Community nurses and home care staff play a pivotal role in identifying and supporting individuals who experience urinary incontinence. However, the ability to identify and support such persons depends on the knowledge, beliefs, practices, and attitudes of care staff. Gaps in home care staffs’ continence-related education and knowledge may contribute to sub-optimal assessment and management of UI.  Additionally, negative or outdated attitudes may affect their engagement in continence care. There is limited research exploring community nurse and home care staff knowledge, attitudes, and education needs regarding UI and continence care. A recent systematic review identified only four studies for inclusion, highlighting this continuing gap [1].  In preparation for a formal program of continence training, this study aimed to assess the knowledge, attitudes, and practices of assessment and management of urinary incontinence of home care staff in a rural region with limited healthcare services.

This study employed a descriptive cross-sectional web-based survey design to assess the knowledge, attitudes, beliefs and practices of home care nursing staff in a rural region in Western Canada. A web-based questionnaire was administered to home care staff in four rural towns using REDCap electronic data capture tools. The questionnaire was co-created with relevant home care administrators and providers. The survey was then distributed to home care staff via the Home Care Administration email system. Once participants clicked on the link, they were taken to an introductory page, where information about the study and their rights as participants was provided. The survey was opened from 27th June 2022 to September 30th, 2022. There was no direct contact between potential participants and researchers.  Participation was voluntary and consent to take part in the study was implied by the completion and submission of the completed survey.

A total of 42 out of a potential 115 (36.5%) home care staff participated in this study. All participants (n=42) were female (100%), the majority was college educated (57%, n=24) and health care aides (47.6%, n=20).  35.7% (n=15) and 40.5% (n=17) of participants respectively reported receiving education/ training on the management and assessment of UI while 64.3% (n=27) and 59.5% (n=25) respectively reported never receiving any education/training on UI assessment or management (Table 1). Of participants who reported receiving education/training, 33.3% (n=5) and 23.5% (n=4) of participants respectively received their education/training on the management and assessment of UI within the last 12 months. 40% (n=6) and 41.1% (n=7) of participants respectively indicated receiving education/training more than a year ago, but within the last 5 years, while 20% (n=3) and 29.4% (n=5) reported receiving education more than 5 years ago but within the last decade. While 57.2% (n=24) of participants reported confidence in managing UI, only 35.7% (n=15) reported confidence in assessing UI.
As illustrated in table 1.0 below, 28.6% (n=12) of participants believed that UI was a normal part of ageing. However, only 2.4% (n=1) of participants agreed that UI only affects older adults, the majority of participants (88.1%, n=37)) disagreed or strongly disagreed with this belief. Participants surveyed generally had a positive attitude towards UI and care provision for clients with UI. For example, approximately 85.7% (n=36) of participants surveyed viewed continence care as their responsibility as home care staff and 78.5% were confident that urinary incontinence could be managed (Table 2.0). Moreover, 90.5% (n=38) of surveyed participants never felt embarrassed about their client’s continence needs and 78.5.% (n=33) of participants felt comfortable supporting clients with UI. 69% (n=29) and 45.2% (n=19) of surveyed participants respectively stated that UI management and assessment was a priority in their work as home care staff. More than half (54.7%, n=23)) of participants surveyed routinely asked about UI when meeting new clients.
In free text comments, participants defined UI as the loss of bladder control, inability to hold urine, leakage of urine or the unintentional passing of urine. Participants mentioned embarrassment and social isolation due to stigma, loss of dignity, decreased independence due to reliance on others, decreased level of participation in physical activities and risks of infections were some of the adverse effects of UI on their client’s quality of life. Home care nurses mentioned provision of information leaflets on UI, referral to physicians and physiotherapist, recommendation of and education on containment products, bladder training as well as the development and adherence to continence care plans as some of treatment, management and support services for clients with UI.

While home care staff generally had fair knowledge and understanding of UI, its causes and risk factors, more than half of the staff surveyed never received any formal or informal education/training on the assessment or management of UI. Despite the reported lack of formal education/training, most home care nurses generally understood the term UI, its risk factors and employed a variety of treatments, management and practices in supporting clients with UI.
 While approximately half of participants reported being confident in managing the UI of their clients, only a third expressed confidence in UI assessment.  This could be attributed to limited education, training or hands on experience on the part of participants. Since home care staff play critical roles in UI assessment and management of older adults, education and training on UI assessment and management may constitute the foundation for the provision of effective and efficient UI care in rural areas. 
A notable finding from our survey was that not only did most home care nurses not feel embarrassed about their client’s continence needs, these nurses routinely asked clients about UI, had positive attitudes towards UI and were comfortable supporting clients with UI. Additionally, despite previous studies reporting nurses believing that UI in older adults was inevitable, only a quarter of home care staff in this study held this belief [2,3]. Few participants held the belief that UI in older adults was irreversible or incurable and despite their limited reported education/training, employed a variety of treatments, management and supports to clients with UI.

While more than half of home care staff in this study reported low levels of education and training in urinary incontinence, and 28.6% (n=12) felt that incontinence was normal in older adults, home care staff held positive attitudes towards UI, UI care and employed a variety of treatments, management and supports for clients living with UI. Both formal and informal training should be developed and provided to home care nurses who are frontline service providers to community dwelling older adults living with UI.

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