Patterns and treatments of Urinary incontinence on special care units

A systematic literature review of incontinence care for persons with dementia: the research evidence

BACKGROUND

Urinary/faecal incontinence in persons with dementia is a potentially treatable condition. However, which type of incontinence care is most appropriate for persons with dementia remains undecided.

AIM

The aim of this study was to perform a systematic review of literature on incontinence care in persons with dementia focusing on assessment/management and prevention.

DESIGN

A systematic search of the literature.

METHOD

The search was performed in the CINAHL, PubMed and Cochrane Library databases.

RESULTS

Of the 48 papers analysed, two were systematic literature reviews of management of urinary incontinence including persons with dementia. These reviews showed that the best-documented effect of toilet assistance for urinary incontinence in elderly persons with/without dementia had prompted voiding. However, prompted voiding in persons with dementia raises ethical concerns related to the person's integrity and autonomy. Timed voiding in combination with additional interventions like incontinence aids, staff training on the technique of transferring participants from bed to commode and pharmacological treatment decreased the number of urinary incontinence episodes in older persons with/without dementia. There is good scientific evidence that prevention of urinary incontinence in elders with/without dementia decreases incontinence or maintains continence. However, the evidence is insufficient to describe the state of knowledge of faecal incontinence.

CONCLUSIONS

Toilet assistance, including timed voiding in combination with additional interventions and prompted voiding, are the available evidence-based interventions; however, nursing incontinence care is an experience-based endeavour for persons with dementia.

RELEVANCE TO CLINICAL PRACTICE

There is a lack of evidence-based nursing interventions related to incontinence care for persons with dementia. More research is needed to show whether experience-based incontinence care is effective and which activities are most appropriate for persons with dementia. However, the practice of effective nursing will only be realised by using several sources of evidence, namely research, clinical experience and patient experience.

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.

The end-of-life experience in long-term care: five themes identified from focus groups with residents, family members, and staff

PURPOSE

We designed this study to examine the end-of-life (EOL) experience in long-term care (LTC) based on input from key stakeholders.

DESIGN AND METHODS

The study consisted of 10 homogeneous focus groups drawn from a purposive sample of LTC residents (2 groups; total n = 11), family caregivers (2 groups; total n = 19), paraprofessional staff (3 groups; total n = 20), and licensed/registered staff (3 groups; total n = 15) from five nursing homes and eight residential care/assisted living communities in North Carolina. We analyzed data by using grounded theory techniques to elicit manifest and latent themes.

RESULTS

Five overarching themes emerged: (a) components of a good death in LTC, (b) normalcy of dying in LTC, (c) the role of relationships in the provision and receipt of care, (d) hospice contributions to care at the EOL in LTC, and (e) stakeholder recommendations for enhancing EOL care in these settings. Underlying these themes was one central category, closeness, based on physical proximity and frequency of contact.

IMPLICATIONS

Findings suggest that promoting collaborative relationships among the four stakeholder groups, increasing social worker involvement, and removing barriers to hospice may enhance the EOL experience in LTC.

The influence of care provider access to structural empowerment on individualized care in long-term-care facilities

OBJECTIVES

Implementing management initiatives that enable formal caregivers to provide quality, individualized care to older adults in long-term-care (LTC) facilities is increasingly important given that the number of LTC residents is projected to triple by 2031. The objective of this study was to explore the relationship between care provider access to structural empowerment and the provision of individualized care in LTC.

METHODS

We computed structural equation models separately for registered nurses and licensed practical nurses (n = 242) and care aides (n = 326) to examine the relationship between access to empowerment structures (i.e., informal power, formal power, information, support, resources, opportunity) and the provision of individualized care. We subsequently undertook invariance analyses to determine if the association between empowerment structures and reported provision of individualized care differed between caregiver groups.

RESULTS

Access to structural empowerment had a statistically significant, positive association with provision of individualized care for both groups. For registered nurses/licensed practical nurses and care aides, empowerment explained 50% and 45% of observed variance in individualized care, respectively. These notable percentages did not differ significantly between caregiver groups.

DISCUSSION

Of the empowerment structures, support, especially in the form of access to educational opportunities and recognition for a job well done, seems to be particularly significant to care providers. Findings from this study suggest that provision of individualized care in LTC may be enhanced when formal caregivers have appreciable access to empowerment structures.

The psychometric testing of a urinary incontinence nursing assessment instrument

OBJECTIVE

This study was conducted to examine the psychometric properties of the Capital Health Authority (CHA) Screening Tool.

DESIGN

A correlational design was used to evaluate the interrater reliability and concurrent validity of the CHA Tool. Alpha coefficients were calculated as measures of internal consistency.

SETTING AND SUBJECTS

Psychometric testing employed convenience sampling to select 12 nurses who work in homecare or geriatric assessment unit settings, and 23 homecare recipients who were experiencing incontinence.

INSTRUMENTS

The Stress Urge Incontinence Instrument and Urodynamic Patient Questionnaire were the criterion measures for concurrent validity of the CHA Assessment Tool.

METHODS

Interrater reliability testing involved examination of nurse participants' ratings of the same 4 videotaped scenarios of a client reporting differential symptoms of incontinence. Concurrent validity was estimated after the administration of the CHA Tool and the Stress Urge Incontinence Instrument and Urodynamic Patient Questionnaire to homecare clients by the researcher.

RESULTS

Correlational analyses revealed good validity and reliability of the urge (r = .81, p < .01, Cronbach's alpha = .83) and stress subscales (r = .78, p < .01, Cronbach's alpha = .66) of the CHA Tool.

CONCLUSIONS

This research provides support for a short assessment tool that will benefit individuals experiencing urinary incontinence, their caregivers, and society through improved continence management. The appropriate management of urinary incontinence symptoms could prevent long-term care admissions.

The Language of Caring: Nurse's Aides' Use of Family Metaphors Conveys Affective Care

PURPOSE

Using a conceptual framework from the field of care work and the theory of boundary work, we explore the use of family metaphors by nurse's aides to describe their affective care for nursing home residents. We focus on how nurse's aides can express affective care in spite of experiencing racial abuse.

METHODS

Using the technique of domain analysis, we present a secondary analysis of semistructured interviews with 30 African American and immigrant aides working in three nursing homes about their experience of racism on the job.

RESULTS

Aides used metaphors associated with family, relationships, and attachment to describe their affective care of residents. They expressed the value of their caring by contrasting it with "uncaring" families. Immigrant aides expressed a form of caring culture shock about the uncared-for situation of American elders.

IMPLICATIONS

Through their use of metaphors of family and attachment, these aides define family care as their gold standard of affective care and communicate that they are attempting to provide good care. Aides distinguished caring tasks from affective care in that they applied affective care in an elective way, so that the caring task was the minimum, universal form of care and added affective care created an enriched form of care. They held out informal elder care in their cultures of origin as a model that is superior to the system of formal elder care in which they work. We use the theory of boundary work to explain how these aides provided affective care in the face of racial abuse.

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.

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

The objective of this study was to assess the use of the Agency for Health Care Policy and Research (now called the Agency for Healthcare Research and Quality) Urinary Incontinence (UI) Guideline (1996) in nursing homes (NHs) using retrospective chart review and nursing assistant screening interviews. The study was conducted in a nonrandom sample of 52 NHs in upstate New York. Two hundred residents developing new UI or newly admitted with UI on the dayshift and who met criteria for evaluation and treatment/management were evaluated in the 12 weeks after onset of or admission with UI. Fifteen percent of newly admitted residents needed evaluation. Of residents already in NHs, 2.3 per 100 beds developed new UI over the 12 weeks. Aspects of UI evaluation rarely done were rectal examination (15%), digital examination of prostate (15%), and pelvic examination (2%). Sixty-eight percent had a culture/sensitivity, 56% a urinalysis, and 6% a postvoid residual. Eighty-one percent had a reversible cause at the time of onset, but only 34% had all addressed. Few (2%) needed urologist evaluation. Treatment was rare (3%), but management using toileting and absorbent products were common. Only 6% achieved resolution of UI. These results suggest that assessment and treatment of UI is manageable (a total of 4.2 new cases per 100 beds per 12 weeks) but quality is not adequate. On average, only 20% of the standards applicable were met, due primarily to lack of awareness of new UI and lack of familiarity with the guideline. Thus, improvements are needed. Recommendations for guideline revision are made.

Development of a risk-adjusted urinary incontinence outcome measure of quality for nursing homes

BACKGROUND

Quality of nursing home care is of ongoing concern. The availability of uniform, patient-level information-the Minimum Data Set (MDS)-offers the opportunity to assess quality based on risk-adjusted health outcomes.

OBJECTIVE

To develop a risk-adjusted measure of quality based on urinary incontinence (UI) outcomes for nursing homes, derived from the MDS.

RESEARCH DESIGN

A retrospective statistical analysis of individual resident level data.

SUBJECTS

MDS+ data for 46,453 residents of 671 nursing homes in New York State during the 1995 to 1997 period.

MEASURES

Improvement in UI status was defined based on the resident's UI status at 3 months post admission relative to status at admission. Individual risk factors were also defined at admission. Facility level quality indicators were developed.

RESULTS

Facility level indicators show substantial variation. An average facility, providing average quality care to a population of average risk, would experience improvement in UI outcomes for 11 of its 25 admissions in a year. The difference between the best and the worst facilities (two standard deviations above and below the average) is eight new residents with improvement in UI outcomes out of 25 annual admissions.

CONCLUSIONS

This study demonstrates the feasibility of measuring quality of UI care based on nationally available MDS data. The measures presented can be used to support internal quality improvement efforts. Before such measures can be used externally, either in the survey process or in quality report cards, they should be further validated.