ARTICLES
|
Urology Nurses Online: ARTICLES |
Mary H. Palmer, PhD, RNC, FAAN;
B. J. Reid Czarapata, CRNP, CURN;
Thelma J. Wells, RN, PhD, FAAN,
FRCN;
Diane K. Newman, RNC, MSN, FAAN
Mary H. Palmer, PhD, RNC, FAAN is a Senior Staff Fellow at the National Institute of Nursing Research in Baltimore, Maryland.
B. J. Reid Czarapata, CRNP, CURNis President of the Urology Wellness Center in Rockville, Maryland.
Thelma J. Wells, RN, PhD, FAAN, FRCN is a Helen Denne Schulte Professor in the School of Nursing at the University of Wisconsin-Madison.
Diane K. Newman, RNC, MSN, FAANis an Adult Nurse Practitioner at Access to Continence Care and Treatment in Philadelphia, Pennsylvania.
This article is reprinted with permission of the Society of Urologic Nurses and Associates (SUNA) from Urologic Nursing, March 1997, 17(1) , p. 2-9. (published by Mosby Yearbook Incorporated).
There is a need for continued collaboration between clinicians and researchers to further improve urinary continence outcomes. This article presents the perspectives of four nurses who conduct continence research or who have independent continence services practices. Each discusses continence outcomes used in long-term care facilities or the community as a researcher or clinician and suggests implications for future nursing development. (Urol Nurs® 1997;17:2-9.)
The use of outcomes in research and clinical practice has become increasingly important for multiple reasons: (1) outcomes are important to measure effectiveness of a treatment, (2) outcomes research can help to identify groups for whom treatments would be effective, and (3) outcomes research can identify modifications to treatments for various subgroups in the population. Besides evaluation of clinical interventions, outcomes are used to assess changes in quality of life and are used in deliberations of cost reduction and cost-effectiveness in all health care settings. The organizational structure and level and number of staff ratios are evaluated in outcomes research especially in terms of their impact on treatment effectiveness.1
This article is based on a symposium presented at a conference of the Society of Urologic Nurses and Associates. It presents the perspectives of four nurses who conduct continence research or run independent continence services practice. Each will discuss continence outcomes used either in the long-term care or the community setting from one of two perspectives: researcher and clinician.
The Researcher's Perspective of Continence Outcomes in the Long-Term Care Setting - Mary H. Palmer
There has been a concerted research focus over the past decade on the epidemiology and treatment of incontinence in the long-term care setting. Standardized definitions for urinary incontinence and a typology of urinary incontinence have been developed to promote communication among researchers and clinicians and to assist in comparing research findings from different studies.2,3
Epidemiological research outcomes
Three major outcomes in epidemiologic incontinence research are used: prevalence, incidence, and remission. The prevalence of incontinence refers to the number of people with the condition at a given time. For example, it has been estimated that 40% to 60% of long-term care facility residents are incontinent of urine.4,5 Incidence refers to the number of new cases of incontinence during a specific period of time such as during a 1-year period. Remission refers to spontaneous recovery from the condition that is not associated with treatment and that occurs during a specific period. There have been few studies investigating incidence and remission of incontinence in the long-term care setting. In one study with older adults newly admitted to nursing homes, the overall 1-year incidence of incontinence was 27%, with men having a higher incidence than women (56% vs 22%). Remission of incontinence was also 27%, with women having higher remission rates than men (30% vs 11%).6 This study did not differentiate between transient incontinence (incontinence that occurs immediately after a fall or during an acute illness) and established incontinence (incontinence that persists over time), which could inflate incidence reportage.
Figure 1
Continence outcomes
| |||||||||||||
Epidemiologic outcomes are important to researchers and clinicians in long-term care. Prevalence rates can be used to plan resources, especially staffing. Incidence refers to risks. Therefore identifying at-risk individuals can help identify strategies to prevent incontinence from occurring, reducing both prevalence and incidence. Investigating remission can help researchers identify factors or interventions that can reverse or improve incontinence.
Research in Clinical Intervention Outcomes in Long-Term Care
Urinary incontinence is a prevalent condition that may adversely affect skin integrity, self-esteem, and quality of life in incontinent long-term care residents. Research regarding treatment of incontinence in the long-term care setting has focused mainly on behavioral interventions: habit training, prompted voiding, check and change, and bladder training.
Habit training consists of a fixed schedule for toileting based on an individual's voiding pattern. Typical schedules are toileting every 2 or 3 hours. The goal of habit training is to identify an individual's voiding pattern and to keep the individual dry with assistance. The person is not expected to return to a normal micturition pattern. The traditional expected outcome has been decreased incontinence.7 One investigation repeated successful habit training based on an individualized toileting schedule established on the individual's preintervention voiding pattern of toileting.8
Prompted voiding intervention involves several steps. Individuals placed on a prompted voiding schedule are checked on a consistent basis, asked whether they are wet or dry, and then prompted to use the toilet. A record is kept of the results of the check for wetness and the results of toileting. The goal of prompted voiding is to increase dryness and to increase patient-initiated requests to use the bathroom. Research has shown that prompted voiding is effective when it has been determined that the person is able to: (1) get drier, that is, the person is able to delay voiding, (2) cooperate with prompted voiding, (3) be mobile, and (4) differentiate wet and dry states.9,10
The success of the prompted voiding intervention depends on staff compliance with the intervention and periodic evaluation of the information about the incontinent individual's dryness level. Research outcomes include dryness level, staff compliance level, and number of wet episodes.8,11-14
Check and change involves physically checking the person and changing wet clothing or absorbent products on a consistent schedule. This intervention is used with individuals who are not able to get drier with other behavioral interventions and who have no discernible voiding pattern. The goals of this intervention are to prevent infection and skin breakdown, promote quality of life, and improve patient and staff satisfaction. Little research has been conducted comparing check and change with other interventions, but appropriate outcomes to be measured are level of bacteriuria, prevalence and incidence of skin breakdown, and patient and staff satisfaction.
Bladder training is appropriate with individuals who have the potential to regain a normal pattern of micturition. An appropriate candidate is a person who is motivated and able to cooperate with the intervention. The toileting schedule is gradually increased or decreased to make it as close to a normal pattern of micturition as possible. Outcomes reported in the literature include the time interval between voiding, bladder capacity, patient satisfaction, and dryness level.
Model of Continence Outcomes
The dichotomy, continent versus incontinent, needs to be further refined to be a useful outcome to nurse researchers and clinicians in the long-term care setting. Many times an intervention does not achieve a cure but is successful in improving continence. Figure 1 illustrates a proposed model of urinary outcomes for residents in the long-term care setting. Three of the four terms were coined by Fonda15; independent continence: the person is continent without assistance, dependent continence: the person is continent solely through the efforts of the caregiver, and social continence: the person does not respond to toileting and assistance with toileting and is therefore kept clean and dry by the caregiver with the use of aids such as devices, catheters, and appropriate absorbent products. In addition, skin integrity is maintained, and urine and odor are contained. The final term, partial continence, was developed to describe an appropriate outcome for an individual who is able to have continent voidings with help from the caregiver through prompted voiding or another intervention but who still has incontinent episodes.16 This model needs testing and further refinement but provides researchers an opportunity to identify outcomes appropriate for specific groups of older adults and research questions.
The Clinician's Perspective of Continence Outcomes Long-Term Care Setting - B. J. Reid Czarapata
Compliance with behavior modification treatments is important to positive outcomes of clinical interventions. Generally behavior modification therapies involve more cooperation and a life-long commitment to a treatment regimen than do traditional medical interventions (e.g., surgery or meditation). In the long-term care setting compliance is a complex issue. Not only is patient compliance to exercise regimens, diet, and the use of specialized equipment addressed, but the compliance of the staff must be addressed as well. The cooperation and support not only of the direct patient-care staff but also of the administrative staff are critical to successful treatment and must be considered in presenting research on behavioral modification techniques.
A compliance score for long-term care facilities was developed by the Wellness Center¹s staff after 3 years of experience implementing behavioral interventions in several long-term care facilities (Figure 2). The following are important factors to achieving positive outcomes. First, administration's willingness to sponsor and support the program is essential. As can be seen in Figure 2, a continuum of support may occur at varying levels from minimal support such as tolerance for the program to full support, which consists of mandatory counseling of employees who fail to adhere to the program. Second, the support of the nursing staff including nursing administration, continuing education personnel, and the aide staff is required.
Figure 2
Compliance score for long-term facilities
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The following section will describe an actual program implemented by the Wellness Center's staff in a local nursing home. Before implementation, two staff inservice classes about the program were offered. The lectures were videotaped to facilitate communication of the information to all staff including new staff members receiving orientation information to the facility.
Attendance at the inservice classes, especially by members of nursing administration and licensed personnel, and the repeated use of the videotape were considered significant in the ability of the facility to adhere to the program. Another important component was the staff's ability to follow the recommendations made by the Wellness Centers staff and the facility's staff recognition of the importance for continence therapy. The inservice program included basic anatomy of the urinary tract, the physiology of voiding, types of incontinence, a brief review of treatments, and the rationale of each treatment. This factor was measured by the number of referrals to the Wellness Center to provide incontinence evaluation after the facility¹s staff performed the federally mandated assessment with the Minimum Data Set.
Figure 3
Continuum of wetting
outcome measures
| ||||||||||||||||||||
Implementation of a Continence Program
In a long-term care facility, where all incontinent patients are currently being assessed and evaluated, the compliance score has demonstrated its usefulness. The assessments and treatment interventions have been ongoing for the past 10 months but with significant difficulty. The compliance score was 1.5 out of a maximum of 5. A 0.5 was applied to the score if staff performance met one or two items in the higher grade but was not strong enough for designation at the higher number. Therefore a grade of 1.5 indicated that the facility was interested in the program, held some inservice classes, and made some referrals but did not carry out recommended treatments, and administration remained uninvolved.
Staff compliance with treatment plans was poor, and the facility was at risk of being closed because it had received a very poor rating at the state inspection survey. Among many measures used to improve conditions, the administration decided to increase the use of the Wellness Centers services. As the compliance score went up to 3.5 to 4.0, the number of the Wellness Centers staff visits per patient to achieve improvement in dryness decreased, and the facility easily passed the next state inspection survey, indicating that the staff had implemented the recommendations made during consultations. Participation in the continence program revealed problems with patient assessment by the nursing staff, communication among staff members, and supervision. These problems were targeted by a quality improvement campaign, and improvements were seen not just in continence care but throughout the whole spectrum of nursing care.
Some preliminary results of the continence program include the following. Two residents who were in Geri-chairs were not toileted by the staff because of an erroneous belief that the residents could not bend enough to toilet. As a result of the intense continence assessment and treatment program, these residents were so successfully toileted they achieved dependent continence. Other study results revealed that of the 34 patients in the continence program, 24 achieved total dryness, 1 patient achieved 98% dryness, and 2 patients were dry after indwelling catheters were removed. Three patients were dry 60% to 85% of the time while two patients had problems such as urgency/frequency and constipation. (Two patients died during the course of the program.)
Other results were as encouraging. Many residents had transient or reversible forms of incontinence. During the period when the compliance score was low, many visits by the Wellness Center's staff solely involved supervising toileting and bowel training routines before initiating any actual therapy, which included biofeedback-assisted pelvic muscle exercise, prompted voiding, medications such as antifungals, antibiotics, and anticholinergics, timed voiding, and urge control measures.
Many patients who were evaluated, treated, and became continent (dependent continence) were initially thought by the facility's staff to be totally inappropriate for any continence intervention. The evaluation and treatment regimen with its clearance of bowel impaction and urinary tract infections, management of vaginal inflammatory processes, increase in oral fluids, and increase in personal interaction with staff resulted in patients' increased awareness of self and surroundings. Consequently this increased function led to improvement in bowel and bladder continence. Evaluation by objective personnel who are not in contact with the patient on a daily basis using preset outcomes to measure level of compliance may be beneficial when initiating a continence program.
Research Perspective of Continence Outcomes in the Community Setting - Thelma Wells
Based on research experience in intervention studies for urinary incontinence in community-dwelling women, several key principles have evolved. These principles have relevance both for similar research in other populations and for clinical practice in general. The first principles are directed toward the intervention or treatment: be clear about treatment and make no assumptions.
Being clear about treatment means defining exactly what the treatment is and what its underlying rationale is. This is especially important for behavioral treatment in urinary incontinence. Currently there is no agreed upon terminology to name such treatment and no agreed upon criteria or standards within types of treatments. Thus any given treatment may vary greatly in terms of behavioral directions and goals. These differences may or may not matter, but until variance is studied under research protocol, it is best clinically to follow treatment as published within one standard frame.
The related principle of treatment is to not assume: (1) that patients understand directions in the same way, (2) that patients do the treatment to the dose required, or (3) that the treatment's direct target behavior or physiology is affected. The researcher must monitor and measure these factors. This includes testing a patient's understanding of instructions through both verbal and written response to questions, after teaching and skill demonstration, if relevant. It is essential to determine the treatment's specific target in the mechanism of urine control. Is it bladder capacity or pelvic muscle strength or voiding delay time? The target point must be measured. If the treatment has not taken, either in terms of patient adherence or a physiological response, then wetting outcome measurement is irrelevant.
Once the treatment target has been evaluated, one can proceed to the complexity of wetting outcome measurement. Figure 3 displays a continuum of measures from opinion to urodynamic tests. Invasiveness and cost increase along the continuum, which also represents increasing objectivity. At the simple end one could argue that only opinion or diary matters, because that is what drives help-seeking behavior, and no other measure is needed. From a clinical frame this is a very reasonable argument. But if research is to advance science, if theory is to be tested, if clear understanding is to occur, then inclusion of at least one objective such as pad or urodynamic test in wetting outcome measurement is essential. Within the categories of measurement there is no one agreed upon instrument but rather a range of options and variance. It is critical to explore options and carefully determine the best wetting outcome measures for a particular research design.
Subject opinion of wetting outcome is a subjective response that can be measured by a direct question with forced choice answers, a statement with Likert response categories, an open-ended question, an analog scale, or as response to a wetting symptom scale such as the Urogenital Distress Inventory.17,18 Vocabulary must be selected with care both in terms of patient reading/comprehension level and the theory underlying treatment analysis. Given the lack of research on subjective response methods in patient opinion of wetting, subject comfort and familiarity with a method and ease of analysis are useful considerations.
Subject diaries may be as simple as a record of wetting only to more comprehensive tools that gather voiding volume, fluid intake volume, bowel behavior, and other details thought to be relevant in urine control. Duration of diary recording is an issue; 2 days is a minimum time frame to elicit useful data, whereas a week or more provides a more meaningful frame. However, subjects generally are not fond of diary recording, and adherence to diary protocols is usually a problem.
Pad tests use preweighed pads, a fluid intake protocol or catheterized protocol fill, and either standardized provocation challenges (office/laboratory procedures) or the subject's usual routine (home procedures). Duration of pad tests vary from brief office testing to 24-hour pad collection for several days. Urodynamic measures vary by type of equipment, protocols used, and challenge point measures. The commonality is observed wetting during a defined point of bladder function testing.
The consequence of wetting affects those with urinary incontinence in a variety of psychosocial ways that are commonly described as quality of life. Two condition-specific measures are available to measure treatment outcome in this domain. The Incontinence Impact Questionnaire is a 30-item measure with four subscales: physical ability such as recreational household chores, social relationships such as having friends to visit and ways of dressing, travel such as being able to travel distances more than 30 minutes away, and emotional health such as fear and embarrassment. Internal consistency reliabilities are reported as ranging from .87 to .90 for the subscales.17 Recently a derived seven-item short form has been reported.18 The Coping with Incontinence Scale is a 39-item tool in 10 subscales such as strengthening muscles, seeking health care strategies, and managing in social situations.19 High internal consistency, stability, and construct validity have been reported for community living elderly incontinent individuals. In addition, one might consider generic measures related to quality of life such as The Beck Depression Inventory20 and the Sickness Impact Profile.21
Outcome measurement always involves risk. In a practical frame this is burden, misuse, and nonuse. Burden is a time issue for both the subject and the researcher. Time translates to money for a basic cost consideration. But another aspect of burden is the feelings that measurements may arouse in subjects and the physical discomfort that some physiological measures create. Misuse may be using a measure incorrectly, misinterpreting the findings of a correctly used tool, or having correctly obtained and interpreted data distorted or manipulated by others. The latter misuse suggests the need to recognize the political context of research. Nonuse is the age-old problem of data greed, that is, collecting more data than are needed or feasible to analyze.
Conceptual risks of outcome measurement tend to fall into one of two errors. Error one, missing the forest for the trees, is the data omission worry that one looks so much that patterns are missed and one cannot see what is obvious. Error two, barking up the wrong tree, is a fixation of loyalty to one measure such that one fails to see tool weaknesses or seek better tools.
The beneficial side of thoughtful outcome measurement from a practical framework includes reimbursement, regulation, and communication. It seems likely that reimbursement will be connected to treatments or services known to work through outcome measurement. The increasing pattern of regulation is to require outcome measurement. A common language about outcomes will facilitate communication between clients and providers and between providers and researchers. Conceptual benefits work to stimulate the development of science in the treatment of urinary incontinence. Measurement is central to basic theoretic conceptualization. Theory challenges measurement, and measurement tests theory. Although there will always be an art to treatment, without rigorous outcome measures there will never be science.
Clinical Perspective of Continence Outcomes in the Community Setting - Diane K. Newman
By the year 2030 nearly one in five Americans will be older than 65 years of age. The most significant rise in our aging population is in those older than 85 years of age, often called the "old-old." This group tends to be frail, dependent, and increasingly in need of services to continue living in their homes. Many are homebound and either cannot leave their homes or do so with considerable difficulty as a result of a temporary or chronic disability.22 Increasingly, these individuals have multiple and complex medical problems. Preliminary data from a survey of 7400 home health agencies indicated that genitourinary conditions were among the 20 leading diagnoses for patients admitted to their caseloads.22 The genitourinary diagnosis most often found is urinary incontinence. An earlier study ascertained that urinary incontinence was one of the 10 leading diagnoses for homebound individuals and was first in total charges to Medicare per person served.23 A recent study of 1778 low-income elderly people found a 23% prevalence of urinary incontinence.24 Although this problem is common in the homebound person, research determining patient outcomes is lacking.
Studies of urinary incontinence in community populations have focused on the burden experienced by unpaid caregivers such as family members caring for dependent elderly persons with urinary incontinence and the effect of urinary incontinence on the health and psychosocial adjustment of incontinent individuals. In a study of family caregivers who cared for persons with urinary incontinence, Noelker25 reported that 53% of care recipients were found to be incontinent. This had significantly more negative effects on family relationships than for caregivers of family members who were continent. In another study of caregivers of community-dwelling, chronically ill older persons, 75% of those who cared for incontinent family members found that maintaining continence was burdensome.26 In a study of caregivers of community-dwelling patients with dementia and urinary incontinence,Ouslander et al.27 found that incontinence was an important factor in many decisions to institutionalize elderly care receivers. Most of the caregivers indicated that they would be interested in education regarding the care of persons with urinary incontinence if the sessions were provided in the home. In all the studies functional disability (i.e., physical, cognitive, or both) was associated with urinary incontinence.
The negative psychologic, physical, social, and financial impact of urinary incontinence on homebound individuals and their caregivers points to the need for a systematic, consistent approach to this problem. Even when urinary incontinence is obvious, no standardized mechanism is available for home care nurses to use to evaluate the cause or severity of urinary incontinence or to suggest actions that should be taken for further evaluation and treatment.
Although urinary incontinence is prevalent in the elderly population, very few studies have focused on the outcome of specific nursing interventions. In the area of assessment and behavioral management of urinary incontinence among homebound individuals, research has been performed.28-30 Rose et al.28 reported the successful use of pelvic muscle rehabilitation augmented with bladder training and biofeedback therapy for cognitively intact patients in home care. Twenty-one elderly homebound patients were visited in their home by nurse practitioners and treated with a combination of behavioral therapies. Subjects reported a 78% improvement in weekly incontinent episodes from baseline. McDowell et al.29 reported two case studies of severely disabled but cognitively intact homebound individuals who were successfully treated with biofeedback-assisted pelvic muscle exercises. Flynn et al.30 reported on a program implemented in a home health agency that involved the use of pelvic muscle exercises for the treatment of urge incontinence. Thirty-seven clients met the inclusion criteria. The number of urinary incontinent episodes per week was reduced by a mean of 82%. The authors concluded that using pelvic muscle exercises resulted in both a clinically and statistically significant decrease in urinary incontinence among the elderly patients. Currently several studies are being performed with a variety of treatment modalities for both cognitively impaired and cognitively intact homebound persons living in both urban and rural areas. The magnitude of the problem of caring for incontinent homebound individuals will no doubt increase as the number of aged persons increases and maintaining dependent elderly patients at home becomes more common.
Treatment of persons with long-term "intractable" urinary incontinence has not been studied. These individuals tend to be frail elderly patients who have cognitive or physical impairments and who cannot respond to behavioral programs such as toileting schedules and pelvic muscle exercises.31 Information regarding the most effective and efficient method to optimize continence in this population is lacking. Maintaining social continence through the use of internal and external catheters, absorbent products, and collection devices is an integral part of primary nursing care of urinary incontinence, and these measures are frequently used in the homebound. Many times these measures are used for containment or management as opposed to cure. However, there is a lack of knowledge concerning the application, complications, and patient outcomes with these interventions. These patients' problems are complex and require a greater use of nurses and paraprofessional personnel to assist both caregivers and clients in managing their problem.
Since 1986 an advanced practice nursing group now called Access to Continence Care and Treatment (ACCT) has provided "continence expertise" through an independent practice model. This novel practice treats an inner-city (Philadelphia, Pennsylvania) population that is largely indigent, minority-based, and culturally diverse. ACCT's staff primarily serves as consultants to home health agencies and a state-funded long-term care program for homebound frail elderly patients, that is administered by the Philadelphia Corporation on Aging. ACCT also provides incontinence services in an office setting and long-term care facilities. ACCT's staff of nurse practitioners and clinical nurse specialists interface with home care nurses and paraprofessionals, social workers, physicians, and case managers in identifying appropriate management of urinary incontinence and related problems. In addition to patient assessment, treatment modalities have included "Dependent" and "Social" continence interventions. ACCT has been able to implement effective therapies in a portion of this population based on outcomes from clinical research on toileting programs and biofeedback-assisted pelvic muscle exercises.
However, most of this "old-old" population has "social continence" managed or "contained" through the use of catheters, toileting devices, and absorbent products. Clinical research and patient outcomes are not available to assist this practice in providing quality nursing care at reasonable costs. Current quality-of-life and objective assessment tools (e.g., bladder records) cannot be effectively measured and completed by this poorly educated and indigent urban population. Research involving patient outcomes will become increasingly important as health care resources decrease and chronic "intractable" urinary incontinence increases.
The nature of urinary incontinence and its complexity will increase the need, use, and cost of nursing care in frail homebound patients. The nursing professional must focus research efforts on assessing the outcomes of basic nursing interventions in this subgroup of the elderly population.
Summary
Continence outcomes have been discussed by clinicians and researchers who work in the long-term care and community settings. Tremendous strides have been made in identifying, developing, and refining appropriate outcomes for incontinent older adults. There is, however, a need for continued collaboration between clinicians and researchers to further improve outcomes that accurately reflect interventions in terms of costs, quality, and effectiveness.
References