Step 2: Assess Prompted Voiding

Prompted voiding has been touted in nursing homes for more than a decade, yet misconceptions still abound about which residents respond best to this highly effective intervention. It’s time for a reality check.

Myth: Only the most cognitively intact incontinent residents respond well to prompted voiding.
Reality: Many incontinent residents with severe cognitive impairments have proven responsive to prompted voiding, with significant reductions in their wet episodes. Indeed, in a study designed to identify predictors of successful prompted voiding, we found no significant differences on Mini-Mental State scores between responders and non-responders (1). In short, cognitive status is not a reliable predictor of responsiveness to prompted voiding.

Myth: Able-bodied incontinent residents are the best candidates for prompted voiding.
Reality: Ability to ambulate and other measures of a resident’s functional status are not good predictors of responsiveness to prompted voiding (1). The reason why the most physically fit residents are usually the most likely to receive prompted voiding is that it is less time-consuming for the staff to assist these residents to the toilet. More impaired residents often respond just as well but are not given the chance.

Myth: There is no reliable and feasible protocol that accurately predicts a resident’s responsiveness to prompted voiding.
Reality: There is such a protocol (1), and it works like this: Provide prompted voiding to incontinent residents for a few days, and then analyze the results. Those who use the toilet appropriately at least two-thirds of the time are “responsive” to the intervention; those who don’t are “unresponsive.” The rationale behind this “run-in” approach is simple common sense: Residents either respond to prompted voiding, or they don’t, and there is no reason to expect different results unless there is a significant change—for better or worse—in the resident’s condition. 

Results from our study on predictors of successful prompted voiding prove the point. Findings showed that a resident’s appropriate toileting rate during the first three days of the intervention was a better predictor of longer term responsiveness than either the resident’s cognitive status or functional ability (1). Functional status measures failed to identify a substantial proportion of residents who were responsive, and in a finding that bears repeating, cognitive status was not at all related to responsiveness. By comparison, an appropriate toileting rate higher than 66% accurately identified the most responders while screening out the most non-responders.

We recognize that translating this finding into daily practice is challenging, but if you have ever imagined yourself in the slippers of one of these frail residents, you’ll see something to celebrate here. Our findings suggest that the human spirit is so resilient that it can manage to triumph—in an unpredictable fashion—over the most severe bodily onslaughts. So in one of the last places many of us would have thought to look for it, we find dramatic evidence of what could be called hope for a better life.

A three-day trial of prompted voiding not only identifies residents responsive to the intervention but also generates data that answers these questions:

• Is a resident motivated to be continent, but not responsive to the prompted voiding protocol because of problems with the lower urinary tract? And if so, can these problems be treated?
• Does a resident have mobility or cognitive problems that preclude safe independent toileting and can these problems be treated?
• What form of urinary incontinence measurement is best for the resident who does not appear to be either a candidate for further treatment or who appears to not want further treatment?

Interview residents pre- and post-trial to assess motivation and preferences
Before starting the trial, a licensed nurse should interview participating residents to assess their motivation to toilet and to identify their preferences for toileting assistance. Use our Toileting Motivation and Preference Assessment form to guide this six-question interview and record responses. The same six questions with the addition of a seventh (also included on the assessment form) should be asked again upon completion of the three-day trial. Our research shows that residents who score two or more on the Minimum Data Set (MDS) recall scale are capable of providing reliable and meaningful responses to these interview questions. Residents who fail this cognitive screen should be excluded from interviews but should still undergo the prompted voiding trial.

The Minimum Data Set Recall Scale

Location: Section B on the MDS, Cognitive Patterns, item 3.

Procedure: Nursing home staff who know the resident should rate the resident’s ability to reliably recall the following (in the last seven days): (a) current season (b) location of own room (c) staff names and/or faces (d) that he/she is in a nursing home. Residents receive one point for each item to yield a total score between 0 (unable to recall any of the four items in last seven days) and 4 (able to recall all four items).

Residents who score two or more should be interviewed about their preferences for incontinence care.

Prompted voiding affects behavior by heightening residents’ awareness of their continence status and encouraging them to ask for toileting assistance. Five steps describe the protocol, which nurse aides should implement for three days, recording results on our Prompted Voiding Trial form.

1. Contact each resident every two hours from 8 a.m. to 4 p.m. (i.e., four times per day).

2. Focus the resident’s attention on voiding by asking whether he or she is wet or dry.

3. Check resident for wetness and give feedback on whether the resident’s self-report was correct or incorrect (e.g., “Yes, Mrs. Jones, you are dry.”)

4. Whether wet or dry, ask the resident if he or she would like to use the toilet (or urinal).

    a. If yes:

1. Assist him/her with toileting.
2. Record the results on the bladder record.
3. Give the resident positive reinforcement by spending an extra minute or two conversing with him or her.

    b. If no:

1. In the event they have not attempted to void in the last four hours, repeat the request to use the toilet once or twice before leaving, and follow step 4(a) if an affirmative response is received.
2. Inform the resident that you will be back in two hours and request that the resident try to delay voiding until then.

5. Record results of each wet check and toileting attempt on our Prompted Voiding Trial form.  After the trial is completed, remember to re-interview residents using our Toileting Motivation and Preference Assessment form.

The prompted voiding trial is an opportune time to complete any urinary incontinence assessment tests that are still outstanding. If you haven’t already done so, take this time to:

• Collect urine for analysis, particularly for residents with a new onset of incontinence

• Measure a resident’s post-void residual, particularly for residents with symptoms of incomplete voiding such as trouble initiating voiding or they report feeling that they have not completely emptied their bladder after a void.

• Conduct a pad test for stress incontinence

Time-Saving Tip: Shorten the prompted voiding trial to two days. Three days is ideal; two days is an acceptable minimum; however…on the third day of prompted voiding should be offered to all residents who fall short of appropriately toileting 66% of the time but who show behavioral and verbal evidence that they are motivated to stay dry.

A resident’s appropriate toileting rate during the trial period determines whether he or she is “responsive” to prompted voiding. To calculate this rate:

• Divide the total number of successful toilets by the total number of toilets plus the number of incontinent voids. Multiply the quotient by 100 to convert it to a percentage.

Residents with appropriate toileting rates at or below 66% seldom show responsiveness with longer term applications of prompted voiding.  Treatment options for these “non-responders” should be based on their behavior during the trial.  Non-responsive residents who express a willingness to improve continence should be further evaluated to identify problems that are potentially treatable by other interventions.  

 As a general rule, any resident who attempts to toilet two times a day, even if unsuccessfully, should be considered motivated to stay dry and should thus receive a follow-up evaluation and after that, another prompted voiding trial.

About 10%-20% of non-responders will show no willingness to improve continence. In interviews, they express no desire to be either changed or toileted more frequently. In prompted voiding trials, they show or verbalize that toileting assistance is unwanted. These residents should be placed on a check-and-change program. No research findings to date suggest that other treatments will be more successful.

Nursing homes that act now to incorporate a toileting assessment into their incontinence management routines will be ahead of the game: The new Minimum Data Set (MDS) assessment instrument, version 3.0, slated for national implementation in October 2009, is expected to include two related items: whether the resident was offered a trial of a toileting program and, if so, how the resident responded (5).