Investigating the standard of continence care in nursing homes

Author

Susi Saxer, PhD, MNS, RN, is postdoctoral research fellow, Institute of Applied Nursing Science of the University of Applied Science (IPW-FHS), St Gallen, Switzerland.

Involuntary loss of urine is a problem, especially in ageing adults (Ostaszkiewicz et al, 2004; Wyman et al, 2004). Urinary incontinence substantially increases the risk of being admitted to hospital or a nursing home (Thom at al, 1997).

Swiss nursing homes assist residents to take part in everyday activities, with medical and nursing services when required. There are communal, municipal, cantonal and private nursing homes, with from 15-20 to 300 residents. The nursing department consists of the head of the department, head of each ward and nurses, student nurses, nurse assistants and volunteers.

Prevalence, incidence and risk factors

The first study evaluated the prevalence, incidence and risk factors for urinary incontinence among nursing home residents aged 65 and older.

Method

A secondary analysis was performed using data from the Minimum Data Set 2.0 Resident Assessment Instrument, which is used for routine patient assessment. This has 16 areas, including those often associated with nursing home residents - for example, cognitive abilities and activities of daily living. The following items from the Minimum Data Set were included in this research:

• Urinary incontinence - this is defined as at least two episodes of involuntary loss of urine within one week. (Residents with a catheter are considered to be continent, but few residents in Swiss nursing homes have a catheter and residents who are incontinent wear pads.);
• Cognitive abilities;
• Mobility;
• Demographic data - gender, age and time of admission.

The sample for prevalence at a specific point in time consisted of 2,610 residents, and for prevalence at admission 2,719 residents were included.

Results

Of the residents studied, 51.5% were incontinent. Men and women were equally affected.

With increasing age, more residents were incontinent. The longer the residents had lived in the nursing home, the more likely they were to be urinary incontinent (Table 1) (Saxer et al, 2008a). When people were admitted, 37% were urinary incontinent. Women were less likely to be urinary incontinent than men (women 34%, men 43%).

At admission and over time, residents who were not able to move in bed were most at risk of developing incontinence. The risk of incontinence at admission was two times higher for residents with ‘difficulties moving in bed’ than for those without. Six months after admission, the risk was 5.9 times higher and 12 months after admission 7.7 times higher (Saxer et al, 2005).

The second most important risk factor was ‘deficits in long-term memory’. At the time of admission, the risk of developing incontinence was 1.4 times higher and six months after admission 5.3 times higher for residents with these difficulties than for people without (Saxer et al, 2005).

Discussion and conclusion

At admission, the prevalence of incontinence was 37%, which is much lower than the prevalence at other times. This may be because residents were in better health at admission.

Women have less urinary incontinence than men at admission. Men may be looked after for longer at home than women (Saxer et al, 2008a).

The lower prevalence of urinary incontinence at admission is an important finding. A specific urinary incontinence assessment at admission is important in the prevention of new incontinence (Saxer et al, 2008a). An examination of risk factors suggests that mental and mobility training could reduce urinary incontinence (Saxer et al, 2005).

Nurses’ and nurse assistants’ knowledge and practice

More than 50% of care home residents have urinary incontinence (Saxer et al, 2008a; Adelmann, 2004; Aggazzotti et al, 2000).

There are effective interventions for urinary incontinence in older people (Fantl et al, 1996). For example, prompted voiding is an important method, especially for older people without or with minor cognitive impairment (Schnelle et al, 2002; Ouslander et al, 2001; Fantl et al, 1996).

A barrier to the implementation of treatments is nurses’ lack of knowledge of assessment and treatment incontinence (Watson et al, 2003; Lekan-Rutledge et al, 1998). Therefore, it is important to assess nurses’ knowledge and practice so that they can receive training and education.

This study aimed to explore nurses’ and nurse assistants’ knowledge and practice about urinary incontinence.

Method

A cross-sectional written questionnaire was used to measure the knowledge and practice of nurses and nurse assistants from different nursing homes. This was developed for this study and validated (Saxer et al, 2008b).
The sample consisted of 199 nurses and 116 nurse assistants in municipal nursing homes in Zurich. The education of nurses lasts three years and the education of nurse assistants one year. Nurses are responsible for providing and planning care. Nurse assistants do more routine care.

Results

Nurses answered 67% of all questions correctly and nurse assistants 56%. More than 90% of the nurses and nurse assistants answered the following two items correctly:

• Urinary incontinence can occur more often in sneezing, coughing and walking;
• Toilet training can improve incontinence in older people requiring care.

More than 80% of nurse assistants did not know the right answer to the item:

• Stress incontinence is caused by psychological problems.

The biggest differences were found in questions about medications and urinary incontinence. Two-thirds of the nurses knew the correct answers, but only one-third of the nurse assistants did (Saxer et al, 2008b). The actions of nurses and nurse assistants were divided into four categories:

• Drinking habits and excretion;
• Assessment and information;
• Documentation;
• Support.

Nurses and nurse assistants perform continence-related actions only ‘sometimes’ or ‘often’ at best. Both groups had the best results in the ‘Support’ category, for example helping a patient to the toilet, and the most deficits in the ‘Documentation’ category. In this category, for example, 40% of the nurses and nurse assistants reported ‘never’ in response to the following item:

• I note in the documentation how much urine the resident loses in an incontinence episode.

The largest difference between nurses and nurse assistants was in the category ‘Assessment and information’ (Saxer et al, 2008b).

Discussion and conclusion

The results show that nurses and nurse assistants have an average knowledge about incontinence.
Nurses, who have the responsibility for the residents and care planning, should have a larger knowledge base. Nurses and nurse assistants do not perform the same tasks and did not have the same deficits, so both groups need support.

It is not surprising that actions for the ‘Assessment and information’ category were carried out by nurses rather than by nurse assistants, because these tasks are more in line with their responsibility.

Actions in the ‘Documentation’ category were often not carried out. The low score of the nurses is remarkable because the responsibility for documentation lies mainly with them. Nurse assistants also have tasks related to documentation, such as filling out a bladder and drink diary. Therefore, both groups need support.

With this support, fewer residents will become urinary incontinent and the care of residents with urinary incontinence will improve.

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