**6. Implications for clinical practice**

#### **6.1 A comprehensive UI assessment**

Given that UI can result from a multitude of interwoven contextual origins "including anatomic, physiologic, pathologic, and external factors" (Parker, 2007, p.70), a comprehensive UI assessment is essential for quality and holistic care for elderly women in LTC experiencing UI. The importance of conducting a comprehensive UI assessment comprised of history taking and physical examination, medication review, fluid intake patterns, a voiding diary, details about UI such as voiding patterns, use of urinary bladder stimulants or irritants, environmental factors, type of UI experienced, and responding to questions about UI is evident in the literature (Benne, 2008; Borrie et al., 2002; Bucci, 2007; Parker, 2007). A voiding and intake diary is an example of one tool that is considered useful in assessing an individual's frequency, time of urination, fluid intake, and number of

Elderly Women and Urinary Incontinence in Long-Term Care 103

upon the quality of continence care elderly women receive in LTC (Du Beau, 2006; Palmer, 2008). Empowering elderly women to regain UI requires education and a shift from providing task related care to incorporating holistic care and opportunities to dialogue with healthcare providers (Lekan-Rutledge, 2004). Empowerment is the practice of assisting individuals to establish control over factors that impact their health (Lau, 2002). Empowerment implies that individuals will assert control over their lives, thus optimizing independence with the support of healthcare providers serving as advocates (Jones & Meleis, 1993). Empowering women to actively participate in their care may lead to

There is a need for educating the public and healthcare providers to dispel the myths and taboos that UI is a normal part of aging, and that the implementation of incontinent products is not the only option or successful solution for UI (Stewart, 2010; Shamliyan et al., 2008). Knowledge regarding alternatives to incontinent products such as habit training, regaining mobility, Kegel exercises, self-management strategies, medications or medical management maybe considered is critical for healthcare providers working in long- term care. Sharing information about possible health promoting interventions and management strategies with women experiencing UI in LTC may provide them with hope for trying alternative methods to incontinence products, while empowering them to make choices and inform decision-making about their continence care. There are too few healthcare providers communicating to the public that UI is treatable, controllable, or preventable (Du Moulin et al., 2009; Zeznock et al., 2009). If more public education and awareness were provided, individuals entering facilities such as long- term care would be better able to manage and understand UI, which in turn potentially may assist in dispelling ageism and ageist

Ageism is a form of discrimination against the elderly causing labelling and stereotyping as a consequence of chronological age (Ward, 2000). Ageism impedes self-esteem and independence, which can lead to marginalization and unsubstantiated assumptions concerning the elderly. Ageism can be manifested by the attitudes of the staff, language used by the staff, lack of decision-making power by women, and lack of decision-making choice by women regarding their incontinent care, such as types of products worn, toileting times, or changing of incontinent products (MacDonald & Butler, 2007). Healthcare providers need to be attentive and reflect on their own attitudes, beliefs, and feelings towards the elderly (Zeznock et al., 2009), given that it dramatically impacts the provision of care, and consequently the self-esteem and psychosocial aspects of the elderly individual (Palmer, 2008). In addition, healthcare providers should be cognisant of their non-verbal and verbal communication, which potentially reinforces ageism. Implementing active therapeutic communication skills are vital for advocating the needs of women experiencing UI in LTC. There exists a lack of knowledge in healthcare providers' perspectives regarding the unique needs of elderly, especially with regards to the provision of individualized and

Managers are responsible to ensure that their staff is educated about ageism, and it's manifestations in the work place. Managers could also foster a work environment whereby

managing incontinence more efficiently and effectively (Roe, 2000).

sensitive incontinent care (DuBeau et al., 2007; Zeznock et al., 2009).

practices in LTC.

**6.4 Dispelling ageism in LTC** 

incontinent episodes (Nitti, 2001). The outcome of this tool supported staff in long- term care to better understand and manage UI.

A thorough and comprehensive assessment of the underlying contributing factors of UI, and the identification of the type of UI experienced are pivotal in determining appropriate interventions and treatment modalities for those experiencing UI (Benne, 2008; Borrie et al., 2002). Possible outcomes of a thorough comprehensive UI assessment may include individualized targeted interventions and approaches that can lead to improved bladder control, and subsequently, a decrease in the frequency of UI (Benne, 2008). An individualized UI care approach, using multiple interventions is recommended that can assist in improving the QoL of elderly women experiencing UI in LTC (Benne, 2008; Borrieet al., 2002; Bucci, 2007; MacDonald & Butler, 2007).

#### **6.2 Individualizing UI care**

 It was apparent from the literature that continence care is comprised of rituals and routines evidenced by scheduled toileting regimes, quotas of incontinent products and procedures for changing of incontinent products. These findings suggested the need for individualized and sensitive continent care for women living in LTC. Individualized care embodies "an interdisciplinary approach which acknowledges elders as unique persons and is practiced through consistent caring relationships" (Happ et al, 1996, p.7). Individualized care also encompasses the principles that all behaviour has meaning, that individual needs are best met when behaviour is understood by the care provider, and that the best manner in which to respond to behaviour is by assessment, intervention, and evaluation (Sullivan-Marx and Strumpf, 1996). According to Bucci (2007) for individualized continence care comprehensive identification, assessment, and diagnosis are necessary. The author supports the implementation of the CHAMMP (Continence, History, Assessment, Medications, Mobility, Plan) Tool, which is a comprehensive evaluation tool to assist in developing individualized care plans for those experiencing UI in LTC. The implementation of care plans that are individualized also provides continuity among staff providing continence care to achieve the desired and shared goal of continence for their residents (MacDonald & Butler, 2007). By implementing approaches in care that are matched with the individual's preferences, needs, and capacities, then overall QoL can be improved (Newman, 2000).

#### **6.3 Empowering women experiencing UI in LTC**

As cited previously, studies have reported that women experiencing UI attempt to normalize UI into their daily lives by employing self-treatment strategies as opposed to seeking medical attention (Beji et al, 2010; Hagglund & Ahlstrom 2007; Milne & Moore, 2006; Skoner & Haylor, 1993). UI is commonly concealed to preserve a women's sense of identity, and accepted as a normal part of ageing and being a woman (Bradway et al., 2010; Bush et al., 2001; Stewart, 2010). Frequently, elderly women lack knowledge of treatments that are available and are not often presented with opportunities to discuss or explain their UI with healthcare providers (Mardon et al, 2006; Zeznock et al, 2009; Dugan et al, 2001). Dugan et al. (2001) reported that almost 70% of older adults experiencing UI were not asked by their healthcare provider about their UI. Gaps in healthcare providers' knowledge about UI and UI management, discomfort in discussing the topic and attitudes towards UI directly impact

incontinent episodes (Nitti, 2001). The outcome of this tool supported staff in long- term care

A thorough and comprehensive assessment of the underlying contributing factors of UI, and the identification of the type of UI experienced are pivotal in determining appropriate interventions and treatment modalities for those experiencing UI (Benne, 2008; Borrie et al., 2002). Possible outcomes of a thorough comprehensive UI assessment may include individualized targeted interventions and approaches that can lead to improved bladder control, and subsequently, a decrease in the frequency of UI (Benne, 2008). An individualized UI care approach, using multiple interventions is recommended that can assist in improving the QoL of elderly women experiencing UI in LTC (Benne, 2008; Borrieet

 It was apparent from the literature that continence care is comprised of rituals and routines evidenced by scheduled toileting regimes, quotas of incontinent products and procedures for changing of incontinent products. These findings suggested the need for individualized and sensitive continent care for women living in LTC. Individualized care embodies "an interdisciplinary approach which acknowledges elders as unique persons and is practiced through consistent caring relationships" (Happ et al, 1996, p.7). Individualized care also encompasses the principles that all behaviour has meaning, that individual needs are best met when behaviour is understood by the care provider, and that the best manner in which to respond to behaviour is by assessment, intervention, and evaluation (Sullivan-Marx and Strumpf, 1996). According to Bucci (2007) for individualized continence care comprehensive identification, assessment, and diagnosis are necessary. The author supports the implementation of the CHAMMP (Continence, History, Assessment, Medications, Mobility, Plan) Tool, which is a comprehensive evaluation tool to assist in developing individualized care plans for those experiencing UI in LTC. The implementation of care plans that are individualized also provides continuity among staff providing continence care to achieve the desired and shared goal of continence for their residents (MacDonald & Butler, 2007). By implementing approaches in care that are matched with the individual's preferences, needs,

As cited previously, studies have reported that women experiencing UI attempt to normalize UI into their daily lives by employing self-treatment strategies as opposed to seeking medical attention (Beji et al, 2010; Hagglund & Ahlstrom 2007; Milne & Moore, 2006; Skoner & Haylor, 1993). UI is commonly concealed to preserve a women's sense of identity, and accepted as a normal part of ageing and being a woman (Bradway et al., 2010; Bush et al., 2001; Stewart, 2010). Frequently, elderly women lack knowledge of treatments that are available and are not often presented with opportunities to discuss or explain their UI with healthcare providers (Mardon et al, 2006; Zeznock et al, 2009; Dugan et al, 2001). Dugan et al. (2001) reported that almost 70% of older adults experiencing UI were not asked by their healthcare provider about their UI. Gaps in healthcare providers' knowledge about UI and UI management, discomfort in discussing the topic and attitudes towards UI directly impact

to better understand and manage UI.

**6.2 Individualizing UI care** 

al., 2002; Bucci, 2007; MacDonald & Butler, 2007).

and capacities, then overall QoL can be improved (Newman, 2000).

**6.3 Empowering women experiencing UI in LTC** 

upon the quality of continence care elderly women receive in LTC (Du Beau, 2006; Palmer, 2008). Empowering elderly women to regain UI requires education and a shift from providing task related care to incorporating holistic care and opportunities to dialogue with healthcare providers (Lekan-Rutledge, 2004). Empowerment is the practice of assisting individuals to establish control over factors that impact their health (Lau, 2002). Empowerment implies that individuals will assert control over their lives, thus optimizing independence with the support of healthcare providers serving as advocates (Jones & Meleis, 1993). Empowering women to actively participate in their care may lead to managing incontinence more efficiently and effectively (Roe, 2000).

There is a need for educating the public and healthcare providers to dispel the myths and taboos that UI is a normal part of aging, and that the implementation of incontinent products is not the only option or successful solution for UI (Stewart, 2010; Shamliyan et al., 2008). Knowledge regarding alternatives to incontinent products such as habit training, regaining mobility, Kegel exercises, self-management strategies, medications or medical management maybe considered is critical for healthcare providers working in long- term care. Sharing information about possible health promoting interventions and management strategies with women experiencing UI in LTC may provide them with hope for trying alternative methods to incontinence products, while empowering them to make choices and inform decision-making about their continence care. There are too few healthcare providers communicating to the public that UI is treatable, controllable, or preventable (Du Moulin et al., 2009; Zeznock et al., 2009). If more public education and awareness were provided, individuals entering facilities such as long- term care would be better able to manage and understand UI, which in turn potentially may assist in dispelling ageism and ageist practices in LTC.
