Managing urinary incontinence.

Preface by Laura Bruck, the Cleveland-based science writer who conducted the interviews for this project: "During my brief tenure as a social services director at a 150-bed long-term nursing facility, discussion of incontinence at the weekly plan of care meetings was limited to 'Mary Jones is incontinent. She's being changed three times a day and has no decubiti.' Programs to reduce incontinence were never mentioned. The residents who could make it to the bathroom on their own or who were able to ask for assistance were the fortunate ones. But once a hip was fractured or confusion was detected, 'toileting' was reduced to diapers and Chux. My biggest battles were with the staff-not just nursing assistants-but LPNs and RNs who would frequently walk into the activity room or lobby and inquire loudly (to compensate fora presumed hearing deficit), 'Are you wet, Mr. Smith?' This was routinely done in front of friends, family and other residents, with no regard for Mr. Smith's dignity or privacy- in essence, humiliating him in his own home. Fortunately, things are beginning to change...."

Leading off this special section on just how they're changing, a conference call involving:

* Joseph D. Ouslander, MD, Medical Director of Eisenberg Village (of the Jewish Homes for the Aging of Greater Los Angeles) and Associate Professor in the UCLA Division of Geriatric Medicine and Gerontology.

* Julie L. Ditzler, RN, BSN, a Long-Term Care Consultant with Creative Nursing Management of Minneapolis, MN.

* Gary Brandeis, MD, Instructor in Medicine, Division of Aging, Harvard Medical School, and Geriatrician, Hebrew Rehabilitation Center for Aged, Beth Israel and Brigham and Women's Hospitals, Boston, MA.

What are some of the positive aspects of incontinence management in nursing homes today?

Dr. Ouslander: I can think of at least two. The first is the publication of the minimum data set (MDS) and the resident assessment protocol (RAP) which mandate that all nursing home residents undergo an incontinence assessment within 14 days of admission and then, quarterly. The second is an apparent decreased use of chronic indwelling catheters. There is a greater awareness of associated morbidity, and the OBRA legislation clearly requires justification for the use of these devices.

Dr. Brandeis: I agree that the impact of the MDS and RAP is a very positive one. Now that these assessments are mandated by law, we're forced to identify and document the magnitude of the problem. This will guide us in the development of future strategies.

Ms. Ditzler: I couldn't agree more. The MDS and RAP have helped nurses focus on the nursing process. I also think the training manual available to staff development people has a wonderful outline of the problem, triggers, and guidelines that prompts nurses to think about the etiology of incontinence rather than assuming it is a normal part of aging.

Dr. Brandeis: It is also significant that incontinence is no longer hidden. It's discussed on TV and in the news. Incontinence control products are readily available. All of this, hopefully, heightens awareness of the problem both inside and outside the nursing home.

What are some of the negative aspects of incontinence management?

Ms. Ditzler: The first negative aspect relates to the tremendous turnover rate among nursing assistants. It's extremely difficult for a nurse manager to develop a program and follow it through when there are daily changes among the people responsible for implementing those programs. The second is a lack of education for direct care staff, and even charge nurses, relative to the ramifications and etiology of incontinence. This has an adverse effect on the manager's ability to implement effective systems.

Dr. Brandeis: The impression that nursing homes are a backwater for medicine where the incontinent resident is merely diapered needs to be changed. The MDS is starting to reverse this impression, but we still have a long way to go. For example, nursing homes don't know yet how to implement the MDS and RAP.

Dr. Ouslander: And not knowing how to use the MDS and incontinence RAP is a major barrier to effective management; it creates a gap between our understanding of the assessment that should be done and the actual performance of that assessment.

Ms. Ditzler: I agree that there's a gap between some of the research and development of assessment systems, and their actual use at the bedside level. The brick wall that keeps us from reducing incontinence and enhancing quality of life is a lack of education.

How Should We Go About Alleviating These Problems?

Dr. Ouslander: We have several ideas. Dr. John Schnelle and I are involved in a computerized incontinence assessment and management system project that helps the staff do the assessment consistent with the RAP. We're testing it in several nursing homes to see how a computerized program will be received.

But any program requires input from the primary physician and, in many nursing homes, there just isn't enough physician involvement. At the very least, you need the involvement of a clinical nurse specialist, nurse practitioner, or physician assistant to carry out the MDS and RAPs.

Dr. Brandeis: I agree. The information is there but who will be best at implementing it still needs to determined. The MDS and RAP were originally aimed at the floor nurses, but additional investigation is needed to test if this is appropriate and feasible. Another approach is to have one skilled person help several nursing homes implement the RAP, make diagnoses and formulate treatment plans.

Ms. Ditzler: I agree that we need help, but I believe strongly in the capability of RNs and LPNs to address this issue. LPNs have tremendous skills that haven't even been tapped. Nurses have the skills and creativity to increase knowledge and implement systems, but they're impeded by a highly regulatory environment, and a lack of money and grants for education and research.

While I appreciate and support the difficulty of their job, regulators often give mixed messages. In my visits to hundreds of homes, I find that, rather than activating theft own knowledge and skills in addressing incontinence, nurses are more inclined to meet the criteria of the surveyor and worry about filling out forms properly.

We need to let the nurses and assistants know that they are valuable and to help them understand that in addition to being law, the MDS is a tool to help identify residents in need of nursing attention. It distinguishes between the resident with no control of the detrusor muscle-the most common cause of urinary incontinence-and the resident who would benefit from intervention beyond merely keeping the skin clean and dry.

Dr. Ouslander: In addition to the practical problems of implementation and a knowledge base, there are a number of attitudinal problems prevalent among both physicians and nurses that need to be overcome. I don't think physicians have viewed incontinence as an important problem, and when someone is admitted with a condition like incontinence, there tends to be a fatalistic attitude that nothing can be done. I also think there's an attitude among nursing staff that to actually do something is more difficult than merely diapering. And the only way to overcome those attitudes is with demonstrations of the success that can be achieved with proper diagnosis and management.

Ms. Ditzler: I think it's that fatalistic attitude that makes some primary care physicians reluctant to give nurses the orders they need for a good assessment. A good nurse who is able to articulate the purpose of outcome can change that by discussing with physicians what can be gained from lab work or clamping off a catheter for bladder retraining.

But I also think that fatalistic attitude is decreasing. The acuity level of residents is changing-that is, more acutely and chronically ill residents are requiring a higher level of care. This presents the nursing home with a new challenge: providing everyone with the opportunity for an incontinence assessment and setting up systems to keep skin free of breakdown while maintaining residents' dignity.

Dr. Brandeis: You have to prove to the staff that all of that can be done efficiently and easily, and show them how they will benefit as well as the resident.

What do you view as the greatest needs in meeting OBRA requirements?

Ms. Ditzler: OBRA wanted to address four major areas. The first is a comprehensive standardized care planning process, and the MDS requires nurses to revisit the nursing process relative to the new law. I help homes redesign their care planning process and understand the entire comprehensive care process. It's really the system, not the staff, that isn't designed to raise quality of care in most homes.

Second, introducing the 75-hour nursing assistance course gave recognition to the need for a greater level of education to serve higher acuity levels of residents; to equip the staff for the physical and emotional aspects of the job; and educate them with respect to individual needs, aging, physical and psychosocial issues. Failing to continually upgrade the education of nurses and nursing assistants does them a real injustice.

The third issue is total quality management, which I define simply as care that meets the expectations and needs of residents and their families. Each nursing home needs to look at its entire system to determine how it ensures they are delivering the best possible service. This is an ongoing process.

The fourth area, residents' rights, sends the message that the nursing home is clearly the residents' home and that their needs must come first. When Dr. Rosalie Kane looked at daily problems of individual nursing home residents, she found that we have a false sense of what residents value and need. So we need to find out what the individual resident values as determining quality of life.

Dr. Ouslander: The first need is for trained personnel and more knowledge. Again, not only for the incontinence RAP, but for most of the others as well. We also need physician backup from a geriatrician or someone interested in geriatrics and long-term care. The RAPS are excellent but you can't just hand them to someone and expect them to perform without the skills or knowledge to implement them. And I think the RN who is trained to handle the RAPS would really become a clinical nurse specialist by virtue of that training.

So we also need attitudinal changes, management systems to help target the residents most likely to respond to particular interventions, and quality assurance mechanisms. That's part of what Dr. Schnelle and I are attempting to do with the computerized program.

Right now in nursing homes, there are a number of programs on paper that aren't, in fact, reality. These need to be made more visible in the "real world," with better ways to assess outcomes of care and to monitor those outcomes and make sure that a range of treatment programs is being conducted according to individual needs.

Ms. Ditzler: Any nurse in the industry will admit to doing many things for paper compliance simply because surveyors want to see them. We do indeed need a dramatic shift from designing care plans to please surveyors to designing plans that meet the needs of residents and drive the quality of care.

Dr. Ouslander is right about the need for assistance, as well. I've consulted in many homes where the RAPs aren't understood. Appropriate incontinence management takes an understanding of management and systems and nursing process, but it doesn't need a full-time nurse specialist to implement.

There is, in fact, a great market for nurse consultants to help smaller homes that are unable to hire a full-time nurse specialist. This is basically what I've been doing. Sometimes it takes someone from the outside to say, "Your system isn't working, here's why, and here's how to change it." I've seen this work very successfully.

Regardless of what system is put into place, it should be remembered that, if it's taught to only one person, you run the risk of losing the entire program if that person should leave. So it's a much safer idea to teach any new system to all the key staff.

What technology, technique, or other factor will be the greatest hope for the future?

Dr. Ouslander: Nursing home residents are extremely heterogeneous. Some are truly there to die, and intensive assessments and treatments for something like incontinence is probably inappropriate. There's another group of residents - those with dementia, mobility problems, a number of chronic conditions - for whom the greatest technology in the world will do no good unless somebody helps them get to the toilet in a systematic matter.

Then there is a smaller subgroup of residents who might benefit from newer technologies. I, for one, feel there's quite a bit of room for developing better pharmacologic agents and delivery systems. There are devices that can be tested, such as electrical stimulation-a still highly experimental technology-that might provide some benefit. There are also newer technologies in simple containment devices, such as external catheters for men and women. There's enough industry interest that a number of products are being developed. There are also some simple surgical procedures on the horizon. Some residents, for example, might benefit from periurethral collagen injection if that's ever approved.

Dr. Brandeis: Once again, I agree with Dr. Ouslander. But returning to the education issue, we need to target the appropriate candidates for the appropriate interventions. While a diaper is probably all that should be done for the resident at the end stage of life, we shouldn't discount the others just because they are in the nursing home. As technology becomes available, we need funding to investigate its appropriateness and efficacy in the nursing home setting.

Currently, I don't see any specific technology that should be operating in the nursing home to manage incontinence. I think additional education and knowledge need to precede any new device.

Ms. Ditzler: To that end, we need much more nursing research in long-term care. Unfortunately, geriatric education is sorely lacking in nursing school curriculums. And while drug therapy has its place, we need more self-help devices and newer techniques - maybe some sort of stimulation or implant - that hasn't been attempted because of a lack of focus on research in geriatrics. We also need an increase in professional nurses in long-term care, Right now, only 3% of RNs work in the field.

How optimistic are you about the future?

Dr. Brandeis: I'm very optimistic. The MDS and RAP have arrived. We need to spend more effort working with them. As evidenced by articles such as this one, the nursing home is slowly changing to an area of medicine in which clinicians are interested. Hopefully this trend will continue and grow.

Dr. Ouslander: I'm also optimistic for the same reasons. The MDS and RAPs may be viewed as an intrusion into clinical practice, but I think they're really pretty well thought out and will help_and, while this may sound somewhat negative, we certainly have lots of room for improvement in incontinence management.

I'm also optimistic that we can get physicians and nurses educated. I like to think that our computerizing the incontinence module is another cause for optimism.

Ms. Ditzler: I can't begin to tell you how optimistic I am. By the year 2000, four of five families will be affected by long-term care. Therefore, much more attention will be paid to the challenges facing the nursing home industry. That is sure to encourage new ideas, research, education, and technologies.

Also, while throwing money into the system doesn't necessarily ensure quality, devoting a certain amount to helping make hospital and nursing home salaries more equitable will attract quality nurses. That's beginning to happen, and is a significant cause for optimism.