ineffectiveness of the creams.

…you have to lather it so thick to actually get a decent effect. And you can just use one of those wipes and you’ve done it. (FG3)

Problems encountered. Participants reported some negative features of the cloths, including patients feeling a cold sensation when they were applied to their skin and risk of cloth wastage when used on patients who were discharged earlier than expected.

You know, we have patients that might just come in 1 or 2 days and they’re gone again so it’s a lot of wastage as well because you can only use it for one patient, you know. (FG6)

FG 6 voiced concerns over the lack of visibility of barrier properties of the cloths and the inability to see where one has applied the cloth due to its transparent appearance on the skin, preferring creams instead:

But you can’t see with something that’s clear. You can’t see how thick it is… and if you change the pad again you can still see if there’s cream, or you need to add more.

However, FG participants believed that if cloths were more visible on application, they would prefer the cloth to layering creams.

Related factors. Nurses emphasized the importance of being educated in 2 areas: how to use the cloths appropriately to ensure they were used optimally and how to identify IAD.

So if I could have a bank of photographs that I could identify and run a PowerPoint presentation of those pictures, because we felt that from the evaluation that we understand what it is and how it comes about and how we can help prevent it, but we wanted to be more confident with identifying it on the ward by having a range of pictures and photographs and examples. (FG5)

Some participants experienced confusion as to how to identify and distinguish between skin conditions, such as incorrectly identifying PIs, emphasizing a need for better education. This was a difficult issue to address because nurses often worked different shifts on different days.

The current study, guided by an implementation science framework,¹⁴ evaluated the impact of initiatives on the prevalence of IAD and incontinence practices across high-risk wards in a LHD. Compared to pre-intervention implementation audit results, IAD and hospital-acquired PI rates were significantly lower across the LHD and incontinence management practices had improved. Substantially fewer incontinence products were used in the post as compared to the pre-implementation audit. More specifically, bed protection products were used sparingly and the majority of patients with incontinence pads had the correct size pad based on the level of soiling. Continence management guidelines and a cluster randomized controlled trial^22,28 showed incorrect pad size results in poor absorbency and leakage of urine and feces, compromising patient skin integrity and predisposing to the development of IAD and PIs.^8,19 In their guidelines on the use of incontinence products, Cottenden et al²² recommended that pad size (ie, absorbency) should be selected in accordance with the volume of the flow to ensure urine and feces are contained and no leakage occurs.

One (1) major practice change was the use of a 3-in-1 barrier cream cloth for patients with incontinence to cleanse, moisturize, and protect patients’ skin after soiling. The nurses in this study provided positive feedback on the product’s effect on time efficiency and the improved skin conditions of patients with incontinence, particularly those with IAD. Many nurses preferred barrier cream cloths to the traditional steps of cleansing, moisturizing, and using a barrier cream because they could combine all the steps by using only 1 cloth.

Critical to the success of the prevention of IAD and any patient intervention is compliance with cleansing and moisturizing methods. To prevent IAD, clinicians should diligently adhere to the best practice principles of following a 3-step process of cleansing, moisturizing, and providing a barrier. However, it can be difficult to monitor and enforce such practices when they are implemented across several wards and changing teams of staff. Reducing the number of steps involved may help reinforce best practice adherence, something that is emphasized in the current guidelines.¹⁷ Other studies^23,29 also have found benefits in using a 3-in-1 barrier cream cloth (with a 3% dimethicone formula) as a solution for IAD. In a randomized controlled trial²³ of 141 nursing home residents in Belgium to compare a 3-in-1 cloth (Comfort Shield Barrier Cream Cloth; Sage Products Inc, Cary, IN) with standard care (water and neutral pH soap) to prevent and treat IAD, the 3-in-1 washcloth was found to provide a significant reduction in IAD prevalence (by 63.7%; P = .003). Similarly, a prospective, descriptive quality improvement study²⁹ of a 3-in-1 barrier cloth, performed in 2 acute care neurology units in a trauma center in the United States, found none of the patients with incontinence who used the 3-in-1 barrier cloth (25/46) developed sacral IAD or a PI. Following the current study and per international literature, the use of the 3-in-1 barrier cloths has become standard practice in the authors’ LHD to prevent and manage IAD.

In the current study, forming a committee to address the evidence-based practice gaps coupled with a leader to drive implementation planning and regular feedback from clinicians led to key stakeholder buy-in and clinician engagement. The committee also worked closely with senior nurses on the ward, as well as NUMs, to monitor and ensure implementation of initiatives. The PARiHS framework guided the process of planning and evaluating initiatives by taking barriers as well as the context into account.^14,15Using this approach enabled clinical nurse engagement, support from senior leaders, and adjustment of the strategy relevant to ward-specific concerns. For example, 1 ward slowly implemented the practice change over several months and encouraged interested nurses to campaign for practice change; other wards decided to rely on their clinical nurse educator to educate all staff and implement initiatives in a shorter time frame. Similar to the current study, a recent quasi-experimental, clustered pre- and post-test design study by Sving et al²⁶ using PARiHS to reduce PIs evaluated the effectiveness of a multifaceted, tailored intervention aimed at improving adherence to PI strategies across 5 wards in a tertiary hospital in Sweden. Significant improvements in PI care were demonstrated, including a higher number of at-risk patients receiving the appropriate and necessary care to prevent PIs.

Current study findings informed next steps — specifically, an economic evaluation study on interventions in the LHD to address skin care, namely to prevent IAD and PIs.³⁰ Other initiatives include the development and implementation of additional strategies to assist with translating evidence into practice, specifically implementation of the evidence-based guidelines³ to prevent IADs across other wards in the LHD and translating the recently published Ghent Global IAD Categorisation Tool (GLOBIAD).³¹ The authors believe a designated local implementation committee with motivated senior leaders to drive practice change was particularly important because it encouraged key stakeholder buy-in and clinician engagement, leading to successful outcomes similar to other studies.^32,33 The key lesson in this study was the importance of using evidenced-based research to examine the problem and identify and evaluate each implementation step.

Unlike incidence studies, cross-sectional studies capture a snapshot of a population at a single point in time. Therefore, some IAD cases may have been missed, thereby underestimating the problem. Another limitation is that focus group data were collected with nurse participants only. The perspectives of other members of the health care team could have provided extra valuable and unique information. Lastly, it is important to acknowledge that the impact of the reduction of IAD and improved incontinence practice is likely to be greater when there are dedicated champions driving an initiative and that care is delivered in a structured way, also known as the Hawthorne effect.^34-36 However, given that this study aimed to close the gap between evidence and practice, the strategies initiated were guided by an implementation science framework (PARiHS) to ensure uptake and sustainability to overcome the Hawthorne effect.

Furthermore, prevalence audits in this study were conducted 6 to 12 months after the intervention was implemented, suggesting that the practice changes had been sustained. A follow-up study in this LHD, 2 to 5 years post-intervention, would be valuable to determine whether adherence to the intervention has continued and if the IAD rate remains low.

Following implementation of evidenced-based initiatives to improve the nature of incontinence practices and prevent IAD on 12 wards in 1 LHD, prevalence rates of IAD and hospital-acquired PI were significantly lower and improvements were noted in prevention of IAD and incontinence practices. Nurse FGs revealed that 1 of the new initiatives, using a 3-in-1 barrier cream cloth, minimized the number of steps in incontinence management and improved skin condition. This suggests that using an evidenced-based approach leads to less work for nurses and better patient outcomes. This study provided valuable insight into addressing a clinical problem in a health district using an implementation science framework and merits further research in wider scale translation and scalability across other settings and other health districts.

The authors acknowledge, and are most thankful for, the commitment and enthusiasm of the district IAD implementation committee and all the nursing staff at Royal Prince Alfred Hospital, Concord Repatriation General Hospital, Canterbury Hospital, and Balmain Hospital. In particular, the authors recognize the efforts of clinical nurse leaders Melissa O’Grady, RN, MN, BN, DipSci, Cert.Cont,Manage, Advanced Clinical Practitioner in Continence; Thomas Leong, RN, MAppSci; Ashleigh Dolton, RN, BN, Grad.Cert.Crit.Care; John Sheehy, RN, BN, MBA; Francesca Rowshanzadeh, RN; Catherine Leahy, RN, BN, Stomal Therapy Nurse; Megan White, RN, BAppSc, MN; Tara Finnie, RN, BN; Carl Sharp, RN; and Judy McGlynn, RN, BN, Grad.Cert. in Aged Care, Grad.Cert. Teaching and Clinical Redesign. The authors gratefully acknowledge Judith Fethney for her assistance in statistical analyses of the patient data and for her review of this manuscript. The authors also thank the former district Director of Nursing, Ms. Katharine Duffy, for her support of this study. Finally, the lead author was awarded the Clinician Researcher Scholarship, a PhD scholarship, by Sydney Research, which in part supported this study.

Ms. Barakat-Johnson is District Lead Nurse Consultant, Sydney Local Health District; and Ms. Lai is a Research Officer, Cancer Nursing Research Unit, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia. Dr. Wand is an Associate Professor, Faculty of Medicine and Health, University of Sydney; and a Nurse Practitioner and Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, Australia. Dr. Coyer is a Professor of Nursing, School of Nursing, Queensland University of Technology and Intensive Care Services, Royal Brisbane & Women’s Hospital, Kelvin Grove, Queensland, Australia; and a Visiting Professor, Institute for Skin Integrity and Infection Prevention, University of Huddersfield, West Yorkshire, UK. Dr. White is a Professor of Nursing, Cancer Nursing Research Unit, Faculty of Medicine and Health, University of Sydney and Sydney Local Health District.

Please address correspondence to: Michelle Barakat-Johnson, RN MN, PhD(c), Sydney Local Health District, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Australia 2050; or Faculty of Medicine and Health, University of Sydney, 88 Mallett Street, Camperdown, Australia 2050; email: michelle.barakatjohnson@health.nsw.gov.au.