Update on a computerized approach to incontinence management.

The ongoing feedback of a computer has trained staff in dramatically reducing episodes of urinary incontinence 

Nursing homes are increasingly pressured to offer quality care and manage an array of regulatory requirements that often strain staffing resources to the limit. Training nursing home staff to meet the various requirements is also time consuming and expensive. Moreover, providing training and in-service programs and management to nursing home staff is an ongoing responsibility. Comprising two-thirds of the nursing home work force and nearly all direct care in the nursing home, well-trained nursing assistants (NAs) are particularly essential to good resident care. Training and management programs should, therefore, be geared toward providing NAs with the critical skills and technologies they need to provide quality care.

In line with this, we have developed an innovative and successful example of a training and management program for urinary incontinence, based on computerized information. We published an initial report on this in a recent issue of Nursing Homes ("Prompted Voiding Enters the Computer Age: Report on a Work in Progress," March 1993, p. 28). As indicated then, the computer has enabled us to move to a new level of in-service training effectiveness.

Traditional Models of Training

Traditionally, the goal of training in a nursing home has been to provide general information through in-service programs and limited on-the-job training. The methods for training often are offered in discontinuous increments through lectures, occasional workshops and rare off-site training sessions in private or academic settings.

In addition, some in-service training is conducted because of OBRA requirements and other regulations. Many of these requirements are becoming increasingly more outcome-oriented, such as the Minimum Data Set (MDS) forms and the Resident Assessment Profiles (RAPs). This has led to an increasing demand for results-oriented training and programming.

Because of its cost, the effectiveness of training is another growing consideration. It is essential that staff time be spent on training strategies that will make a difference in resident care.

To date, there is virtually no research evidence in long-term care literature that suggests that traditional strategies have resulted in either persistent skill improvement or quality care. What is needed in today's long-term care is a training strategy that can make quick and specific changes in staff behavior, demonstrate changes in residents' well-being and provide a system for ongoing maintenance of the program.

Modern Training Criteria

To alter staff's behavior -- particularly that of direct line staff, such as nursing assistants -- the training and management program needs to incorporate tasks that make a difference in resident care and in the work role. The technology used to deliver this training needs to be practical, allow independence, provide rewards and be linked to resident outcomes. The training strategy must ensure that the standards of work are well-articulated and quality control is perceived as a part of work responsibilities. Finally, providing opportunities for NAs to be a part of a decision-making process and regular feedback is also helpful.

These are the criteria guiding the computer-aided Incontinence Management System (IMS |C~), which was implemented recently at Maple Leaf Health Care Center in Manchester, NH.

Developing the Program

Pre-Training Phase

When it was first suggested to the nursing home staff at Maple Leaf that they would have the opportunity to become specialists in the management of urinary incontinence, their initial response was skeptical and less than enthusiastic. As direct caregivers, the nursing assistants needed to "buy in" to the program and see it as their own responsibility to make it succeed. Consequently, to further sensitize staff, information was given to them regarding the negative impact of incontinence on residents. They were also shown research findings indicating that the new program actually reduced incontinence for many residents. Because they were going to be trained in a direct "hands-on" technology which had been proven to positively affect the health of residents, staff felt motivated to "buy in."

That motivation was greatly enhanced when the staff learned that two of the nation's leading experts on incontinence -- Drs. M. Patrick McNees and John Schnelle -- were enlisted to do the actual training, specifically, two-and-a-half days' worth. As a further motivational factor, the incontinence management program was easily incorporated into the federal requirements of the MDS, which must be completed for every resident. When incontinence is identified and linked to the RAPs (Resident Assessment Protocols), it must be addressed in the resident care plan. The computer-aided incontinence management system provides a specific approach to address incontinence and can be incorporated in the care planning process.

Next in the pre-training phase, nurses and nursing assistant roles were assigned for the training and for implementation of the program. Specific roles included an internal consultant, a quality control specialist, supervisors, a data entry person, and a team of NAs to initiate prompted voiding. Personnel were selected based on their expertise and availability.

The most difficult position to fill was that of the data entry person. Since the goal was not to increase staffing for the program, a nursing assistant who had basic computer knowledge was identified. This nursing assistant was the best possible candidate for the job. She had a good working relationship with her peers, served as a role model and boosted the morale of fellow nursing assistants.

All staff involved with program training and implementation were then given reading assignments. During the week prior to implementation, a tentative training schedule was generated and the staff's work schedule was established. The computer hardware and software were also installed.

Training Phase

On the first day, one-half hour was spent with administrative staff for a brief overview of the two-day intensive training schedule. At 7:00 a.m. the training in the computer-aided Incontinence Management System |C~ began. Nursing assistants were given background information and an explanation of the program. Briefly, the program involved training staff to apply the prompted voiding procedure to incontinent residents and to enter assessment data and quality control check data in the computer. The prompted voiding procedure requires the performance of four tasks every two hours with incontinent residents. The tasks are: 1) asking residents if they are wet or dry; 2) checking incontinent residents for wetness; 3) prompting them to toilet; and 4) praising appropriate toileting. On a simple assessment sheet, the NA circles whether the resident was wet or dry, and notes the time, toileting, whether the resident was correct or not in identifying wetness, and whether the void was continent or incontinent. By entering this information in the computer -- sometimes immediately, sometimes at the end of the shift -- during a six-day assessment, residents are identified who can be placed on the prompted voiding program. About 40% of the residents have been so identified. A control chart is then generated by the quality control manager who conducts regularly scheduled wet checks of residents. She enters the data in the computer to manage, monitor and evaluate the ongoing application of the procedure.

To facilitate the education and acceptance of the program, the sessions were structured but marked by informality, with trainers and staff on a first name basis. The training was also enhanced by having buffet food service available throughout the program, without regard to scheduled meal breaks and free to all staff. Paying attention to such seemingly small details prevented disruption of valuable training sessions, and kept appetites satisfied.

For the actual training in the prompted voiding procedure, hands-on demonstration with the NAs at the resident's bedside was conducted. The trainer worked with the staff by modeling the procedure, and providing instruction, valuable reinforcement, and positive feedback when the NAs performed the procedure themselves.

At the same time, nursing staff were learning how to use the computer software program and conduct quality control checks. The software was designed so that there were two components: one program which was the "play" model, and one which was "real." Using a "play" model, with no real consequences for mistakes, eased the acceptance of the program. NAs could actually have "hands on" experience with the computer by entering data and printing out some graphs. Nursing staff came away with a feeling of accomplishment and fewer fears of making mistakes or damaging the computer program.

The first day of training continued through last rounds at 7:00 p.m. The nursing assistants had a two-hour overlap of their shifts in the afternoon, with the afternoon NAs coming in one hour early and the day aides staying one hour late. After a brief educational session at 2:00 p.m., the evening NAs were brought to the nursing units and trained in prompted voiding by the day NAs. On the second day the training sessions began at 7:00 a.m. and again continued until 7:00 p.m. On this day, the trainers acted only as advisors. Essentially on their own, staff knew that help was readily available, if needed. More residents were added to conduct initial prompted voiding assessments that day and the nursing assistants were provided with positive reinforcement. Computer and quality checks training was also continued. It is important to note that the night shift aides and professional nurses were also exposed to these initial sessions. Having all of the nursing staff in the facility trained in some way gave them an understanding and enhanced acceptance of the program. Late in last morning, all of the staff trainees were brought together for a final session. At that time they were given a final review of the entire program. The staff also were presented with certificates signed by both trainers verifying completion of "A Program in the Management of Urinary Incontinence" with 20 contact hours. The certificate was something personal for them to keep as a reward for their efforts, but also was a valuable means for them to attain continuing education credits.

That afternoon the trainers gave a presentation to invited guests, members of the community, and other staff. In this way, a broad audience had an opportunity to be educated and understand what was required for the program to be successful over time.

Maintenance Phase

The program is now in the hands of the staff at Maple Leaf Health Care Center. They have been working with it for about one year. The major long-term concern has been keeping the nursing assistants focused on the program, carrying on with the assessments and prompted voiding protocol. By conducting ongoing control checks, the quality control nurse has been the prime motivator behind the nursing assistants. She provides staff with regular computer-generated reports, encouragement and assistance as well as positive feedback. She posts graphs for staff to visualize their own progress, or lack of it, and keeps a running log of events, performing comprehensive data analysis. Another nurse has designed graphs to show progress of individual residents. All of this data can be incorporated into the MDS.

As a reminder of the initial staff training phase and aimed at motivating the staff further, a collage was displayed with photos showing the staff and trainers at work during the training sessions. An engraved tribute to staff from the trainers is also displayed. Each staff trainee also received a personal letter of commendation for participation in the program.

Successful Outcomes

The program's success can be demonstrated in observable positive changes in residents, nursing home staff and in the image of the nursing home itself.

In general, the staff have noted that residents on the program are more alert, responsive to staff and, increasingly, to their total environment. Initially, wet rates for the residents selected for the prompted voiding program started at 37%. The wet rates quickly dropped to 20%, then gradually lowered to about 10% for a period of time. After nine months in the program, wet rates lowered to 4%. After a year, they remain at between 4 and 6%.

As another outcome measure, one month prior to instituting the incontinence management system, a survey of urinary incontinence was done in cooperation with the New Hampshire Health Care Association. This assessment was based on the Category D definition of urinary incontinence in the Minimum Data Set (MDS). Category D is defined as those residents with multiple daily incontinent episodes. Maple Leaf Health Care center had 44 residents listed in Category D. One year later the number of residents listed in that category had dropped to 32.

Success can be measured in individual achievements as well. A 93-year-old resident had been wearing an incontinent brief and had been non-ambulatory prior to the prompted voiding program. Since the start of the incontinence management program, she has become mostly continent during the day time, wearing ladies briefs with a panty liner during the day. Through this accomplishment she has improved her self-esteem, is less depressed, and has started feeding herself, something she had not been doing for some time. Her mental status has improved dramatically as a result of increased and improved interactions with staff and peers. She is more alert and active, and is now able to ambulate with her walker a distance of 200 feet.

All levels of staff have benefitted from their involvement in the program. Satisfaction is gained in watching wetness rates drop, in observing individual performance rates improve for nursing assistants, and most importantly, in witnessing the positive benefits to residents. This may be one explanation why the staff turnover rate at Maple Leaf is lower than at other Lemire Enterprises' Facilities. Only two out of twenty-one employees involved in the initial training have since resigned from Maple Leaf.

Nursing assistants, in particular, have been noticed by supervisory staff to have improved self-esteem and a demonstrated pride in their ability to conduct the program. When the facility received the New Hampshire Health Care Association's 1992 Quality Commitment Award, nursing assistants were chosen to give an oral presentation describing the program and exhibiting their success on graphs to a group of 100 Association members.

The image of the nursing home has been enhanced, as well, having received recognition for its urinary incontinence training efforts from the ownership, sister facilities, and the New Hampshire Health Care Association and the American Health Care Association.

The ongoing positive impact for the residents, staff and the nursing home of this innovative and effective training and management program has been demonstrated. The implications for the future are for a committed staff and a sizeable number of drier and more responsive residents who have demonstrably improved quality of life.

Other Applications Coming

Though the computerized system described in this article has first been applied to and evaluated with incontinence, it should have general applicability for a wide variety of resident care needs. Other modules currently under development or planned for near-future development include: Exercise/Fitness; Nighttime Incontinence; Nutritional Intake/Body Weight; and Pressure Sores. Each module not only will tie into a central resident data base, but will be capable of sharing information with other care modules. A computer-assisted quality improvement system is also currently under development for the IMS |C~. Meanwhile, the IMS |C~ is currently in use in three nursing homes in Iowa, two in Alaska, three in Washington, three in California and two in New Hampshire. Cecile Menard, RNC, MHA is Director of Marketing and Resident Relations for Lemire Enterprises and Assistant Administrator of Villa Crest Nursing Home, both in Manchester, NH. Valerie Crooks, DSW, is Project Director of IMS |C~ North Rim Systems Issaquah, WA, (206-938-8738) and Research Associate at the Borun Center for Gerontological Research, UCLA. M. Patrick McNees, PhD is Director of North Rim Systems. John F. Schnelle, PhD, is Director of the Borun Center for Gerontological Research, UCLA.