Hypothesis / aims of study
Incontinence is one of the main reasons for institutionalisation in residential care homes, with ~75% of residents affected by urinary incontinence and up to 50% experiencing faecal incontinence.
Incontinence can have detrimental effects on individual physical and psychological health, and economic, social and functional wellbeing. It is linked with increased falls, skin breakdown, depression, social isolation and impaired quality of life (1).
Best practice guidelines recommend that urine and bowel control issues be properly assessed, managed and reviewed at regular intervals or if a change occurs. Discussions should be held with the resident and family to determine goals or preferences for continence care, and conservative management strategies should be employed first including lifestyle modification, toileting plan development and using continence aids as required. However, even in adequately staffed care homes, residents are often toileted twice daily; less than what is ideal (2).
Our aim was to explore staff and resident experience with assessment and management of incontinence in a residential care home in south-east Queensland. We drew on four quality indicators for toileting and containment strategies proposed in the KPMG Global Strategy Group report published 2018 (3) and address four research questions:
1. How well are staff completing assessments, care plans and reviews for residents with a diagnosis of urinary or faecal incontinence?
2. What toileting and containment strategies are used, and do they align with best practice guidelines?
3. How do residents and staff experience continence assessment and management strategies?
4. How does resident experience with continence assessment and management impact on their emotional well-being?
Study design, materials and methods
A concurrent mixed methods study was conducted in a 120-bed residential care home; involving an audit of all clinical records, and semi-structured interviews with five residents with incontinence and four front-line staff.
The desk-top audit was designed to provide a snapshot of how continence was assessed, managed and responded to. It was conducted by a continence specialist and involved analysis of secondary data from information management systems.
Semi-structured interviews were conducted by a researcher with staff and residents to explore their experience, and to understand the impact of continence assessment and management practices on resident emotional wellbeing. The 30-40-minute interviews were conducted privately; and were recorded and transcribed verbatim. Thematic analysis elicited emergent themes to derive meaning.
Results
Of 120 residents, 99 experienced some form of incontinence requiring aids. The average age of residents experiencing incontinence was 87.4 years and 61 were women. The study population characteristics were broadly representative of Australian aged care home residents. Findings from the quantitative desk-top analysis and semi-structured interviews were highly congruent.
The desk-top analysis showed 98% of residents had completed continence assessments and 95% had completed toileting assessments. Just 35% had their care plans reviewed according to best-practice. This was consistent with the qualitative data which indicated completion of continence and toileting assessments, however changes to continence care plans relied mostly on recommendations from personal care workers rather than formal reviews by nurses. Interview data identified that residents were generally unaware that their continence and toileting needs were assessed; they did not have discussions with staff about their continence needs; and were generally not involved in making decisions about management strategies.
Desk-top analysis revealed a lack of documented conservative management strategies such as high-fibre diet to address constipation, exercise plans specific for continence or toileting plans. In addition, all residents diagnosed with incontinence were using either pads or pull-ups, with some excessive pad usage. This was consistent with the qualitative data which also identified containment products were the primary management strategy, and that thicker pads were preferred to prevent leakage and delay the need to clean and change residents. Further, response to calls for toileting assistance were not met in a timely manner. Staff described excessive demands on limited staff numbers to meet the increasing level of high care needs of residents.
While most residents stated that incontinence had minimal impact on participation in daily activities, they reported feelings of embarrassment, felt reluctant to talk about incontinence, and felt humiliated when staff were unable to attend to their needs in a timely manner. Interestingly, those who had a medical cause for their incontinence appeared more comfortable talking about it compared to those with no identified cause. Staff were sensitive to the emotional wellbeing of residents; were discrete in providing care, and often diverted attention of residents through light conversation. However, staff also expressed frustration and feelings of guilt about inability to respond to calls in time. All participants highlighted the importance of strong relationships between residents, family members and staff to manage incontinence.
Interpretation of results
Findings indicate a lack of communication with residents about continence needs and that residents or family members are not routinely involved in decision-making about management strategies. Residents often have low expectations about treatability of their incontinence, or the quality of continence care they receive, which is likely reinforced by lack of knowledge of continence assessment and care by staff. This is a two-fold issue for residents: (i) the possible belief that incontinence is an inevitable part of ageing, and (ii) that residents in general have basic or poor knowledge about continence. Debunking this myth with residents, families and staff and ensuring that residents and family are provided with information and resources about incontinence is an essential priority.
Another key finding was heavy reliance on product usage for management with lack of other conservative strategies. As part of a continence assessment and an agreed care plan, conservative strategies to manage incontinence should be trialed initially. These include dietry modifications, toileting after meals, assistance to toilet in a timely manner, the correct toileting position, and responding promptly to changes in individual continence patterns. If a continence aid is ill-fitting, inefficiently absorbing urine, or not changed when appropriate, there is potential impact to skin integrity.
Finally, all staff have a critical role in minimising negative impacts on emotional wellbeing. Investigating contributing factors as part of a continence assessment and eliminating these factors where possible, helps to prevent over-treatment, especially with antibiotics. Educating residents and care staff about appropriate personal hygiene, escalating suspicions of urinary retention, eliminating constipation and encouraging fluid intake by residents are some strategies that should be employed. In addition, nursing staff need to be educated and supported with resources to utilise the information gathered from a continence assessment to manage continence better and look for ways to improve symptoms, to enable quality continence care.