Running Head: PROMOTING URINARY CONTINENCE 1
The role for nurses in promoting urinary continence in long-term care
Melissa Jenkins
0517969
Trent University
PROMOTING URINARY CONTINENCE 2
Introduction
A nurse often encounters a resident when they are experiencing an unstable
transition (FITNEinc, 2011). Aging is the largest, longest transition faced by every
individual but it is not usually unstable, however it can become so when an individual
deviates from what is considered healthy aging. Urinary incontinence (UI) is not an aspect
of healthy aging despite the opinions of the aging population (Touhy, Boscrat, & Cleary,
2010; Ostaszkiewicz, O’Connell, & Dunning, 2012). The Registered Nurses’ Association of
Ontario’s (RNAO) best practice guideline (BPG) Promoting continence using prompted
voiding (2011a) addresses urinary incontinence and provides nurses with the best
available evidence on interventions that can be used to promote urinary continence. BPGs
do not give set instructions for care but aid nurses in making decisions on resident care as
well as the development of policies and procedures (RNAO, 2011a).
UI contributes to lower levels of self-reported quality of life (Aguilar- Navarro et al.,
2012; Ostaszkiewicz et al. 2012). Nursing assistants ranked UI second to pain when
considering the effects on quality of life (Lawhorne et al., 2008). In the long-term care
(LTC) setting it is estimated that 81% of residents suffer from some kind of UI within six
months of admission, whereby on admission only 43% were incontinent (Touhy et al.,
2010). Promoting continence can alleviate the monetary burden on the healthcare system
and the physical burden of caregivers while improving the quality of life for many elderly.
Urinary Incontinence as a Self-care Deficit
Orem’s theory of self-care states that the reasons people participate in self-care is
for universal, developmental, or human deviational reasons and the ultimate goal in life is
PROMOTING URINARY CONTINENCE 3
to provide care for oneself (Banfield, 2011). Universal reasons are required by every
person such as water, air, food, elimination, and the balance between social needs
(Banfield, 2011). Developmental reasons are associated with growth and development and
finally health deviational reasons are changes that are out of the normal range of human
function such as seeking healthcare (Banfield, 2011). Self-care deficits occur when a
discrepancy exists in the care that is needed and what is being provided (Banfield, 2011).
The inability to control urinary voiding and where it occurs is a universal self-care
deficit and is the focus of the Promoting continence using prompted voiding BPG (RNAO,
2011a). The guideline also focuses on UI as a risk factor related to other self-care deficits
especially falls. Other self-care deficits can also contribute to UI, for example constipation,
diet, and fluid intake (Touhy et al., 2010).
The BPG defines the seven types of UI with the most common being stress or urge
(RNAO, 2011). Transient UI is the loss of urine resulting from causes outside the urinary
system such as stool impaction or restricted mobility (RNAO, 2011a). The involuntary loss
of urine occurring after a strong urge to void is called urge UI (RNAO, 2011a). Stress UI is
the loss of urine during coughing or sneezing as a result of increased abdominal pressure
(RNAO, 2011a). Mixed UI results from both stress and urge. Functional UI is the loss or
leakage of urine associated with the inability to reach a bathroom in time to void because of
some cognitive, physical or environmental barrier (RNAO, 2011). Overflow UI is associated
with bladder distension and finally total UI is the continuous and unpredictable loss of
urine (RNAO, 2011a).
PROMOTING URINARY CONTINENCE 4
During aging there are physical changes that occur to the urinary tract that when
compounded with other factors can increase the chances of developing UI. As we age the
bladder decreases in capacity, increases in irritability, has contraction during filling, and
does not empty completely (Touhy et al., 2010). These changes contribute to an increase in
frequency, urgency, nocturia, and vulnerability for infection as well as a shortened period
between the urge to void and the actual need to void (Touhy et al., 2010).
Compounding factors can be human or environmental. Human factors are
associated with medical diagnosis, mobility or cognitive impairments, and being
overweight. Many medical conditions contribute to a person’s ability to control when they
void. Stroke, Multiple Sclerosis, and Parkinson’s disease affect neurological control of
muscles, including the muscles of the bladder. Impaired mobility restricts a person’s ability
to make it to the toilet in time to void. Cognitive impairment such as a diagnosis of
dementia can affect the ability to locate a bathroom upon recognizing the urge to void or
may impact whether the urge is recognized (Specht, 2011). Having excessive weight
increases the amount of pressure on the bladder and surrounding muscles which
eventually weakens them contributing to stress UI (Thom et al., 2010).
Environmental factors can also contribute to the development of UI. These are often
related to accessibility of the bathroom, commodes, or bedpans. This includes the distance
to the toilet, the lighting, the amount of clutter, and whether the resident is restrained.
Restraints restrict resident mobility and prevent them from being able to access the
bathroom or commode by themselves. Clutter and poor lighting present tripping hazards
making it difficult to reach the bathroom safely or at all. A resident may also not want to get
PROMOTING URINARY CONTINENCE 5
up to go to the bathroom for fear of falling especially if they have a history of falls. Poor
lighting can also prevent those who have poor eye sight from recognizing the toilet.
Location of bathrooms, commodes, and bedpans should be within a reasonable distance for
residents and be clearly marked (Specht, 2011). For example LTC facilities are often
designed so bathrooms are located in resident rooms which may not be an accessible
distance from common areas. Also two residents often share a bathroom, which as could be
occupied by the other resident when the urge to void is felt.
Nursing Interventions
BPGs are based mainly in relevant research and are informed by an inter-
professional team consisting of experts in the field. These guidelines also undergo scrutiny
using the AGREE II tool, which often ranks the RNAO BPGs near the top of their lists. The
way that the BPGs are developed makes them a valuable tool for guiding decisions and
informing the practice of registered nurses (RN), registered practical nurses (RPN), and
personal support workers (PSW).
The RNAO BPG Promoting continence using prompted voiding (2011a) suggests that
the best way to combat UI is to provide each resident with a personalized prompted
voiding schedule. Using a prompted voiding schedule has shown to decrease the number of
incontinent voids and increase the number of continent ones (RNAO, 2011a; Specht, 2011;
Vinsnes et al., 2012). To ensure the successfulness of a prompted voiding schedule several
other factors must first be addressed. These factors include history of UI, frequency of UI,
cognitive ability, diet and fluid intake, and other barriers to the resident.
PROMOTING URINARY CONTINENCE 6
A history of UI should be established on admission, addressing when it started, the
type, and the current method of coping (RNAO, 2011a). Other key factors of initial
assessment should also include the cognitive and functional ability of the resident (RNAO,
2011a; Specht 2011). Cognitive and functional ability are predictors of whether prompted
voiding will be successful as an intervention and may also help address the risk factors
related to mobility, medical diagnosis, and ability to recognize the urge and find a toilet that
are associated with UI (Specht, 2011). Other risk factors that can be addressed during the
assessment phase are the use of medications that may contribute to UI and the presence or
history of urinary tract infections. Medications can have direct effects (ex. diuretics) and
indirect effects through side effects of medications such as blurred vision, constipation,
weakness, and dizziness (RNAO, 2011a). The use of restraints as a barrier to the resident’s
ability to perform self-care can also be addressed in assessment by reviewing any orders
for their use. Awareness of the barriers faced by the resident can help the nurse plan
appropriate interventions or decide whether prompted voiding is the best intervention for
that resident.
Before initiating a prompted voiding schedule the nurse must first determine when
the best times to prompt the resident are (RNAO, 2011a). This can be done through the
collection of a 3 (or more) day voiding diary. This diary marks the time of day of the UI
event, the amount of urine released, whether the urge was felt, and potentially the type of
UI event. Having a reliable record of bladder function helps plan when best to prompt and
aid the resident in voiding (Naoemova, De Wachter, Wuyts, & Wyndaele, 2008; Specht,
2011).
PROMOTING URINARY CONTINENCE 7
Diet and fluid intake can also have a significant effect on UI. Providing a diet
designed to avoid constipation removes the potential for that as a contributing factor and
removes added pressure on the urinary tract (RNAO, 2011b). Providing a balanced diet can
also help address reducing excessive body weight which has been shown to reduce the
prevalence of UI in obese or overweight women by 47% (Subak et al., 2009). Providing
adequate fluids also reduces the risk for urinary tract infections and decreases the
concentration of urine to provide less bladder irritation (Specht, 2011). The BPG suggests
that caffeinated and carbonated beverages should be avoided but also stresses that how
residents respond to these beverages varies so eliminating these from the diet may have no
effect on some residents while having an effect on others (RNAO, 2011a). By
recommending an adjustment in diet and fluid intake the number of UI events can be
reduced or eliminated.
The successful implementation of BPG recommendations is influenced by the
multifactorial elements pertaining to the nurse and the organization. Some of these
elements are systematic, related to policies, or environmental. Concordance of facility
policy with the BPG provide the nurse with practice guidelines that are both the best-
evidence based practice and the expected practice by the facility eliminating any conflict
that might amount otherwise (RNAO, 2011a). Adequate staffing and supplies enable PSWs,
RNs, and RPNs to be better care-providers through increased time with residents and the
necessary equipment to provide the best care possible. Adequate staffing is not always the
case though and directly affects the ability to implement BPG regarding UI. For example,
one PSW may be assigned up to 25 residents to care for, some of which may require care at
the same moment forcing the PSW to decide which resident to help first, potentially
PROMOTING URINARY CONTINENCE 8
causing the other to have an incontinent event instead of a successful void. Lack of
equipment can also create similar conflicts, especially when it is shared between multiple
areas of a LTC facility. Due to lack of funding, increasing staffing or buying more equipment,
may not always an option and alternative solutions need to be found.
The physical environment can also contribute to the nurse’s ability to implement the
BPG. Accessibility and size of bathrooms are not just barriers to the resident but also for
the nurse. When a facility is designed, built, or renovated, the size needed to maneuver
resident, wheelchair/walker, and/or lift should be considered. This can limit the strain
placed on the nurse while trying to physically aid residents into bathrooms and make it
easier for the resident.
A nurse’s attitude can affect how successful the intervention is. If the nurse feels
passionately about reducing the incidence of UI, then their compliance in implementing
prompted voiding will increase (RNAO, 2011a). This is especially true if the nurse believes
that the recommendation will result in positive outcomes for the resident (RNAO, 2011a).
The knowledge base of the nurse is also a critical factor in ability to properly assess risk
factors for the resident as well as different mechanisms for managing these risk factors.
Education of nursing staff to the different medications that can affect UI directly and
indirectly will aid in identifying them during assessment. Familiarity with BPGs for the use
of restraints, prevention of constipation, and fall prevention will also help the nurse
manage UI as these are intricately linked. Finally, the nurse’s ability to identify signs of
fatigue or burnout can reduce the risk to themselves and to their residents (Di Constanzo,
2013). Nurse fatigue can reduce the effectiveness and quality of resident care. Recognizing
PROMOTING URINARY CONTINENCE 9
the factors contributing to fatigue helps nurses create healthy work environments for
themselves and others (RNAO, 2011c).
Realistic Outcomes
Any reduction in the number of incontinent events should be considered to be a
positive outcome and depending on the factors contributing to UI this may be the only
outcome (Specht, 2011). The idea behind any intervention should be to maintain the
independence, health, and dignity of the resident especially in a comfortable manner
(Specht, 2011). By using the strengths of the resident the nurse can foster continued
growth and development which is essential to resident wellbeing (McMahon & Fleury,
2012). Also by reducing the number of incontinent events, the nurse can provide the
resident with a higher quality of life and reduce the burden on caregivers (Specht, 2011).
This reduction in UI can also save healthcare providers money by reducing the amount of
incontinent products that need to be purchased (Yoon et al., 2012).
Conclusion
As a healthy, young individual you take for granted the things that you can do for
yourself, like getting up to go to the bathroom when you feel the need. BPGs help nurses
make decisions about experiences or disease processes that they may not fully understand
from a physical or psychological aspect. UI is prevalent in LTC, reducing the quality of life
for many older adults. Through implementation of a prompted voiding schedule UI can be
reduced or eliminated and help to restore wellbeing to the residents life. BPGs if
implemented appropriately have the potential to create better care-providers that provide
better care.
PROMOTING URINARY CONTINENCE 10
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