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Articles by guest authors for our Coloplast® Care Corner newsletters

These newsletters are sent to Healthcare practitioners with interest in the ostomy specialty. Guest articles feature unique perspectives to consider when teaching ostomy patients.

To sign up for the newsletters, or to submit your idea, article, or educational tips and tricks, email us at: ostomy_care@coloplast.us.

Collaborative article teaches payor audience about reimbursement challenges for ostomy supplies

About the Article

A recent collaboration of industry is bringing to light some challenges for consumers with ostomies when faced with decreased reimbursement of their medically necessary ostomy supplies.

Contributors were American Association for Homecare, United Ostomy Associations of America, Inc, United Spinal Association, Wound Ostomy and Continence Nurses Society, Wound, Ostomy and Continence Nursing Certified Board.

Read the full white paper here:  AAH Ostomy White Paper FINAL 08 17 21 (aahomecare.org)

Key points in the article:

  1. Patient choice should be protected, and supplies should not be substituted by the DME/HME providers without the patient's consent. Often a patient’s body and stoma profile are unique and may require specially fitting supplies.
  2. Payors who are not following Medicare fee schedules and do not update their own fee schedules risk putting the patient in a tough situation. Not all DME and HME dealers will accept reimbursement on ostomy pouches. With these opposing forces, patients may face larger than necessary out of pocket costs. 
  3. If patients are forced to switch product lines, they risk experiencing a poor fit, leakage and ultimately skin complications which could lead to additional healthcare utilization (clinic visits, ER or Readmissions to the hospital).
  4. It is well accepted that a proper fitting ostomy pouch can prevent leakage and skin complications and may improve outcomes. All payors should consider the cost of prevention vs the cost of readmissions and ER visits when deciding on fee schedules for appliances.
  5. Care coordination and product assessments can help improve outcomes through patients staying in properly fitting appliances. Education by suppliers and manufacturers assist not only the end-users but home care nurses as well.

What should you do?

Clinician/prescriber reader should:

  1. Continue to prescribe the products most appropriate for the patient needs using Dispense As Written
  2. Advocate for the patient if the payor’s fee schedule is insufficient by demonstrating the medical necessity for the recommended product
  3. Refer the patient to a dealer who will honor their prescription rather than switching patients out of the recommended product
  4. Enroll patients in manufacturers patient support programs and request follow up information on the patient satisfaction with the product

Payor reader should:

  1. Familiarize themselves with cost and incidence of ostomy related complications that may be reduced with the proper product and patient support
  2. Take a patient-centric long-term approach in determining adequate fee schedules
  3. Consider total cost of care including mental health when considering narrowing the DME provider network or a reduction in the fee schedule
  4. Increase the fee schedule to the Medicare level

Patient reader should:

  1. Be aware of the ostomy patients’ rights developed by UOAA and the right to use the product of their choice if supported by the clinician recommendation
  2. Complain to their clinician, ostomy supplier and their insurance company if they are dissatisfied with the product or service
  3. Join a patient support organization and support advocacy with the payors and policy makers at the state and federal level

Coloplast® Care ostomy advisors are available to help with product availability and questions – between acute and home health care and identifying dealer options for product supplies based on insurance. The Coloplast Care program also provides ongoing self-assessment tools, quality of life guidance (including setting up routines and instructions for use) and even ongoing support group webinars.

Payors should look at complimentary patient product and lifestyle support programs provided by manufacturers to see if there are documented outcomes. With Coloplast Care, a large study has shown lower healthcare utilization (readmissions and ER visits) compared to the patient group that did not have post-surgical product and lifestyle support.1 When paired with quality products as well, a large health system in the Midwest, reported an increase in patient satisfaction scores2. For more information on how Coloplast can impact outcomes, please contact your sales representative.

Read the full white paper here. ●

Information from Coloplast Care is for educational purposes only. It is not intended to substitute for professional medical advice and should not be interpreted to contain treatment recommendations. You should rely on the healthcare professional who knows your individual history for personal medical advice and diagnosis.

Citation: American Association for Homecare, United Ostomy Associations of America, Inc, United Spinal Association, Wound Ostomy and Continence Nurses Society, Wound, Ostomy and Continence Nursing Certified Board (2021). The Critical Need to Provide Ostomy Supplies Specific to Patient Need to Improve Health Outcomes [White paper].

References

  1. Rojanasarot, S., The Impact of a Readily Available, Post-Discharge Support Program for Ostomy Surgery Patients on Preventable Health Care Utilization, JWOCN, 2018;45(1):43-49.

  2. Helder, D., O’Day, M., Measuring System Impact by Improving the Ostomy Patient Experience from a Product Standardization Project in a 13-Hospital Integrated Delivery Network in the Midwest. JWOCN, 2017, 44(35): S53.

Considerations for Physical Recovery from Ostomy Surgery

Charlotte Foley

About the Author

Charlotte Foley, MS OTR/L, CBIS, received her Occupational Therapy degree at Boston University and began her career in the adult Inpatient Rehabilitation setting. She now works in the adult Acute Care setting at Providence Alaska Medical Center in Anchorage, Alaska. Because of her own personal and professional experience, Charlotte founded and runs her own education and consulting business, Restorative Ostomy Solutions, to empower a better physical recovery for individuals following ostomy surgery.

Charlotte has received compensation from Coloplast to provide this information.

Physical recovery from ostomy surgery is multifaceted. It involves the innate ability of the body to heal, and active participation of the individual recovering from surgery to engage and participate in the process. The greater the structures in place to support physical recovery from ostomy surgery, the better quality of life that an individual will have. In addition to the wound and structural healing required following surgery, there are four categories of physical rehabilitation that should not be overlooked:

  • Breathwork
  • Early Mobilization
  • Core Rehabilitation
  • Lifestyle Management

Proper breathing is vital in physical recovery, not only at the cellular level for the delivery of oxygen rich blood to the healing surgical site, but also because of the functional implications on the body. The goals of breathwork following surgery include: decreasing intra-abdominal pressure (IAP), coordinating the inner core, and improving cardio-pulmonary function. Breathwork training such as diaphragmatic breathing, coughing techniques, and breath coordination during functional movement can assist with ensuring the surgical site remains intact. It can also decrease risk for parastomal hernia, musculoskeletal issues, pelvic floor dysfunction, and post-operative pulmonary complications.

If possible, a walking program should be initiated the day of surgery. Walking after surgery is important for the heart, lungs, and digestion. It is also an excellent place to begin strengthening the core following surgery, if performed in a skilled manner. Walking should be initiated on flat ground so as not to increase IAP and strain the surgical site. Incorporation of hiking poles can improve muscular endurance, neuromuscular connections of the core, and overall individual confidence (Hanuszkiewicz, 2020). Walking program progression can be evaluated on an individual basis, and in cases where walking is not an option, alternative early mobilization is advised to ensure similar positive outcomes to those who are more mobile.

Current guidelines recommend to “commence gentle abominable exercise 3-4 days after surgery” (ACSN clinical guidelines). Despite this recommendation, research shows that “87% of patients did not do any core/abdominal exercises at all and 83% were not advised to by their nurse or surgeon” (Russell, 2017). This discrepancy between what is being advised and what is being practiced is notable, but not all that surprising due to the complexity of ostomy surgery and the fear of increasing complications following surgery. However, despite this fear, the benefits of strengthening the core are undeniable. Exercises can specifically target the core, such as pelvic tilts and knee rolls, but they can also include manual techniques such as scar mobilization, myofascial work and visceral manipulation.

In addition to targeted exercises, physical rehabilitation can be viewed in the context of daily tasks, such as transitioning in and out of bed, standing and sitting, and physically being able to manage the ostomy. Implications on sexual and pelvic health should also be considered because of the connection of the abdomen to the pelvic floor. Finally, the impact of coping with such a significant life event should be taken into account in regard to impact on physical recovery from surgery.

Overall, impacts of surgery on quality of life are numerous, and physical recovery can impact an individual’s ability to engage in daily activities in the home, community, work environment, and leisure settings. However, significant abdominal surgery post-op complications can be mitigated by an interdisciplinary approach to care that involves Occupational Therapy (OT) and Physical Therapy (PT). If you are looking for more information on the topics outlined above, don’t hesitate to reach out to your local OTs and PTs, as they are trained in the pertinent skills to support physical recovery and quality of life following surgery. ●

References

Association of Stoma Care Nurses (2016). ASCN stoma care national clinical guidelines. Retrieved from https://ascnuk.com/_userfiles/pages/files/national_guidelines.pdf

Hanuszkiewics, J., WoZZniewski, M., & Malicka, I. (2020). The influence of nordic walking on isokinetic muscle endurance and sagittal spinal curvatures in women after breast cancer treatment. Acta of Bioengineering and Biomechanchics, 22(2), 47-54. DOI: 10.37190/ABB-01545-2020-02

Russell, Sarah (2017). Parastomal hernia and physical activity. Are patients getting the right advice? British Journal of Nursing, 26(17), S12-S18.

Responses to Disability: How People Cope with Chronic Illness and Disability, by Michael Gerald, PhD.

About the Author

Michael Gerald, PhD, is a licensed Clinical Mental Health Counselor and Certified Rehab Counselor. He is currently employed as an Assistant Professor in Rehabilitation Counseling at Utah State University (USU) in Logan, UT. Michael has provided clinical mental health services as a Crisis Counselor, Substance Abuse Counselor, Correctional Mental Health Provider, and Private Practice Mental Health.

Michael has received compensation from Coloplast to provide this information.

Whether someone acquires a Chronic Illness or Disability (CID) later in life or is born with a CID, they will inevitably need to engage in some degree of coping in order to mitigate the varying psychological, physical, and social consequences of their CID. Previously termed adjustment to CID, the manner in which people cope with their CID is currently referred to as response to CID. Response to CID can be broadly understood as a dynamic process of emotional, cognitive, and behavioral changes in response to CID that gradually approach adaptive functioning. Stress due to disabilities can come multiple sources: threats to life and health; threats to body integrity and comfort; threats to independence, autonomy, and privacy; threats to self-concept; threats to life goals; threats to relationships; and threats to economic well-being. The manner in which people respond to their CID depends on their personality and self-identity, social relationships, socioeconomic status, culture, environment, lifestyle, responsibilities, and individual goals.

Although we need to be cautious in evaluating responses to CID, as there is not a right way to cope with one’s CID, we can identify two broad coping strategies: adaptive and maladaptive. Coping represents a constellation of behaviors that are intended to help an individual manage, tolerate, or reduce stress associated with major life events. Adaptive coping is coping behavior that helps individuals reduce stress, while enhancing well-being and functioning. An ostomate may utilize coping strategies such as attending a support group in order to improve their response to CID. Conversely, maladaptive coping may help an individual reduce stress, but it also inhibits growth potential and contributes to declines in health and functioning. An ostomate may turn to drugs or alcohol to cope with their CID, which may worsen their underlying health conditions.

It is vitally important to note that living with a CID is not always, and certainly does not have to be, a negative experience. Although CID can impact a person’s self-esteem, self-identity, social identity, self-worth, or body image, it does not always have to do so negatively. However, persons experiencing a CID may experience distressing emotional experiences such as: grief and loss; fear/anxiety; anger; depression; or guilt and shame. As a result, people respond to CID in differing ways. A person’s response to CID is typically aimed at helping a person maintain the degree of functioning they had prior to the onset of CID, or in the case of congenital disabilities, maximize functioning while living with their CID. Five common ways in which people respond to CID are: Denial; Regression; Compensation; Rationalization; and Diversion of Feelings.

Denial is a commonly understood concept across disciplines, but in the case of CID it involves an individual denying the existence or severity of their CID. Denial often receives a ‘bad rap’ in that it is considered maladaptive, but for many, especially at the onset of CID, it can provide a period of coping in which they are able to continue living their life as they normally would because they have not yet addressed some of the potential negative consequences of CID. Denial, however, can be maladaptive if it leads an individual to forego management recommendations or reject the implications of a condition. Regression refers to an individual subconsciously reverting to an earlier stage of development, which typically would manifest as becoming more dependent, more passive, and less emotionally regulated. Regression may lead an individual to adopt a fixed mindset, believing themselves to be incapable of leading their life as they would like due to their CID. Rationalization involves individuals seeking out socially acceptable reasons for their behavior or to excuse themselves for not reaching goals or accomplishing tasks. Individuals may overly identify with the limitations of their CID and rationalize goals they do not pursue or opportunities they do not take advantage of.

Compensation is a very common response among persons with CID. Compensation refers to an individual learning to counteract functional limitations in one area by becoming stronger and more proficient in another area. A well-known example of this was Stephen Hawking, whose ALS diagnosis progressively led to his losing motor control and function, but it did not impact his cognitive functioning and he was able to devote his available resources to academic endeavors. Compensation is not always targeted in a healthy direction, as an ostomate may perceive their ostomy as unattractive and develop excessive exercise behaviors to improve their body image. Lastly, Diversion of Feelings is an equally common response to CID (particularly in media depictions of CID) in which an individual diverts negative emotional states or ideas into socially acceptable behaviors. An example of this response would be “channeling” one’s anger or fear due to their CID into drive and passion. Diversion of Feelings can become unhelpful, though, if a person never addresses the negative emotional states they seek to divert.

In summary, persons with CID may experience stressors and life changes that require a coping response in order to mitigate the consequences of CID and improve or maintain functioning as part of their overall adjustment or response to CID. Be mindful of the fact that response to disability is highly variable and there is no right way to cope with CID. Instead, as practitioners, we should be evaluating how a CID has affected someone’s life (if at all), what kind of self-talk they are engaging in surrounding their CID, what their goals are for the future, and how they might be responding to their CID cognitively, emotionally, and physically. One of the most critical components of response to CID is what meaning I ascribe to CID: is my CID a blessing? A curse? A non-issue? Another fork in the road? How people make meaning of their CID is correlated with whether they will respond in a manner that is adaptive or maladaptive. Additionally, the onset of a CID has the potential to challenge one’s self-concept, or our sense of self that is comprised of self-esteem, group identity, and self-efficacy (Bogart, 2014). Because our self-concept is heavily influenced by our social connections, social supports, and culture, helping persons with CID and Ostomies connect with other persons with Ostomies or bowel/bladder dysfunction can help them to develop an adaptive self-concept and sense of belongingness, while reducing stigmatized attitudes towards disability (Bogart, 2014). Specific research within the ostomy community has demonstrated that connection of persons with Ostomies to others with positive messaging around living with an ostomy, such as websites like Uncover Ostomy (UO), can positively impact their adjustment by combating internalized stigma (Frohlich & Zmyslinski-Seelig, 2016). ●

References

Bogart, K. R. (2014). The role of disability self-concept in adaptation to congenital or acquired disability. Rehabilitation Psychology, 59(1), 107-115. doi:10.1037/a0035800

Frohlich, D. O., & Zmyslinski-Seelig, A. N. (2016). How Uncover Ostomy challenges ostomy stigma, and encourages others to do the same. New Media and Society, 18(2), 220-238. doi:10.1177/1461444814541943

Four Models of Disability, by Michael Gerald, PhD.

About the Author

Michael Gerald, PhD, is a licensed Clinical Mental Health Counselor and Certified Rehab Counselor. He is currently employed as an Assistant Professor in Rehabilitation Counseling at Utah State University (USU) in Logan, UT. Michael has provided clinical mental health services as a Crisis Counselor, Substance Abuse Counselor, Correctional Mental Health Provider, and Private Practice Mental Health.

Michael has received compensation from Coloplast to provide this information.

Often when we think about or discuss disability, medical conditions, or chronic illness we tend to think of diagnoses. “What do you have?” So, to speak. According to the Americans with Disabilities Act (ADA, 1990) a disability is defined by: the presence of a physical, cognitive, intellectual, or psychiatric condition (or a combination); pervasive impairment in social and occupational functioning; and the potential for experiencing prejudice, discrimination, stigma, and reduced opportunities as a result. The level of impairment an individual with a disability experiences has to do with a combination of their internal resources, their environment, and the course of the medical condition/chronic illness/disability itself. Models of Disability provide a set of guiding assumptions, concepts, and propositions about the nature of phenomena or human experience. Models of Disability help us to explain why or how a disability may be impacting someone. Models of Disability further provide: definitions of disability; the location of the problem; who is responsible for solving it; what the needs are of a person with a disability; policies that may be beneficial in mitigating disability; and who will study and work with persons with disability.

In the present article, I will describe four Models of Disability: Biomedical; Environmental; Functional; and Sociopolitical or Social.

The Biomedical Model is perhaps the most prevalent and readily understood of the models of disability and it is the foundation of the field of medicine. In the Biomedical Model the “problem” of disability lies within the individual and represents some pathology that needs to be cured, usually (although not always) by a healthcare provider. For example, a person with Inflammatory Bowel Disease (IBD) may receive prescription drug treatment for their Crohn’s Disease as well as surgical removal of parts of their bowel in order ameliorate symptoms and restore functioning. Medical supplies, such as ostomy pouches and flanges, certainly are born out of the Biomedical Model of disability. The Biomedical Model, of all the models, has the most objective standards for diagnosis and causal attribution, and has provided persons with disabilities with treatments, surgical options, and other techniques for restoring functioning. However, it is often criticized by persons with disabilities for: not taking the individual’s environment into account; objectifying persons with disabilities and their bodies; and relieving society of any responsibility for disability.

The Environmental and Sociopolitical Models of disability share some similarities in their definition of the problem and interventions to improve functioning for persons with disabilities. The Environmental Model of disability places the “problem” of disability in the individual’s physical environment and postulates the environment can cause, define, or exacerbate disability. Mitigation, therefore, of the consequences of disability requires addressing disabling, unresponsive, or insensitive environments. Curb cutouts for persons who use a wheelchair, grab bars in a bathroom for persons with limited coordination or mobility, or crossing signals that chirp for persons with visual impairments are all examples of environmental adaptations that can help promote functioning in persons with disabilities. The Sociopolitical, or Social, Model of disability views prejudice and discrimination (or attitudes) as causing disability. The “problem” of disability, therefore, lies in discriminatory attitudes of society and its unwillingness to provide equal access for persons with disabilities. The Social Model of disability was the inspiration for the Americans with Disabilities Act of 1990 (ADA) and Centers for Independent Living (CIL). For persons with bowel/bladder dysfunction and resultant ostomies, stigmatizing attitudes towards ostomies can negatively impact adjustment to ostomy surgery, as those attitudes may inhibit their employer from making accommodations or their school from believing they can continue their education.

The Functional Model defines disability in terms of the functional capacity that is affected by a given disability or diagnosis. For instance, a professional pianist who loses a finger is likely to experience much more functional impairment due to the loss than a professional soccer player. Disability, therefore, is mostly determined based on an individual’s functional capacities, their roles and responsibilities, and their environment. The Functional Model approaches treatment of disability and its consequences through adaptive technology, vocational training, and tailored job placement. For persons undergoing ostomy surgery, their level of functioning is impacted depending upon their lifestyle. Someone who is active, exercises a lot, may want to utilize products that allow them to maintain that level of activity, such as belly bands or smaller pouches.

In summary, our models of disability help us as practitioners to identify how a disability may be impacting someone’s life and what interventions would be best suited to mitigate those consequences. Persons with ostomies may not need more surgery or new medication, they may simply need better access to their environments. Persons with ostomies may not need new equipment, they may need help advocating against prejudicial attitudes regarding their ostomy.

For me, personally, as a person with an ostomy, I have always relied on the Functional Model of Disability (even before I knew what that was!) to guide me. What do I want to do? What are my limitations? What could I do to make that possible? My ostomy is permanent, I cannot change that, but in order to work and exercise how I want I can control my diet, how I maintain my pouch, what supplies I bring with me, how much I sleep, and so on and so forth. When working with persons with ostomies, asking questions about what people want to be doing rather than simply asking what is wrong can help better point us toward effective solutions. ●

Communicating with Adolescents: our words matter, by Lynn Mohr, PhD. APRN PCNS-BC CPN

About the Author

Lynn Mohr, PhD APRN PCNS-BC CPN, is an Associate Professor/Associate Department Chair, Women, Children, Family Nursing at Rush University College of Nursing. Dr. Mohr has over 40 years of pediatric experience and her research focuses on the needs of adolescents with gastrointestinal ostomies where she has developed a theoretical framework for how adolescents work thru this experience. Dr. Mohr is a Fellow in the Illinois Institute of Medicine, Oversees Fellow in the Royal Academy of Medicine, London and a Fellow of the CNS Institute. She also is a past national president for the Society of Pediatric Nursing.

Lynn has received compensation from Coloplast to provide this information.

When providing healthcare guidance, working with adolescents can present many unique challenges. Many of these challenges can be mitigated with both (a) a better understanding of how adolescents think and (b) how our own communication patterns can impact our message.

Understanding adolescent thought and development is the first step to improving patient/provider communication. Usually spanning ages 12-18, adolescence represents a dynamic period in human growth and development. In addition to biological and sexual maturation, teens face questions of personal identity, sexuality, and autonomy (Christie & Viner, 2005). In addition, adolescents also experience a psychological and social shift as they move from the concrete reasoning and individualistic roots of childhood to the abstract reasoning and corporate behaviors which mark adulthood. These sudden changes are often accompanied by feelings of anxiety, awkwardness, and self-criticism which are often compounded by complex peer-relationships and the widening influence of social media (Croll, 2005).

Consequently, adolescents often vacillate between childlike and adult behaviors. In grappling with their changing lives, they become focused on their present realities rather than their long-term goals (Ginsburg, 2018). They seek solace in cultivating experiences and relationships as these provide security and a sense of self. Furthermore, the rapid growth often leads to feelings of invincibility and subsequent poor assessments of “risky” situations and long-term consequences.

While adolescent angst is nothing new, healthcare providers cannot underestimate the role it plays in effective patient communication. To practice developmentally informed adolescent communication Ginsburg (2018) together with my own research offer the following for providers working with adolescents:

  1. Remain Calm.

    Don’t speak until you have regulated your own emotions. Resist the urge to “strengthen” your message by speaking in loud or condescending tones. Rather than focusing on your own feelings, give the adolescent your full attention. Remember to choose your words wisely as they are powerful.

  2. Resist Lecturing.

    Patient engagement in risky, inappropriate, or dangerous behaviors often prompts a “lecture” which begins by covering consequences and ends with a “what were you thinking?” Such lectures, however, rely on the skills which teens lack most, such as abstract thinking, long-range planning, and risk-estimation (Ginsberg, 2018). While teenagers may pick up on our concern, they do not connect with our message. Not only are such lectures ineffective in the short term, but long-term they can be disempowering.

  3. Ask, Don’t Tell.

    Use question language such as “Tell me about? How did that work? I worry that might lead to ….. what do you think?”. Remember to never be shocked or surprised by what an adolescent tells you. Don’t ridicule an adolescent’s question or comments. Instead respond with “I could see why that seems to be something good, and I am concerned about…. What do you think? or I can tell that you are worried about…..” Using the word “but” in a sentence can negate anything positive the adolescent may have tried to explain, so replace “but” with “and”. When something “goes wrong”, ask questions like “What are your plans so this doesn’t happen again?”, “What did you learn from this?”, and “What would you tell another adolescent?” (Mohr, 2012).

  4. Acknowledge Existing Wisdom and Reinforce Safe Thought Patterns.

    Adolescents don’t crave feedback because of their insecurity, rather because it helps them learn (Ginsberg, 2018). Acknowledge when they have done something well and notice effort. Talk through an issue and ask their opinion on how something might work for them. Take time to discover their story and communicate that you value them. Often adolescents have worked through their own illnesses in creative ways. Positive feedback promotes trust and care.

  5. Make Directions Meaningful & Avoid Distractions.

    Practice “the pause” after each direction step, allowing space for questions and anxieties to surface. Remember to exercise patience as incorporating new information takes time. Make sure you have accurate information and if you do not, then apologize and move forward. Avoid multitasking behaviors as much as possible.

  6. Work with Their Strengths.

    Using computer-based programs or video-based learning works well. Build on the need for autonomy by teaching patients how to manage activities such as dating, dancing, work, dress etc. Incorporate their desire for connection and experiences by sharing stories from your own learning, connecting them to other adolescents who have been or are in similar situations, and recommending educational websites or other activities (such as adolescent ostomy camp).

  7. Promote a Positive Body Image.

    Acknowledge how their appearance might be affected by their illness or treatment. Sharing information about the effects of treatments and medications encourages discussion. Using questions such as “Other adolescents have asked about or shared about …is this something you have wondered about?” These questions encourage the adolescent to express their own concerns and fears. Asking about upcoming activities and if the adolescent has thought about how they will handle can encourage conversations about care rather than anxiety (Mohr, 2012).

In summary, understanding how adolescents think and modifying our communication styles to help promote patient ownership of solutions can make the difference between our teenage patients either absorbing or discounting the information we provide. By meeting teenagers where they are, our interactions have the potential to not only be effective, but also enjoyable as well. ●

To download the “Teen Life with an Ostomy” booklet to which Lynn contributed as an author, click here.

References

Christie D , Viner R . ABC of adolescence: adolescent development Br Med J. 2005 ; 330 ( 7486 ): 301-304

Croll J . Body image and adolescents . In: Stang JS , Story M , eds. Guidelines for Adolescent Nutrition Services . Minneapolis, MN : University of Minnesota ; 2005 : 155-166. http://www.epi.umn.edu/let

Ginsberg, K. The Teen Brain; 2018. Center for Communication for Parents and Teens. https://parentandteen.com/category/communication-strategies/

Mohr, L.D. Adolescent Growth and Development Issues in Adolescents with an Ostomy: A primer for WOC nurses. J Wound Ostomy Continence Nurs. 2012;39(5):515-521.

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