These guidelines are not binding on nurses, other health providers, or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury, or expense arising from any such errors or omission in the contents of this work.With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from RNAO. Appropriate credit or citation must appear on all copied materials as follows: Registered Nurses' Association of Ontario. Supporting adults who anticipate or live with an ostomy. 2nd ed. Toronto (ON): Registered Nurses' Association of Ontario; 2019.Declarations of competing interest that might be construed as constituting an actual, potential, or apparent conflict were made by all members of the RNAO expert panel, and members were asked to update their disclosures throughout the guideline development process. Information was requested about financial, intellectual, personal, and other interests and documented for future reference. No limiting conflicts were identified. Details regarding disclosures are available at .# Table of Contents

# Table of Contents
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Purpose and Scope Purpose RNAO's BPGs are systematically developed, evidence-based documents that include recommendations on specific clinical, healthy work environment, and health system topics that are intended for nurses, members of the interprofessional team, educators, leaders, policy-makers, researchers and persons and families with lived experience. BPGs promote consistency and excellence in clinical care, education, and administrative practices and policies with the aim of achieving optimal health outcomes for people, communities, and the health system as a whole.
This BPG replaces the RNAO BPG Ostomy Care and Management, which was released in 2009. The purpose of this BPG is to provide nurses and the interprofessional team with evidence-based recommendations for the most effective strategies to support adults (18 years and older) who anticipate or live with an ostomy that will (a) promote self-management G , (b) enhance access and delivery of care, and (c) lead to positive health outcomes. For this BPG, persons who anticipate an ostomy are those who are in the preoperative phase and awaiting an ostomy surgery. This BPG recognizes that adults who anticipate or live with an ostomy and their support network G are experts in their health and decision making; collaboration among the interprofessional team, the person anticipating or living with an ostomy, and their support network (if needed) therefore is essential for achieving improved health outcomes.
In October 2017, RNAO convened an expert panel to determine the scope of this revised BPG and to develop recommendation questions to inform the systematic reviews G . The RNAO expert panel included persons with lived experience and was interprofessional in composition, comprising of individuals with knowledge and experience in clinical practice, education, research, and policy across a range of health service organizations, practice areas, and sectors. These experts shared their insights on supporting and caring for adults who anticipate or live with an ostomy across the continuum of care (e.g., acute care, rehabilitation, community, and primary care). A systematic and comprehensive analysis was completed by the RNAO Best Practice Guideline Development and Research Team and the RNAO expert panel to determine the scope of this BPG and to prioritize recommendation questions for its development (see Appendix D).

# Scope
To determine the scope of this BPG, the RNAO development team conducted the following steps:
 Reviewed the previous RNAO BPG, Ostomy Care and Management (2009).  Conducted a guideline search and gap analysis.
 Undertook a scoping review G of the literature to determine the depth of peer-reviewed studies in the area of pediatric populations (younger than 18 years) living with an ostomy.
 Conducted six key informant interviews.
 Held two virtual focus groups with experts in the field, including front-line health providers G , researchers, and persons with lived experience.
The analysis informed the scope of this BPG. This BPG will focus on adults (18 years and older) who live with or anticipate an ostomy. The scoping review identified a lack of peer-reviewed studies addressing pediatric populations living with an ostomy. It was thus concluded that a separate search for evidence and approach to guideline development was warranted to address this population.
 Regulated health provider: In Ontario, the Regulated Health Professional Act, 1991 (RHPA) provides a framework for regulating 23 health professions, outlining the scope of practice and the profession-specific controlled or authorized acts that each regulated professional is authorized to perform when providing health care and services (5).
 Unregulated health provider: Unregulated health providers fulfill a variety of roles in areas that are not subject to the RHPA. They are accountable to their employers but not to an external regulating professional body (e.g., College of Nurses of Ontario). Unregulated health providers fulfill a variety of roles and perform tasks that are determined by their employer and employment setting. Unregulated health providers only have the authority to perform a controlled act as set out in the RHPA if the procedure falls under one of the exemptions set out in the Act (6).

# BAC K G R O U N D
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Ostomy care program: An organization-level approach to standardize care for persons who anticipate or live with an ostomy. The ostomy care program includes structured treatment, management, and follow-up strategies developed by an interprofessional team, which may consist of NSWOCs, nurses, surgeons, physicians, social workers, dieticians, and pharmacists (among others).
Parastomal hernia: Occurs when one or more loops of the bowel protrude through the abdominal wall, creating a bulge around the peristomal skin G (7).
Topics Outside the Scope of this Best Practice Guideline
The following conditions and topics are not covered within the scope of this BPG:
 Pharmaceutical interventions for the prevention and management of ostomy-related complications.
 Surgical procedures in the creation of a stoma.
 Surgical interventions for the prevention and management of ostomy-related complications.
 Pediatric populations anticipating or living with an ostomy.

# Recommendation Questions
Within the determined scope defined above, the following priority recommendation questions and outcomes were developed by the RNAO expert panel and informed the development of this BPG:
Outcomes: Psychological health status and self-identity.
Note: These priority recommendation questions are condensed versions of the more comprehensive PICO G (population, intervention, comparison, outcomes) research questions developed by the RNAO expert panel to guide the systematic reviews and development of this BPG. For the PICO research questions and the detailed process of how the RNAO expert panel determined these priority questions and outcomes, see Appendix D.

# BAC K G R O U N D
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Recommendations
Recommendations in this BPG address access to the appropriate specialist to support comprehensive care (i.e., NSWOCs G ), the need for a standardized ostomy care program within health service organizations, guidance on the prevention of parastomal hernias, and quality of life assessments in adults who anticipate or live with an ostomy. The evidence-based recommendations in this BPG are applicable to all practice settings where adults who anticipate or live with an ostomy are accessing services (such as, but not limited to, acute care, long-term care, community settings, and rehabilitation settings).
In this BPG, no recommendation questions were identified that addressed the core education and training strategies required for curricula, ongoing education, and professional development of nurses or the interprofessional team in order to support adults living with or anticipating an ostomy. Please refer to Appendix C for education statements G that educators, managers, administrators, and academic and professional institutions can use to support the uptake of this BPG.
Note: Recommendations in this BPG were developed for adults who anticipate or live with an ostomy, but in some cases, recommendations also may be applicable to adults with continent diversions G (bowel or urinary).

# RNAO Guidelines and Resources that Align with this Best Practice Guideline
Other RNAO guidelines and other resources may support implementation of this BPG. See Appendix B for RNAO guidelines and other resources on the following related topics:
 Client centred learning.
 Culturally sensitive care.
 Implementation science, implementation frameworks, and resources.
 Interprofessional collaboration.
 Person-and family-centred care.
 Self-management of chronic conditions.
 Therapeutic relationships.
For more information on the guideline development process, systematic reviews, and search strategy for this BPG, see Appendix D.

# BAC K G R O U N D
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Interpretation of Evidence and Recommendation Statements
RNAO Guidelines are developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) G and Confidence in the Evidence from Reviews of Qualitative Research (CERQual) G methods. For more information about the guideline development process, including the use of GRADE and GRADE-CERQual methods, refer to Appendix D.

# Certainty of Evidence
The certainty of evidence (i.e., the level of confidence we have that an estimate of effect is true) for quantitative research is determined using GRADE methods (8). After synthesizing the evidence for each prioritized outcome, the certainty of evidence is assessed. The overall certainty of evidence is then determined by considering the certainty of evidence across all prioritized outcomes per recommendation question. GRADE categorizes the overall certainty of evidence as high, moderate, low, or very low. See Table 1 for the definition of these categories.

# Table 1: Certainty of Evidence

# CERTAINTY OF EVIDENCE DEFINITION High
We are very confident that the true effect lies close to that of the estimate of the effect.

# Moderate
We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

# Low
Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

# Very Low
We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of the effect.  

# BAC K G R O U N D
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Confidence in Evidence
The confidence in evidence for qualitative research G (i.e., the extent to which the review finding is a reasonable representation of the phenomenon of interest) is determined using GRADE-CERQual methods (hereafter referred to as CERQual) (9). For qualitative evidence, an overall judgment of the confidence is made per finding in relation to each recommendation statement, as relevant. CERQual categorizes the confidence in evidence as high, moderate, low, or very low. See Table 2 for the definitions of these categories. 

# CONFIDENCE IN EVIDENCE DEFINITION High
It is highly likely that the review finding is a reasonable representation of the phenomenon of interest.

# Moderate
It is likely that the review finding is a reasonable representation of the phenomenon of interest.

# Low
It is possible that the review finding is a reasonable representation of the phenomenon of interest.

# Very Low
It is not clear whether the review finding is a reasonable representation of the phenomenon of interest.
Source: Reprinted from Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. Implement Sci. 2018;13(Suppl 1):1-10. Table 3, Description of level of confidence in a review finding in the CERQual approach; p. 6. Reprinted with permission.
Note: The assigned certainty and/or confidence in evidence can be found directly below each recommendation statement. For more information on the process of determining the certainty and/or confidence in the evidence and the documented decisions made by RNAO Guideline Development Methodologists, see Appendix D.

# Strength of Recommendations
Recommendations are formulated as strong or conditional by considering the certainty and/or confidence in evidence and the following key criteria (see Discussion of Evidence for definitions):
 Balance of benefits and harms.
 Values and preferences.
 Potential impact on health equity.

# BAC K G R O U N D
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Strong Recommendation
"A strong recommendation reflects the expert panel's confidence that the desirable effects of an intervention outweigh its undesirable effects (strong recommendation for an intervention) or that the undesirable effects of an intervention outweigh its desirable effects (strong recommendation against an intervention)" (8). A strong recommendation implies that the majority of persons will be best served by the recommended action (8).

# Conditional Recommendation
"A conditional recommendation reflects the expert panel's confidence that the desirable effects probably outweigh the undesirable effects (conditional recommendation for an intervention) or undesirable effects probably outweigh desirable effects (conditional recommendation against an intervention), but some uncertainty exists" (8). A conditional recommendation implies that not all persons will be best served by the recommended action: "there is a need for more careful consideration of personal circumstances, preferences, and values" (8).

# Note:
The strength of the recommendation statement is detailed directly below each recommendation statement and in the Summary of Recommendations. For more information on the process the expert panel used for determining the strength of each recommendation, please see Appendix D.

# Discussion of Evidence
The Discussion of Evidence that follows each recommendation includes the following main sections:
- Benefits and Harms: Identifies the potential desirable and undesirable outcomes reported in the literature when the recommended practice is used. Content in this section solely includes research from the systematic review.

# Values and Preferences:
Denotes the relative importance or worth of the health outcomes of following a particular clinical action from a person-centered perspective. Content for the Values and Preferences section may include research from the systematic reviews and (when applicable) the RNAO expert panel.

# Health Equity:
Identifies the potential impact that the recommended practice could have on health across different populations. Content for the Health Equity section may include research from the systematic reviews and (when applicable) the RNAO expert panel.

# Expert Panel Justification of Recommendation:
Provides a rationale for why the expert panel made the decision to rate a recommendation as strong or conditional.
Practice Notes: Highlights pragmatic information for nurses and members of the interprofessional team. This section may include supporting evidence from the systematic review and/or from other sources (e.g., the RNAO expert panel).
- Supporting Resources: Includes a list of relevant resources (such as websites, books, organizations, and more) that support recommendations. Content listed in this section was not part of the systematic review and therefore not all content was quality appraised. As such, the list is not exhaustive and the inclusion of a resource in one of these lists does not imply an endorsement from RNAO.

# BAC K G R O U N D
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Summary of Recommendations
This Guideline replaces the RNAO BPG Ostomy Care and Management (2009). A summary of how the recommendations in this Guideline compare to the recommendations in the previous Guideline is available at .

# RECOMMENDATIONS STRENGTH OF THE RECOMMENDATION
Recommendation Question #1: Should access to nurses specialized in wound, ostomy, and continence or no access to nurses specialized in wound, ostomy, and continence be recommended?
Outcomes: Peristomal dermatitis, peristomal irritation, ostomy leakage, quality of life, hospital length of stay and readmission rates to hospital .

# Recommendation 1 .1
The expert panel recommends that health service organizations provide access to nurses specialized in wound, ostomy, and continence as essential members of the interprofessional team for all persons who anticipate or live with an ostomy .

# Strong Recommendation 1 .2:
The expert panel recommends that access to nurses specialized in wound, ostomy, and continence includes the following support within the ostomy care continuum:  Performing preoperative stoma site marking .  Providing perioperative education and counselling .  Providing ongoing follow-up consultation and management .  Involving persons who anticipate or live with an ostomy and their support network in all steps of care, as appropriate .

# Strong
Recommendation Question #2: Should an ostomy care program or no ostomy care program be recommended?
Outcomes: Patient satisfaction, hospital length of stay, readmission rates to hospital and staff satisfaction.

# Recommendation 2 .1:
The expert panel recommends that health service organizations implement an internal expertguided, standardized ostomy care program that is developed using an interprofessional, teambased approach .

# Strong BAC K G R O U N D
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Recommendation 2 .2:
The expert panel recommends that health service organizations include the following interventions within a standardized ostomy care program:
 Preoperative education and counselling on ostomy surgery, daily living, and self-care .  Postoperative education regarding stoma self-management and potential complications .  Discharge planning that is based on a readiness criteria and includes follow-up information .  Scheduled home visits and telephone follow-up within the first four weeks .  Access to nurses specialized in wound, ostomy, and continence perioperatively and on an ongoing basis, as necessary .

# Strong
Recommendation Question #3:
Should prevention strategies for parastomal hernia development or no prevention strategies for parastomal hernia development be recommended?
Outcomes: Parastomal hernia rates . 

# Guideline Evaluation
As you implement the recommendations in this BPG, we ask you to consider how you will monitor and evaluate its implementation and impact.
The Donabedian model informs the development of indicators for evaluating quality health care, which includes three categories: structure, process, and outcome (10).
 Structure describes the required attributes of the health system, health service organization or academic institution to ensure quality care. It includes physical resources, human resources, and information and financial resources.
 Process examines the health-care activities being provided to, for, and with persons or populations as part of the provision of quality care.
 Outcome analyzes the effect of quality care on the health status of persons and populations, health workforce, health service organizations, academic institutions or health systems (10).
For additional information, please refer to the RNAO Toolkit: Implementation of Best Practice Guidelines, Second Edition (2012).
Tables 3, 4, and 5 provide potential structure, process and outcome measures to assess Guideline success. It is important to evaluate evidence-based practice changes when implementing a Guideline. Select the measures most relevant to the practice setting. There are few data repositories/indicator libraries available for ostomy support in Ontario and Canada. The following measures will support quality improvement and evaluation.
Table 3 provides potential structure measures associated with all recommendation statements, to assess attributes related to human resources.     

# Stakeholder Acknowledgment
As a component of the guideline development process, feedback was obtained from participants across a wide range of health service organizations, practice areas, and sectors. Participants include nurses and people with lived experience. Stakeholders G representing diverse perspectives were solicited for their feedback (see Appendix D). RNAO wishes to acknowledge the following individuals for their contribution in reviewing this BPG. Stakeholder reviewers have given consent to the publication of their names and relevant information in this BPG. 

# Background Context
What is an Ostomy?
An ostomy is a surgically created opening in the abdominal wall that results in the external diversion of feces and urine (1). An ostomy may be permanent or temporary, and the surgery is performed for various etiologies, including (but not limited to) diverticulitis, colorectal cancer, bowel obstruction, inflammatory bowel disease G , or bladder cancer (11). Each procedure results in a stoma, which is the end of the small or large intestine that can be seen protruding through the abdominal wall (2). The most common types of ostomy are the following:
 Colostomy: A surgically created opening from the colon to the abdominal wall to allow the elimination of feces (3).
 Ileostomy: A surgically created opening from the last part of the small intestine (ileum) to the abdominal wall to allow elimination of small bowel effluent (3).
 Urostomy: A surgically created opening to divert the flow of urine by transplanting the ureters into an isolated segment of the ileum, bringing one end through the abdominal wall to create a stoma. Urine flows from the kidney to the ureters, then through the ileal conduit, exiting through the stoma (3).
For some people, it is possible to have a continent bowel or urinary diversion in which an internal reservoir is surgically created using a section of the bowel to collect feces or urine. Continent diversions may or may not result in the creation of a stoma, and they eliminate the necessity for a pouching system G to be worn outside the body (2).

# Prevalence and Impact of Living with an Ostomy
An estimated 1.3 million people around the world have an ostomy, whether it be an ileostomy, colostomy, or urostomy (12). North Americans constitute a large portion of this population, with an estimated 750,000 living with an ostomy (13). In Canada alone, approximately 13,000 new ostomy surgeries are performed every year (13).
The creation of an ostomy is a life-changing event and has implications for various aspects of a person's healthrelated quality of life (11). Living with an ostomy may cause changes to physical and emotional well-being, and it may require lifestyle adjustments. One of the most common physical outcomes of living with an ostomy is the risk for stoma-related complications. Approximately 20 per cent to 71 per cent of persons with an ostomy experience stoma related complications, the most common being ostomy leakage and peristomal skin problems (14). Peristomal skin complications affect one third of persons with a colostomy and two thirds of persons with a urostomy or ileostomy (15).
Another common complication is the incidence of parastomal hernias. A parastomal hernia occurs when one or more loops of the bowel protrude through the abdominal muscle, creating a bulge around the peristomal skin (7).
Living with a parastomal hernia has been associated with impairments in quality of life, stressors related to body image, fatigue, and the physical burden of the hernia (1). The reported incidence of parastomal hernia varies widely within the literature, ranging from 0 per cent to 78 per cent; it is caused by risk factors such as high body mass index and waist circumference (7,16,17). When persons living with an ostomy have access to evidence-based care provided by knowledgeable and skilled health providers, however, many of these complications are preventable and treatable (18,19).

# BAC K G R O U N D
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Living with an ostomy can impact a person's psychological health and affect social functioning (20). For instance, living with an ostomy can negatively impact body image, sexual function, mood, and daily activities, thus impairing a person's overall psychological health (11,21). Lifestyle considerations and adjustments may also be required for aspects of daily life, such as diet, exercise, intimacy, and self-management of the ostomy (13). Despite so many challenges, if the right resources and supports are in place, it is certainly possible for persons to live an active and meaningful life after ostomy surgery.
There currently are no definite statistics determining the costs associated with living with an ostomy. However, maintaining an ostomy through the regular use of supplies can be expensive. In Canada, the type and availability of financial support for adults living with an ostomy varies across provinces, ranging from complete coverage to no coverage at all, resulting in many people having to pay out-of-pocket fees (22). Living with an ostomy, whether it is temporary or permanent, also increases the risk of costly complications (23). Research suggests that costs of care are substantially higher for persons with peristomal skin complications related to an ostomy (24). It is estimated that average treatment costs are $77 CDN greater (including pouching systems and accessories) over a seven-week period of treatment for people with peristomal skin complications versus those without peristomal skin complications (25).

# Streamlining Ostomy Support
In accordance with the Charter of Ostomates Rights (Appendix K), persons living with an ostomy have the right to comprehensive, personalized, and accessible care (26). As the number of persons living with an ostomy increases, the need to provide such care becomes increasingly critical for health service organizations and health systems in order to meet the needs of the persons they serve (23).
The interprofessional team supporting persons living with an ostomy throughout the health continuum includes (but is not limited to) NSWOCs, nurses, surgeons/physicians, social workers, dietitians, and pharmacists. In particular, NSWOCs are designated experts who are highly trained, both in the psychological aspects of care and the care of persons with fecal and urinary diversions (27). "NSWOC" is a protected title and limited to certain jurisdictions, however, its equivalent may be represented in other locations with titles such as stoma nurse, WOC nurse, or ostomy nurse. An NSWOC is deemed certified if they graduate from a WCET-accredited ostomy education program and pass a national certification exam (4). Ostomy champion roles may assist and support the NSWOC expert in many organizations, but they are not independent subject experts.
Comprehensive ostomy care, which includes access to expert health providers, is related to improved health outcomes. Comprehensive care requires collaboration among the interprofessional team, the person anticipating or living with an ostomy and their support network, along with standardized work processes and care pathways. Furthermore, use of evidence-based practice enables informed decision making at the person, organization, and system levels to ensure improved health outcomes. Consistent use of evidence-based practices related to ostomy care is ultimately enabled by policies and programs that standardize work processes.

# Conclusion
Prevention strategies, timely interventions, knowledgeable providers, and accessible resources are required to facilitate optimal well-being for persons who anticipate or live with an ostomy. This BPG provides evidence-based best practice recommendations that will help health service organizations and the interprofessional team to support adults (18 years and older) anticipating or living with a colostomy, ileostomy, or urostomy to enhance access and care delivery, promote self-management, and lead to positive health outcomes. The expert panel recommends that health service organizations provide access to nurses specialized in wound, ostomy, and continence as essential members of the interprofessional team for all persons who anticipate or live with an ostomy.

# RECOMMENDATIONS

# Strength of recommendation: Strong

# Certainty of the evidence of effects: Low
Confidence in evidence: Low

# Discussion of Evidence: Benefits and Harms
Evidence demonstrates that access to a NSWOC may promote positive health outcomes in persons living with or anticipating an ostomy. Studies examined the benefits of one or more of the following interventions: performing preoperative stoma site marking G , providing perioperative G education and counselling, providing ongoing followup consultation and management, and involving persons who anticipate or live with an ostomy and their support network. These interventions were provided by a NSWOC (or a NSWOC as a key member of the interprofessional team) compared to no access to a NSWOC in persons who anticipate or live with an ostomy.
The studies found that regardless of the intervention, access to a NSWOC may reduce the incidence of peristomal dermatitis or skin irritation, readmission rates to hospital, hospital length of stay and the rates of ostomy leakage; access also may improve quality of life in persons anticipating or living with an ostomy across various health settings (community and hospital) (11,(28)(29)(30)(31)(32)(33)(34)(35). The evidence was of low certainty due to limitations in how studies were conducted, use of different tools to measure outcomes across studies and the small number of study participants. In qualitative studies reporting on facets of quality of life, persons living with an ostomy indicated that care provided by NSWOCs could help address their psychosocial concerns and help them resume a normal life (36,37). The qualitative evidence was of low confidence due to limitations in how studies were conducted and the small number of study participants. There were no harms related to the interventions provided by NSWOCs in the literature.
For more detailed information of the impact of the intervention (access to NSWOCs) on each of the prioritized outcomes (peristomal dermatitis, peristomal irritation, ostomy leakage, quality of life, hospital length of stay and readmission rates to hospital), please refer to the evidence profiles available here: .
See Recommendation 1.2 for details on the specific interventions provided by NSWOCs and their associated benefits and harms.

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Values and Preferences
The evidence indicates that persons with an ostomy attributed high value to the role of the NSWOC. Persons with an ostomy value the opportunity to speak about their challenges and concerns, and to receive timely follow-up advice from a NSWOC (37).

# Health Equity
The expert panel suggests that availability and timely access to expert assessment and management provided by a NSWOC in all care settings would improve health equity, particularly in rural settings. Literature demonstrates that living in a rural area was associated with a lack of access to expert ostomy assessment and management (38). Group education provided by NSWOCs may be more effective at increasing quality of life for persons living with an ostomy in rural areas, as these persons may be at greater risk for social isolation (32).

# Expert Panel Justification of Recommendation
There were benefits to having access to NSWOCs and no harms were found. However, the certainty in this evidence was low. The expert panel determined that persons would value improvements in outcomes and attributed high value to ensuring that persons who anticipate or live with an ostomy have equitable access to NSWOCs to decrease the risk of complications (peristomal dermatitis, peristomal irritation and ostomy leakage), improve organization-related outcomes (readmission rates to hospital and hospital length of stay) and improve quality of life across populations. Therefore, the expert panel determined the strength of the recommendation to be strong.

# Practice Notes
There are no practice notes associated with this recommendation. The expert panel recommends that access to nurses specialized in wound, ostomy, and continence includes the following support within the ostomy care continuum:
 Performing preoperative stoma site marking.
 Providing perioperative education and counselling.
 Providing ongoing follow-up consultation and management.
 Involving persons who anticipate or live with an ostomy and their support network in all steps of care, as appropriate.

# Strength of recommendation: Strong

# Certainty of the evidence of effects: Low
Confidence in evidence: Low

# Discussion of Evidence: Benefits and Harms
Studies examined one or more of the following interventions: performing preoperative stoma site marking, providing perioperative education and counselling, providing ongoing follow-up consultation and management, and involving persons with an ostomy and their support network in all steps of care, as appropriate. These interventions were provided by a NSWOC (or the NSWOC as a key member of the interprofessional team) compared to no access to an NSWOC. The studies found benefits in outcomes for persons anticipating or living with an ostomy across various health settings (community and hospital) (11,(28)(29)(30)(31)(32)(33)(34)(35). The evidence was of low certainty due to limitations in how studies were conducted, use of different tools to measure outcomes across studies and the small number of study participants. For qualitative studies, the confidence in evidence was also low due to limitations in how studies were conducted and the small number of study participants. There were no harms related to these interventions provided by NSWOCs in the literature.
For more detailed information of the impact of the intervention on each of the prioritized outcomes (peristomal dermatitis, peristomal irritation, ostomy leakage, quality of life, hospital length of stay and readmission rates to hospital), refer to the evidence profiles available here: .
The key interventions provided by the NSWOC throughout the ostomy care continuum and the associated health outcomes are outlined below. Please see Table 6 under Practice Notes for more details on specific components of the interventions.

# Performing Preoperative Stoma Site Marking
The evidence was limited to two studies. The evidence suggests that persons who receive stoma site marking by a NSWOC may experience a reduction in hospital length of stay and peristomal dermatitis (34,35).

# Providing Perioperative Education and Counselling
There is consistent evidence that suggests when NSWOCs provide preoperative and/or postoperative education and counselling, it may reduce hospital length of stay (28,31,33) and rates of peristomal dermatitis/irritation (28,29,31,35). The majority of studies suggest that when NSWOCs provide preoperative and/or postoperative education and counselling, it may improve quality of life (28, 31, 32) and reduce readmission rates to hospital (28,31,33).

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Refer to Appendix J for a sample ostomy teaching record to guide perioperative education and counselling for persons anticipating or living with an ostomy. Refer to Appendix M for nutritional management tips for persons living with an ostomy, which is an important component of perioperative education and counselling.

# Providing Ongoing Follow-up Consultation and Management
There is consistent evidence that suggests when NSWOCs provide ongoing follow-up consultation and management, it may improve quality of life (29,30). The evidence regarding peristomal dermatitis/irritation was limited to one study; it suggests that when NSWOCs provide ongoing follow-up consultation and management, rates of peristomal dermatitis/irritation may be reduced (29).
In findings from qualitative research reporting on quality of life, persons living with an ostomy expressed that ongoing follow-up consultation and management by NSWOCs could help address their psychosocial concerns and help them resume a normal life (36,37).

# Involving Persons Who Anticipate or Live with an Ostomy and Their Support Network in all Steps of Care, as Appropriate
Education provided by NSWOCs for persons who anticipate or live with an ostomy and their support network may have benefits. The evidence regarding the outcome quality of life was limited to one study; it suggested that involving the support network may improve quality of life for persons who anticipate or live with an ostomy (32). Furthermore, the evidence regarding peristomal dermatistis/irritation and ostomy leakage was also limited to one study, which suggested that involving the support network may decrease rates of peristomal dermatitis/irritation and ostomy leakage (28).

# Values and Preferences
See Recommendation 1.1 for the applicable values and preferences. The research suggests that the values and preferences associated with this recommendation are consistent with those outlined in Recommendation 1.1.

# Health Equity
See Recommendation 1.1 for the applicable impact on health equity. The research and the expert panel suggest that the impacts on health equity associated with this recommendation are consistent with those outlined in Recommendation 1.1.

# Expert Panel Justification of Recommendation
There were benefits to the use of the following interventions when conducted by a NSWOC or the NSWOC as a key member of the interprofessional team: preoperative stoma site marking, providing perioperative education and counselling, providing ongoing follow-up consultation and management, and involving persons who anticipate or live with an ostomy and their support network in all steps of care, as appropriate. No harms were found. However, the certainty in this evidence was low.
The expert panel determined that persons would value improvements in outcomes and attributed high value to ensuring that persons who anticipate or live with an ostomy have equitable access to NSWOCs to decrease risks of complications (peristomal dermatitis, peristomal irritation, and ostomy leakage), to improve organization-related outcomes (readmission rates to hospital and hospital length of stay), and to improve quality of life across populations. The expert panel therefore determined the strength of the recommendation to be strong.

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Practice Notes 

# KEY INTERVENTION DETAILS FROM THE EVIDENCE

# Performing preoperative stoma site marking
 No further details from the evidence regarding performing preoperative stoma site marking.
 Procedural information can be found within the grey literature, under the Supporting Resources section for this Recommendation.

# Providing perioperative education and counselling
Preoperative education and counselling included the following:
 A description of the surgical procedure and what an ostomy is (31,33).
 An explanation of preoperative interventions (e.g. stoma site marking) (28,33).
 Instruction and practical demonstration of stoma site care (28).
 Reviewing ostomy supply needs (28).
 Describing in-hospital interventions to expect after surgery (28,31).
 Explaining how to manage common complications (28,32,33).
 Describing the impact of a stoma on daily life (e.g. sexuality) (31).
 Reviewing changes to diet and hydration needs (28,33).

# Postoperative education and counselling included the following:
 Directions and hands-on experience on how to change a pouching system and care for the stoma (31,33).
 Providing a description of supplies (31,33).
 Reviewing changes to diet and hydration (33).
 Providing resources for social support (31).

# Educational delivery considerations for preoperative group education:
 Encouraging discussion, asking questions, and sharing lived experiences (28,32).
 Reinforcing through a video demonstration that a person living with an ostomy can do anything (32).

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# KEY INTERVENTION DETAILS FROM THE EVIDENCE

# Providing ongoing follow-up consultation and management
Follow-up consultation and management included the following:
 Conducting a peristomal assessment (29,37).
For resources to aid in conducting a peristomal assessment, please refer to:
 Appendix G for ostomy assessment terms.
 Appendix H for ostomy assessment parameters and definitions.
 Appendix I for a sample assessment and management form for peristomal skin breakdown.
 Conducting a pouching system assessment (29).
 Evaluating and guiding a person's stoma self-care (36,37).
 Helping persons to accept their new condition, and helping them to see that they can continue activities and have control over their lives (36,37).
 Answering questions or concerns (36,37).
 Providing appropriate referral as needed (in the context of telephone follow-up) (37).

# Involving persons with ostomy and their support network in all steps of care, as appropriate
 No further details from the evidence regarding involving persons anticipating or living with an ostomy and their support network in their care. The expert panel recommends that health service organizations implement an internal expertguided, standardized ostomy care program that is developed using an interprofessional, teambased approach.

# Strength of the recommendation: Strong

# Certainty of the evidence of effects: Low
Confidence in evidence: Low

# Discussion of Evidence: Benefits and Harms
A standardized ostomy care program is an organization-level approach established within individual health service organizations to standardize care for persons anticipating or living with an ostomy. The ostomy care program includes structured treatment, management, and follow-up strategies developed and implemented by an interprofessional team that is internal to each organization, which may consist of NSWOCs, nurses, surgeons/physicians, social workers, and dietitians (among others).
Findings from quantitative research suggest that implementing an internal expert-guided, standardized ostomy care program within health organizations-compared to not implementing an ostomy care program-may reduce hospital length of stay and 30-day readmission rates to hospital, and improve patient satisfaction for persons anticipating or living with an ostomy (18,19,31,33,(39)(40)(41)(42)(43). The evidence was of low certainty due to limitations in how studies were conducted, use of different tools to measure outcomes across studies and the small number of study participants. There were no harms related to these interventions provided within the ostomy care program in the literature.
For more detailed information of the impact of the intervention (ostomy care program) on each of the specified outcomes (patient satisfaction, hospital length of stay, readmission rates to hospital and staff satisfaction), refer to the evidence profiles available here: .
See Recommendation 2.2 for further details regarding specific interventions included within the ostomy care program and the associated benefits and harms.
Refer to Appendix L for a sample ostomy care program patient checklist that can be used by the person anticipating an ostomy surgery.

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Values and Preferences
Evidence suggests that persons living with an ostomy attributed high value to clear postoperative education, such as understanding common post-operative occurrences and how to resolve complications while at home (41). Some persons also requested the opportunity for family involvement so that they are well informed and can ask questions, as well as more information on types of stomas and where to order supplies (44). Persons living with an ostomy prefer having direct access to an assigned NSWOC or health provider compared to an emergent health visit to address complications after discharge (41).

# Health Equity
The expert panel suggests that implementation of an internal, expert-guided, standardized ostomy care program would improve health equity by ensuring the consistency of care delivered across populations. An interprofessional, internal, expert-guided and standardized ostomy care program requires the appropriate health human resources. This may be a challenge in some settings.

# Expert Panel Justification of Recommendation
There were benefits in implementing an internal, expert-guided, standardized ostomy care program and no harms were found. However, this evidence was of low certainty. The expert panel determined that persons would value improvements in outcomes and attributed high value to ensuring that health service organizations implement a standardized ostomy care program to improve patient satisfaction, to improve organization-related outcomes (readmission rates to hospital and hospital length of stay) and to enhance staff satisfaction. Therefore, the expert panel determined the strength of the recommendation to be strong.

# Practice Notes
The expert panel attributed high value to having experts in ostomy care (e.g., NSWOCs) within health service organizations to guide the implementation of a standardized ostomy care program. Experts are identified as those with formal knowledge and experience in providing care for persons who anticipate or live with an ostomy. The expert panel emphasized the importance of collaboration among the interprofessional team to support standardization of care across the organization. The expert panel recommends that health service organizations include the following interventions within a standardized ostomy care program:

# RECOMMENDATIONS
 Preoperative education and counselling on ostomy surgery, daily living, and self-care.
 Postoperative education regarding stoma self-management and potential complications.
 Discharge planning that is based on a readiness criteria and includes follow-up information.
 Scheduled home visits and telephone follow-up within the first four weeks.
 Access to nurses specialized in wound, ostomy, and continence perioperatively and on an ongoing basis, as necessary.

# Strength of the recommendation: Strong

# Certainty of the evidence of effects: Low
Confidence in evidence: Low

# Discussion of Evidence: Benefits and Harms
Studies examined one or more of the components of a standardized ostomy care program within health service organizations. All interventions involved collaboration among one or more members of the interprofessional team. When compared to no standardized ostomy care program, the proposed interventions within a standardized ostomy care program displayed benefits in outcomes for persons who anticipate or live with an ostomy (18,19,27,33,(39)(40)(41)(42)(43)45). The evidence was of low certainty due to limitations in how studies were conducted and the use of different tools to measure outcomes across studies. The qualitative evidence was of low confidence due to limitations in how the study was conducted and the small number of study participants. There were no harms in the literature related to these interventions provided within the ostomy care program.
For more detailed information on the components of this intervention on each of the specified outcomes (patient satisfaction, hospital length of stay, readmission rates to hospital and staff satisfaction), refer to the evidence profiles available here: .
The key interventions included within a standardized ostomy care program and the associated health outcomes are outlined below. See Table 7 under Practice Notes for more details on specific interventions.

# Preoperative Education and Counselling on Stoma Surgery, Daily Living, and Self-care
There is consistent evidence that suggests when persons anticipating stoma surgery receive preoperative education and counselling, it may reduce hospital length of stay (19,31,33). The majority of studies also suggest that when persons anticipating stoma surgery receive preoperative education and counselling, it may reduce readmission rates to hospital (19,33,43). The evidence regarding the outcome patient satisfaction is limited to one study and suggests that when persons anticipating stoma surgery receive preoperative education and counselling, it may improve patient satisfaction (27).

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Postoperative Education regarding Stoma Self-management and Potential Complications and Discharge Planning That is Based on a Readiness Criteria and Includes Follow-up Information
There is consistent evidence that suggests when persons receive postoperative education, discharge planning that is based on a readiness criteria and includes follow-up information prior to discharge, it may reduce hospital length of stay (19,31,43) and improve patient satisfaction (27,40,41). The majority of studies suggest that when persons receive postoperative education, discharge planning that is based on a readiness criteria and includes follow-up information prior to discharge, readmission rates to hospital may be reduced (18,19,33,40,42,43).

# Scheduled Home Visits and Telephone Follow-up within the First Four Weeks
There is consistent evidence that suggests when persons receive scheduled home visits and telephone follow-up, it may reduce readmission rates to hospital (33,40,42,43) and it may improve patient satisfaction (27,40,45). In all studies, health providers carrying out the scheduled home visits and telephone follow-up included NSWOCs, colon and rectal surgeons, physicians, nurse practitioners, or visiting registered nurses.
There is consistent qualitative evidence that indicates that persons who receive home visits and/or telephone follow-up calls experience feelings of reassurance, safety, gratitude, and satisfaction with care (40,45). The evidence regarding the outcome staff satisfaction was limited to one qualitative study. In this study, NSWOCs who provided telephone follow-up support expressed finding meaningful worth through recognizing the significant impact they have on the lives of persons who anticipate or live with an ostomy (37).

# Access to Nurses Specialized in Wound, Ostomy, and Continence Perioperatively and on an Ongoing Basis, as Necessary
There is consistent evidence that suggests access to NSWOCs perioperatively and on an ongoing basis may improve patient satisfaction (27,40,41,45) and reduce hospital length of stay (31,33,40). The majority of studies suggest that access to NSWOCs perioperatively and on an ongoing basis may reduce readmission rates to hospital (18,33,40,42).
One qualitative study reported that persons who received telephone follow-up calls from NSWOCs felt excited, comfortable, safe, and reassured, and that they had greater satisfaction with care received (37).

# Values and Preferences
Research suggests that persons living with an ostomy attributed high value to having direct access to (or contact information of) a NSWOC (41). Persons with an ostomy indicated that they wanted clear and consistent postoperative education on stoma management, stoma supplies, potential stoma complications, and courses of actions to resolve issues (41). Persons with an ostomy also preferred receiving follow-up telephone calls from hospital staff, as such calls provided reassurance that no pertinent information related to their treatment and recovery had been missed (37).
In relation to staff satisfaction, NSWOCs who conducted the telephone follow-up calls attributed high value to receiving training related to communication skills and counselling techniques; such training helped them to overcome difficulties, such as language barriers, time limitations, and poor patient moods (37). They also felt that providing psychological support to patients to boost confidence and courage and help them resume normal lives was the most valuable component of the telephone follow-up intervention (37).

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Health Equity
See Recommendation 2.1 for the applicable impact on health equity. The expert panel suggests that the impact on health equity associated with this Recommendation is consistent with what is outlined in Recommendation 2.1.

# Expert Panel Justification of Recommendation
There were benefits of the intervention components included as part of a standardized ostomy care program within health service organizations. No harms were found. However, the certainty in this evidence was low. The expert panel determined that persons would value improvements in outcomes and attributed high value to health organizations implementing a standardized ostomy care program to improve patient satisfaction and organization-related outcomes (readmission rates to hospital and hospital length of stay) and to enhance staff satisfaction. Therefore, the expert panel determined the strength of the recommendation to be strong.

# Practice Notes
The expert panel attributed high value to providing persons with an ostomy with direct access to an NSWOC, as needed, during the first four weeks after surgery and on an ongoing basis in order to improve patient satisfaction and decrease readmission rates to hospital.
The expert panel emphasized that scheduled home visits should be conducted by nurses possessing the appropriate knowledge and skills.
The expert panel emphasized that persons who anticipate or live with an ostomy, and who have concerns regarding medications, be directed to their pharmacist.
The expert panel attributed high value to health providers conducting an ostomy assessment immediately postoperatively and throughout the ostomy care program. Refer to Appendices G, H and I for ostomy assessment terms, definitions, parameters and sample assessment form that can be used for persons who live with an ostomy.
The expert panel emphasized that the interventions within the ostomy care program are based on a plan of care promoting self-efficacy that has been established in collaboration with the person, their support network (if needed) and the interprofessional team.

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition  Explaining what an ileostomy is (33).
 Demonstrating pouching systems and techniques (33).
 Introducing concepts of stoma output management in relation to diet and antidiarrheals (33).
 Describing the surgical procedure and showing pictures of stomas (31).
 Describing the potential impact of stoma on relationships, sexuality, showering, and other activities of daily life (31).
 Explaining postoperative routines (31).
 Holding practice sessions to change and manage stomas (31).
 Provision of information regarding the purchase of stoma care equipment (31).

# Postoperative education regarding stoma selfmanagement and potential complications

# Discharge planning that is based on a readiness criteria and includes follow-up information
Postoperative education and discharge planning included the following:
 Strategies to improve self-management of the ostomy in the hospital (18,33,42).
 Using a readiness criteria or checklist to determine when a person can be discharged; for instance, using a person-centred checklist to teach stoma care and evaluate readiness for discharge (18,33,42).
 Establishing discharge and follow-up plans that include providing home care support or referral (40)(41)(42)(43).
 Providing an overview of signs and symptoms of dehydration and/or other complications (40,41).
 Providing instructions on how to document intake and output and monitor for signs and symptoms of dehydration for persons with an ileostomy (33,42).

# Scheduled home visits and telephone followup within the first four weeks.
Scheduled home visits and telephone follow-up included the following:
 Providing a telephone consult regarding intake/output and how to avoid dehydration (40).
 Home visits by trained nurses after hospital discharge for four continuous weeks to assess for signs of dehydration, pouching issues, stoma output, and infection (42).
 Providing appropriate referral for stoma nurse clinic, surgical consultation, or emergency room based on evaluation from the telephone consultation (45). The expert panel suggests that health providers implement the following interventions to prevent parastomal hernias for persons who anticipate or live with an ostomy:

# RECOMMENDATIONS
 Conduct a risk factor assessment related to body mass index and waist circumference.
 Provide expert advice on weight management, as needed.
 Perform stoma site marking preoperatively.
 Provide postoperative education related to:
 abstinence from heavy lifting postoperatively;
 consideration of lightweight support garments; and
 abdominal exercises beginning within three months of surgery.

# Strength of the recommendation: Conditional

# Certainty of the evidence of effects: Very Low
Confidence in evidence: Not Applicable

# Discussion of Evidence: Benefits and Harms
Research suggests that six key interventions performed by health providers that support prevention of parastomal hernias may decrease incidence of parastomal hernias in persons who anticipate or live with an ostomy (16). However, two studies by Thompson and Trainer as cited in Bland and Young (1) reported a 17 per cent increase in the incidence of parastomal hernias after implementation of an early hernia prevention program that utilized the six key strategies. The studies concluded that the rise was related to participant non-adherence. The studies also reported a long term reduction in incidence of parastomal hernias among those who adhered to the early hernia prevention program (1). The body of evidence was of very low certainty due to limitations in how studies were conducted and the small number of study participants.
For more detailed information on the impact of the components of hernia prevention strategies on the outcome rates of parastomal hernia, please refer to the evidence profiles available here: .
The hernia prevention strategies and their impact on rates of parastomal hernia in persons who live with an ostomy are summarized on the next page. Specific components of the interventions noted in the literature and identified by the expert panel are outlined under Practice Notes. 

# RECOMMENDATIONS

# Perform Stoma Site Marking Preoperatively
The evidence regarding performing stoma site marking preoperatively is limited to one study. According to Person et al. as cited in Bland and Young (1), preoperative stoma site marking by a NSWOC may reduce rates of parastomal hernia in persons living with an ostomy. The rate of parastomal hernia was 3.8 per cent in the group that received stoma site marking compared to 24.5 per cent in the group that did not receive a stoma site marking.

# Provide postoperative education related to: Abstinence from Heavy Lifting Postoperatively; Consideration of Lightweight Support Garments; and Abdominal Exercises Beginning within Three Months of Surgery
According to two studies by Thompson and Trainer as cited in Bland and Young (1) and North (16), persons who anticipate or live with an ostomy-and who receive advice on abstinence from heavy lifting, consideration of lightweight support garments and instructions to begin specific abdominal exercises within three months after surgery as part of a hernia prevention program-may experience a decrease in the rates of parastomal hernias. One research study reported that after implementing the program, the rates of parastomal hernia were 15 per cent in all study participants and 1 per cent among those who were fully compliant (compared to 23 per cent local incidence and 44 per cent overall incidence reported in existing studies) (16). The 2005 and 2007 studies by Thompson and Trainer as cited in Bland and Young (1) indicated that reduction in parastomal hernias was 14 per cent after implementing the hernia prevention program compared to 28 per cent before the program. There was limited and very low certainty of evidence about how long a person with an ostomy needs to abstain from heavy lifting postoperatively. Please refer to Practice Notes for the expert panel consensus time frame on abstaining from heavy lifting postoperatively.

# Values and Preferences
Evidence indicates that only 45 per cent of participants who ordered a support garment utilized it on a regular basis, and only 27 per cent of participants believed that wearing the garment was important to prevent hernia (1).

# Health Equity
The expert panel recognizes that there is limited evidence that supports the benefits of lightweight support garments in prevention of parastomal hernias. In addition, persons of lower socio-economic status may have challenges with access to lightweight support garments due to cost.

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Expert Panel Justification of Recommendation
The expert panel determined that there is likely high variability in how much persons living with an ostomy value the outcomes associated with this recommendation. Given the unclear benefits associated with wearing lightweight support garments compared to other factors (such as cost and comfort), persons with an ostomy may choose not to receive the intervention. In addition, the overall evidence for hernia prevention strategies was of very low certainty. Therefore, the expert panel determined the strength of the recommendation to be conditional. 

# Practice Notes

# Conducting a risk factor assessment related to body mass index (BMI) and waist circumference
 An online calculator to measure BMI is provided in the Supporting Resources section.
 A risk factor assessment should be conducted preoperatively, postoperatively and on an as needed basis.

# Providing expert advice on weight management, as needed
 Referral to a registered dietician for education regarding nutrition and weight management.

# Advising abstinence from heavy lifting postoperatively
 Providing immediate postoperative education on the following:
 Heavy lifting.
 Weight transfer.
 Splinting with coughing, nausea, or vomiting.
 Avoiding straining with constipation.
 Avoid lifting no more than 10 lbs for the first month after surgery, and then slowly work back up to lifting normal weights.

# Consideration of lightweight support garments before discharge
 Providing information on support garments.

# Providing instructions on abdominal exercises to begin within three months of surgery
 Surgeons to recommend abdominal exercises with specific instructions on when to begin and how to perform them.
 Providing appropriate referral to a physiotherapist to provide education on abdominal exercises and proper body mechanics to perform during the first three months after surgery.

# Additional considerations
 Providing education on what a parastomal hernia is.
 Having an anti-emetic protocol in place immediately after surgery.

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition 

# Abdominal exercise
Gently place your hands on your lower tummy. Breathe in through your nose and, as you breathe out, gently pull your tummy button down towards your spine. Feel the muscles tighten, try to hold for a count of 3 and then relax. Breathe in and out normally.

# Pelvic tilting
Place your hands in the hollow of your back. Tighten your tummy muscles (as exercise 1), flatten your lower back onto your hands and tilt your bottom. Breathe normally. Hold for 3 seconds and release gently.

# Knee rolling
Tighten your tummy muscles (as exercise 1) and gently lower both knees to one side as far as is comfortable. Bring them back to the middle and relax. Repeat to the other side. This exercise has the added benefit of releasing trapped wind.
Aim to do each of these exercises five times, three times a day. Do more repetitions as you feel able. In order to guide person-centred care, the expert panel recommends that health providers assess quality of life in persons who anticipate or live with an ostomy. Specific areas of focus should include the following:
 Psychological distress (anxiety and depression).
 Self-identity (sexuality and body image).

# Strength of the recommendation: Strong

# Certainty of the evidence: Very Low
Confidence in evidence: Low

# Discussion of Evidence: Benefits and Harms
Systematic review results highlight the lack of literature on the impact of conducting a quality of life assessment for persons who anticipate or live with an ostomy. As a result, literature was examined to understand the relationship between anticipating or living with an ostomy, and quality of life outcomes of psychological distress and selfidentity. Studies demonstrate the impact of living with an ostomy on quality of life through the use of quality of life assessments. The evidence was of very low certainty due to limitations in how studies were conducted, the use of different tools to measure outcomes across studies and the small number of study participants. For qualitative studies, the evidence was of low confidence due to some limitations in how studies were conducted and the small number of study participants.
The creation of an ostomy is a life-changing event and may have implications on various aspects related to quality of life, most notably psychological health and self-identity. Descriptive studies report that 46 per cent to 63 per cent of people expressed feelings of depression following stoma surgery and had lower quality of life scores in the mental health domain compared to the general public (46,47). Conversely, a descriptive study reported no difference between the general public and persons with a stoma in quality of life scores after surveying 2,329 community-dwelling persons with an ostomy (48). However, specific to the mental health domain of the survey, Nichols (48) reported that persons with an ostomy were more likely to indicate feeling "down in the dumps" most or all of the time and downhearted and depressed most or all of time. Furthermore, Knowles et al. (49) reported that results from survey data indicated that nearly 50 per cent of respondents who had Crohn's disease G and were living with an ostomy had scores indicating possible or probable anxiety disorder, while 42 per cent had a depressive symptom score.
A majority of the literature reported that living with an ostomy may have a negative impact on aspects of self-identity, most notably on body image and sexuality. Descriptive studies reported that body image was inferior for persons living with a permanent stoma after rectal cancer surgery compared to those without a stoma, while most persons

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition reported their sexual life was affected negatively after creation of a stoma (50,51). Persons who were diagnosed with rectal cancer and were living with an ostomy were more likely to be fearful of resuming sexual activity or to have problems undressing in front of a partner, interference with personal relationships, decreased ability to be intimate, and less satisfaction with appearance (52). For persons who were sexually active, descriptive studies reported that 33 per cent of them resumed sexual activity after stoma surgery (46,47).
Similarly, qualitative studies found that persons living with an ostomy expressed several changes in sexual function, such as erectile dysfunction, vaginal dryness, and pain during intercourse. Persons also experienced psychological impacts such as fear and anxiety related to sexual competence and/or the potential for pouching system mishaps during intimacy (53,54).
Fewer studies reported that living with an ostomy has no substantial (or a lesser) effect on body image and sexuality (55,56). Furthermore, some persons in two qualitative studies expressed that their self-perceptions about body image did not change, while others described negative self-perceptions about body image (53,54).

# Values and Preferences
In a qualitative study, persons with an ostomy expressed that they valued nurses as a source of practical and psychological support (54). In another qualitative study, persons with an ostomy expressed that they expect sexual counselling from a nurse to help them normalize their sexual lives (53). Persons with an ostomy also expressed the importance of support from family and friends during the adaption stage after ostomy surgery (54).

# Health Equity
No studies were found that directly assessed the impact of conducting a quality of life assessment on health equity. In a study conducted by Knowles et al. (49), 77 per cent of participants reported no current or past professional support to address their mental health concerns, despite a substantial portion of participants who had psychological concerns. These findings highlight the need for improved access to psychological services for persons living with an ostomy (49). Psychological services may include further assessment and management of psychological distress (anxiety and depression) and self-identity (sexuality and body image).

# Expert Panel Justification of Recommendation
The impact of a quality of life assessment was not evident in the literature. Instead, evidence regarding the impact of living with an ostomy on psychological health and self-identity was explored, which was of very low certainty. However, as the majority of literature reported on the negative effects of living with an ostomy on psychological health status and self-identity, the expert panel felt it is necessary to assess quality of life in all persons who anticipate or live with an ostomy as a precaution so that the appropriate follow-up can be completed (if needed). Therefore, the expert panel determined the strength of the recommendation to be strong.

# Practice Notes
The  How has getting the necessary ostomy supplies been for you?
For those who are in committed relationships:
 Some people who have the same surgery as you report feelings of discomfort or anxiety with resuming sexual or intimate activities with their partner. Have you experienced this?
For those who are not in a relationship:
 Some people who have the same surgery as you report that becoming involved in an intimate relationship is problematic. Have you been experiencing this since surgery?
The expert panel emphasized the importance of follow-up care after completing a quality of life assessment. Followup care can include the following:
 Providing education and counselling on how to mititigate negative feelings.
 Providing referrals for further support (e.g., psychotherapists, psychiatrists, and counselors).
 Incorporating the person's needs (such as emotional or cultural needs) into the plan of care. 

# Research Gaps and Future Implications
The RNAO Best Practice Guideline Development and Research Team and expert panel identified priority areas for future research (outlined in Table 10). Studies conducted in these areas would provide further evidence to support high-quality and equitable support for adults who anticipate or live with an ostomy. The list is not exhaustive; other areas of research may be required. Outcomes: Parastomal hernia rates.
 The effectiveness of abdominal exercises in the prevention of parastomal hernias.
 The identification of specific abdominal exercises to prevent occurrence of parastomal hernias.
 Exploring the benefits of preoperative versus postoperative abdominal exercises to prevent occurrence of parastomal hernias.
 The effectiveness of lightweight support garments in the prevention of parastomal hernias.
 The identification of specific instructions and considerations related to heavy lifting at any point after stoma surgery. 

# Implementation Strategies
Implementing guidelines at the point of care is multi-faceted and challenging. It takes more than awareness and distribution of guidelines for practice to change: guidelines must be adapted for each practice setting in a systematic and participatory way to ensure that recommendations fit the local context (57). The 2012 RNAO Toolkit: Implementation of Best Practice Guidelines, Second Edition provides an evidence-based process for doing this. It can be downloaded at www.RNAO.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition.
The Toolkit is based on emerging evidence that successful uptake of best practices in health care is more likely when the following occur:
 Leaders at all levels are committed to supporting guideline implementation.
 Guidelines are selected for implementation through a systematic, participatory process.
 Stakeholders for whom the guidelines are relevant are identified and engaged in the implementation.
 Environmental readiness for implementing guidelines is assessed.
 The guideline is tailored to the local context.
 Barriers and facilitators to using the guideline are assessed and addressed.
 Interventions to promote use of the guideline are selected.
 Use of the guideline is systematically monitored and sustained.
 Evaluation of the guideline's impact is embedded in the process.
 There are adequate resources to complete all aspects of the implementation.
The Toolkit uses the "Knowledge-to-Action" framework to demonstrate the process steps required for knowledge inquiry and synthesis (58) (see Figure 3). It also guides the adaptation of the new knowledge to the local context and implementation. This framework suggests identifying and using knowledge tools (such as guidelines) to identify gaps and begin the process of tailoring the new knowledge to local settings.
RNAO is committed to widespread deployment and implementation of our BPGs. We use a coordinated approach to dissemination, incorporating a variety of strategies, including the following:
- The Nursing Best Practice Champion Network, which develops the capacity of individual nurses to foster awareness, engagement, and adoption of BPGs.
- The BPG Order Set TM provide clear, concise, and actionable intervention statements derived from practice recommendations. BPG Order Sets can be readily embedded within electronic records, but they can also be used in paper-based or hybrid environments.
- The Best Practice Spotlight Organization (BPSO) designation, which supports implementation at the organization and system levels. BPSOs focus on developing evidence-based cultures with the specific mandate to implement, evaluate, and sustain multiple RNAO BPGs.

# RECOMMENDATIONS
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition
In addition, we offer annual capacity-building learning institutes on specific BPGs and their implementation.
Information about our implementation strategies can be found at:  
 RNAO

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Crohn's disease: Chronic idiopathic disease that causes inflammation of the lining of the gastrointestinal tract. This condition usually presents with abdominal pain and chronic diarrhea (3).
Diversion: Surgical creation of an alternative route through the abdominal wall to divert feces and urine (2).

# Downgrade:
In GRADE and GRADE-CERQual, when limitations in the individual studies potentially bias the results, the certainty of evidence will decrease (63). For example, a body of quantitative evidence for one priority outcome may begin with high certainty, but due to serious limitations in one or more of the five GRADE criteria, it will be rated down by one or two levels (64).
Education statement: Organizational approaches to the delivery of education in health service organizations and academic institutions to support evidence-based practice. Education statements are based on an analysis of educational recommendations across several BPGs on diverse clinical topics and populations. Education statements can be applicable to all clinical BPGs and can be contextually adapted within health service organizations and academic institutions to support implementation of clinical recommendations.
Effluent: Fecal or urinary discharge from the stoma after ostomy surgery (65).

# Evidence-based nursing practice:
The integration of research evidence with clinical expertise and patient values; unifies research evidence with clinical expertise and encourages the inclusion of patient preferences (66).

# Evidence-to-Decision (EtD) frameworks:
A table that facilitates expert panels to make decisions when moving from evidence to recommendations. The purpose of the EtD framework is to summarize the research evidence, outline important factors that can determine the recommendation, inform panel members about the benefits and harms of each intervention considered, and increase transparency about the decision-making process in the development of recommendations (67).

# GRADE:
The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) is a methodological approach to assess the certainty of a body of evidence in a consistent and transparent way, and to develop recommendations in a systematic way. The body of evidence across identified important and/or critical outcomes is evaluated based on risk of bias, consistency of results, relevance of the studies, precision of the estimates, publication bias, large effect, dose response, and opposing confounding (67). cont.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition When using GRADE, five components contribute to the assessment of confidence in the evidence for each outcome. These components are as follows:
- Risk of bias, which focuses on the flaws in the design of a study or problems in its execution. 2. Inconsistency, which looks at a body of evidence and assesses whether the results point in the same direction or are different. 3. Imprecision, which refers to the accuracy of results based on the number of participants and/or events included, and the width of the confidence intervals across a body of evidence. 4. Indirectness, whereby each primary study that supports an outcome is assessed and a decision is made regarding the applicability of the findings to the population, intervention, and outcome outlined in the research question. 5. Publication bias, where a decision is made about whether the body of published literature for an outcome potentially includes only positive or statistically significant results (67).
Health provider: Refers to both regulated (e.g., nurses, physicians, dieticians and social workers) and unregulated (e.g., personal support workers) workers that are part of the interprofessional team.

# Regulated health provider:
In Ontario, the Regulated Health Professional Act, 1991 (RHPA) provides a framework for regulating 23 health professions, outlining the scope of practice and the profession-specific controlled or authorized acts that each regulated professional is authorized to perform when providing health care and services (5).
Unregulated health provider: Unregulated health providers fulfill a variety of roles in areas that are not subject to the RHPA. They are accountable to their employers but not to an external regulating professional body (e.g., College of Nurses of Ontario). Unregulated health providers fulfill a variety of roles and perform tasks that are determined by their employer and employment setting. Unregulated health providers only have the authority to perform a controlled act as set out in the RHPA if the procedure falls under one of the exemptions set out in the Act (6).

# Hernia (parastomal):
A parastomal hernia occurs when one or more loops of the bowel protrude through the abdominal wall, creating a bulge around the peristomal skin (7).
Ileostomy: A surgically created opening from the last part of the small intestine (ileum) to the abdominal wall to allow the elimination of small bowel effluent. An ileostomy can be either temporary or permanent (3).

# Inflammatory bowel disease:
The term refers to a group of chronic, relapsing gastrointestinal tract conditions, with ulcerative colitis and Crohn's disease being two main forms (68).
Interprofessional team: "A team comprised of multiple health providers (regulated and unregulated) who work collaboratively to deliver comprehensive and quality health care and services to people within, between, and across health settings" (60). Key interprofessional team members supporting adults who anticipate or live with an ostomy include NSWOCs, nurses, surgeons, physicians, social workers, dietitians, and pharmacists.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Meta-analysis: A systematic review of randomized controlled trials that uses statistical methods to analyze and summarize the results of the included studies (69).

# See systematic review
Nurse: "Refers to registered nurses, licensed practical nurses (referred to as registered practical nurses in Ontario), registered psychiatric nurses, and nurses in advanced practice roles such as nurse practitioners and clinical nurse specialists" (70).
Nurse specialized in wound, ostomy, and continence (NSWOC): "A registered nurse with advanced and specialized knowledge and clinical skills in wound, ostomy, and continence care who has graduated from a World Council of Enterostomal Therapists (WCET  ) recognized education program" (4). A NSWOC provides specialized holistic assessment and management as an interprofessional team member to meet the needs to individuals/families with ostomies, acute and chronic wounds, and urinary and fecal continence problems" (4).
The NSWOC equivalent may be represented with other titles around the world, such as (but not limited to): stoma nurse; wound, ostomy, continence nurse (WOC nurse); or ostomy nurse.
Ostomy: Ostomy refers to a surgically created opening in the abdominal wall that results in the external diversion of feces and urine. The most common types of ostomy are colostomy and ileostomy for feces and urostomy for urine (2). A permanent ostomy refers to an ostomy "that will never be closed" (59). In the case of a temporary ostomy, "usually the surgical plan is to reconnect the intestine and to close the ostomy" (59).
Ostomy care program: An ostomy care program is an organization-level approach to standardize care for persons anticipating or living with an ostomy. The ostomy care program includes structured treatment, management, and follow-up strategies developed by an interprofessional team that may consist of NSWOCs, nurses, surgeons, physicians, social workers, dieticians, and pharmacists (among others).
Ostomy leakage: Exudate that seeps out of the stoma.
Outcomes: A dependent variable, or the clinical and/or functional status of a patient or population, that is used to assess if an intervention is successful. In GRADE, outcomes are prioritized based on if they are critical for decision making, important but not critical for decision making, or not important. Use of these outcomes helps literature searches and systematic reviews to be more focused (67).
Perioperative: Something occurring "around the time of surgery. This usually lasts from the time the patient goes into the hospital or doctor's office for surgery until the time the patient goes home" (71).

# Peristomal dermatitis (allergic and irritant):
Peristomal dermatitis (allergic) is skin damage caused by pouching system adhesives, powders, or barriers. Allergic dermatitis occurs at the site where offending agents or adhesives contact the skin (65). Peristomal dermatitis (irritant) is skin damage resulting from contact with fecal or urinary drainage. Irritant contact dermatitis is the most common peristomal skin complication and occurs at the site of effluent leakage (65).

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Peristomal irritation: Peristomal irritation is a common complication resulting from moisture-associated skin damage. It may cause the peristomal skin to be inflamed, sore, itchy, and red (72).
Peristomal skin/plane: An area of "3 to 4 inches (10 x 10 cm) of skin surface surrounding an abdominal stoma" (59).
PICO question: A framework to outline a focused question. It specifies four components:
- The patient or population that is being studied.
- The intervention to be investigated.
- The alternative or comparison intervention. 4. The outcome that is of interest (67).

# Pouching systems (ostomy pouching systems):
A system "composed of a skin barrier and a collection device to collect drainage (effluent) and protect the skin. Pouching systems are one-piece or two-piece products. The pouch attaches to the skin barrier, which adheres to the abdomen, and is fitted over and around the stoma to collect stool or urine" (59).
Qualitative research: An approach to research that seeks to convey how human behaviour and experiences can be explained within the contexts of social structures and through the use of an interactive and subjective approach to investigate and describe phenomena (73).

# Quasi-experimental study:
A study that estimates causal effects by observing the exposure of interest, but in which the experiments are not directly controlled by the researcher and lack randomization (i.e., before-andafter designs) (74).

# Randomized controlled trial (RCT):
An experiment in which the investigator assigns one or more interventions to participants who are randomly allocated to either the experimental group (receives intervention) and the comparison (conventional treatment) or control group (no intervention or placebo) (69).
Recommendation: A course of suggested action(s) that directly answers a recommendation question. A recommendation is based on a systematic review of the literature and is made in consideration of its potential benefits and harms, values and preferences from a person-centered perspective, and impact on health equity. All recommendations are given a strength, either strong or conditional through expert panel consensus. It is important to note that recommendations should not be viewed as prescriptive, as recommendations cannot take into account all of the unique features of individual, organizational and clinical circumstances (8).

# Recommendation question:
A priority research area of practice, policy or education identified by expert panel members that requires evidence to answer. The recommendation question may also aim to answer a topic area around which there is ambiguity or controversy. The recommendation question informs the research question, which guides the systematic review.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Scoping review: "Scoping reviews have been described as a process of mapping the existing literature or evidence base. Scoping reviews can be used in a number of ways, for example identifying research gaps and summarizing findings of research. They can also be used to inform systematic reviews" (75).
Self-management: "The tasks that individuals must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management, and emotional management of their conditions. The goal of self-management is increased confidence in the ability to change, rather than compliance with the caregiver's advice. The purpose of self-management support is to help persons become informed about their conditions and take an active role in treatment" (76).
Stakeholder: An individual, group, or organization that has a vested interest in the decisions and actions of organizations, and may attempt to influence decisions and actions (77). Stakeholders include all of the individuals and groups who will be directly or indirectly affected by the change or solution to the problem.
Stoma: An opening created on the abdominal wall by ostomy surgery to allow elimination of urine and feces. A stoma is usually dark pink in colour (2).
Stoma site marking: "Selection of the ideal location on the abdomen for a stoma prior to surgery by a trained health professional, usually a NSWOC or surgeon to help prevent future stoma complications and pouching problems" (59).

# Support network:
A term used to refer to those whom the person identifies as significant in his or her life. This can include individuals who are related (biologically, emotionally, or legally) and/or those with close bonds (friendships, commitments, shared household and child-rearing responsibilities, and romantic attachment) (70,78).

# Systematic review:
A comprehensive review of the literature that uses clearly formulated questions and systematic and explicit methods to identify, select, and critically appraise relevant research. A systematic review collects and analyzes data from the included studies and presents them, sometimes using statistical methods (69).
See meta-analysis Urostomy (ileal conduit): A surgical procedure to divert the flow of urine by transplanting the ureters into an isolated segment of the ileum, bringing one end through the abdominal wall to create a stoma. Urine flows from the kidney to the ureters, then through the ileal conduit, exiting through the stoma. A urostomy can be either temporary or permanent (3).

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Appendix B: RNAO Guidelines and Resources that Align with this Guideline
The following are topics that align with this Guideline and with suggested RNAO guidelines and resources from other organizations.

# TOPIC RESOURCE(S)
Client centred learning Academic institutions should consider integrating guideline content into theoretical and practice-based courses for nurses and other regulated health providers, including social workers, physiotherapists, occupational therapists, dieticians and pharmacists in pre-licensure and post-licensure programs. Pre-licensure education establishes foundational knowledge that can be strengthened and augmented, as necessary, within health service organizations. Post-licensure education at the graduate level may include preparing nurses and other regulated health providers for advanced practice roles and functions within clinical practice, education, administration, research, and policy (79). As such, the integration of guideline content into curricula will differ in terms of educational content and complexity based on the overall educational objectives of the program. In both cases, integrating guideline content into curricula supports student learning consistent with evidence-based practices, with the ultimate goal of enhancing the health outcomes of persons and families.
To support the integration of evidence-based guidelines into curricula, the following approaches may be utilized: (a) developing multi-level guideline-related learning objectives and (b) designing guideline-related teaching and learning strategies (80). Both approaches are outlined below.
A) Developing multi-level guideline-related learning objectives: Guideline-related learning objectives at multiple levels of a program (pre-licensure and post-licensure) facilitate integration of guideline content into curricula. At the program level, such integration broadens student knowledge, attitude, judgment, and skills.
For instance, a program-level outcome at a graduate level may include student awareness of elements of implementation science to support uptake and sustained use of guidelines in clinical settings (80). At the course level, integration of guideline content supports student learning that is consistent with evidence-based practices within academic and practice settings. For example, course-level outcomes at the undergraduate level may include students being able to gain increased knowledge about guidelines, select guidelines relevant to practice (and provide rationale for their selection), and integrate guideline recommendations into plans of care for persons and families (80).
B) Designing guideline-related teaching and learning strategies: Teaching strategies should be tailored to address the program-level educational objectives and needs of learners, and to equip the learner to improve practice and promote positive outcomes (81). The various guideline-related teaching and learning strategies are outlined below.
 Lectures: Educators can use lectures as a means to provide a broad understanding of guidelines, specifically the rigorous process of guideline development and their various recommendations. Lectures can provide students with an understanding of the scope and strength of evidence that inform the recommendations (80).
 Interactive classroom activities: Interactive learning activities within the classroom setting can support students to obtain additional information, participate in problem-solving, and articulate knowledge gained. Examples include (a) assigning group work to help students learn how to navigate a guideline and become familiar with its recommendations, (b) using case studies to provide students with opportunities to identify and apply guideline recommendations in care plans, and (c) using videos and role playing to promote skills in articulating the rationale for selecting specific guidelines/recommendations in care plans (80).
 Simulation: High-quality digital simulation within skills lab settings can ease the uncertainty of students related to clinical practice; it can also increase skill acquisition, self-confidence, and satisfaction. Faculty trained in pedagogy can use simulation to teach students content related to safe and effective person and family care within a standardized clinical environment (82). Educators can support students to incorporate guideline content into simulated practice sessions when teaching evidence-based practice (80).  (80).

# A P P E N D I C E S
Supporting Adults
 Access to BPG-related resources: Educators can promote and facilitate access to BPG-related links and resources. For example, providing access to the RNAO Nursing Best Practice Guidelines App (see https:// rnao.ca/bpg/pda/app) enables students to access content from guidelines within classroom and practice settings (80).
 Assignments and tests: Students may be asked to incorporate guidelines into their learning plans or write a reflective journal related to a guideline important to their area of practice. Tests or exam questions that demonstrate critical thinking related to guidelines can also be used. Overall, guideline-related assignments and tests can assist students to reflect upon guidelines, understand their application, and critique them (80).
 Preceptorship or mentorship in clinical placements: Preceptors within clinical settings play an integral role in teaching practical skills that complement the theoretical learning of students. Preceptors are responsible for providing clinical teaching and supervision, and they perform formal student evaluation (83). Preceptors can support students to integrate guideline content into their learning objectives and clinical activities to promote evidence-based knowledge and practice.

# EDUCATION STATEMENT 2:
Health service organizations use strategies to integrate evidence-based guidelines into education and training of nurses and other health providers.

# Discussion of Literature:
The thematic analysis of the education recommendations in a number of BPGs found the second theme of: "health service organizations use strategies to integrate evidence-based guidelines into education and training of nurses and other health providers, " as foundational to evidence-based practice capacity building.  Education and training programs should be based on the principles of adult learning, including the following:
 Adults have an awareness of learning needs/goals.
 Adults are self-directed and autonomous.
 Adults value and utilize prior life experiences.
 Adults have readiness to learn.
 Adults are motivated to learn.
 Adults are presented knowledge and skills in the context of practical, real-life situations (85).
Furthermore, education and training should be appropriate to the health provider's scope of practice and their defined role. Education and training strategies may include the following:
 In-service education sessions: In-service education sessions can be planned by clinical experts within practice settings to support the utilization of a specific guideline or recommendations stimulating evidence-based practice among staff. The education may include one-on-one or group sessions and should address the needs of learners. It is recommended that the education sessions are followed with refresher or booster sessions to provide feedback and enhance staff learning (86,87).
 Workshops/seminars: Highly interactive workshops/seminars help nurses and health providers maintain practice based on best evidence when they incorporate a variety of teaching-learning strategies, including pre-circulated materials, small group discussions using case studies, and multimedia such as Power Point and videos that integrate relevant guidelines/recommendations. RNAO's Best Practice Champions Workshop and BPG Learning Institutes are examples of programs that provide education on how to implement BPGs within practice settings (88).
 Quality improvement: Participating in quality improvement within workplace settings can support nurses and health workers to recognize sentinel events and examine ways to improve care. Meeting accreditation standards is an important quality improvement activity that bridges gaps between current and best practices and supports continued competence. Examples of strategies that nurses and other health providers can use to meet accreditation standards include the following:
 Participating in a unit-based guideline implementation process to promote patient safety, reduce risks, and improve care outcomes.  Choosing guideline-specific recommendations to facilitate practice change.  Sharing knowledge and lessons learned from reviewing guidelines with the accreditation committee (89,90).

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# EVALUATION
All educational strategies require evaluation to (a) monitor the adoption of knowledge and (b) measure the impact on clinical outcomes. RNAO has developed the Educator's Resource: Integration of Best Practice Guidelines (2005) to provide strategies for educators within academia and practice settings to introduce BPGs to student nurses, faculty, nurses and other health providers. The resource provides guidance on student evaluation strategies that include self-evaluation peer-evaluation and end-of-course evaluations by the educator.
Furthermore, RNAO has developed the Practice Education in Nursing (2016) BPG to provide evidence-based recommendations that support with the application of knowledge to various practice settings by student nurses. The guideline also assists nurses nurse educators, preceptors and other members of the interprofessional team to understand the effective use of teaching-learning strategies in clinical settings.
The RNAO Toolkit: Implementation of Best Practice Guidelines (2012)- identifies the following strategies for evaluation of provider practice change and health outcomes for persons within health service organizations:
 Pre-and post-tests for staff educational sessions.
 Staff focus groups/interviews.
 Observation of patient-provider encounters.
 Chart audits to determine the impact on person and family outcomes.
 Person and family satisfaction surveys or interviews.
- The RNAO Toolkit: Implementation of Best Practice Guidelines (2012) is under review and the next edition is expected to be issued in 2020.
Other quality improvement opportunities include participating in incident reporting, patient safety initiatives, and other health initiatives within areas of practice.
 Post-licensure mentorship: Post-licensure mentorship involves providing new graduates or less experienced staff with guidance for skill development and support for growth of professional roles.
Research suggests that working with mentors reduces stress and improves satisfaction for new staff during the transition process (91). Mentors can support integration of guideline content while teaching evidencebased practice.
- A guideline search and gap analysis was undertaken. Two Guideline Development Methodologists (one of them being the Guideline Development Lead) searched an established list of websites for guidelines and other relevant content published between January 2007 and August 2017. The resulting list was compiled based on knowledge of evidence-based practice websites and recommendations from the literature. RNAO expert panel members were asked to suggest additional guidelines (see Figure 4 in Appendix E). The purpose of the guideline search and gap analysis was to gain an understanding of existing guidelines regarding ostomy care and support in order to identify opportunities for addressing the purpose and scope of this BPG. Detailed information about the search strategy for existing guidelines, including the list of websites searched and the inclusion criteria used, is available at https:// rnao.ca/bpg/guidelines/ostomy.
The guidelines were reviewed for content, applicability to nursing scope of practice, accessibility, and quality. The two Guideline Development Methodologists appraised three international guidelines using the AGREE II tool and came to consensus on an overall score for each guideline (92). Guidelines with a score of six or seven (on a 7-point Likert scale) were considered to be of high quality. The systematic reviews that answered research questions in high quality guidelines were considered to be beyond the scope of this guideline. The following guidelines were appraised as indicated:
 Miller D, Pearsall E, Johnston D, et al. Executive summary: enhanced recovery after surgery: best practice guideline for care of patients with a fecal diversion. J Wound Ostomy Continence Nurs. 2017 Jan/Feb;44(1):74-7. (Score: 4 out of 7. This guideline was used as a supporting resource in this BPG)  Ostomy Guidelines Task Force. Management of the patient with a fecal ostomy-best practice guidelines for clinicians. J Wound Ostomy Continence Nurs. 2010 Dec;37(6):596-8. (Score: 3 out of 7. This guideline was not used as a supporting resource in this BPG because the content was not as relevant)
 World Council of Enterostomal Therapists (WCET). WCET international ostomy guideline. Perth (Australia): WCET; 2014. (Score: 4 out of 7. This guideline was used as a supporting resource in this BPG)
- A scoping review of the literature was performed to determine the depth of peer-reviewed studies in the area of pediatric populations (younger than 18 years) living with an ostomy.
Six key informant interviews took place with experts in the field including front-line health providers, researchers, and individuals with lived experiences, to understand the needs of nurses, members of the interprofessional health team, and persons with lived experience.
- Two virtual focus groups were convened to understand the needs of nurses, members of the interprofessional health team, and persons with lived experience.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Assembly of the Expert Panel
RNAO aims for diversity in membership of an expert panel in alignment with its Organizational Statement on Diversity and Inclusivity which is part of the RNAO Mission and Values (93). RNAO also aims for persons impacted by guideline recommendations, especially persons with lived experiences and caregivers, to be included as expert panel members.
There are numerous ways in which RNAO finds and selects members of an expert panel, including searching the literature for researchers in the topic area; recommendations from key informant interviews; drawing from established professional networks such as RNAO interest groups, Champions Network  , and BPSO  ; other nursing and health provider associations; topic-relevant technical associations or organizations; and advocacy bodies.
For this Guideline, the RNAO Best Practice Guideline Development and Research Team assembled a panel of experts from nursing practice, administration, research, education and policy, as well as other members of the interprofessional team representing a range of sectors and practice areas, and persons with lived experiences (see the RNAO Expert Panel).
The expert panel engaged in the following activities:
 Approved the scope of this BPG.
 Determined the recommendation questions and outcomes to be addressed in this BPG.
 Participated in a consensus development process to finalize recommendation statements.
 Provided feedback on the draft of this BPG.
 Participated in the development of evaluation indicators.
 Identified appropriate stakeholders to review the draft guideline prior to publication.
The expert panel co-chairs led the following activities:
 Monthly co-chair meetings with the Guideline Development Methodologists and Guideline Development Project Coordinator.
 Facilitated expert panel meetings.
 Provided in-depth guidance on clinical and/or research issues.
 Moderated and acted as tiebreakers in voting processes.

# Declarations of Competing Interest
Declarations of competing interest that might be construed as constituting an actual, potential, or apparent conflict were made by all members of the RNAO's expert panel, and members were asked to update their disclosures throughout the guideline development process. Information was requested about financial, intellectual, personal, and other interests and documented for future reference. No limiting conflicts were identified. Declarations of competing interest are posted as a separate document on the RNAO webiste: .

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Identifying Priority Recommendation Questions and Outcomes
In October 2017, the RNAO Best Practice Guideline Development and Research Team convened to determine the priority recommendation questions and outcomes for this Guideline. A comprehensive list of recommendation questions that the Guideline could potentially address was developed at the in-person meeting, informed by the following:
 The guideline gap analysis.
 The scoping review of the literature.
 Key informant interviews and focus groups.
 Expert panel discussion at the in-person meeting.
This comprehensive list of potential recommendation questions was presented to the expert panel for a vote. Each expert panel member was allowed four votes for preferred recommendation questions. The four recommendation questions with the most votes were deemed the final recommendation questions. Expert panel co-chairs did not participate in the vote as they functioned as tiebreakers for the fourth recommendation question.
Following this initial vote-and in alignment with GRADE standards for assessing and presenting the evidenceoutcomes were identified and prioritized per recommendation question. A comprehensive list of outcomes per recommendation question was developed at the in-person meeting, informed by the following:
 The scoping review of the literature.
 Key informant interviews and focus groups.
 Expert panel discussion at the in-person meeting.
Based on the comprehensive list of outcomes, the expert panel was asked to rank order the relative importance of each outcome per recommendation question. Each panel member participated in a confidential online rank order vote. It was deemed feasible to have a total of 13 prioritized outcomes across the four recommendation questions. Expert panel co-chairs did not participate in the vote as they functioned as co-facilitators. Voting results were presented to the expert panel. Through a facilitated discussion, priority outcomes were determined per recommendation question. Each recommendation question informed a PICO research question which guided the systematic reviews. The four recommendation questions and their respective PICO research questions are presented below:
Recommendation Question 1: Should access to nurses specialized in wound, ostomy, and continence or no access to nurses specialized in wound, ostomy, and continence be recommended?

# PICO Research Question 1 Population:
Adults anticipating or living with an ostomy. Intervention: Access to nurses specialized in wound, ostomy, and continence. Comparison: No access to nurses specialized in wound, ostomy, and continence.

# Outcomes:
Peristomal skin breakdown*, ostomy leakage, quality of life, hospital length of stay and readmission rates to hospital.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition 

# Outcomes:
Quality of life and financial priorities.
Recommendation Question 4: Should the use of standardized assessment tool for quality of life to customize care plan (for education and referral) or no use of standardized assessment tool for quality of life to customize care plan (for education and referral) be recommended?

# PICO Research Question 4 Population:
Adults anticipating or living with an ostomy. Intervention: Use of a standardized assessment tool for quality of life to customize care plan (for education and referral). Comparison: Usual care.

# Outcomes:
Psychological health status and self-identity.
- The peristomal skin breakdown outcome was not found in the literature. As a result, peristomal dermatitis and peristomal irritation were chosen as surrogate outcomes after consultation with expert panel co-chairs. A surrogate outcome is one that is a similar measure to the desired outcome and reflects what would contribute to the desired outcome.
 The preoperative stoma site marking outcome was not found in the literature. A surrogate outcome was not chosen in replacement as there deemed to be a sufficient number of outcomes related to Research Question #2.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition Literature regarding access to affordable ostomy supplies was not found. As access to affordable supplies was highlighted as a priority topic by the expert panel, RNAO is taking policy initiatives on universal funding for ostomy supplies to promote optimal health outcomes for all adults who anticipate or live with an ostomy.
In consultation with the co-chairs, an alternate priority research question identified by the expert panel was chosen.
The respective priority outcome was also determined by the co-chairs. The revised Recommendation Question #3 is outlined below:
Recommendation Question 3: Should prevention strategies for parastomal hernia development or no prevention strategies for parastomal hernia development be recommended?

# PICO Research Question 3 Population:
Adults living with an ostomy. Intervention: Prevention strategies for parastomal hernias. Comparison: Usual care.

# Outcomes:
Rates of parastomal hernias.
Literature specific to the use of standardized assessment tool for quality of life to customize care plan (for education and referral) was not found. In consultation with the co-chairs, a broader recommendation question was identified that could indirectly inform the need for quality of life assessment in adults who anticipate or live with an ostomy. The revised Recommendation Question #4 is outlined below:  and 8). Detailed information on the search strategy for the systematic reviews, including the inclusion and exclusion criteria and search terms, is available at .
Recommendation
All studies were independently assessed for relevance and eligibility by the two Guideline Development Methodologists based on the inclusion and exclusion criteria. Any disagreements were resolved through consensus.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition All included articles were independently assessed for risk of bias by study design using validated and reliable tools.
Randomized controlled trials G were assessed using the Risk of Bias 2.0 tool (94), quasi-experimental studies G and other non-randomized studies were assessed using the ROBINS-I tool (95), systematic reviews were assessed using the AMSTAR 2 tool (96) and qualitative studies were assessed using the CASP qualitative checklist (97). Two reviewers reached consensus on all scores through discussion.
Data extraction was performed simultaneously. Reviewers completed independent data extraction for 75 per cent of the studies. The remaining studies were split between the reviewers and were cross-checked for accuracy. In total, 36 studies were included across all four systematic reviews.
In January 2019, an additional guideline search was conducted in an established list of websites for guidelines published between September 2017 and January 2019 to identity recommended resources. One guideline was found however it was for purchase, and therefore not accessible. Furthermore, searches in all databases were re-run on January 11, 2019 to capture recent research. Studies were screened for relevancy to inform values and preferences and health equity for all recommendations. Findings from one study were incorporated in the discussion of evidence for Recommendation 2.1 and 2.2.

# Determining Certainty and Confidence of Evidence

# Certainty of Evidence
The certainty of quantitative evidence (i.e., the extent to which one can be confident that an estimate of an effect is true) is determined using GRADE methods (8). First, the certainty of the evidence is rated for each prioritized outcome across studies (i.e., for a body of evidence) per research question (8). This process begins with the study design and then requires an examination of five domains-risk of bias, inconsistency, imprecision, indirectness, and publication bias-to potentially downgrade G the certainty of evidence for each outcome. Following the initial consideration for rating down, the following three factors that permit rating up the certainty of evidence are assessed: large magnitude of effect, dose-response gradient, and effect of plausible confounding. See Table 11 for a definition of each of these certainty criteria.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition 

# Risk of bias
Limitations in the study design and execution that may bias study results.
Valid and reliable quality appraisal tools are used to assess the risk of bias. First, risk of bias is examined for each individual study and then examined across all studies per defined outcome.

# Inconsistency
Unexplained differences (heterogeneity) of results across studies.
Inconsistency is assessed by exploring the magnitude of difference, and possible explanations, in the direction and size of effects reported across studies for a defined outcome.

# Indirectness
Variability between the research and review question and context within which the recommendations would be applied (applicability). There are four sources of indirectness which are assessed:
 Differences in population.
 Differences in interventions.
 Differences in outcomes measured.
 Differences in comparators.

# Imprecision
The degree of uncertainty around the estimate of effect. This is usually related to sample size and number of events. Studies are examined for sample size, number of events, and confidence intervals.

# Publication bias
Selective publication of studies based on study results. If publication bias is strongly suspected, downgrading is considered.
Source: The GRADE Working Group. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach 2013. Available from: #h.svwngs6pm0f2.
Following the initial consideration for rating down the certainty of quantitative evidence, there are three factors assessed that permit rating up the certainty of evidence for observational studies:
- Large magnitude of effect: If the body of evidence has not been rated down for any of the five criteria and a large estimate of the magnitude of intervention effect is present, there is consideration for rating up (8).
- Dose-response gradient: If the body of evidence has not been rated down for any of the five criteria and a doseresponse gradient is present, there is consideration for rating up (8).

# Effect of plausible confounding:
If the body of evidence has not been rated down for any of the five criteria and all residual confounders would result in an underestimation of treatment effect, there is consideration for rating up (8).

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition
The overall certainty of evidence is the combined rating of the certainty of evidence across all prioritized outcomes per recommendation question. GRADE categorizes the overall certainty of evidence as high, moderate, low, or very low. See Table 12 for the definitions of these categories.
For this Guideline, the five GRADE certainty criteria for potentially rating down and the three GRADE certainty criteria for potentially rating up were independently assessed by the two Guideline Development Methodologists. Any discrepancies were resolved through consensus. An overall certainty of evidence per recommendation question was assigned based on these assessments. Recommendations that were derived from the recommendation questions were accordingly assigned this certainty of evidence. 

# High
We are very confident that the true effect lies close to that of the estimate of the effect.

# Moderate
We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

# Low
Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.

# Very Low
We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect. 

# Confidence in Evidence
Similar to GRADE, there are four CERQual criteria G to assess the confidence in qualitative findings related to a phenomenon of interest:
- Methodological limitations.
- Relevance.
- Coherence.

# Adequacy.
See Table 13 for a definition of each of these criteria.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition 

# Methodological limitations
The extent to which there are concerns about the design or conduct of the primary studies that contributed evidence to an individual review finding.

# Coherence
An assessment of how clear and cogent the fit is between the data from the primary studies and a review finding that synthesises that data. By "cogent," we mean well supported or compelling.

# Adequacy of data
An overall determination of the degree of richness and quantity of data supporting a review finding.

# Relevance
The extent to which the body of evidence from the primary studies supporting a review finding is applicable to the context (perspective or population, phenomenon of interest, setting) specified in the review question.
Source: Reprinted from Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQUAL to qualitative evidence synthesis findings: introduction to the series. Implement Sci. 2018;13(Suppl 1):1-10. Table 2, Definitions of the components of the CERQual approach; p. 5. Reprinted with permission.
For qualitative findings related to one of the prioritized outcomes, these four criteria were independently assessed by the two Guideline Development Methodologists. Discrepancies were resolved through consensus. An overall judgment of the confidence in each review finding was made based on these assessments above (see Table 14 for the confidence of evidence judgments). Recommendations that included qualitative evidence were assigned an overall confidence in evidence based on the corresponding review finding. 

# High
It is highly likely that the finding is a reasonable representation of the phenomenon of interest.

# Moderate
It is likely that the finding is a reasonable representation of the phenomenon of interest.

# Low
It is possible that the review finding is a reasonable representation of the phenomenon of interest.

# Very Low
It is not clear whether the review finding is a reasonable representation of the phenomenon of interest.
Source: Reprinted from Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQUAL to qualitative evidence synthesis findings: introduction to the series. Implement Sci. 2018;13(Suppl 1):1-10. Table 3, Description of level of confidence in a review finding in the CERQual approach; p. 6. Reprinted with permission.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Summarizing the Evidence
GRADE and GRADE CERQual evidence profiles are used to present decisions on determining the certainty and confidence of evidence, as well as general information about the body of research evidence, including key statistical or narrative results. Evidence profiles summarize the body of evidence for each systematic review per outcome and are developed by the two Guideline Development Methodologists.
Evidence profiles for the body of quantitative studies present the decisions made by the two reviewers on the five key GRADE certainty domains for rating down and the three GRADE certainty domains for rating up. The evidence profiles present general information about the body of evidence, including a description of the intervention, key results, and transparent judgments about the certainty underlying the evidence for each outcome (8). For this Guideline, meta-analyses G were not performed; results were therefore synthesized in narrative format in the evidence profiles.
CERQual evidence profiles were created for the body of qualitative evidence for each systematic review per outcome. Similar to the GRADE evidence profiles used for quantitative research, the CERQual evidence profiles present the body of evidence supporting each theme related to outcomes for every recommendation question. These evidence profiles presented the decisions made by the two Guideline Development Methodologists on the four key CERQual criteria and transparent judgements about the confidence underlying the evidence for each theme.
The GRADE and CERQual evidence profiles for each systematic review, organized per outcome, can be accessed online at .

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# Formulating Recommendations

# Evidence-to-Decision Frameworks
Evidence-to-Decision (EtD) frameworks G outline proposed recommendations and summarize all necessary factors and considerations based on available evidence and expert panel judgement for formulating the recommendation statements. EtD frameworks are used to help ensure that all important factors required to formulate recommendations are considered by an expert panel (8). Both quantitative and qualitative evidence are incorporated into the frameworks. The Guideline Development Methodologists draft the frameworks with available evidence from the systematic reviews.
For this Guideline, the EtD frameworks included the following areas of consideration for each drafted recommendation statement (see Table 15):
 Background information on the magnitude of the problem.
 Includes the PICO question and general context related to the research question.
 The balance of benefits and harms of an intervention.
 Certainty and/or confidence of the evidence.
 Values and preferences.
 Health equity.

# Decision Making: Determining the Direction and Strength of Recommendations
Expert panel members are provided with the EtD frameworks to review prior to a scheduled two-day in-person meeting to determine the direction (i.e., to provide a recommendation for or against an intervention) and the strength of the recommendations in the guideline. Expert panel members also are given access to the complete evidence profiles and full-text articles.
Using the EtD frameworks as a guiding document, the expert panel members participated in an online vote from May 15th to May 30th, 2018. The following questions were posed to all expert panel members for each draft recommendation:
 Is there important uncertainty about or variability in how much people value the main outcomes?
 Does the balance between desirable and undesirable effects favor the intervention or the comparison?
 What would be the impact on health equity?
The Likert scales created by the GRADEpro software were used for voting on each factor (98). There also was the opportunity for expert panel members to provide written comments related to each of the judgement criteria.
The results of the online vote were calculated and presented to the expert panel at the two-day in-person meeting held June 21-22, 2018. The online vote results were used to help guide discussion. The expert panel co-chairs and the Guideline Development Lead facilitated the meeting to allow for adequate discussion for each proposed recommendation.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition
The decision on direction and strength of each recommendation statement was determined by discussion and a consensus vote of 70 per cent. The voting process was moderated by the expert panel co-chairs and Guideline Development Lead. In determining the strength of a recommendation statement, the expert panel was asked to consider the following (see Table 15):
 The balance of benefits and harms.
 Certainty and confidence of the evidence.
 Values and preferences.
 Potential impact on health equity.
Following the in-person meeting, the final decisions made on all recommendations were summarized and sent to the full expert panel electronically. 

# Benefits and harms
Potential desirable and undesirable outcomes reported in the literature when the recommended practice or intervention is used.
"The larger the difference between the desirable and undesirable effects, the higher the likelihood that a strong recommendation is warranted. The narrower the gradient, the higher the likelihood that a conditional recommendation is warranted" (99).
Includes research exclusively from the systematic review.

# Certainty and confidence of evidence
The extent of confidence that the estimates of an effect are adequate to support a recommendation. The extent of confidence that a review finding is a reasonable representation of the phenomenon of interest (100).
Recommendations are made with different levels of certainty or confidence; the higher the certainty or confidence, the higher the likelihood that a strong recommendation is warranted (99).
Includes research exclusively from the systematic review.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# FACTOR DEFINITION SOURCES

# Values and preferences
The relative importance or worth of the health outcomes of following a particular clinical action from a person-centred perspective.
"The more values and preferences vary or the greater the uncertainty in values and preferences the higher the likelihood that a conditional recommendation is warranted" (99).
Includes evidence from the systematic review (when available) and other sources, such as insights from the expert panel.

# Health equity
Represents the potential impact of the recommended practice or intervention on health outcomes or health quality across different populations.
The greater the potential for increasing health inequity, the higher the likelihood that a conditional recommendation is warranted.
Includes evidence from the systematic review (when available) and other sources, such as insights from the expert panel.
Source: Adapted by the RNAO expert panel from The GRADE Working Group. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach 2013. Available from: #h.svwngs6pm0f2.

# Drafting the Guideline
The Guideline Development Methodologists wrote the draft of this Guideline. The expert panel reviewed the draft and provided written feedback. A teleconference was held October 2nd, 2018, to review panel feedback and incorporate changes, as necessary. The Guideline then proceeded to external stakeholder review.

# Stakeholder Review
RNAO is committed to obtaining feedback from (a) nurses and other health providers from a wide range of practice settings and roles, (b) knowledgeable administrators and funders of health services, and (c) stakeholder associations as part of the guideline development process.
Stakeholder reviewers for RNAO BPGs are identified in two ways. First, stakeholders are recruited through a public call issued on the RNAO website (RNAO.ca/bpg/get-involved/stakeholder). Second, individuals and organizations with expertise in the guideline topic area are identified by the RNAO Best Practice Guidelines Development and Research Team and the expert panel, and are directly invited to participate in the review.
Stakeholder reviewers are individuals with subject matter expertise in the guideline topic or those who may be affected by its implementation. Reviewers may be nurses, members of the interprofessional team, nurse executives, administrators, research experts, educators, nursing students, or persons with lived experience and family members.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition
Reviewers are asked to read a full draft of the BPG and participate in the review of it prior to its publication. Stakeholder feedback is submitted online by completing a survey questionnaire. The stakeholders are asked the following questions:
 Is the guideline title appropriate?
 Is the guideline development process description clear?
In addition, the stakeholders are asked the following questions about each recommendation:
 Is this recommendation clear?
 Do you agree with this recommendation?
 Is the discussion of evidence thorough and does the evidence support the recommendation?
The survey also provides an opportunity to include comments and feedback for each section of the BPG. Survey submissions are compiled and feedback is summarized by the RNAO Best Practice Guidelines Development and Research Team. The survey results are reviewed and discussed with the expert panel. If necessary, the guideline content and recommendations are modified prior to publication to reflect the feedback received.
For this Guideline, the stakeholder review process was completed from October 19th to November 2nd, 2018 and diverse perspectives provided feedback (see Stakeholder Acknowledgment).

# Procedure for Updating the Guideline
The RNAO commits to updating all BPGs, as follows:
- Each BPG will be reviewed by a team of specialists in the topic area every five years following publication of the previous edition.
- RNAO International Affairs and Best Practice Guidelines Centre staff regularly monitor for new systematic reviews, randomized controlled trials, and other relevant literature in the field.
- Based on that monitoring, staff may recommend an earlier revision period for a particular BPG. Appropriate consultation with members of the original expert panel and other specialists and experts in the field will help inform the decision to review and revise the BPG earlier than planned. 5. New editions of BPGs will be disseminated based on established structures and processes.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition 

# Os tilted
Opening of bowel is tilted from center of stoma.

# Prolapsed
The telescoping of the bowel through the stoma, making the stoma longer.

# Raised
Stoma is sitting above level of the skin.

# Retracted
Disappearance of the normal stoma opening below skin level.

# Black (necrosis)
Ischemia of the stoma from inadequate blood supply.

# Dusky
Purple to a deep wine-coloured hue from altered blood supply.

# Edematous
Interstitial collection of fluid.

# Friable
Fragile tissue that bleeds easily.

# STOMA APPEARANCE

# Moist
Mucosal tissue is damp.

# Pale
Diminished colour.

# Pink
Pink in colour.

# Red
Red in colour.

# Red (Dark)
Stoma has a deep/dark red hue.

# Slough
Dry or wet, loose or firmly attached, yellow to brown dead tissue.

# Turgor
Ability to change shape and return to normal appearance after lightly touching stoma (elasticity).

# Trauma
Injury to surface of stoma like a cut, abrasion, or bruise.

# Cancerous lesion
Able to visualize cancerous lesion/tumor on or attached to stoma.

# Pseudoverrucous lesions
Wart-like lesions from chronic moisture irritation on or directly around stoma.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# PERIOSTOMY SKIN Macerated
Wet, white.

# Mucosal transplant
Seeding of viable intestinal mucosa along suture line and onto peristomal skin.

# Parastomal hernia
A deficit in the fascia that allows loops of the intestine to protrude in areas of weakness. Can present as abnormal bumps on the abdomen around the stoma.

# Pseudo-verrucous lesions
Wart-like lesions from chronic moisture irritation around stoma.

# Psoriasis
Chronic disease characterized by proliferation of epidermis that often appears as an erythematic, thick, silvery-white, and scaling plaque.

# Pyoderma gangrenosum
Ulcerative inflammatory skin condition of unknown etiology that starts as pustules and break open to form full thickness ulcers often with undermining, ragged edges, and overhanging margins.

# Trauma
Loss of epidermis around stoma.

# Ulceration
Ulcer located around stoma. 

# Length & Width
Length: Longest measurement.
Width: Measured at widest area perpendicular to length.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition STOMA COLOUR: Stoma colour is usually pink or red but may vary depending on blood supply.

# Pink/red
Pink or red: ealthy with normal/adequate blood supply.

# Dusky
Bluish hue due to altered blood supply.

# Necrotic
Purple to a deep wine coloured hue due to ischemia of the stoma. The stomal tissue may turn to yellow slough and can progress to black dry tissue (eschar).

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition STOMA TISSUE: Stoma tissue is usually moist and damp. The tissue can vary depending on blood supply, damage, trauma, etc.

# Moist
Mucosal tissue is damp.

# Edematous
Shiny, swollen, translucent, smooth appearance; due to interstitial collection of fluid.

# Slough
Soft, moist, devitalized tissue; may be white, yellow, tan or green. May be loose or firmly adherent.

# Friable (no image available)
Stoma tissue is fragile and bleeds easily with minimal contact.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition STOMA HEIGHT: An elevation above skin level of approximately 2cm is ideally for a good fit of the appliance. Due to surgical complication of body habitus, stomas can be either retracted or prolapsed.

# Protruding
Stoma protrudes above level of the skin by approximately 2cms.

# Flush
Stoma sits at the same level of the skin.

# Retracted
The stoma is pulled down below the level of the skin.

# Prolapsed
A prolapsed sttoma is a stoma that develops a length longer than what was created at the time of surgery. The prolapse is created by the outward telescoping of the bowel. The length of the prolapse can vary.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition PERISTOMAL SKIN: the skin surrounding the stoma.

# Intact
Unbroken skin.

# Excoriated
Superficial loss of tissue that presents irregular with areas of erythema, and rash.

# Red
Intact skin with redness that may have varying degrees of intensity from bright red to dark red; redness may be due to chemical effluent, fungal or sensitivity/allergy.

# Creases
A dip or fold in the abdomen. The depth may vary from shallow to very deep.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# MUCOCUTANEOUS JUNCTION: The point where the epidermis and the mucosa merge

# Intact
Mucocutaneous junction is well approximated.

# Separated
Area of detachment(s) from the stoma to the skin (dehiscence).
The separated area may be circumferential or partial. 

# Rod/ bridge
This device may be a commercially available rod, a Penrose drain or red rubber catheter. It may, or may not, be sutured.

# Stents
A short-term small plastic tube which sits in each of the ureters and exits through the stoma; used to divert urine while the surgical area recovers. 

# Allergic contact dermatitis
Peristomal erythema that mirrors the image of the allergen.
May be moist and pruritic.
Remove allergen.
Allergen may be a tape border or the barrier or both.
 Medicated cortisone spray to relieve itch.
 Crusting if moist.
 If tape allergy use no tape product.
 If barrier allergy, consider a different company.
 May consider barrier between skin and pouch (e.g., skin protectant, transparent film, or hydrocolloid.
 Consider patch testing.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# DESCRIPTION CLINICAL PRESENTATION TREATMENT OBJECTIVE

# TOPICAL TREATMENT OPTIONS

# Wound to peristomal skin
Wound to peristomal skin.
Identify cause of wound.
Heal the wound.
Prevent pouching system leakage.
 Moisture balance to wound, follow wound treatment plan.
 If using convexity, consider wider convexity or barrier ring instead to offload pressure.

# Pyoderma gangrenosum
Wound to peristomal skin.
Very painful purple borders.
Usually a history of autoimmune disease (e.g., inflammatory bowel disease, rheumatoid arthritis).
Identify cause of wound.
Manage pain.
Heal the wound.

# Prevent pouching system leakage
 Physician/NP and CPCET referral required.
 Prescription for steroids (steroid cream to be avoided as prevents pouch adherence).
 Moisture balance to wound.
 If using convexity, consider wider convexity or barrier ring instead to offload pressure.
 Sharp debridement is contraindicated.

# Stoma with fungating tumour
Cancerous tumour protrudes beyond the epidermis causing pouching challenges.
May be dry or moist, have odour and is painful.
Prevent pouching system leakage.
Prevent bleeding.
Provide psychosocial support.
 Flexible pouching system.
 Cut wide to avoid tumour if needed to obtain a seal.
 Consider closed pouching system.
 Lubricate inside of pouch if friction causes bleeding (pouch rubbing against tumour).

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition

# DESCRIPTION CLINICAL PRESENTATION TREATMENT OBJECTIVE TOPICAL TREATMENT OPTIONS

# Peristomal skin denudation due to leakage
Superficial erythema that is moist.
May be painful and pruritic.
Usually occurs where pouching system is leaking.
Treat and prevent leakage.
Change pouching system immediately if leaking.
 Identify cause of leak.
 Crusting procedure.
 Correct leakage, fill in crevices/creases, or add a barrier ring/paste.
 Change to a convex appliance if stoma located in a fold or crease, or if stoma is flushed or mobile.

# Peristomal growths
Growths protruding from the mucocutaneous junction.
Are painful and present a pouching challenge.
Refer to CPCET and physician/NP.
Prevent pouching system leakage.
 Consult with physician/NP and CPCET.
 Use paste or ring to create an even pouching surface. Treat inflammation and localized infection.
Prevent recurrence.
 Crusting procedure as needed.
 Clip hair to remove.
 Use adhesive remover to remove pouching system.

# Yeast/candidiasis
Fungal infection of the skin usually related to leakage.
Area is denuded, red and has satellite lesions.
Can be pruritic.
Treat and prevent leakage.
Change pouching system immediately if leaking.
Treat fungal rash (i.e., crust with antifungal powder).
 Identify cause of leak.
 Crusting procedure using antifungal powder.
 Correct leakage, fill in crevices/creases, or add a barrier ring/paste.
 Change to a convex pouching system if stoma located in a fold or crease, or flush or mobile stoma.
Source: Reprinted from Interior Health. Peristomal skin breakdown: assessment and management. ; 2015. Reprinted with permission.

# A P P E N D I C E S
Supporting Adults Who Anticipate or Live with an Ostomy -Second Edition  Overview of types of ostomies from a non-profit volunteer organization dedicated to all people with an ostomy and their families.
 Website includes variety of information including, but not limited to, ostomy products, living life to the fullest, ostomy products, and healthy living.  Journal article with overview of safe management of ileostomates with high-output stomas.

# A P P E N D I C E S
Supporting