Use of the Agency for Health Care Policy and Research Urinary Incontinence Guideline in Nursing Homes

Urinary Incontinence in Older Adults Takes Collaborative Nursing Efforts to Improve

There is a misconception that urinary incontinence (UI) in older adults, usually above the age of 65 is a part of aging. More than 50% of residents in long-term care (LTC) settings are affected by UI and it is associated in many cases with markedly reduced quality of life. It has become evident that incontinence can be cured or successfully managed. However, many nurses lack sufficient knowledge to intervene appropriately. The purpose of this review is to share how the collaborative efforts of nurses at all levels may lead to increased assessment and interventions of UI in this population.

Effectiveness of conservative urinary incontinence management among female nursing home residents-A cluster RCT

BACKGROUND

Guideline-compliant conservative management of urinary incontinence (UI) is the first step of the initial management for UI and is recommended for long-term care in older persons. Recent studies have focused on the effects of guideline-compliant UI management. However, most of these studies were tested in another setting than nursing homes and were not focused on conservative management.

AIMS

To measure the effectiveness of 29 evidence-based nursing recommendations regarding the conservative management of UI in Austrian nursing homes.

METHODS

The study is a cluster randomized intervention trial with institution as the unit of randomization. Twelve nursing homes in two Austrian provinces (Styria, Carinthia) were randomly allocated to the intervention group (IG) and control group (CG). Data were collected from participating residents over a three-month period. The intervention consisted of the implementation of recommendations for the conservative management of UI among female nursing home residents. The primary outcome variable was the daily UI experienced by the participating residents.

RESULTS

Residents in the (IG n = 216) had a lower risk (OR = 0.14, p = 0.02) of experiencing daily UI and were less likely to receive absorbent products (OR = 0.01, p = 0.01) than residents in the CG (n = 165). Residents in the IG (OR = 5.16, p = 0.00) were five times more likely to receive recommended interventions (e.g., bladder training) than residents in the CG.

CONCLUSION

Introducing guideline-compliant management into nursing practice can increase the likelihood of evidence-based interventions for the conservative management of UI. The intervention in this study targeted on nurses/nurse managers and can be recommended for the nursing home setting.

Factors associated with long-term mortality for stroke unit patients in Latvia

AIM

The aim of this study was to evaluate how pre-stroke risk factors, neurological symptoms, and the level of disability shortly after stroke are associated with poststroke mortality during a 7-year period after stroke, for persons treated in a stroke unit.

METHODS

The data of 231 patients were included in the study. Patients who were treated in the stroke unit at the Riga East University Hospital between February 1, 2009, and July 20, 2009, were included in this study. Three stepwise Cox proportional hazard analyses were performed to analyze mortality in the 7 years following stroke. Pre-stroke risk factors (type of stroke, arterial hypertension, diabetes mellitus, atrial fibrillation, smoking, alcohol abuse, obesity, recurrent stroke, age, gender), neurological symptoms (motor deficit, sensory disturbance, aphasia, poststroke urinary incontinence (PSUI), mental status), and limitations of activity (feeding, bathing, grooming, dressing, toilet use, transfers, mobility, stairs) were evaluated as factors associated with mortality after stroke.

RESULTS

A total of 145 (62.8%) patients died during the study period. The final model for each group of factors included only one of the factors used for the analysis. Patients who had alcohol abuse were 40% more likely to die earlier. The hazard for those with PSUI is 1.72 times higher than those without PSUI. The independence in grooming showed a 39% lower likelihood of dying earlier.

CONCLUSION

Alcohol abuse as a pre-stroke risk factor, poststroke urinary incontinence as a neurological symptom, and dependence in grooming as a factor of disability were associated with earlier mortality in the first seven years after stroke.

"Dignity": A central construct in nursing home staff understandings of quality continence care

AIMS AND OBJECTIVES

To explore nursing home staff members' beliefs and expectations about what constitutes "quality continence care" for people living in nursing homes.

BACKGROUND

Most nursing home residents require assistance to maintain continence or manage incontinence. Best practice guidelines promote active investigation of incontinence, treatment of underlying potentially reversible causes, and initial conservative interventions to prevent, minimise and/or treat incontinence. Despite research showing the positive benefits of implementing active interventions, translating the findings of research into practice in nursing homes has been modest. Understanding the perspectives of individuals who provide continence care may help bridge the gap between evidence and practice.

DESIGN

A qualitative exploratory descriptive design.

METHODS

Qualitative interviews were conducted with 19 nursing home staff: eight registered nurses, four enrolled nurses and seven personal care workers working in a nursing home in Australia between 2014-2015. Data were analysed inductively to identify themes and subthemes that described and explained staff beliefs about quality continence care in nursing homes.

FINDINGS

Participants' understanding and expectations about quality continence care were linked to beliefs about incontinence being an intractable and undignified condition in nursing homes. The key theme to emerge was "protecting residents' dignity" which was supported by the following six subthemes: (i) using pads, ii) providing privacy, (iii) knowing how to "manage" incontinence, (iv) providing timely continence care, (v) considering residents' continence care preferences and (vi) communicating sensitively.

CONCLUSION

The findings provide new insight into the basis for continence care practices in nursing homes. Education about continence care should challenge beliefs that limit continence care practice to cleaning, containing and concealing incontinence. There is a need for a multidimensional framework that is informed by social, psychological and biomedical research about incontinence, research about the fundamental elements of care, care-dependent individuals' expectations about care, and values about dignity and care.

RELEVANCE TO CLINICAL PRACTICE

The in-depth exploration led to an understanding of the basis for continence care practices that centre on cleaning, containing and concealing residents' incontinence in some nursing homes. There is a need to review the quality of education for the aged care workforce about incontinence to ensure it equips them with a broad understanding of the fundamentals of care and how to enact dignity in continence care through a resident-centred approach.

The effect of pelvic floor muscle training in urinary incontinent elderly women: a sistematic review

Introduction The International Continence Society (ICS) determines that the pelvic floor muscles training (PFMT) is the first-choice treatment of urinary symptoms in women. Objective The aim of this study was to systematize randomized controlled clinical trials that address the effects of PFMT in the treatment of urinary symptoms in older women using objective outcome measures. Method Systematic review search was performed eletronic the following databases: Medline, Pubmed, Lilacs, PEDro and manual research conducted in the references of the studies. Were considered eligible women aged over 60 years who performed PFMT in isolation, without the involvement of another technique. The PFMT performed in clinic or at home, with or without the supervision of a therapist and with or without the use of biofeedback as an adjunct. Considered as outcome measures urodynamic studies, voiding diary that assesses daytime urinary frequency, nocturnal urinary frequency, urinary incontinence and exchange absorbent, and, finally, the absorbent test that quantifies loss urinary grams. The assessment of methodological quality of the studies was conducted by PEDro scale. Results Three studies were reviewed in full. Only one trial was rated high methodological quality. There was significant improvement in urinary symptoms after treatment proposed in the three selected studies. Conclusion Considering the studies available so far are weak the evidence for the use of PFMT in the treatment of urinary symptoms in elderly women.

Evidence based practice in long term care settings

PURPOSE

The purpose of this manuscript is to discuss the need for use of evidence based practice (EBP) in LTC, the current use of evidence in long term care facilities and what we know about adoption of the use of EBP in LTC.

METHODS

Literature review and reporting of findings from the M-TRAIN study that was a quasi-experimental design to test the effectiveness of an intervention to increase the use of EBPs for urinary incontinence and pain in 48 LTC facilities.

RESULTS

Barriers to adopting EBPs include lack of available time, lack of access to current research literature, limited critical appraisal skills, excessive literature to review, non-receptive organizational culture, limited resources, and limited decision-making authority of staff to implement change. Strategies to promote adoption of EBP include the commitment of management; the culture of the home; leadership; staff knowledge, time, and reward; and facility size, complexity, the extent that members are involved outside the facility, NH chain membership, and high level of private pay residents. Findings from the M-TRAIN add, stability of nurse leader and congruency between the leaders perception of their leadership and the staff's perception of the leadership.

CONCLUSION

There is clear evidence of the need and the benefits to residents of LTC and to the health care system yet adoption of EBP continues to be slow and sporadic. There is also evidence for the process of establishing best evidence and many resources to find the available EBPs. The urgent need now is finding ways to best get the EBPs implemented in LTC. There is growing evidence about best methods to do this but continued research is needed. Clearly, residents in LTC deserve the best care possible and EBPs represent an important vehicle by which to do this.

Translating research into practice in nursing homes: can we close the gap?

PURPOSE

A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model.

DESIGN AND METHODS

The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices.

RESULTS

A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature.

IMPLICATIONS

NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.

Does improved functional performance help to reduce urinary incontinence in institutionalized older women? A multicenter randomized clinical trial

Background

Urinary incontinence (UI) is a major problem in older women. Management is usually restricted to dealing with the consequences instead of treating underlying causes such as bladder dysfunction or reduced mobility.

The aim of this multicenter randomized controlled trial was to compare a group-based behavioral exercise program to prevent or reduce UI, with usual care. The exercise program aimed to improve functional performance of pelvic floor muscle (PFM), bladder and physical performance of women living in homes for the elderly.

Methods

Twenty participating Dutch homes were matched and randomized into intervention or control homes using a random number generator. Homes recruited 6–10 older women, with or without UI, with sufficient cognitive and physical function to participate in the program comprising behavioral aspects of continence and physical exercises to improve PFM, bladder and physical performance. The program consisted of a weekly group training session and homework exercises and ran for 6 months during which time the control group participants received care as usual. Primary outcome measures after 6 months were presence or absence of UI, frequency of episodes (measured by participants and caregivers (not blinded) using a 3-day bladder diary) and the Physical Performance Test (blinded). Linear and logistic regression analysis based on the Intention to Treat (ITT) principle using an imputed data set and per protocol analysis including all participants who completed the study and intervention (minimal attendance of 14 sessions).

Results

102 participants were allocated to the program and 90 to care as usual. ITT analysis (n = 85 intervention, n = 70 control) showed improvement of physical performance (intervention +8%; control −7%) and no differences on other primary and secondary outcome measures. Per protocol analysis (n = 51 intervention, n = 60 control) showed a reduction of participants with UI (intervention −40%; control −28%) and in frequency of episodes (intervention −51%; control −42%) in both groups; improvement of physical performance (intervention + 13%; control −4%) was related to participation in the exercise program.

Conclusions

This study shows that improving physical performance is feasible in institutionalized older women by exercise. Observed reductions in UI were not related to the intervention. [Current Controlled Trials ISRCTN63368283]

Distance coursework and coaching to improve nursing home incontinence care: lessons learned

OBJECTIVES

To determine whether a distance coaching course on improving nursing home incontinence care could be replicated and brought to scale with a larger group of nursing homes without sacrificing outcomes.

DESIGN

The study collected descriptive and comparative data.

SETTING

Fourteen nursing homes in the original course and 34 in the replication course.

PARTICIPANTS

Participants in the study were supervisors and staff from enrolled nursing homes who completed the distance coaching courses on incontinence management.

MEASUREMENTS

Data for both courses were collected using a resident assessment form to evaluate implementation of new practices, pre- and posttraining quizzes, a course evaluation survey, and a supervisor's report.

RESULTS

There were few significant differences between the course groups with respect to course participation, knowledge transfer, and training program preferences. Although Course 1 nursing homes reported assessing more residents on average than Course 2 homes (22 vs 12), this difference is probably an artifact of differences in the reporting methodologies for the two courses.

CONCLUSION

This study found qualified support for using a distance coaching course to facilitate adoption of evidence-based incontinence care practices in nursing homes. The findings also underscore the challenges associated with designing dissemination and implementation programs that are effective and feasible to implement with nursing homes. Nursing home educators should consider this study's findings when designing new training programs. Outcomes may improve if some dissemination resources are diverted to distance coaching activities that support nursing home improvement efforts over extended periods.

Residents' perspectives on urinary incontinence: a review of literature

BACKGROUND

Individuals in residential aged care facilities experience urinary incontinence more than any other single population. Despite these factors, the impact of the condition on their quality of life, their perspectives of living with the condition, and their preferences for care have received little research attention.

AIM

To provide a descriptive overview of research about; the impact of urinary incontinence on residents' quality of life; residents' perspectives of having urinary incontinence; and their preferences for continence care'.

DESIGN

A descriptive review of literature.

METHOD

A broad search was undertaken for qualitative and quantitative research that evaluated residents' quality of life related to urinary incontinence; their perspectives on having urinary incontinence, and their preferences for managing it. Data were displayed in tabular format, summarized, and described.

RESULTS

Ten studies were identified and reviewed (six qualitative and four quantitative). They reveal many residents' value having independent bowel and bladder function, but believe that incontinence in inevitable and intractable. Some adopt self management strategies, however considerable barriers hinder their ability to maintain continence and manage incontinence. Residents often have low expectations, and hence decline further evaluation and treatment. Some express satisfaction with continence care even if this care is not consistent with their preferences. Little is known about how cognitively impaired residents perceive their condition. However some individuals with cognitive impairment respond with acute anxiety when carers' attempt to provide continence care.

CONCLUSION

Residents' perspectives on incontinence and preferences for continence care relate to low expectations for improvement. Such misconceptions should be addressed and residents and their family members should be given a range of options from which to choose. As urinary incontinence impacts on residents' quality of life, it is also important that continence care is delivered in a participative and sensitive way.

The coach is in: improving nutritional care in nursing homes

PURPOSE

 This article describes and evaluates a long distance coaching course aimed at improving nutritional care in nursing homes (NHs). The course was structured to provide more support than traditional training programs offer. 

METHODS

 In a series of 6 monthly teleconferences led by an expert in NH nutritional care, participating NH staff received step-by-step instructions for implementing an evidence-based nutritional management program. After each session, participants were asked to implement the care step they had just learned. Coaching calls helped facilitate implementation. Staff in 18 NHs in 12 states completed the course. Evaluation data were collected using a resident data form, pre- and post-training quizzes, a participant course evaluation survey, and a supervisor's report. 

RESULTS

 NH staff attended an average of 4.8 teleconferences, with 5 staff members typically attending each teleconference. Average quiz scores increased 30% (p < .0001) from pre- to post-training. A majority of course participants (N = 35) said they would participate in a similar course (82.9%) and would recommend the course (80%). Just under half preferred the coaching course to a more traditional 1- to 2-day conference. Nine of 12 reporting supervisors said their facility planned to continue the new nutritional care program. The 10 NHs that submitted resident data assessed an average of 5 residents using the recommended protocols. 

IMPLICATIONS

 We recommend the coaching course format. Dissemination outcomes may improve if resources currently used for short-duration training activities are used instead on coaching activities that support NHs over extended periods.

Clinical significance of postvoid residual volume in older ambulatory women

OBJECTIVES

To examine the prevalence, natural history, and clinical significance of high postvoid residual (PVR) volume in ambulatory older women.

DESIGN

Prospective cohort study.

SETTING

Group health plan in Washington state.

PARTICIPANTS

Nine hundred eighty-seven ambulatory women aged 55 to 75.

MEASUREMENTS

PVR was measured using bladder ultrasonography at baseline, 1 year, and 2 years. Participants completed questionnaires about urinary symptoms and provided urine samples for microbiological evaluation.

RESULTS

Of the 987 participants, 79% had a PVR less than 50 mL, 10% of 50 to 99 mL, 6% of 100 to 199 mL, and 5% of 200 mL or greater at baseline. Of women with a PVR less than 50 mL, 66% reported at least one urinary symptom at baseline. Of women with a PVR of 200 mL or greater, 27% reported no significant symptoms at baseline. In adjusted analyses using data from all study visits, women with a PVR of 100 mL or greater were more likely to report urinating more than eight times during the day (odds ratio (OR)=1.42, 95% confidence interval (CI)=1.07-1.87), and women with a PVR of 200 mL or greater were more likely to report weekly urgency incontinence (OR=1.50, 95% CI=1.03-2.18) than those with a PVR less than 50 mL. High PVR was not associated with greater risk of stress incontinence, nocturnal frequency, or urinary tract infection in adjusted analyses. Forty-six percent of those with a PVR of 200 mL or greater and 63% of those with a PVR of 100 to 199 mL at baseline had a PVR less than 50 mL at 2 years.

CONCLUSION

More than 10% of ambulatory older women may have a PVR of 100 mL or greater, which is associated with greater risk of some urinary symptoms, but many with high PVR are asymptomatic, and high PVR frequently resolves within 2 years. Symptom-guided management of urinary symptoms may be more appropriate than PVR-guided management in this population.

Systematic review of the management of incontinence and promotion of continence in older people in care homes: descriptive studies with urinary incontinence as primary focus

AIM

This is a review of descriptive studies with incontinence as the primary focus in older people in care homes.

BACKGROUND

Incontinence is prevalent among residents of care home populations.

DATA SOURCES

MEDLINE and CINAHL were searched from 1996 to 2007 using the highly sensitive search strings of the Cochrane Incontinence Review Group for urinary and faecal incontinence including all research designs. Search strings were modified to enhance selectiveness for care homes and older people and exclude studies involving surgical or pharmacological interventions. Searching of reference sections from identified studies was also used to supplement electronic searches. The Cochrane Library was searched for relevant systematic reviews to locate relevant studies from those included or excluded from reviews. The search was limited to English-language publications.

METHODS

A systematic review of studies on the management of incontinence, promotion of continence or maintenance of continence in care homes was conducted in 2007-2009. This is a report of descriptive studies. Results. Ten studies were identified that reported on prevalence and incidence of incontinence (urinary with or without faecal), policies, assessment, documentation, management or economic evaluation of its management. Use of incontinence pads and toileting programmes comprised the most common management approaches used. No studies were identified that attempted to maintain continence of residents in care homes.

CONCLUSIONS

Studies on maintaining continence and identifying components of toileting programmes that are successful in managing or preventing incontinence and promoting continence in residents of care home populations along with their economic evaluation are warranted.

Continence profiles. A way to enhance assessment of urinary continence in German nursing practice

The German expert standard "Promotion of urinary continence in nursing" was developed and implemented to support nursing practice. The group of experts involved identified the assessment of (in)continence situations and the evaluation of outcomes as a central problem for successful continence care. They, therefore, developed an assessment instrument in the German language, namely six continence profiles, to help differentiate between continence and incontinence. It also takes into account the extent to which the relevant situation can be promoted or compensated by the application of measures, on the one hand, and independently or dependent on nursing staff assistance, on the other hand. The profiles were developed based on theories and implemented into practice as a model. The current paper describes the theoretical background and development process as well as early results from implementation and testing. However, a comprehensive scientific study must still be performed.

How do people make continence care happen? An analysis of organizational culture in two nursing homes

PURPOSE

Although nursing homes (NHs) are criticized for offering poor quality continence care, little is known about the organizational processes that underlie this care. This study investigated the influence of organizational culture on continence care practices in two NHs.

DESIGN AND METHODS

This ethnographic study explored continence care from the perspectives of NH stakeholders, including residents and interdisciplinary team members. Data were collected through participant observation, interviews, and archival records.

RESULTS

Human relations dimensions of organizational culture influenced continence care by affecting institutional missions, admissions and hiring practices, employee tenure, treatment strategies, interdisciplinary teamwork, and group decision making. Closed system approaches, parochial identity, and an employee focus stabilized staff turnover, fostered evidence-based practice, and supported hierarchical toileting programs in one facility. Within a more dynamic environment, open system approaches, professional identity, and job focus allowed flexible care practices during periods of staff turnover. Neither organizational culture fully supported interdisciplinary team efforts to maximize the bladder and bowel health of residents.

IMPLICATIONS

Organizational culture varies in NHs, shaping the continence care practices of interdisciplinary teams and leading to the selective use of treatments across facilities. Human relations dimensions of organizational culture, including open or closed systems, professional or parochial identity, and employee or job focus are critical to the success of quality improvement initiatives. Evidence-based interventions should be tailored to organizational culture to promote adoption and sustainability of resident care programs.

Nursing home staffing and training recommendations for promoting older adults' quality of care and life: Part 1. Deficits in the quality of care due to understaffing and undertraining

Caught between the inability or unwillingness of nursing home corporations and owners to redistribute revenue and the reluctance of federal and state agencies to increase payments to nursing homes, the nation's most vulnerable older adults are not receiving the care they deserve. Widespread recognition of substandard care and quality of life of older adults in nursing homes has existed for decades. In addition, there is substantial evidence that poor quality of care is related to inadequate numbers and training of nursing staff. Still, policy makers and nursing home owners have failed to take needed action. In the first article of this two-part series, major deficits in the care of older adult nursing home residents are reviewed, and research documenting the relationship between nursing home staffing and the quality of care and life of residents is summarized.

A phase II exploratory cluster randomized controlled trial of a group mobility training and staff education intervention to promote urinary continence in UK care homes

OBJECTIVES

To assess feasibility, acceptability and potential efficacy of group exercise and staff education intervention to promote continence in older people residing in care homes. To establish measures and information to inform a larger trial.

DESIGN

Phase II pilot exploratory cluster randomized controlled trial.

SETTING

Six purposely selected care homes in the West Midlands, UK.

SUBJECTS

Thirty-four care home residents (mean age 86, 29 female), 23 with cognitive impairments.

INTERVENTION

Physiotherapy-led group exercise and staff continence and mobility facilitation training.

MAIN OUTCOME MEASURES

Reported continence status, Rivermead Mobility Index. Feasibility was assessed by uptake and compliance, and acceptability by verbal feedback. A staff knowledge questionnaire was used.

RESULTS

Thirty-three residents, cluster sizes from 3 to 7. The number of residents agreeing with the statement 'Do you ever leak any urine when you don't mean to?' in the intervention group decreased from 12/17 at baseline to 7/17 at six weeks in the intervention group and increased from 9/16 at baseline to 9/15 at six weeks. The Rivermead Mobility Index scores were better in the intervention group (n=17; baseline: 6.1, six weeks: 6.2) compared with controls (n=16; baseline: 5.9, six weeks: 4.75). The intervention was feasible, well received and had good compliance.

CONCLUSIONS

Group mobility training and staff education to promote continence is feasible and acceptable for use with care home residents, including those with cognitive impairment.

Nurses' knowledge and practice about urinary incontinence in nursing home care

BACKGROUND

An important barrier in the implementation of effective incontinence treatments is the level of knowledge of the nurses concerning assessment and treatment of urinary incontinence. Therefore, it is important to assess current nurses' knowledge and practice in urinary incontinence care so that nurses can receive adequate training and education.

AIMS AND OBJECTIVES

This article reports on the development and testing of the Urinary Incontinence Practice and Knowledge Scale as well as the results of nurses' practice and knowledge about urinary incontinence.

METHODS

A cross-sectional design with a convenience sample of nurses and nurse assistants was used.

RESULTS

Nurses answer two-thirds of the questions correctly. The level of knowledge of the nurse assistants is lower than that of nurses. Education and experience in the field are associated with the level of knowledge. Nurses and nurse assistants perform continence-related actions only 'sometimes' or 'often' at best. Both groups have best results in the subscale 'Support' and they have most deficits in 'Documentation'.

CONCLUSION

Nurses and nurse assistants need more education and training in urinary incontinence care. Special focus should lie on documentation. The results give information towards adequate education and training for nurses as well as nurse assistants.

[Situation of nursing home residents with continence problems: a study in two German nursing homes]

AIM OF THE STUDY

To describe the situation of residents with continence problems (CP) in two German nursing homes.

METHODS

Medical and nursing records of all residents were reviewed and categorised according to a standardised protocol. Structured interviews were performed with the responsible nursing staff of each resident. Qualitative methods like focus groups and participating observations were used to collect further information.

RESULTS

In the investigated nursing homes 177 residents with and 70 without CP were identified (81.5% women; mean age 83.7 years). For these 247 residents 57 physicians and 116 nurses or nurses-aides were in charge. 71% of female and 76% of male residents had at least one CP. The three most common CP among residents were combined urinary and faecal incontinence (32%), urinary incontinence (21%), and urinary catheters (17%). Residents with CP were significantly more dependent in functional abilities like toileting, dressing or cognitive function than those without CP (P<0.01). In a high proportion of residents with CP physicians (64%) were not consulted nor were relatives (86%) involved in continence related activities.

CONCLUSION

Nursing home residents are commonly affected by continence problems which are associated with functional dependency and relevant co-morbidity. The public and expert debate on continence problems of nursing home residents has to be promoted to achieve long-term changes.

The nature and impact of urinary incontinence experienced by patients receiving community nursing services: A cross-sectional cohort study

BACKGROUND

Nurses have played a pivotal role in the delivery of continence services yet little is known about the nature or impact of urinary symptoms experienced by patients in receipt of such care.

AIM

To define the nature and impact of urinary symptoms experienced by patients in receipt of community nursing services.

METHOD

The Leicestershire Urinary Symptoms Questionnaire was administered to 1078 patients with incontinence identified from 176 community nurses' caseloads in 157 general practices in England. Information included type and severity of urinary symptoms, impact on quality of life, help with coping, use of continence products and health service resources.

RESULTS

Nine hundred and ninety nine (92.7%) patients (median age 79.0 years) returned completed questionnaires. Most patients had incontinence between 1 and 5 years duration, women were more likely than men to have had long standing ( > 5 years) symptoms and more than half the sample reported severe leakage. Women were more likely than men to report symptoms of stress incontinence (71.7% and 46.8%, respectively, p < 0.001) and urge incontinence UI (86.3% vs. 74.8%, respectively, p < 0.01). Half of the men and most women also experienced leakage as a result of difficulty getting to, on or off, a toilet/commode. Men were more likely than women to report getting up three or more times a night to pass urine (53.6% vs. 37.0%, respectively, p < 0.05). Most patients reported that their symptoms had a significant impact on many aspects of quality of life, and 45.7% would be very dissatisfied to continue "the way they are now". Professional help appeared principally one of containment.

CONCLUSION

Many people with incontinence receiving community nursing services experience two or more urinary symptoms which, in the majority, have a significant impact on quality of life. Many older patients were not satisfied to "put up" with their urinary symptoms. Current service provision appears to be failing those who are most in need of such care.

Exploring the facets of continence care: a continence survey of care homes for older people in Birmingham

AIMS

This study aimed to explore continence prevalence, knowledge and care in Birmingham care homes, UK.

BACKGROUND

There is an increasing need to respond to rising numbers of care home residents suffering from incontinence in the UK. A lack of staff knowledge, training and treatment options can make this problematic.

METHOD

A survey was developed and sent to 186 care homes in Birmingham catering for those 65 years old and over. A freepost envelope was provided for return of the completed form.

RESULTS

Sixty-six (35%) surveys were returned providing a representative sample. Eighty per cent of nursing home residents and 49% of residential home residents were reported incontinent. Half of the staff (53%) had some form of qualification in caring/nursing. Absorbent products were used to manage incontinence in over 50% of homes. Advanced age was cited as the main cause of incontinence. Sixty-eight per cent of homes used the continence advisory service and/or district nursing services.

CONCLUSIONS

While results proved encouraging in relation to numbers of qualified staff there is a need for improved continence awareness. Focus on aetiology, assessment procedures and treatment options are needed. While external service use levels were encouraging there appeared to be a need for an exchange of knowledge between services to optimize care.

RELEVANCE TO CLINICAL PRACTICE

While there is an existing body of knowledge relating to continence prevalence and management in nursing homes this research base is lacking for residential care settings. This survey addresses this imbalance by combining information from both settings. This paper also provides an insight into the components that have an impact upon continence promotion, prevention and management. By establishing a picture of current practice an indication of areas for improvement can be exposed.

Nursing Staff Beliefs and Expectations About Continence Care in Nursing Homes

OBJECTIVE

The purpose of this qualitative study was to consider the current beliefs of nursing assistants and directors of nursing about management of urinary incontinence (UI) among the residents in nursing homes.

DESIGN

This was a qualitative study using purposive sampling and a focus group methodology.

SETTING AND SUBJECTS

Three focus groups including 38 participants were held in 2 different regions. Two of the focus groups comprised nursing assistants and 1 comprised directors of nursing.

METHOD

The focus groups were facilitated by 2 different advanced practice nurses (BR and LJK), and 2 similar interview guides were used: 1 for the nursing assistants and 1 for the nurses. The interviews were tape recorded and transcribed verbatim; data were analyzed via content analysis.

RESULTS

Ten themes were identified from the data; 3 focused on resident factors that influence UI, 4 related to staff and family contributors to UI, and 3 focused on recommendations to improve UI management in the nursing home setting.

CONCLUSIONS

The findings from this study can be used to guide interventions to decrease or eliminate barriers to continence care and thereby facilitate the implementation of clinical practice guidelines and evidence-based interventions to improve urinary continence among nursing home residents.

The effect of urinary incontinence on quality of life in older nursing home residents

OBJECTIVES

To determine whether nursing home residents with urinary incontinence (UI) have worse quality of life (QoL) than continent residents, whether the relationship between UI and QoL differs across strata of cognitive and functional impairment, and whether change in continence status is associated with change in QoL.

DESIGN

Retrospective cohort study using a Minimum Data Set (MDS) database to determine cross-sectional and longitudinal (6 month) associations between UI and QoL.

SETTING

All Medicare- or Medicaid-licensed nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota during 1994 to 1996.

PARTICIPANTS

All residents aged 65 and older, excluding persons unable to void or with potentially unstable continence or QoL status (recent nursing home admission, coexistent delirium, large change in functional status, comatose, near death).

MEASUREMENTS

UI was defined as consistent leakage at least twice weekly over 3 months and continence as consistent dryness over 3 months. QoL was measured using the validated MDS-derived Social Engagement Scale.

RESULTS

Of 133,111 eligible residents, 90,538 had consistent continence status, 58,850 (65%) of whom were incontinent. UI was significantly associated with worse QoL in residents with moderate cognitive and functional impairment. New or worsening UI over 6 months was associated with worse QoL (odds ratio = 1.46, 95% confidence interval = 1.36-1.57) and was second only to cognitive decline and functional decline in predicting worse QoL.

CONCLUSION

This is the first study to quantitatively demonstrate that prevalent and new or worsening UI decreases QoL even in frail, functionally and cognitively impaired nursing home residents. These results provide a crucial incentive to improve continence care and quality in nursing homes and a rationale for targeting interventions to those residents most likely to benefit.

Understanding barriers to continence care in institutions

This work seeks to identify factors that facilitate or diminish care-providers' propensity to improve continence care in long-term care (LTC) settings. We conducted a cross-sectional qualitative study using focus group methodology in four long-term care institutions in Montreal, QC. Forty-two nurses, nursing assistants, and orderlies caring for incontinent elderly residents were asked how they perceived urinary incontinence (UI), how it was being managed, and what factors enabled or hindered continence care in their institution. Content analysis was used. Facilitating and inhibiting elements of three individual/internal factors (beliefs about UI, attitudes towards the elderly, and knowledge about UI) and five institutional/external factors (workload demands, type of patient, environmental support, co-worker support, and attributes of UI interventions) emerged as important determinants of care-providers' propensity to manage UI. To be successful, continence programs must target multidimensional elements that take into account personal, systems, and organizational level factors.

Urinary incontinence: economic burden and new choices in pharmaceutical treatment

In the year 2000, an estimated 17 million community-dwelling adults in the United States had daily urinary incontinence (UI), and an additional 33 million suffered from the overlapping condition, overactive bladder. Estimates of the total annual cost of these conditions range up to 32 billion US dollar; the largest components are management costs and the expenses associated with nursing home admissions attributable to UI. In most cases, patients with UI can be treated with pharmaceutical agents, in addition to behavioral therapy. Until recently, pharmaceutical therapy for UI has been limited, especially because the adverse effects of available agents resulted in poor adherence to treatment regimens. Recent innovations in molecular design and new dosage forms of UI medications offer the promise of fewer and less severe adverse effects and, thus, better treatment outcomes for patients. Additionally, the availability of multiple agents within a therapeutic class offers health care providers a spectrum of choices with which to personalize treatment for each individual patient. New pharmacologic treatment options for UI have the potential to allow greater independence for older persons who reside at home and to delay or avoid the costs of admission to long-term care facilities. Alternate dosage forms, which include patches and sustained-release formulations, may benefit patients who have difficulty chewing, swallowing, or remembering to take medications. Although these newer products are generally more expensive than older forms of therapy, they typically have more favorable cost-effectiveness ratios. Access to these new medications for patients enrolled in public and private health care plans may help to reduce the economic and social burden of UI care.

Prevalence and Correlates of Perineal Dermatitis in Nursing Home Residents

BACKGROUND

Perineal dermatitis is an adverse outcome of incontinence, which is common in older nursing home residents; yet knowledge about perineal dermatitis in this population is sorely lacking.

OBJECTIVES

To determine the prevalence and significant correlates of perineal dermatitis in older nursing home residents.

METHODS

Assessment data from 59,558 records in the Minimum Data Set (MDS) were linked with 2,883,049 orders in the medical record which enabled definition of variables related to perineal dermatitis, identification of cases, and determination of the prevalence of perineal dermatitis. Data from two subsamples, each with the records of 10,215 older nursing home residents, were analyzed using logistic regression to identify the significant correlates of perineal dermatitis.

RESULTS

Perineal dermatitis was found in 5.7% (n = 3,405) of residents and 73% of these were incontinent. Having perineal dermatitis was significantly associated with (a) impairments in tissue tolerance (i.e., more health problems, presence of a fever, requiring nutrition support, and having more problems of diminished perfusion or oxygenation); (b)problems of the perineal environment (i.e., having fecal incontinence only, double incontinence, and more items associated with mechanical chafing); and (c) altered toileting ability from daily use of restraints.

DISCUSSION

Several correlates of perineal dermatitis (mechanical chafing, fecal and double incontinence, and use of restraints) appear modifiable through nursing intervention. Clinical interventions should consider the complex health status of this population.

True prevalence of urinary incontinence among female nursing home residents

OBJECTIVES

Urinary incontinence is a significant problem in nursing home residents in the United States. Estimates of its prevalence have often been based on data from medical records obtained at nursing home admission. To measure the sensitivity of this method of defining the prevalence of urinary incontinence among female nursing home residents, we examined data from a clinical survey.

METHODS

We analyzed data from the National Nursing Home Survey, which collected information from nursing homes for each resident concerning admission diagnoses, presence of an indwelling Foley catheter or ostomy, need for assistance from equipment or personnel in using the toilet, and difficulty controlling urination.

RESULTS

Residents' medical records revealed a very low rate of admission diagnoses of incontinence. However, clinical queries revealed a high prevalence of bladder dysfunction. More than one half of all female nursing home residents were reported to have "difficulty controlling urination," and more than one half needed assistance in using the toilet.

CONCLUSIONS

Although only 1% to 2% of nursing home residents have a diagnosis of urinary incontinence, the true prevalence of bladder dysfunction in this group is much greater. The sharp divergence of National Nursing Home Survey data from published studies on the prevalence of incontinence in nursing homes highlights the limitations of using administrative data to study the epidemiology of bladder dysfunction.

Sustaining a Best-Care Practice in a Nursing Home

This study tested whether an action research organizational intervention fostering participatory management practices would sustain a nursing best-care practice protocol in a nursing home. An experimental nursing home (EH) and a control nursing home (CH) with similar characteristics were studied over a 4-year period. A pretest/posttest quasi-experimental design was used. Baseline data were co[lected on residents, families, and the staffs at the EH and the CH. Staff turnover rates, demographics of participant groups, and surveys concerning job stress, nursing care, family involvement, and satisfaction of residents and family members served as proximal outcomes to indicate whether organizational changes had occurred in the EH. Sustaining best practices in a nursing home requires not only significant organizational change but also changes in regulatory support for quality care, sufficient staff resources to implement and monitor the practices, and a change coordinator with sufficient formal or informal influence.

9 myths of incontinence in older adults: both clinicians and the over-65 set need to know more

Despite progress made in the research into and treatment of urinary incontinence, its incidence is rising among older adults. Many reasons for this disturbing finding have been posed: clinicians' insufficient knowledge of urinary incontinence, the reluctance of patients to discuss it, and inadequately individualized care. Common misconceptions of bladder health in older adults are explored to address these concerns and help prepare nurses in all settings to provide care that prevents and treats incontinence.

Future directions for incontinence research with frail elders

BACKGROUND

The most vulnerable older adults are often referred to as the frail elderly. There is a high prevalence of urinary incontinence (UI) in this population, yet there is little research to guide nurses in providing effective continence care to this vulnerable group of elders.

OBJECTIVES

To summarize current knowledge on UI in frail older adults and suggest future areas for research in this population.

METHODS

Existing literature about UI in the frail elderly was analyzed to generate a plan for future research.

RESULTS

Gaps exist in the knowledge base needed to guide the nursing care of incontinent frail elders in the following areas: effectiveness of interventions, caregiver characteristics and management models, prevalence, risk factors, and reliability and validity of outcome measures. There are barriers to conducting research in long-term care settings.

CONCLUSIONS

Despite the challenges inherent in doing research with incontinent frail elders, there is an urgent need for research to guide the nursing care of this population in all healthcare settings.

Translating Research on Incontinence Into Practice

BACKGROUND

Translating research evidence into clinical practice (TRIP) is an important initiative for health services so that care delivered is cost-effective, is efficient, and improves patient outcomes. Most TRIP studies have reported on disseminating and implementing clinical practice guidelines, protocols, or care pathways and have been undertaken in acute rather than community settings.

OBJECTIVES

To identify the factors that influence incontinence TRIP and to present key international studies on incontinence TRIP.

METHODS

Existing literature on TRIP was analyzed to generate a plan for future research.

RESULTS

Several methods to effect incontinence TRIP are described, including clinical practice guidelines and protocols, clinical pathways, partnerships between organizations, a model for incorporating UI research based on generic questions, and implementation strategies that incorporate change theory and consideration of barriers.

CONCLUSIONS

Future research is needed on incontinence TRIP in the following areas: barriers, the best theoretical approaches, the effectiveness of empowerment approaches, the value of mentors, effective strategies for nurses and unlicensed personnel, the impact of international collaboration, and regulations across settings.

Prevention of urinary incontinence in adults: population-based strategies

BACKGROUND

Urinary incontinence (UI) affects large numbers of adults, especially older adults, with an estimated 200 million adults worldwide having this life-altering condition.

OBJECTIVES

To identify key populations at risk for urinary incontinence and propose population-based strategies to promote continence with a substantive focus on UI prevention.

METHODS

Critical review of extant literature and iterative synthesis were undertaken to generate an action plan to guide future UI prevention research.

RESULTS

Key populations identified to be at risk for UI are women in selected occupations, childbearing women, older adults with lifestyle risk factors, older adults with comorbid conditions, and nursing home residents. Population-based research activities are proposed. Growing evidence supports the benefit of pelvic floor muscle training to prevent childbirth and prostatectomy-related UI. Bladder training has demonstrated preventive capacity.

CONCLUSIONS

Because of its high prevalence and chronic but preventable nature, UI is most appropriately considered a public health problem. Nursing research is needed to test prevention programs for UI using a population-based public health focus.

Use of Health Behavior Change Theories to Guide Urinary Incontinence Research

BACKGROUND

Urinary incontinence in adults has been the focus of researchers for over 40 years. Health behavior change theories, predominantly operant conditioning, have guided much of the intervention research. In recent years cognitive theories have been used to guide behavioral interventions for urinary incontinence. Most research has focused on individual rather than group or community behavior. Few, if any, health behavior change theories have been tested on population-based interventions.

OBJECTIVES

To explore urinary incontinence research guided by health behavior change theories.

METHODS

Existing literature on health behavior change theories was analyzed to generate a plan for future research.

RESULTS

Gaps in knowledge are identified and discussed and recommendations for future research are made.

CONCLUSIONS

The development and testing of new theories will guide the next generation of incontinence researchers and ultimately lead to reducing the incidence and prevalence of incontinence.

Caring for the incontinent elder: advanced practice nursing concepts

Urinary incontinence (UI) in the older adult is a multisystem health problem that has an impact on the lives of millions of older adults. Advanced practice nurses (APNs) specializing in gerontology,family, and adult practice are equipped educationally with the expertise to prevent, assess, and manage this health problem. The emerging emphasis on UI prevention will help guide the practice of APNs in the future. APNs will serve older adults well in prevention and management of UI by capitalizing on their roles as expert clinicians, researchers, consultants, educators, and collaborators with the interdisciplinary teams.

Advancing Quality of Urinary Incontinence Evaluation and Treatment in Nursing Homes Through Translational Research

AIM

This article presents the development of ongoing research to improve the evaluation and treatment of urinary incontinence (UI) in nursing homes through "A Model for Use of the Urinary Incontinence Guideline in US Nursing Homes" under the initiative Translating Research into Practice (TRIP II).

BACKGROUND

The previous research provided the definition of the clinical practices needing improvement, the relative size of the population needing care, and an estimate of the manpower required. The model proposed nurse practitioners (NPs) as consultants to nursing homes to perform the basic incontinence evaluation and treatment, thereby (1) improving incontinence evaluation and treatment, (2) reducing UI, (3) reducing complications, and (4) increasing cost savings attributable to UI.

APPROACH

A quasi-experimental research design with pre- and post-comparison was selected utilizing four control and four experimental NP caseloads followed for 16 weeks post-onset (n = 320).

FINDINGS

Findings are not yet available from this study, which is ongoing.

DISCUSSION

The real-world challenges presented by this translational research and their solutions are discussed.

Quality improvement and incontinence in long-term care

The quality improvement framework provides a practical way for nursing homes to prevent and reduce urinary incontinence (UI)for residents. It provides a means for facilities to identify organizational factors that may be hindering appropriate continence care from being provided to residents. It enables nursing homes to integrate evidence-based UI practices and monitor the consistent application of those practices by staff. The regular collection and analysis of data related to UI is essential for identifying problems,seeking accurate solutions, providing staff with feedback regarding their performance, and evaluating the overall quality of continence care provided to residents.

Urinary incontinence in the nursing home: practical approach to evaluation and management

This article provides a practical, evidence-based approach to the evaluation and treatment of the older incontinent nursing home resident. The concept of targeting treatment to those individuals who have cognitive and sensorimotor impairments and who are most likely to benefit is discussed. The efficacy and feasibility of comprehensive continence care programs, the use of clinical care guidelines in the nursing home, and the need for translational research in this area are addressed briefly.