Management of night-time urinary incontinence in residential settings for older people: an investigation into the effects of different pad changing regimes on skin health

Absorbent pads are the main method of managing urinary incontinence in residential settings for older people. Improvements in technology have resulted in highly absorbent products which may be worn all night, but the effects of prolonged pad wearing on aged skin are unknown. The aim of this study was to examine the effects of two different pad changing regimes on skin health. A cross-over design was used. Subjects from residential settings were randomly allocated to one of two pad changing regimes: a frequent pad changing regime or a less frequent pad changing regime. Each regime lasted 4 weeks and was followed by the alternative regime. Skin measurements were taken twice during each regime using (i) the Diastron Erythema meter, (ii) a visual grading scale, (iii) the Servomed evaporimeter, and (iv) a pH meter. The primary outcome variable was the Diastron Erythema meter index. Eighty-one subjects completed the study. No significant differences were found in the severity of erythema, or skin pH, between regimes. Measurements of trans-epidermal water loss were significantly higher in the less frequent pad changing regime indicating that skin was 'wetter' (P = 0.01; 95% CI: 2.89-21.39). Five subjects developed grade 2 pressure ulcers (abrasions) during the less frequent pad changing regime, but none in the frequent pad changing regime; this result was not significant (P = 0.1; 95% CI: 0-1.09). No evidence was found that a less frequent pad changing regime has an effect on skin erythema or pH. There is evidence that skin is wetter which may make it more vulnerable to friction and abrasion. The statistically non-significant finding of greater incidence of grade 2 pressure ulcers is a cause for concern and merits further investigation because of the clinical significance of loss of skin integrity.     

Exploring the relationship between personal control and the hospital environment

Aims and objectives. This paper describes the further development of the substantive theory Optimising Personal Control to Facilitate Emotional Comfort. In previous work, emotional comfort was identified as a therapeutic state that was influenced by several factors, one of which was the hospital environment. This paper focuses on aspects within the hospital environment that patients perceive to influence their feelings of personal control. Background. A relationship between control and health has been discussed in previous literature. There are indications that aspects of the hospital environment can impact on a patient's perception of control. This project explored personal control in relation to the hospital environment from the perspective of patients. Method. Grounded theory method was used. Data were collected from patients’ interviews and field observations and analysed using the constant comparative method. Interviews were tape‐recorded and transcribed verbatim. A qualitative data computer program was used to manage the data. Results. The results confirmed the findings of the original study where hospitalised patients were found to experience feelings of reduced personal control. The conditions of level of security, level of knowing and level of personal value were described in terms of their contribution to the patient's feelings of personal control. Conclusions. Specific directions for further research into the development and evaluation of therapeutic hospital environments that promote personal control and the associated emotional comfort are provided. Relevance to clinical practice. This research highlights the importance of considering patients’ feelings of personal control during their hospital stay. Several directions for establishment of therapeutic environments within hospitals are provided, but more research in this area is recommended.     

Older people’s views of dignity and how it can be promoted in a hospital environment

Aim. The study investigated the lived experiences of older patients who had been in hospital, to explore their views on dignity and the factors which promote dignity. Background. The UK government’s new ambition for old age ( New Ambition for Old Age: Next Steps in implementing the National Service Framework for Older People: A Report from Professor Ian Philip, DH ) states that older people should be treated with dignity. The dignity in Care Campaign ( ‘Dignity in Care’Public Survey, October 2006: Report of the Survey, DH ) highlighted the need to raise staff’s awareness and understanding of dignity. Design. A purposive sample of older people took part in semi- structured interviews which focussed on their recent experiences of hospital admission. Qualitative data analysis was used. Method. Ten participants aged 73–83 were interviewed by a nurse researcher at home. All of the participants had an unplanned admission and were discharged home. Results. The participants although generally satisfied with their care had strong views on dignity. The following factors had the potential to promote dignity; privacy for the body, cleanliness, independence and being able to exert control, sufficient time from staff, attitudes to older people and communication. Conclusions. This study suggests that independence and effective communication are of central importance in maintaining dignity through achieving control of their situation. The participants observed that factors such as speaking inappropriately and waiting for personal care undermined older people’s perceptions of dignity. Several participants feared for their own dignity should they have cognitive problems later in their lives. Relevance to clinical practice. Staff need to be aware that communicating in a way that conveys empathy and responds to the individual as a valued person is an important factor in maintaining dignity. Nurses on hospital wards particularly need to take measures to safeguard the dignity of older people with cognitive problems who have difficulty in making their needs known.     

The influences of prompted voiding for urinary incontinence among older people in nursing homes

Research question: What are the influences of prompted voiding (PV) for urinary incontinence (UI) among older people in nursing homes? Research problem: This study aims to evaluate the effects of PV for UI of older people's subjects in nursing homes. Management of UI among older people is needed to overcome the possibility of new problem for older people. A randomized controlled study was performed of pre‐test post‐test design for 12 subjects (6 of control and 6 of intervention group). An intervention group followed PV instructions for 24 hours during 28 days, while the control group was instructed to urinate in toilet or to use diapers. Outcome variables were measured using incontinence severity index (ISI). There was statistically significant main effect across ISI among intervention group pre‐ (8.67 ± 1.97) and post‐ (6.67 ± 2.73) intervention of PV (P = .007). While there was statistically significant differenced ISI between control and intervention group (9.67 ± 1.86 vs 6.67 ± 2.73) post‐intervention of PV (P = .005). There was higher reduced ISI in the intervention group (?M ?2.00 ± 1.09) after 28 days of PV (P = .001). PV could be used to increase the older people's initiative to go to toilet and decrease incontinence episodes during a short time by their self in the nursing home.     

Effects of absorbent incontinence pads on pressure management mattresses

AIM: The aim of this paper is to report a study to determine the effects of absorbent pads on the pressure-relieving properties of 'standard' and pressure management mattresses. BACKGROUND: Pressure ulcers and incontinence often co-exist. There is a strong association between poor mobility and continence problems and patients using pressure management products are therefore also likely to be using absorbent pads. METHODS: An instrumented articulated anthropometric phantom with simulated soft body 'tissues' in the gluteal and sacral areas was used as the 'subject'. The phantom was raised and lowered on to three mattresses (standard foam, visco-elastic foam and surface-cut foam) in three states: naked, wearing a dry pad (Tena Super, SCA Hygiene AB) and wearing a wet pad. The pressure mapping device Xsensor was used to record the distribution of pressure over the sacral and ischial areas of the phantom. Peak pressure was used as the primary outcome variable and 10 repeats were made on each mattress under each condition. RESULTS: There were substantial and significant differences for all three mattresses in recorded peak pressures between the naked buttocks and the buttocks wearing a dry pad. There were no significant differences between measurements made using the dry vs. wet pad. Peak pressures frequently occurred over areas of pad folds. Additional testing showed that pads that were 'smoothed' by hand had significantly lower peak pressures than 'unsmoothed' pads. CONCLUSIONS: Absorbent pads have a substantial adverse effect on the pressure redistribution properties of mattresses. Pad folds appear to contribute to this effect, which can be ameliorated slightly by smoothing. Absorbent pad manufacturers should consider engineering pads that minimize disruption to pressure management. Further examination of continence and pressure management products is necessary to establish optimum combinations for nursing care.     

Exploring the facets of continence care: a continence survey of care homes for older people in Birmingham

Aims. This study aimed to explore continence prevalence, knowledge and care in Birmingham care homes, UK. Background. There is an increasing need to respond to rising numbers of care home residents suffering from incontinence in the UK. A lack of staff knowledge, training and treatment options can make this problematic. Method. A survey was developed and sent to 186 care homes in Birmingham catering for those 65 years old and over. A freepost envelope was provided for return of the completed form. Results. Sixty‐six (35%) surveys were returned providing a representative sample. Eighty per cent of nursing home residents and 49% of residential home residents were reported incontinent. Half of the staff (53%) had some form of qualification in caring/nursing. Absorbent products were used to manage incontinence in over 50% of homes. Advanced age was cited as the main cause of incontinence. Sixty‐eight per cent of homes used the continence advisory service and/or district nursing services. Conclusions. While results proved encouraging in relation to numbers of qualified staff there is a need for improved continence awareness. Focus on aetiology, assessment procedures and treatment options are needed. While external service use levels were encouraging there appeared to be a need for an exchange of knowledge between services to optimize care. Relevance to clinical practice. While there is an existing body of knowledge relating to continence prevalence and management in nursing homes this research base is lacking for residential care settings. This survey addresses this imbalance by combining information from both settings. This paper also provides an insight into the components that have an impact upon continence promotion, prevention and management. By establishing a picture of current practice an indication of areas for improvement can be exposed.     

National audit of continence care for older people: results of a pilot study*

INTRODUCTION AND AIM: Bladder and bowel problems are common in the elderly and are associated with a considerable morbidity and impact on quality of life. Inequalities in service provision and access to services have been recognized but there has been no systematic approach to measuring the quality of continence care for older people. This study aimed to develop quality standards, to assess the reliability and utility of the resulting audit package and to report on the standards of care provided in primary care, secondary care and care home setting. METHOD: Fifteen sites in secondary care, primary care and in long-term care settings were randomly selected to pilot the audit package. Data collectors completed audit questionnaires relating to the structure [organization] of care, the outcomes of care, and the process of care for 20 subjects with urinary incontinence and 10 subjects with faecal or double incontinence. RESULTS: The audit tool was reliable (median kappa score of 0.7). Access to integrated continence services, as defined by Good Practice in Continence Services was inadequate. Eighty-five per cent of hospitals had no written policy for continence care. There were deficiencies in obtaining information, in carrying out basic and specialist examinations and investigations and in determining the cause of incontinence. There was a high prevalence of catheter use in secondary care settings. CONCLUSION: The pilot has indicated significant inadequacies in continence care and demonstrates that in many sites the National Service Framework milestone for integrated continence services has not been met. A national audit of continence care is required to determine the extent of inadequate continence care.     

Betwixt and between: a critical ethnography of comfort in New Zealand residential aged care

Aims and objectives. This research sought to explore the nature of comfort within the context of three New Zealand nursing homes and examine how nursing and other actions contribute to residents’ comfort. Background. Comfort has been acknowledged as a key nursing goal since the days of Florence Nightingale, but the nature of comfort and how nurses can contribute to and enhance patient/resident comfort is unclear. Comfort is often considered to be merely the absence of discomfort. Design. A critical ethnographic approach was used to facilitate understanding of nursing home residents’ comfort. Fieldwork included 90 days of participant observation, interviews with 27 residents and 28 staff and extensive document examination. Results. Comfort was multidimensional, idiosyncratic, dynamic and context dependent, rather than merely the absence of discomfort. This multidimensional nature meant residents could be ‘betwixt and between’ comfort and discomfort simultaneously. The constraints of one‐size‐fits‐all care delivery practices and the tensions inherent in communal living compounded residents’ discomfort. Conclusions. Individualized care, based on comprehensive and accurate nursing assessment, is fundamental to the comfort of residents. Relevance to clinical practice. Staff working in nursing homes must re‐examine their care delivery practices to ensure these do not disempower residents. Ensuring the comfort of each resident is a nursing priority and the key component of individualized care.     

The prevalence of and the related factors for urinary and fecal incontinence among older residing in nursing homes

Aims and objectives. To determine the prevalence of urinary incontinence and fecal incontinence among older people residing in nursing homes in Istanbul. Background. Urinary incontinence (UI) is a multifactorial condition associated with age‐related changes and disorders of the genitourinary system and systemic problems affecting normal micturition. The impact of UI and fecal incontinence (FI) on older people living in nursing homes is more significant than those living in the community. Design. Cross‐sectional study. Methods. This study was performed with 1110 older people who were 60 years and older residing in five government rest homes on the European side of Istanbul in Turkey. An interview was conducted with the residents that had sufficient cognitive function and agreed to participate. Demographic findings and complaints about incontinence were analyzed using a special questionnaire. Results. The total number of older people who participated was 694; 56·5% females and 43·5% males; 43·4% of females and 20·9% of males. Urge incontinence was common in both groups. FI was more common among females (14%, males 6%) and the mean duration of symptoms was longer. The related factors for UI among older females revealed that history of an episiotomy, frequency, urgency, fecal incontinence and functional incapacity among males; whereas history of stroke and pulmonary disorders were independent variables that increased the incidence of frequency, recurrent urinary tract infections and fecal incontinence. The related factors for fecal incontinence among older females included history of stroke and functional status. Diabetes mellitus requiring medical treatment, frequency, functional incapacity and urinary incontinence were significant related factors for fecal incontinence among males. Conclusions. According to similar studies, the urinary and fecal incontinence rates in nursing home residents were lower compared to the other countries. Incontinence was more common among females according to males. Understanding related factors of incontinence are important for providing care and counseling in nursing homes. Relevance to clinical practice. Nurses can provide appropriate information and support at each step in the protecting, screening, diagnosis and treatment process so that elders’ incontinence is minimized.     

A systematic review of topical skin care in aged care facilities

Aim. This systematic review aimed to evaluate the best available evidence regarding the effectiveness of topical skin care interventions for residents of aged care facilities. Introduction. Natural changes to skin, as well as increased predisposition to pressure sores and incontinence, means residents of aged care facilities readily require topical skin care. A range of interventions exist that aim to maintain or improve the integrity of skin of older adults. Methods. Pubmed, Embase, Current Contents, CINAHL and The Cochrane Library databases were searched, as well as Health Technology Assessment websites up to April 2003. Systematic reviews and randomized or non‐randomized controlled trials were evaluated for quality and data were independently extracted by two reviewers. Results. The effectiveness of topical skin interventions was variable and dependent on the skin condition being treated. Studies examined the effectiveness of washing products on incontinence irritated skin. Disposable bodyworns may prevent deterioration of skin condition better than non‐disposable underpads or bodyworns. Clinisan, a no‐rinse cleanser may reduce the incidence of incontinence associated pressure ulcers when compared with soap and water. Conclusion. In general the quality of evidence for interventions to improve or maintain the skin condition in the older person was poor and more research in this area is needed. Relevance to Clinical Practice. Skin care is a major issue for nurses working with older people. On the basis of this review no clear recommendations can be made. This lack of strong evidence for nurses to base effective practice decisions is problematic. However, the ‘best’ evidence suggests that disposable bodyworns are a good investment in the fight against skin deterioration. No rinse cleansers are to be preferred over soap and the use of the bag bath appears to be a useful practice to reduce the risk of dry skin (a risk factor for breaches in skin integrity).     

Assessment of the nutritional status among residents in a Danish nursing home - health effects of a formulated food and meal policy

Aims and objectives. To gain information about the effects of implementation of a written food and meal policy and to evaluate to what extent systematic nutritional assessment and intervention would result in weight stability among the residents. Background. Studies have shown that aged residents living in institutions suffer from malnutrition or are at risk of malnutrition. Health policies have pointed out that more attention should be given to individualised nutritional care. Several techniques are available to identify malnourished nursing home residents, but very few studies have reported findings of studies based on systematic nutritional assessment. Design and methods. A quasi‐experimental study based on a time series design used the residents as their own controls. The study included all 20 residents who resided at the nursing home at baseline in September 2004. Five residents died during the study period (mean age 84·4 years, range 62–91 years). Altogether 15 residents (75%) were assessed all five times during the study period. Results. The proportion of weight‐stable residents increased significantly over the study from 52·6% (CI 99%: 23·1–80·2) at baseline to 87·7% (p < 0·01) at the end of the study. The proportion of weight losers significantly decreased from 42% (CI 99%: 23·1–80·8) to 13·3% (p < 0·01). The weight ranges indicate substantial weight changes, but over time the weight ranges became narrower, indicating a tendency towards weight stability. Conclusions. Although the nursing home had a formulated food and meal policy, this study shows the importance of a regular nutritional assessment combined with an individualised care planning. Relevance to clinical practice. Regular weighing combined with individualised care planning results in weight stability in nursing home residents. Individualised approach for nutritional care led by a qualified nurse is just as important in nursing homes as it is in hospitals.     

Promoting urinary continence with older people: key issues for nurses

Urinary incontinence is one of the most common and distressing of the conditions experienced by older people. It is not just associated with physical and cognitive frailty but also features significantly in the fit community living population. Urinary incontinence is known to be hidden and under-reported. Yet the needs of older people across the globe in relation to urinary incontinence will increase with the changing demography.
Palliative strategies to contain urinary incontinence predominate in practice, although the reasons for this are not fully understood. Conservative approaches including lifestyle adjustments and behavioural therapies form the mainstay of active continence promotion but their routine use by nurses working with older people seems to be minimal. Promoting continence with older people is an area of practice long overdue for significant and sustainable practice development.     

The meaning of living with dementia and disturbing behaviour as narrated by three persons admitted to a residential home

Aim. The aim of our study was to illuminate the meaning of living with dementia and disturbing behaviour, as narrated by three persons admitted to a residential home. Background. Living with dementia and so‐called disturbing behaviour in an institution involves interaction with care providers and fellow residents and poses a challenge to all who are involved. Methods. We asked the head nurses at a residential home to select persons with dementia and disturbing behaviour who were willing to be interviewed and able to communicate verbally. We performed 10 informal conversational interviews with three persons. The interviews were transcribed into text and interpreted using a phenomenological hermeneutic method inspired by Ricoeur's philosophy. Results. The findings indicate that the meaning of living with dementia and disturbing behaviour, as narrated by three persons admitted to a residential home, is about being surrounded by disorder, being trapped by restriction and being set aside, as well as about being included. The findings are interpreted as a collapse of relations to self and others intertwined with occasional episodes of togetherness. This is reflected on in relation to the literature on homelessness and at‐homeness and loss and maintenance of personal and social selves. Relevance to clinical practice. The view others have of the person with dementia and of disturbing behaviour determines the nursing care given. Taking the residents’ personal history and actual context into account, disturbing behaviour may be seen as a way persons with dementia express their story and maintain their self.     

Development of a simple scoring tool in the primary care setting for prediction of recurrent falls in men and women aged 65 years and over living in the community

Aim. We documented the number of falls and falls risk profile over two years to derive a falls risks prediction score. Background. Simple falls risk assessment tools not requiring equipment or trained personnel may be used as a first step in the primary care setting to identify older people at risk who may be referred for further falls risk assessment in special clinics. Design. Survey. Method. Men (n = 1941) and 1949 women aged 65 years and over living in the community were followed up for two years to document the number of falls. Information was collected regarding demography, socioeconomic status, medical history, functional limitations, lifestyle factors and psychosocial functioning. Measurements include body mass index, grip strength and stride length. Logistic regression was used to determine significant predictions of falls and to calculate predictive scores. Result. Twelve factors in men and nine factors in women were used to construct a risk score. The AUC of the receiver operating characteristic curve was >0·70 for both men and women and a cut off score of ≥8 gave sensitivity and specificity values between 60–78%. The factors included chronic disease, drugs, functional limitation, lifestyle, education and psychosocial factors. When applied to future predictions, only low energy level and clumsiness in both hands in men and feeling downhearted in women, were significant factors. Conclusions. A risk assessment tool with a cut off score of ≥8 developed from a two‐year prospective study of falls may be used in the community setting as an initial first step for screening out those at low risk of falls. Relevance to clinical practice. A simple tool may be used in the community to screen out those at risk for falls, concentrating trained healthcare professionals’ time on detailed falls assessment and intervention for those classified as being at risk.     

Restraint use among nursing home residents: cross‐sectional study and prospective cohort study

Aims and objectives. To investigate (1) the prevalence of physical restraints and psychoactive medication, (2) newly administered physical restraints, frequency of application of the devices and frequency of psychoactive medication on demand during 12‐month follow‐up and (3) characteristics associated with restraint use in nursing homes. Background. High quality data on restraint use in German nursing homes are lacking so far. Such information is the basis for interventions to achieve a restraint‐free care. Design. Cross‐sectional study and prospective cohort study. Setting and subjects. Thirty nursing homes with 2367 residents in Hamburg, Germany. Methods. External investigators obtained prevalence of physical restraints by direct observation on three occasions on one day, psychoactive drugs were extracted from residents’ records and prospective data were documented by nurses. Results. Residents’ mean age was 86 years, 81% were female. Prevalence of residents with at least one physical restraint was 26·2% [95% confidence interval (CI) 21·3–31·1]. Centre prevalence ranged from 4·4 to 58·9%. Bedrails were most often used (in 24·5% of residents), fixed tables, belts and other restraints were rare. Prevalence of residents with at least one psychoactive drug was 52·4% (95% CI 48·7–56·1). The proportion of residents with at least one physical restraint after the first observation week of 26·3% (21·3–31·3) cumulated to 39·5% (33·3–45·7) at the end of follow‐up (10·4 SD 3·3 months). The relative frequency of observation days with at least one device ranged from 4·9–64·8% between centres. No characteristic was found to explain centre differences. Conclusions. The frequency of physical restraints and psychoactive drugs in German nursing homes is substantial. Pronounced centre variation suggests that standard care is possible without restraints. Relevance to clinical practice. Effective restraint minimisation approaches are urgently warranted. An evidence‐based guideline may overcome centre differences towards a restraint‐free nursing home care.