Urinary incontinence (UI) is highly prevalent amongst older residents of nursing homes (NH) with estimates varying between 43 - 79% [1].  Given the high prevalence of moderate to severe cognitive impairment and associated physical disabilities in the NH residents of today, only a minority can successfully be managed with interventions such as prompted voiding.  The majority of residents are managed by check and change routines but evidence suggests that, even given these limitations, UI is poorly managed in this setting [2].  In the majority of NH, continence assessment is a labour intensive process which requires residents voiding and continence patterns to be assessed over a period of time by a method of “ask, check and change.” The requirements of this process often lead to sub-optimal performance and the resulting care plans and delivery of care are compromised.  
This study examined NH care aides views on the utility, experience and impact of a system for electronically aided construction of continence care plans.

This study was the qualitative arm of a prospective, quasi-experimental, controlled clinical trial of the use of an electronic incontinence identification system (Tena Identifi), versus usual care on the quality, resource use and outcomes of continence care for older residents of NH. Tena Identifi is an integrated electronic monitoring system based upon a wearable continence pad which allows registration of resident’s micturition patterns over a 72 hour period, allowing an individualised continence care plan to be constructed. The intervention included training for staff and support for data analysis. The study enrolled care aides (unregulated staff providing >75% of direct resident care) and care unit managers involved in the use of the Identifi system. Participants gave written informed consent for one to one semi structured interviews with a single trained research assistant which covered their initial impressions, perceptions of utility, experience, impact on care staff, residents and others and benefits and limitations of the Identifi system.  Interviews were recorded verbatim and transcribed and de-identified before being analysed using content analysis by a team of one researcher experienced in qualitative analysis and 3 trained research coordinator/assistants. Codes were developed, collapsed into categories from which themes were created.

Twelve care aides (2 male, 10 female) and 2 care managers (both female) were interviewed. Two of the care aides worked on the night shift while all others worked the day shifts (morning or evening or both). Interviews lasted between 11.1 and 56.3 minutes (mean 26 minutes). After the data analysis was complete, 71 codes were identified and collapsed into 14 categories. Three themes were developed: 1) “The learning curve”, 2) ”Better for the resident“ and 3) “How it helps, how it doesn’t”. Categories underlying themes are shown in the table. 

Theme 1: Participants described being intrigued upon first learning about the system, electronically tracking residents voiding patterns was particularly novel and appealing to participants who admitted that it was both challenging and impractical to frequently check on and ask residents whether they needed to void. Participants were also apprehensive about its implementation, with some concerned that the system was designed to monitor their performance on the job while others felt it was a ‘bit too much’ to electronically track residents voiding patterns. Early beliefs that the system would add extra workload to their current duties were also expressed. Despite these reservations, participants were willing to give the system a chance to prove its value. Visual representation of residents voiding patterns presented in the system report was essential in allowing them to understand the continence needs of residents at different periods of the day.
Theme 2: Prior to introduction of the Identifi system, staff reported employing various methods to understand resident’s continence needs. These included: constant visual monitoring of resident’s reactions and behaviours, asking residents whether they needed to be toileted or had voided and needed care, smell checks and manual pad. Staff observed that these methods were sometimes ineffective and resulted in residents being left wet for a long time. Participants mentioned that sometimes they either just increased the pad absorbency or put the residents in night pads because they held more and reduced the need for care. Participants were pleased with the Identifi system’s ability to present them with visual data that allowed them to personalize resident care and not just routinely group residents into a single care approach.  Identifi provided a standardized assessment for care which was less intrusive than the methods previously employed. The system also proved useful in explaining care to other staff members unfamiliar with the resident and in explaining care to families, where care related concerns were expressed. Apart from providing appropriate pads, participants could be pre-emptive with residents with continence related responsive behaviours. Participants reduced time spent on continence care allowed them to spend more time on other areas of care.
Theme 3: The Identifi system was deemed most suitable for residents who were not independent or sufficiently cognitively intact to self-toilet or use call bells, were bedridden or considered as “heavy wetters”, but lacked utility for those with associated fecal incontinence. Difficulty placing or removing the logger and losing the logger were some of the challenges observed by participants. They specifically cited the thought of losing the logger as being a source of distress for them during the study.  Participants suggested improvements to the system such as offering a wireless system

User views of a novel system for the construction of continence care plans were overwhelmingly positive, despite initial misgivings. Users described the additional benefits of the introduction of a standardized assessment system, including those to the resident, other formal caregivers and to resident’s families. Users described drawbacks and possible changes to the system

A standardized system of continence assessment for nursing home residents provides benefit in terms of quality of care for residents and is likely to improve the quality of work life for those caring for them.

Neurourol Urodyn. 2009;28(4):288-294.
Journal of Advanced Nursing. Feb 2011;67(2):228-250.