The role for nurses in promoting urinary continence …...The role for nurses in promoting urinary continence in long-term care Melissa Jenkins 0517969 Trent University PROMOTING URINARY

Running Head: PROMOTING URINARY CONTINENCE 1

The role for nurses in promoting urinary continence in long-term care

Melissa Jenkins

0517969

Trent University

PROMOTING URINARY CONTINENCE 2

Introduction

A nurse often encounters a resident when they are experiencing an unstable

transition (FITNEinc, 2011). Aging is the largest, longest transition faced by every

individual but it is not usually unstable, however it can become so when an individual

deviates from what is considered healthy aging. Urinary incontinence (UI) is not an aspect

of healthy aging despite the opinions of the aging population (Touhy, Boscrat, & Cleary,

2010; Ostaszkiewicz, O’Connell, & Dunning, 2012). The Registered Nurses’ Association of

Ontario’s (RNAO) best practice guideline (BPG) Promoting continence using prompted

voiding (2011a) addresses urinary incontinence and provides nurses with the best

available evidence on interventions that can be used to promote urinary continence. BPGs

do not give set instructions for care but aid nurses in making decisions on resident care as

well as the development of policies and procedures (RNAO, 2011a).

UI contributes to lower levels of self-reported quality of life (Aguilar- Navarro et al.,

2012; Ostaszkiewicz et al. 2012). Nursing assistants ranked UI second to pain when

considering the effects on quality of life (Lawhorne et al., 2008). In the long-term care

(LTC) setting it is estimated that 81% of residents suffer from some kind of UI within six

months of admission, whereby on admission only 43% were incontinent (Touhy et al.,

2010). Promoting continence can alleviate the monetary burden on the healthcare system

and the physical burden of caregivers while improving the quality of life for many elderly.

Urinary Incontinence as a Self-care Deficit

Orem’s theory of self-care states that the reasons people participate in self-care is

for universal, developmental, or human deviational reasons and the ultimate goal in life is


to provide care for oneself (Banfield, 2011). Universal reasons are required by every

person such as water, air, food, elimination, and the balance between social needs

(Banfield, 2011). Developmental reasons are associated with growth and development and

finally health deviational reasons are changes that are out of the normal range of human

function such as seeking healthcare (Banfield, 2011). Self-care deficits occur when a

discrepancy exists in the care that is needed and what is being provided (Banfield, 2011).

The inability to control urinary voiding and where it occurs is a universal self-care

deficit and is the focus of the Promoting continence using prompted voiding BPG (RNAO,

2011a). The guideline also focuses on UI as a risk factor related to other self-care deficits

especially falls. Other self-care deficits can also contribute to UI, for example constipation,

diet, and fluid intake (Touhy et al., 2010).

The BPG defines the seven types of UI with the most common being stress or urge

(RNAO, 2011). Transient UI is the loss of urine resulting from causes outside the urinary

system such as stool impaction or restricted mobility (RNAO, 2011a). The involuntary loss

of urine occurring after a strong urge to void is called urge UI (RNAO, 2011a). Stress UI is

the loss of urine during coughing or sneezing as a result of increased abdominal pressure

(RNAO, 2011a). Mixed UI results from both stress and urge. Functional UI is the loss or

leakage of urine associated with the inability to reach a bathroom in time to void because of

some cognitive, physical or environmental barrier (RNAO, 2011). Overflow UI is associated

with bladder distension and finally total UI is the continuous and unpredictable loss of

urine (RNAO, 2011a).


During aging there are physical changes that occur to the urinary tract that when

compounded with other factors can increase the chances of developing UI. As we age the

bladder decreases in capacity, increases in irritability, has contraction during filling, and

does not empty completely (Touhy et al., 2010). These changes contribute to an increase in

frequency, urgency, nocturia, and vulnerability for infection as well as a shortened period

between the urge to void and the actual need to void (Touhy et al., 2010).

Compounding factors can be human or environmental. Human factors are

associated with medical diagnosis, mobility or cognitive impairments, and being

overweight. Many medical conditions contribute to a person’s ability to control when they

void. Stroke, Multiple Sclerosis, and Parkinson’s disease affect neurological control of

muscles, including the muscles of the bladder. Impaired mobility restricts a person’s ability

to make it to the toilet in time to void. Cognitive impairment such as a diagnosis of

dementia can affect the ability to locate a bathroom upon recognizing the urge to void or

may impact whether the urge is recognized (Specht, 2011). Having excessive weight

increases the amount of pressure on the bladder and surrounding muscles which

eventually weakens them contributing to stress UI (Thom et al., 2010).

Environmental factors can also contribute to the development of UI. These are often

related to accessibility of the bathroom, commodes, or bedpans. This includes the distance

to the toilet, the lighting, the amount of clutter, and whether the resident is restrained.

Restraints restrict resident mobility and prevent them from being able to access the

bathroom or commode by themselves. Clutter and poor lighting present tripping hazards

making it difficult to reach the bathroom safely or at all. A resident may also not want to get


up to go to the bathroom for fear of falling especially if they have a history of falls. Poor

lighting can also prevent those who have poor eye sight from recognizing the toilet.

Location of bathrooms, commodes, and bedpans should be within a reasonable distance for

residents and be clearly marked (Specht, 2011). For example LTC facilities are often

designed so bathrooms are located in resident rooms which may not be an accessible

distance from common areas. Also two residents often share a bathroom, which as could be

occupied by the other resident when the urge to void is felt.

Nursing Interventions

BPGs are based mainly in relevant research and are informed by an inter-

professional team consisting of experts in the field. These guidelines also undergo scrutiny

using the AGREE II tool, which often ranks the RNAO BPGs near the top of their lists. The

way that the BPGs are developed makes them a valuable tool for guiding decisions and

informing the practice of registered nurses (RN), registered practical nurses (RPN), and

personal support workers (PSW).

The RNAO BPG Promoting continence using prompted voiding (2011a) suggests that

the best way to combat UI is to provide each resident with a personalized prompted

voiding schedule. Using a prompted voiding schedule has shown to decrease the number of

incontinent voids and increase the number of continent ones (RNAO, 2011a; Specht, 2011;

Vinsnes et al., 2012). To ensure the successfulness of a prompted voiding schedule several

other factors must first be addressed. These factors include history of UI, frequency of UI,

cognitive ability, diet and fluid intake, and other barriers to the resident.


A history of UI should be established on admission, addressing when it started, the

type, and the current method of coping (RNAO, 2011a). Other key factors of initial

assessment should also include the cognitive and functional ability of the resident (RNAO,

2011a; Specht 2011). Cognitive and functional ability are predictors of whether prompted

voiding will be successful as an intervention and may also help address the risk factors

related to mobility, medical diagnosis, and ability to recognize the urge and find a toilet that

are associated with UI (Specht, 2011). Other risk factors that can be addressed during the

assessment phase are the use of medications that may contribute to UI and the presence or

history of urinary tract infections. Medications can have direct effects (ex. diuretics) and

indirect effects through side effects of medications such as blurred vision, constipation,

weakness, and dizziness (RNAO, 2011a). The use of restraints as a barrier to the resident’s

ability to perform self-care can also be addressed in assessment by reviewing any orders

for their use. Awareness of the barriers faced by the resident can help the nurse plan

appropriate interventions or decide whether prompted voiding is the best intervention for

that resident.

Before initiating a prompted voiding schedule the nurse must first determine when

the best times to prompt the resident are (RNAO, 2011a). This can be done through the

collection of a 3 (or more) day voiding diary. This diary marks the time of day of the UI

event, the amount of urine released, whether the urge was felt, and potentially the type of

UI event. Having a reliable record of bladder function helps plan when best to prompt and

aid the resident in voiding (Naoemova, De Wachter, Wuyts, & Wyndaele, 2008; Specht,

2011).


Diet and fluid intake can also have a significant effect on UI. Providing a diet

designed to avoid constipation removes the potential for that as a contributing factor and

removes added pressure on the urinary tract (RNAO, 2011b). Providing a balanced diet can

also help address reducing excessive body weight which has been shown to reduce the

prevalence of UI in obese or overweight women by 47% (Subak et al., 2009). Providing

adequate fluids also reduces the risk for urinary tract infections and decreases the

concentration of urine to provide less bladder irritation (Specht, 2011). The BPG suggests

that caffeinated and carbonated beverages should be avoided but also stresses that how

residents respond to these beverages varies so eliminating these from the diet may have no

effect on some residents while having an effect on others (RNAO, 2011a). By

recommending an adjustment in diet and fluid intake the number of UI events can be

reduced or eliminated.

The successful implementation of BPG recommendations is influenced by the

multifactorial elements pertaining to the nurse and the organization. Some of these

elements are systematic, related to policies, or environmental. Concordance of facility

policy with the BPG provide the nurse with practice guidelines that are both the best-

evidence based practice and the expected practice by the facility eliminating any conflict

that might amount otherwise (RNAO, 2011a). Adequate staffing and supplies enable PSWs,

RNs, and RPNs to be better care-providers through increased time with residents and the

necessary equipment to provide the best care possible. Adequate staffing is not always the

case though and directly affects the ability to implement BPG regarding UI. For example,

one PSW may be assigned up to 25 residents to care for, some of which may require care at

the same moment forcing the PSW to decide which resident to help first, potentially


causing the other to have an incontinent event instead of a successful void. Lack of

equipment can also create similar conflicts, especially when it is shared between multiple

areas of a LTC facility. Due to lack of funding, increasing staffing or buying more equipment,

may not always an option and alternative solutions need to be found.

The physical environment can also contribute to the nurse’s ability to implement the

BPG. Accessibility and size of bathrooms are not just barriers to the resident but also for

the nurse. When a facility is designed, built, or renovated, the size needed to maneuver

resident, wheelchair/walker, and/or lift should be considered. This can limit the strain

placed on the nurse while trying to physically aid residents into bathrooms and make it

easier for the resident.

A nurse’s attitude can affect how successful the intervention is. If the nurse feels

passionately about reducing the incidence of UI, then their compliance in implementing

prompted voiding will increase (RNAO, 2011a). This is especially true if the nurse believes

that the recommendation will result in positive outcomes for the resident (RNAO, 2011a).

The knowledge base of the nurse is also a critical factor in ability to properly assess risk

factors for the resident as well as different mechanisms for managing these risk factors.

Education of nursing staff to the different medications that can affect UI directly and

indirectly will aid in identifying them during assessment. Familiarity with BPGs for the use

of restraints, prevention of constipation, and fall prevention will also help the nurse

manage UI as these are intricately linked. Finally, the nurse’s ability to identify signs of

fatigue or burnout can reduce the risk to themselves and to their residents (Di Constanzo,

2013). Nurse fatigue can reduce the effectiveness and quality of resident care. Recognizing


the factors contributing to fatigue helps nurses create healthy work environments for

themselves and others (RNAO, 2011c).

Realistic Outcomes

Any reduction in the number of incontinent events should be considered to be a

positive outcome and depending on the factors contributing to UI this may be the only

outcome (Specht, 2011). The idea behind any intervention should be to maintain the

independence, health, and dignity of the resident especially in a comfortable manner

(Specht, 2011). By using the strengths of the resident the nurse can foster continued

growth and development which is essential to resident wellbeing (McMahon & Fleury,

2012). Also by reducing the number of incontinent events, the nurse can provide the

resident with a higher quality of life and reduce the burden on caregivers (Specht, 2011).

This reduction in UI can also save healthcare providers money by reducing the amount of

incontinent products that need to be purchased (Yoon et al., 2012).

Conclusion

As a healthy, young individual you take for granted the things that you can do for

yourself, like getting up to go to the bathroom when you feel the need. BPGs help nurses

make decisions about experiences or disease processes that they may not fully understand

from a physical or psychological aspect. UI is prevalent in LTC, reducing the quality of life

for many older adults. Through implementation of a prompted voiding schedule UI can be

reduced or eliminated and help to restore wellbeing to the residents life. BPGs if

implemented appropriately have the potential to create better care-providers that provide

better care.


References

Aguilar-Navarro, S., Navarrete-Reyes, A. P., Grados-Chavarria, B. H., Garcia-Lara, J. M. A.,

Amieva, H., & Avila-Funes, J. (2012). The severity of urinary incontinence decreases

health-related quality of life among community-dwelling elderly. Journal of

Gerontology, 67,1266-1271. doi:10.1093/Gerona/gls152

Banfield, B. E. (2011). Nursing agency: The link between practical nursing science and

nursing practice. Nursing Science Quarterly, 24, 42-47

Di Constanzo, M. (2013, February). Manage fatigue, minimize risk. Registered Nurse Journal,

12-16

FITNEinc. (2011). The nurse theorists V2 –Afaf Meleis Promo. Available from

http://www.youtube.com/watch?v=xSn2qqmcwaA

Lawhorne, L. W., Ouslander, J. G., Parmelee, P. A., Resnick, B., & Calabrese, B. (2008).

Urinary incontinence: a neglected geriatric syndrome in nursing facilities. Journal of

the American Medical Directors Association, 7, 29-35.

doi:10.1016/j.jamda.2007.08.003

McMahon, S. & Fleury, J. (2012). Wellness in older adults: a concept analysis. Nursing

Forum, 47, 39-51. doi: 10.1111/j.1744-6198.2011.00254.x

Naoemova, I., De Wachter, S., Wuyts, F. L., & Wyndaele, J. J. (2008). Reliability of the 24-h

sensation- related bladder diary in women with urinary incontinence. International

Urogynecology Journal, 19, 955-959. doi: 10.1007/s00192-008-0565-3

http://www.youtube.com/watch?v=xSn2qqmcwaA


Ostaszkiewicz, J., O’Connell, B., & Dunning, T. (2012). Residents’ perspectives on urinary

incontinence: a review of literature. Scandinavian Journal of Caring Science, 26, 761-

772. doi:10.1111/j.1471-6712.2011.00959.x

Registered Nurses’ Association of Ontario. (2011a). Promoting continence using prompted

voiding. Toronto, Canada: Registered Nurses’ Association of Ontario.

Registered Nurses’ Association of Ontario. (2011b). Preventing constipation in the older

adult population. Toronto, Canada: Registered Nurses’ Association of Ontario.

Registered Nurses’ Association of Ontario. (2011c). Preventing and mitigating nurse fatigue

in health care. Toronto, Canada: Registered Nurses’ Association of Ontario

Specht, J. K. (2011). Promoting continence in individuals with dementia. Journal of

Gerontological Nursing, 37, 17-22. doi: 10.3928/00989134-20110106-10

Subak, L. L., Wing, R., West, D. S., Franklin, F., Vittinghoff, E., Creasman, J. M., . . . Grady, D.

(2009). Weight loss to treat urinary incontinence in overweight and obese women.

The New England Journal of Medicine,

Thom, D. H., Brown, J. S., Schembri, M., Ragins, A. I., Subak, L. L., & Van Den Eeden, S. K.

(2010). Incidence of and risk factors for change in urinary incontinence status in a

prospective cohort of middle-aged and older women: the reproductive risk of in Kaiser.

The Journal of Urology, 184, 1394-1401. doi: 10.1016/j.juro.2010.05.095

Touhy, T. A., Boscart, V., & McCleary, L. (2010). Hydration and Continence. In T. A. Touhy

& K. F. Jett (Eds.). Ebersole and Hess’ gerontological nursing & healthy aging (pp. 136-

154). Toronto, Canada: Elsevier Canada


Vinsnes, A. G., Helbostad, J., Nyrønning, S., Harkless, G. E., Granbo, R., & Seim, A. (2012).

Effect of physical training on urinary incontinence: a randomized parallel group trial

in nursing homes. Clinical Interventions in Aging, 7, 45-50. doi: 10.2147/CIA.S25326

Yoon, J. Y., Lee, J. Y., Bowers, B. J., & Zimmerman, D. R. (2012). The impact of organizational

factors on the urinary incontinence care quality in long-term care hospitals: a

longitudinal correlational study. International Journal of Nursing Studies, 49, 1544-

1551. doi: 10.1016/j.ijnurstu.2012.07.011

Documents

The role for nurses in promoting urinary continence …...The role for nurses in promoting urinary continence in long-term care Melissa Jenkins 0517969 Trent University PROMOTING URINARY