Conceptual framework. The Stevens Star Model of Knowledge Transformation is used to understand the characteristics, type, and quality of information used in various aspects of evidence-based practice. The Star Model depicts a cycle of change in the form of a 5-pointed star, with each corner of the star denoting a different step (Figure 1).19
Star point 1: discovery research. New information is uncovered through research. Asking the right questions is the key to producing useful, accurate evidence, and the elements of patient (P), intervention (I), comparison (C), outcome (O), and time (T) are used to this end. The authors specified the current research questions according to the PICOT format. All questions refer to women with a diagnosis of SI.
• How does care based on an 8-week SICP affect UI frequency?
• How does care based on an 8-week SICP affect UI quantity?
• How does care based on an 8-week SICP affect quality of life?
• How does care based on an 8-week SICP affect perceived pelvic muscle self-efficacy?
Star point 2: evidence summary. This stage consists of compiling a useful comparison of findings.5 The authors carried out a keyword search of several databases using the search terms “stress urinary incontinence,” “female,” “nurse,” “pelvic floor muscle exercises,” “conservative treatment,” “guidelines,” and “protocol.” The search retrieved a total of 933 studies (PubMed: n = 143; Cochrane Library: n = 8; Google Scholar: n = 291; CINAHL: n = 75; OVID: n = 189; Medline: n = 169; and Science Direct: n = 58). Duplicates (n = 65), publications that were not available in full text (n = 158), publications that were not in English or Turkish (n = 13), and descriptive studies (n = 686) were not included in the review. Guidelines, systematic compilations, and meta-analyses with a high level of evidence published in national and international journals between 2000 and 2016 were included. This left 11 publications: 6 systematic reviews, 1 scoping review, 1 meta-analysis, and 3 sets of guidelines to be used in developing the SICP.
Star point 3: translation to guidelines. This step covers the integration of evidence into practice. In this process, clinical practical guidelines, care standards, clinical paths, protocols, and algorithms can be created.18,19 The current study addressed the task of developing the SICP (Table 1).
Star point 4: practice integration. This stage covers putting evidence into practice.18,19 The authors used a panel of 11 experts (3 physicians, 4 faculty members in nursing, 3 nurses with graduate degrees who had specialized in incontinence, and 1 expert in Turkish language and literature) to evaluate the content validity of the SICP. The experts assessed the care protocol on the basis of a 4-point Likert-type of scale where: 1 = not suitable; 2 = a little suitable, needs revisions in the procedural step; 3 = considerably suitable, needs minor changes in the procedural step; and 4 = very suitable. The content validity ratio of each item was calculated in the 11 experts’ evaluation. The content validity index was 91.9%.
The content validity of the training booklet (Table 2) prepared according to the SICP was verified by the 11 experts and its content validity index was 89%. The result of the analysis of the training booklet “Evaluation of Compliance of Printed Materials”25 was 25.61 ± 1.66, indicating a high level of readability. The form used to assess the suitability of the printed materials was composed of 6 sections and 27 questions. In the assessment, 1 point was given for a “yes” and 0 points for a “no.” The total score was assessed as a number between 1 and 27. The higher the score on the form, the higher the readability of the materials.25 The reliability and information quality of the printed training material was evaluated by using the DISCERN instrument.26 The DISCERN total mean score was 67.15 ± 6.98. DISCERN consists of 3 sections and 16 questions. The scale is a 5-point Likert-type instrument; the first 15 questions were marked as “yes,” “partially,” and “no.” The total score was assessed to be a number between 15 and 75. Lower scores indicate lower quality.26 Finally, the readability of the booklet was evaluated using the Flesch formula, which showed a score of 73, indicating that the booklet was easy to read.27
Star point 5: process, outcome evaluation. The last stage of the Star model is an evaluation of evidence-based practice including patient outcomes, personnel and patient satisfaction, efficiency, effectiveness, economic analysis, and impact on health conditions.18
Outcomes study methods. The outcomes evaluation was completed using a pretest-posttest control group experimental design. Care was provided according to a protocol developed using the Star model. Study procedures were reviewed and approved by Kirikkale University’s Medical Ethics Committee (approval no. 16/01, dated July 6, 2016).
The study was conducted in the urology polyclinic of a university hospital in Turkey from December 2016 to January 2018. Inclusion criteria were being female and 18 years of age or older and literate, having an initial diagnosis of SI and no sensory disorder affecting communication, and agreeing to participate in the research. Patients who were pregnant, had a urinary tract infection, or had a history of SI treatment were excluded from the study. Exclusion criteria were nonadherence to the protocol, being unable to contact the participant for follow-up, and the participant’s desire to withdraw from the study.
Participants that matched the sample criteria were recruited into the study. After their consent was obtained, they were randomized into an intervention and a control group. Randomization was achieved by assigning the first participant applying to the polyclinic to the intervention group and the next participant to the control group, continuing alternately in this way.
The researcher provided the intervention group with care according to the SICP. The hospital’s routine care protocol was provided to the control group. The intervention group was regularly monitored for the 8-week duration of the study.
At baseline, participants completed the patient characteristics form, the King’s Health Questionnaire (KHQ), and the Broome Pelvic Muscle Exercise Self-Efficacy Scale (Broome PMSES) and performed a 1-hour pad test. Participants were then given a 3-day voiding diary and instructions for completion of the diary at home. All participants completed the KHQ, Broome PMSES, 1-hour pad test, and voiding diary again immediately after the 8-week intervention period (postintervention assessment) and then 4 weeks later (follow-up assessment). The participants were given appointments by telephone, and face-to-face interviews were conducted (weeks 8 and 12). The participants (intervention group and control group) were offered counseling services throughout the 8-week period by telephone every week. The control group received standard care (eg, daily routine SI management in the institution) but no other interventions or educational materials during the 8-week study period. After the end of the study, the researcher provided the control group with education and gave them the booklet.
The researcher provided the intervention group with care in accordance with the SICP (Table 2). One of the researchers gave each participant one-on-one education in line with the SICP as well as the booklet prepared according to the SICP. The participants were interviewed by telephone in each of the first 8 weeks and were offered counseling within the scope of SICP; they were then reevaluated at the end of the 8 weeks (postintervention). No intervention was carried out from the eighth to the twelfth weeks.
Data collection. Research data were collected using paper and pencil. The participants who consented to join the study and fulfilled the inclusion criteria were provided with information about the research. After their written and verbal consent was obtained, they were asked to fill out the data collection tools. The researcher was present to answer any questions the participants had during the data collection. When a participant could not read a particular part of the form, the researcher read the question aloud. Completion of all forms took approximately 20 to 30 minutes. The data collection procedures were designed to preserve the privacy of the participants. The interviews took place in a quiet and private room. Confidentiality was maintained, and only the researchers had access to the data.
Patient characteristics form. The participants completed the demographic and health questionnaire.17,21,28 The descriptive characteristics form contained data on the patient’s age body mass index, number of births, type of delivery, episiotomy, menopause, and the duration of incontinence.
KHQ. This 32-item tool measures quality of life. Scores range from zero to 100, with low scores indicating good quality of life.29 Cronbach’s alpha for the subscale ranges from 0.72 to 0.89.30 In the current sample, Cronbach’s alpha for the subscales ranged from 0.72 to 0.82.
Broome PMSES. This instrument was developed to measure perceived self-efficacy in PFM exercises. It consists of 23 items organized in 2 subscales. The total score ranges from zero to 100, and scores are classified as follows: ≤ 32 points, low self-efficacy; 33 to 55 points, medium self-efficacy; and ≥ 56 points, high self-efficacy.31 The scale has a Cronbach’s alpha of 0.95.32 In the current sample, the Cronbach’s alpha was 0.94.
Three-day voiding diary. This is a semi-objective tool used to record voiding frequency, amount of urine, amount and type of liquid intake, incontinence frequency, and frequency of pad-changing.21
One-hour pad test. This test provides an objective measure of the quantity of urine leakage in a 1-hour period. Before the test, the dry pad is weighed using precision scales; this weight is deducted from the wet weight to give the weight of leaked urine.33 The participant is given the pre-weighed pad, asked to drink 500 mL water, and to rest in a seated position for 30 minutes. During the following 30 minutes, the participant stands up and sits down 10 times, coughs 10 times, runs in place for 1 minute, bends to pick something up from the floor 5 times, and then climbs a flight of stairs. The pad is taken from the participant and re-weighed on the same precision scales. The weight of the dry pad is deducted from the weight of the wet pad, and the weight of urine is recorded.
Data analysis. Data were analyzed using the SPSS Statistics Standard Pack v21 (IBM). The databases and the analysis were checked by 2 researchers. Descriptive statistics (means, standard deviations, frequencies, and percentages) were calculated. Group differences (intervention group and control group) were assessed with the chi-square test, Fisher’s exact test, Friedman’s 2-way analysis of variance, and the Mann-Whitney test. The statistical significance level was accepted as P < .05.