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Joseph G. Ouslander, John F. Schnelle, Gwen Uman, Susan Fingold, Jennifer Glater Nigam, Edward Tuico, Barbara Bates-Jensen, 1995, in Journal of the American Medical Association, 273(17):1366-1370.
This report describes a simple, noninvasive assessment strategy that enables nursing home staff to identify incontinent residents who respond well to prompted voiding. Of the 191 residents in seven nursing homes who completed the demonstration trial, 41% were deemed responsive to the intervention. On average, their wet episodes dropped from 8.7 to 2.0 per day as a result of the intervention, during which research staff prompted them to use the toilet every two hours between 7 am and 7 pm.
The best predictors of responsiveness were the number of wet episodes and the appropriate toileting rate during the first three days of the trial. Residents who appropriately toileted 66% or more of the time or who were found wet on 20% or fewer daily checks maintained improved continence for an additional nine weeks of prompted voiding. The researchers recommend that nursing homes implement the three-day "run-in" trial to identify residents who are most responsive to prompted voiding. "Responders" should continue to receive toileting assistance, while the non-responders should be considered for further evaluation and alternative interventions.
John F. Schnelle, Cathy A. Alessi, Sandra F. Simmons, Nahla R. Al-Samarrai, John C. Beck, Joseph G. Ouslander, 2002, in Journal of the American Geriatrics Society, 50:1476-1483.
An incontinence care and exercise intervention called FIT, for Functional Incidental Training, resulted in significant improvements in physical mobility and continence for most residents who received the intervention. The staffing requirements needed to implement the intervention, however, are high and exceed the resources available in most nursing homes.
In this randomized, controlled trial, research staff prompted each of 94 intervention residents to toilet every two hours, five days a week, between 8 am and 4:30 pm. Before or after providing incontinence care, staff encouraged the residents to walk or, if nonambulatory, to wheel their chairs and to repeat sit-to-stands up to eight times. Once a day, each resident was given upper body resistance training. Before and after each care episode, staff offered fluids to residents. After 32 weeks of FIT, intervention residents maintained or improved performance on 14 of 15 outcome measures, whereas the performance of the 96 residents in the control group declined.
The mean time required to implement the intervention each time care was provided was 20.7 minutes. Consequently, one nurse aide for every five residents would be needed to implement the intervention. Less than 10% of the nation's nursing homes are staffed at this level. The researchers conclude, "Fundamental changes in the staffing of most nursing homes will be necessary to translate efficacious clinical interventions into everyday practice."
John F. Schnelle, in Comprehensive Clinical Psychology. Bellack AS, Hersen M. (Eds.) Pergamon, NY. 1998; 433-454.
This chapter describes the prevalence of urinary incontinence among older adults, discusses treatment options, and presents detailed guidelines for assessing and managing urinary incontinence among nursing home residents. Particular attention is paid to prompted voiding programs, the most extensively evaluated toileting assistance program for nursing home residents. The role behavioral healthcare professionals can play in assessing and managing incontinence is highlighted. The author also identifies areas related to incontinence treatment that need further study.
John F. Schnelle, Mary P. Cadogan, June Yoshii, Nahla R. Al-Samarrai, Dan Osterweil, Barbara M. Bates-Jensen, and Sandra F. Simmons, 2003, in Medical Care, 41(8):909-922.
Federal regulations require nursing homes to complete resident assessments periodically using the Minimum Data Set (MDS) assessment protocol. Results are used to generate quality indicators (QI) for each facility as a means of identifying poor outcomes in a number of clinical areas. But the use of QIs as a measure of quality of care is controversial due in part to concerns about the accuracy of staff-generated MDS data.
This study, conducted in 14 nursing homes, collected independent data that showed that the only two currently used MDS incontinence QIs--"prevalence of incontinence" and "prevalence of incontinence without a toileting plan"--do not reflect real differences in the quality of incontinence care provided to residents. None of the facilities, for example, evaluated residents' responsiveness to toileting assistance. Residents who received toileting assistance were comparatively less cognitively and physically impaired, which suggests that staff used invalid resident characteristics to determine who received services. Although facilities with better scores on both MDS incontinence QIs were more likely to document in medical records that residents received toileting assistance, there were no difference between homes in resident reports of the assistance they actually received. Across all facilities, participants capable of accurately reporting care activity said they received an average of 1.8 toileting assists per day (range 1.6-2.0), which is insufficient to improve urinary incontinence. There also were no differences in reports of received assistance between residents noted in the MDS as being on scheduled toileting and those who were not. This finding points to disturbing discrepancies between care documented and care actually provided.
Theodore M. Johnson, Joseph G. Ouslander, Gwen C. Uman, and John F. Schnelle, 2001, in Journal of the American Geriatrics Society, 49:710-718.
What treatments for urinary incontinence are preferred for nursing home residents? This study asked this question of frail older adults, family members of nursing home residents, and long-term-care nursing staff. Among all respondents, 85% "definitely" or "probably" preferred diapers, and 77% "definitely" or "probably" preferred prompted voiding to indwelling catheterization. There were, however, differences among the respondent groups. Nurses preferred prompted voiding to diapers more than did older adults or family members. Older adults, compared with family and nurse respondents, more strongly preferred medications to diapers. In open-ended responses, older adults (nine of them nursing home residents and 70 residential care residents) said they would choose a treatment based in part upon criteria of feeling dry, being natural, not causing embarrassment, being easy, and not resulting in dependence. The comments also indicated that older adults and families did not believe nursing home staff would provide prompted voiding often enough to improve continence. Because of the divergence of opinions among different proxy respondents, the researchers recommend that, when possible, nursing home residents be asked first for their treatment preference.
Sandra F. Simmons and John F. Schnelle, 1999, in The Gerontologist, 39(3):1-11.
This study compared four different interview strategies to measure 111 incontinent nursing home residents' "met need" related to incontinence and mobility care. In one method-perhaps the most commonly used strategy in nursing homes-residents were asked direct satisfaction questions (e.g., "Overall, are you satisfied with how often someone helps you to walk?"). A second method asked residents about their preferences for care (e.g., "Would you like for someone to help you walk more often?" "How many times during the day would you like someone to help you to walk?") The last two methods compared resident reports about how often they preferred to receive care to how often they actually did receive care based first on research staff observations (Method 3) and then on their own reports (Method 4). Incontinent residents who passed a simple cognitive screen (residents were asked to state their name or identify two common items) were interviewed.
Results showed that only 25% of the residents provided illogical responses, a finding that dispels the widespread assumption that only a small subset of cognitively intact residents can provide meaningful information about the care they receive. Of the four methods tested, the third method proved superior with respect to response stability. Method 1 yielded the most unstable responses. The third method also revealed comparatively higher levels of "unmet need," but by doing so, is considered more useful for guiding improvement efforts. The authors acknowledge that Method 3 is the most time-consuming to implement because it requires objective, direct observations of the care actually provided to residents. They argue, however, that this type of monitoring should be conducted at least annually in any case.
John F. Schnelle, Emmett Keeler, Ron D. Hays, Sandra Simmons, Joseph G. Ouslander, and Albert L. Siu, 1995, in Journal of the American Geriatrics Society, 43:1112-1117.
In this study, family members of nursing home residents and older board-and-care residents were asked in a written survey to compare the value of interventions that improve continence and mobility to other nursing home perks such as improved meals or moving to a more private room. By wide margins, the respondents rated the functional improvement programs higher than the other, more customary options. The top-rated programs were a physical therapy program that provides 15 additional minutes of supervised activity and exercise a day, an incontinence prevention program that cuts the number of wetness episodes in half for a resident, and a program that improves the amount a resident can walk by a few minutes a day. These services were significantly preferred to any of the bottom-rated, non-rehabilitative services, which included having one additional nurse aide on the unit during the day shift, moving from a triple room to a single, from a triple room to a double, and from double room to a single. The researchers point out that while nursing home consumers often complain about privacy and food issues, they rarely request services that improve continence and walking, most likely because they are unaware of such rehabilitative programs.
Joseph G. Ouslander, Nahla Al-Samarrai, and John F. Schnelle, 2001 in Journal of the American Geriatrics Society, 49:706-709.
Does prompted voiding improve continence at night? No, not according to this study, which attempted a nighttime toileting assistance program with 61 incontinent nursing home residents. Wetness rates remained relatively high at night-49%--while appropriate toileting rates were low-18%. Ideally, wetness rates should drop below 20% and appropriate toileting rates should be above 66%. Even residents who responded well to daytime prompted voiding showed poor results at night. The researchers recommend that night care be individualized, with the goals of minimizing sleep disruption and protecting at-risk residents from skin problems. Prompted voiding and other toileting assistance interventions should be reserved for those residents who are bothered by nighttime incontinence and who demonstrate, through a two- or three-night trial, their willingness to toilet at night.
John F. Schnelle, Patrice A. Cruise, Cathy A. Alessi, Nahla Al-Samarrai, Joseph G. Ouslander, 1998, in Nursing Research, 47(4):197-204.
An intervention that combined individualized nighttime incontinence care with a noise and light abatement program significantly reduced awakenings among 92 residents in four nursing homes. The intervention was developed in response to findings from an earlier nursing home study that found that 42% of nighttime waking episodes lasting four minutes or longer were associated with noise, light, or incontinence care activities.
For the intervention, incontinent residents were first assessed to determine their risk of developing skin problems. Nurses conducted hourly incontinence rounds and provided incontinence care only if a resident was found awake during the round. Residents at low risk for skin problems were allowed to sleep for as many as four consecutive hourly checks, but were awakened on the fifth if asleep. Residents at high risk for skin problems were allowed to sleep for only two consecutive hourly checks and awakened on the third if asleep.
The noise and light abatement program centered on common sense procedures such as closing doors to residents' rooms, fixing squeaky equipment, turning off unattended TVs and radios, and using table lamps instead of overhead lights when providing incontinence care. There were no adverse, intervention-related changes in skin health or most other risk factors associated with skin. The intervention also proved no more labor intensive to provide than usual care.
John F. Schnelle, Patrick McNees, Valerie Crooks, and Joseph G. Ouslander, 1995, in The Gerontologist, 35(5):656-665.
A computerized total quality management model was used to implement a prompted voiding incontinence intervention in eight nursing homes. Research staff measured resident wetness for one month, provided training in the implementation of the program in less than five days, and measured resident wetness for six months. Seven of the eight nursing homes significantly improved resident dryness for a six-month period. However, objective improvement in resident dryness was not a sufficient incentive for nursing home staff to maintain the program; extensive monitoring of the nursing home computers by modem and telephone feedback from the research staff was necessary to produce successful maintenance. The researchers cite frequent staff turnover in nursing homes as one impediment to maintaining the intervention. Lack of positive feedback for improved outcomes from both external surveyors and the residents themselves may also explain why nursing home staff backslide into old care routines.