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gerontological care and practice

Developing a to o l to assess person-centred continence care

AbstractThis article presents an overview of the first phase of a study to determine thecontextual indicators that enable or hinder evidence-based continence careand m ana gem ent. The main focus of the article is to provide an insight intothe value of understanding practice 'context' and its impact on the provisionof person-centred continence care.

Jayne Wr igh t RGN MSc, is aresearch associate. Universityof UlsterProfessor Brendan McCormackDPh ii(Oxoi), BSc(Hons), PGCEA,RGN, RM N, is director ofnursing research. Un iversityof Ulster and Royal HospitalsTrust, and adjunc t professor,Monash University, Victoria,AustraliaAlice Coffey Med, BS, RNT,RGN, RM, is a researchassociate. School of Nursingand Midwifery, UniversityCollege CorkProfessor Ge raldine McCarthyPhD, MSc, Med , RNT, RN,is head of school. Schoolof Nursing and Midwifery,University College Cork

Key iflfordsIncontinencePatient focused care

These key words are basedon the subject headings fromthe British Nursing Index. This

In rehabilitation settings for older people, thepromotion and improved management of con-tinence is a key theme in developing practice.Currently, practice in this area generally reflectsthe need to help people wh o experience conti-nence problems to remain clean and to preventskin damage. Despite major advancements inthe evidence base underpinning continencepromotion and management of incontinence(Department of Health (DH) 2001), there con-tinues to be little emphasis placed on detailedand individualised assessment or programmesof treatment. Existing evidence of the utilisa-tion of research in practice identifies 'context' asa key issue. McCormack ef al (2002) identifiedthree elements of practice context that need tobe assessed in order for research evidence tobe u tilised: existing measures of effectiveness;leadership; and workplace culture.This article presents an overview of the firstphase o f a two-year A ll-Ireland research project(funded by the N orthern Ireland Department ofHealth, Social Services and Public Safety R&DOffice, and the Republic of Ireland Health ResearchBoard) between the University of Ulster and Uni-versity College Cork. In b oth locations the focusis on rehabilitation units for older people. Thetwo-year research project aimed to: determ ine contextua l indicators tha t enable

or inhibit effective continence promotion andcontinence management

continence promotion and strategies test the reliability and validity of the instrume

in rehabilitation settings.The overall research question was: 'W ha t a

the components of practice context tha t enabor hinder proactive approaches to the promotioof continence and treatment in rehabilitatiosettings for older people?'The study was conducted in two phases. Phaone consisted o f an in-dep th case study desigset with in the PARIHS (1998) framew ork to idetify the factors that enhance or hinder evidencbased continence care. At the end of phase onkey indicators arising from data collection ananalysis were identified and developed into practice assessment tool in order to establispractice development approaches that lead tperson-centred continence practices.Phase tw o focused on developing the too l antesting its validity and reliability.

ContextResearch provides evidence of what might bachieved under ideal circumstances; it create'context-free' guidance. However, it is recognised that we do not work within context-fresituations. This is supported by the CanadiaHealth Service Research Foundation (2005which argues that getting evidence into practicis not context free. It states: 'The role of sciencis somewhat detached from and unconcerne

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gerontological iiare aiiil practicerelationship of three key elements: the nature ofthe evidence (research, clinical experience andpatients' preference); the quality of the context(culture, leadership and evaluation); and expertfacilitation (characteristics, role and style) (McCor-mack ef al 2002). Each of these elements hascharacteristics arranged along a continuum ofweak to strong. In the article related here, weset out to understand how the characteristics ofcontext impact on continence strategies and inparticular to study the context of rehabilitationsettings for older people

Table 2 provides a summary of the data collec-tion methods, sample and analysis.F in a l aoaSyses: con tent fr am ew or kThe final stage was to analyse all the data w ithinthe context framework in order to identify thestrong and weak characteristics of the contextwithin which continence care was provided. Thedata were themed under the three elements(culture, leadership, evaluation) and each of thecharacteristics along the continuum of weak tostrong evidence - ie, whether the evidence was'strong' and enhanced person-centred continencecare or 'weak' and hindered person-centred con-tinence care.

This process is illustrated in Tables 3 and 4. Table3 is an extract from the element of leadership andthe characteristic o f 'didactic approaches to learn-ing/teaching/managing' along the continuum tostrong context of 'enabling/empowering approachto teaching/learning/manag ement'. Table 4 isan extract from the element of culture and thecharacteristics of 'low regard for the individual'along the continuum to the strong context of'values individual staff and clients'. The themesthat arose from the data for each of the char-acteristics are listed in the column under eachof the headings. It was these themes that werelater developed into the statements for the toolto assess context.Findings and discussionUsing the context fram ework to analyse the dataprovided a picture of the context w ithin the unitsand its significance to hindering or enhancingevidenced-based continence care. The evidencesupports the assertion that the context (leader-

the leadership was more autocratic than trans-forma tional. Witho ut transformational leadershipteam members were unable to optimise their skills,abilities and knowledge. Leaders described astransformational have the ability to bring d ifferenttypes of evidence (research, patients' experienceand clinical experience) together and implementevidence into practice to bring about new waysof wo rking (Manley and Dewing 2002).

The staff showed awareness of the limitingeffect that leadership had on their ab ility to bringabout change to continence practice. As one per-son said: 'New ideas sort of come and go andyou're sort of, you know, can't get on w ith newthings. We have meetings and everyone says yesbut nothing happens. It's not right but I just keepmy head dow n now. Don't wan t to keep askingabout things.'

In Table 4 the data reflects a weak culturewhere care was task-based and did not reflect aculture that respected the individual. Continenceproblems reflected reactive continence care withlimited assessments and an over-reliance on theuse of the 'pad and pants' approach found w ithinthe literature (Gray 2003, Bland ef a/2003).

Having continence problems was seen as anaccepted part of ageing and this led the nursesto lose sight of the significance continence has inrehabilitating the older person. Using the contextframew ork helps identify factors that need to bein place for person-centred continence care. InTable 4, for example, a strong culture that reflectsperson-centred care is one tha t reflects the personas a unique individual.

The multidisciplinary team did display awarenessof the deficiencies in their continence care and inthe unit's management, and of the challengesahead. This was expressed by one person in thefollowing way: 'W e could do patient training asa group to help patients understand continence.Don't think we do enough now , just get the padsand don't ask what they know.' They agreed thatcontinence was not afforded high priority and thatthe environment in which they worked was notaltogether conducive to person-centred care.

The three elements of context and the cor-responding characteristics identified within thePARIHS framework captured the aspects of con-text with in the study. All the data mapped one of

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gerontological care and practice

Table 2. Sum ma ry of data co llection metho ds, sum mary a nd analysisData collection m ethods1 Existing measures of co ntinencennanagenrient and effectivenesswere measured using the RoyalCollege of Physicians' audit scheme(Brock lehurst 1998). This consistsof quest ionnaires to review theincidence and manag ement o f ur inaryand faecal incontinence and urethralcatheterisat ion2. Facilities audit

3. Staff knowledge questionnaire( i rwin eta/2001)

4. Observations of practice using asemi-structured interview schedule

5. The Nursing W ork Index (NWI-R)(Aiken eta/2 000 ) is a questionnairecombining th ree research instrumentsto measure the nursing work-pract iceenvi ronment6. Focus groups w ith members of themultidisciplinary teams

PurposeA quanti tat ive instrument to identi fythe number of older people with acontinence problem, types of problemsand a pproaches to assessment care andtreatment of continence

To review th e clinical area's facilit iesfor continence such as toile t facilit ies.education programmes for staff, access tocontinence aids etc

Staff knowledge of continencemanagem ent was measured using acontinence knowledge questionnairedevised by Irwin etal (2001)

Non-pa rt ic ipant observat ion of practicewas condu cted. The observat ion schedulewas semi-structured. The schedule wasdeveloped using the Essence of Care (DH2001) continence benchmark standard andManley's cultura l indicators (2000). Theseacted as a focus for the observat ion o f bestpracticeLeadership was examined by pro bing intonursing autonomy decision-making and

work satisfaction

The focus groups followed analysis ofthe data collected in the previous stages.The aim was to gain views of the contextof continence practices with in thepart icipatory units. A furthe r aim was todiscuss and gain deeper insight into thedata col lected during the observat ionof the culture. Manley's (2000) culturalindicators for me d a basis for the discussion

Sample sizeN=220 patients were iden ti f iedby staff or throu gh patient carerecords

Information was gained fromthe c linical nurse leaders orcontinence link nurses in fivewards and one day hosp italin the Northe rn Ireland si teand two 40-bed units in theSouthern Ireland siteQuestionnaires were distr ibu ted

; to 96 nursing, medical andtherapy staff in the Northern

Ireland site and 53 werereturned . In Southern Irelandquestionnaires were distr ibutedto 58 nursing, medical andtherapy staff and 44 (83 percent) were returnedIn total 16 hours of observationwere u ndertake n in each studysite over two -ho ur periods atdi f ferent t imes of the day

All nurses within the twostudy sites N= 90 (No rth) N= 43(South) (51.4 per cent returne d)

Two focus groups took placein the Southern Ireland studysite and four in the North ernIreland study site. These wer eattended by members of themultidisciplinary team (26 into ta l )

Data analysisThe data were' analysed using SPSSversion 12

Ana lysed using SPSS12

\ Analysed using SPSS

1

The data wereanalysed using Elyeta/ (1991) ten-stage thematicanalysis and thecharacteristics o fcontext f rom thePARIHS fram ew orkAna lysed using SPSS12

The focus grou pdata was analysedusing ten-stagethematic (Ely 1991)analysis and mergedwith the previousdata wi th in thecontext f ramework

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gerontological care and practice

T a b l e 3 . L e a d e r s h i p e l e m e n tDidactic approaches to learning/teaching/managing Enabling/empowering approach to teaching/learning/managingClassroom-basedteaching and educationBased on a narrow formof knowledge

I Non-reflective practiceHierarchical learn ingI (being told what to do)Practice, no t evidence-basedLimited priority given tolearningIssues remain unsolved; and no follow throu gh

Limited introductions to pa tientsby the staff by care delivery [I do n'tunderstand]. The N/A [nursingassistant?] worked unsupervised.Therefore no learning of continencecould took placeThere were plenty of opportunitiesfor patient education but none taken.Even when patient asked 'What are mytablets for? ' The patient was not told'I was told they used to have leafletsfor patients but that "no-one readthem so we took them dow n"'FG (focus group): 'If youwant to knowsomething you ask and sister or somesenior tells you; that's how it is andthat's how we learn. You learn bywatching and doing, following others''Huh, they d on't discuss anything andnot private things anyway. Can they dosomething? I wear these here pads bu ttha t means I can't get to the bottle butif I don't wear the pads I we t myself.Can they do anything else?' [Commentby patient at audit]'In-service training [is where new ideascome from]. Someone goes on a coursethen brings the information back.There is a lot of training needed whichhas come out of developing the MDTnotes. Once a year in-service trainingas staff change'

FG: 'We could do patient training as agroup to help the patients understandcontinence. Don't think we do enoughnow just get the pads and don 't askwhat they know'FG: '...but sometimes they [thepatients] are saying " I have beencalling and calling and nobody came",which can happen a t times on everyward but I just wonder whether thingsare regular and if people are beingapproached as regularly as they wouldlike to be'FG: 'I think th at we should share moreand learn more from each other. Newideas come and go and that's that, butwe could learn as we all know a lot...'

Development of practice fromwithin the team as well asoutsideDraws on differe nt types ofknowledge (craft, proportionetc)Based on evidence of bestpracticeLearning takes place with in theworkplace throug h reflectionin and on practice, supervisionand action learningLeaders role modellingNone: blame cultureFacilitative approachKnowledge and skills ofpractice development

from 'context' merged with feedback on 'individual teams and systems'in evaluation; 'promotes learning organisation' merged w ith effective'organisational structure'; 'autocratic decision-making' merged with'traditional, command and control leadership'.ConclusionThe context framework provides a dear means to enable an under-standing of the issues affecting person-centred continence care. Formany practitioners the concept of the three elements of context willnot have been considered before as factors that enhance or hindercontinence care. The data illustrate the value of understanding the

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Table 4. Regard for th e individual: Continuum (from w eak to strong)We ak con text Evidence EvidenceLow regard forindividualsLow regard for theeffect of continenceproblems on the olderperson's quality of l ife(dignity, respect)Lack of value of eachprofession towards eachotherLow regard forcontinence promotionin the rehab i l i tat ionprocessOlder people treatedas one homogen eousgroup with the sameneeds and wa ntsA reactive approach tocontinence takenNo therapeuticcommunicat ionClosed questions

Lights on over sleeping patients; some trying toshield their eyes fro m th e lightPatient woken for personal careFifty per cent of pa tients had physical factors thataffected continence (RCP audit)No patient was offered the oppo rtunity t o use thetoile t unless they askedTherapist walks around talking a bout pat ient atend of bed deciding who to w alk.Walked away; no explanation to the pa t ient ofwhy they were in the bay talking abo ut themGeneral lack of eye contact, m oving o n all the t imeto the next pa t ient or doing other act ivi ty w hi letalking. Body language not conducive to goodcommunication and intimate discussionThere were plenty of opportunit ies for pat ienteducation but none taken. Even whe n patientasked 'Wh at are my tablets for?', the patien t wasnot to ldLanguage labelling: 'Is he norma l?' wh en referringto die t; 'She's a feed 'Nursing assistant asked pa tient if he had finish edon the to ile t wi th do or open and wi th the pat ienton the toi let. Then another NA came along andstood w ith him , saying 'Have you finished?'Domestic came on and ope ned al l the window s atbo t to me nd of the ward and i twas very cold. This

: went unchallenged by any of the staffOne pa tient spoke to every nurse but this was alljust banter, noth ing m eaningful. But the otherswho did not instigate conversations with the staffwere no t spoken toThe patients using pads were not o ffered th e toi let

, 'I am no t inco ntinent as such. The catheter is inplace because I can't get to the toi let in t ime andth e nurses say I am too heavy. I suppose it is easierfor all concerned' [comment by patient at audit]RCP aud it: only 2 per cent of pa tients hadbladder charts. No bladder e duca tion; 53.7 percent of patients were using pads tha t were s til loccasionally w et and 38.85 per cent were usingpads tha t were usually wet.

There were some very good interact ions.The students introduced themselvesand to ld the pat ient what was go ing tohappen and gave them t im e; good use ofbody languageOne person had been an inpatient a ndwas new to the day h ospital ; he wasgreeted by everyone and the ward-basedtherapy s taff came to see him.Buzzers answered promptlyPatient encouraged and assisted to walkto the toi le t in helpful and calm wayPeeking be hind the curtains by oneperson but generally they asked if theycould come behind and kept them dosedFG: 'The environme nt is a big factor... the embarrassment; things like notwa nting to use commodes so i t's usefulto have the use of toi lets '

Strong contextValues individualstaff and clientsHigh regard forthe effect ofincontinence onthe older person'squal i ty of l i feProactivecontinence careand managementiVIembers of theMDT value eachotherTherapeutic,facilitativecommunicat ionEach person (staffand patients/carers) recognisedas a uniqueindividual

ReferencesAiken L, Patrician P (2000) Measuringorganisationai traits of hospitals. Therevised nursing wor k index. NursingResearch. 49, 3, 146-153.Bland D etal (2003)The effects ofimplementation of the agency forhealth care poiicy and research urinaryincontinence guidelines in primary care.Journ of Amer GeriatricSoc. 51, 7, 979-984.

Canadian Health Service ResearchFoundation (2005) Conceptualising andCombining Evidence for Health SystemGuidance (Final Report). CHSRF, Ontar io.Department of Health (2001) The Essenceof Care. Patient-focused Benchmarking forHealth Care Practitioners. HSMO, London.Ely M era/(1991) Doing QualitativeResearch: Circles within Circles. Falmer

Gray M (2003) The importance ofscreening, assessing and managing urinaryincontinence in primary care. Journaiof the American Academy of NursePractitioners. 15, 3, 102-107.Kitson A ef a/ (1998) Enabling theinnplementation of evidence basedpractice: a conceptual fram ework.Quality in Healthcare. 7, 149-158.

Manley K, Dewing J (2002) Theconsultant nurse role. NHS Journai ofHealthcare Professionals. May, 8-9.McCormack B efa/(2002) Gettingevidence into practice: the meaning ofcontext. Journal of Advanced Nursing.38 , 1,94-104.Rycroft-Malone J efa/(2002). Getting

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