Trends in improved incontinence management.

Products are improving, but how they're used is the key and staff has the key

Though new products and devices continue to develop, the most recent advances in nursing home-based urinary incontinence management have had more to do with increased knowledge and more effective approaches on the part of staff. These advances are, specifically, a growing interest in primary care nursing and more thorough resident assessments prompted by OBRA's MDS and RAPs.

Over the past two to three years, the primary care approach to nursing has been growing in popularity and is one of the most significant advances we've seen in years with respect to enhanced quality of all aspects of resident care, including incontinence. At our six nursing facilities, we've implemented what has proven to be an extremely successful primary care approach that centers around a continuing, consistent relationship between the nurse-caregiver and the resident. Rather than being continually assigned to a different group of residents, our nursing assistants now care for the same residents each day. Over the course of a pay period, those nursing assistants truly begin to know the residents assigned to their care and become familiar with their habits, their voiding patterns and their idiosyncracies - all of which improves incontinence management a great deal.

In the long-run, this type of approach can also result in cost savings, since use of incontinence products is much more efficient when it is tailored to residents' specific needs - e.g., a washable brief with a disposable pad for the resident known to be a "dribbler," as opposed to a superabsorbent product for the resident who produces large volumes of urine and requires frequent changes.

Because the nurse with a relatively fixed caseload has a better understanding of the individual needs of each resident under his/her care, primary nursing also helps to ensure the optimal preservation of residents' dignity This is far preferable to a system in which residents are repeatedly queried about their toileting habits by "strangers" who appear on different shifts.

True, there are still those who feel that the primary care approach is not applicable to long-term care. On the contrary, there is no setting more appropriate for this. Where is there greater need for the nursing staff to become well-acquainted with the individuals in their care, especially since many will live out the remainder of their lives in the facility? Doing so can only improve quality of care, not to mention job satisfaction.

We are also beginning to see the positive effects of the MDS and RAPs, as implemented in 1990. The requirement to develop a medical care plan as part of the resident assessment instrument has drawn more physicians into the incontinence care picture, increasing both their level of knowledge and involvement. Nursing personnel have also become better educated and more conscientious about follow-up as their awareness of incontinence and its problems has increased. This has helped to offset what is still a significant shortage of nursing assistants nationwide.

The implementation of the revised MDS 2.0 (assuming it survives Washington budget conundrums) will lead to greater sophistication with respect to diagnosing incontinence, assessing residents and developing bowel and bladder programs. MDS 2.0 includes several more items to consider in assessing the incontinent resident than did its older counterpart, and the section on determining the cause of incontinence has been expanded to provide much more in-depth evaluation.

Anticipating this new standard, many nursing homes have developed better programs for managing incontinence - e.g., structuring programs to identify those residents for whom the cause of incontinence might be best suited to "rehabilitation." If a resident is deemed to be a good candidate for bladder retraining, for example, attention can be focused on voiding patterns so caregivers can develop toileting programs specifically timed to avoid accidents. If it is determined that a resident's incontinence has a physiological or neurological basis that cannot be corrected, attention can be focused on identifying the product or products that best meet the resident's needs. Primary nursing is neatly suited to this. As in so many areas of nursing home care, inservices are essential. At our facilities, a corporate education coordinator monitors all programs and seminars on this topic, and we select staff members to attend based on their areas of expertise and interest. We also purchase a number of videos and other educational materials to supplement our training.

Such training, as important as it is for our licensed nursing staff, is absolutely essential for our nursing assistants. It is they, of course, who ultimately perform the bulk of incontinence care. Nursing assistant training is an area that still needs a great deal of strengthening in most nursing homes across the country.

As for incontinence care products, while there have been few technological breakthroughs in recent years, their quality and availability have increased markedly. This supports the primary nursing approach in allowing us to better select products with the needs of each resident in mind and adapt a particular system to meet a resident's particular needs. Some companies are working on new products and devices designed specifically for women who, of course, comprise the vast majority of the nursing home population and pose greater challenges in this area than do men. Unfortunately, however, none that I am aware of has proven cost-effective to date.

Most of the surgical interventions being developed for incontinence seem to be geared toward treating alert, active, community-dwelling individuals. However, an increasing number of physicians, primarily urologists, are working to develop more effective modalities with which to treat or cure incontinence in all settings. This is, no doubt, a positive trend. But when - or if - those modalities become clinically feasible for the nursing home population, the emphasis must remain on better resident assessment and more complete education of the nursing home staff.

Indeed, nursing has a priority role. While increased physician involvement is invaluable, in my opinion, it is the licensed nurse who needs to direct care at every step: the planning process, implementation of care plans, determining what works and what does not, and finding alternatives when strategies and products prove inappropriate or inadequate.

Julie Ditzler, RN, BSN, is Executive Administrator of The Thro Company, a Mancato, MN-based provider of long-term services in skilled nursing care.