**5.3 Managing UI in LTC**

Distinct odours and piles of clean diapers are considered the hallmarks of nursing homes (Tulloch, 1989). The paucity of research and literature relating to UI in long- term care makes it difficult to change these images as the hallmarks of long -term care. There is obviously a need for more exploratory work to describe living and management of UI in long -term care. Managing the burden of UI in LTC is a major concern to administrators and healthcare providers. The increased availability of incontinence products augments the "cultural knowledge" that UI is a normal process for which pads and briefs are the best solution (Mitteness, 1990). The use of disposable absorbent products such as adult diapers or briefs, underpads and panty liners are major strategies for managing wetness for elderly women with UI in long- term care (Brink, 1990; Palmer, 2008; Wagg et al, 2004; Watson et al., 2003). The purpose of these disposable incontinence products are to "soak up" urine or contain incontinence for the dignity and comfort of the resident, protect clothing, furniture, floors and bedding, while simultaneously controlling odour (Brink, 1990; Getliffe et al., 2007). Advances in technology "have led to absorbent products that are designed to contain large quantities of urine and to protect the skin from the effects of incontinence" (Palmer, 2008, p.439). Hu et al. (1990) added that the staff use the disposable under pads to lift and reposition residents by pulling on the product. This practice results in tearing of the product, and thus leaking of urine contributes to odour. The use of absorbent products and pads should be based primarily on residents' assessments, requirements, and preferences and not for staff convenience (Palmer, 2008).

Mitteness (1990) cited that healthcare providers were informing the elderly that nothing could be done for their UI as it was just considered as a normal part of aging. This message was considered to support residents by providing a protective effect on one's self-esteem

healthcare pertaining to their incontinence. Likewise, Hagglund and Ahlstrom (2007) in a phenomenological hermeneutic approach interviewed 14 women with UI in Sweden. One of the findings pointed out that some women had experienced a less satisfying encounter when they sought help for their UI. In some instances, women felt that they were treated nonchalantly by healthcare providers, and were not being taken seriously. Also, some women felt that they were wounded by the manner in which they were treated by some healthcare providers, but they did have a respectful experience when they accessed another

Yet, some healthcare providers have found have to positively influence those experiencing UI (Borrie et al., 2002; MacDonald & Butler, 2007). One example is Borrie et al (2002) , who reported the use of specialized nurses (nurse continence advisors) with education and training in managing UI to positively impacted UI care, and reduced the incidence of UI, and use of incontinence pads in Ontario, Canada. The nurse continence advisors used behavioural interventions and lifestyle counselling, which proved to be a cost- effective management strategy consistent with recommendations and guidelines of the Canadian Continence Association. Given the shifting of demographics of our population, the extent to which healthcare providers' attitudes and behaviours exists in the delivery of care to the elderly, and specifically to women, requires close scrutiny and careful examination by

Distinct odours and piles of clean diapers are considered the hallmarks of nursing homes (Tulloch, 1989). The paucity of research and literature relating to UI in long- term care makes it difficult to change these images as the hallmarks of long -term care. There is obviously a need for more exploratory work to describe living and management of UI in long -term care. Managing the burden of UI in LTC is a major concern to administrators and healthcare providers. The increased availability of incontinence products augments the "cultural knowledge" that UI is a normal process for which pads and briefs are the best solution (Mitteness, 1990). The use of disposable absorbent products such as adult diapers or briefs, underpads and panty liners are major strategies for managing wetness for elderly women with UI in long- term care (Brink, 1990; Palmer, 2008; Wagg et al, 2004; Watson et al., 2003). The purpose of these disposable incontinence products are to "soak up" urine or contain incontinence for the dignity and comfort of the resident, protect clothing, furniture, floors and bedding, while simultaneously controlling odour (Brink, 1990; Getliffe et al., 2007). Advances in technology "have led to absorbent products that are designed to contain large quantities of urine and to protect the skin from the effects of incontinence" (Palmer, 2008, p.439). Hu et al. (1990) added that the staff use the disposable under pads to lift and reposition residents by pulling on the product. This practice results in tearing of the product, and thus leaking of urine contributes to odour. The use of absorbent products and pads should be based primarily on residents' assessments, requirements, and preferences

Mitteness (1990) cited that healthcare providers were informing the elderly that nothing could be done for their UI as it was just considered as a normal part of aging. This message was considered to support residents by providing a protective effect on one's self-esteem

healthcare provider.

healthcare providers and the public.

and not for staff convenience (Palmer, 2008).

**5.3 Managing UI in LTC** 

(Herzog et al., 1989). Physicians perceived UI as a nursing task and often avoid dealing with the issue, thus ignoring the effect of UI on self-esteem of elderly women, while nurses often inappropriately focused on the management of soiling rather than on the management of incontinence (Mitteness, 1990). Staff in nursing homes reported finding UI care frustrating, time-consuming and aesthetically unpleasant, leading to staff burnout, and poor morale (Yu & Kaltreider, 1987). Notably, if caregivers view UI negatively, rather than a QoL concern, elderly women who are physically and psychologically devastated by the effects of UI are rendered helpless (Mitteness, 1990).

A study conducted by Birgersson et al. (1993) of six elderly women with a mean age of 80.5 years, living in a Swedish nursing home, identified that a decrease in self-esteem was closely linked with the manner in which nurses assisted them in changing their incontinence products. Elderly women were in a state of vulnerability regarding their intrinsic value and autonomy as a result of having UI and wearing an incontinence product. These authors send a powerful message to healthcare providers concerning UI in elderly women. The need to treat women who have UI with respect, support, and include them in decisions-making and choices regarding their UI is essential.

The implementation of fluid management and voiding schedules are strategies employed by some nursing staff in LTC as an attempt to reduce or eliminate UI (Brink, 1990). Nursing staff will often restrict fluids in the evening in order to reduce night-time toileting or wetting (Brink, 1990). However, imposing such a strategy as a policy for all residents is excessive and places individuals at risk for dehydration. The goal for creating such a policy raises the question of quality of care. By trying to control UI in elderly women, nursing staff may, in fact, be attempting to minimize their workload associated with UI. Little data was found to document the outcome of these shortages on overall care and resident's well-being.

Routine voiding schedules are considered habit training procedures that will avoid incontinence by having the resident empty their bladder regularly (Earthy & Nativ, 2009; Klusch, 2003). Voiding schedules are usually indicated for many residents living in LTC, yet too often voiding schedules become a regular regime to control incontinence (Palmer, 2008; Resnick 1992). Imposing such a strategy on a competent elderly woman, capable of making informed decisions regarding her UI has ramifications for self-esteem and QoL. A simple request to go to the washroom to void could be denied by the staff, because it is not her scheduled bathroom time. Additionally, these women who do not need to void, are forced to toilet. If voiding schedules are to assist residents in maintaining comfort and decreasing the number of incontinent episodes, they must be individualized (Birgersson et al., 1993). By providing individualized care, nurses may enable elderly women experiencing UI to increase their autonomy and self-esteem and ultimately their QoL.

Freundl and Dugan (1992) examined the relationships between attitudes, knowledge, and institutional culture in relation to management of UI in the elderly. The Incontinence Stress Questionnaire-Staff Reaction (ISQ-SR) was used to measure staff attitudes towards UI in the elderly. The participants were 336 nursing personnel from 16 different LTC agencies accrued by convenience sampling. Prevalence of UI was calculated at 72%, however written protocols were not always apparent. Also, over 50% of the agencies acknowledged to using catheters as a management strategy for UI, and almost all of the agencies used incontinence products. With regards to education, findings indicated that few of the agencies reported

Elderly Women and Urinary Incontinence in Long-Term Care 101

as powders and perfumes to disguise the scent of urine. The lack of opportunity by women to implement the psychological and behavioural strategies they desire contribute to decreased self-esteem and further social isolation (Dowd, 1991). Consequently, it becomes imperative that healthcare providers in LTC shift their thinking of UI as a health and QoL issue, and to understand why elderly women use particular strategies to cope with UI.

**5.5 The effects of UI on the QoL from the elderly women's lived experiences in LTC**  There is limited literature pertaining to the impact of UI on the QoL of elderly women experiencing UI in LTC from their lived experiences. O'Dell et al. (2008) in a descriptive qualitative study interviewed 25 women aged 65-96 with pelvic floor dysfunction, to increase understanding of the views of frail elderly women in residential care related to QOL, values, and preferences for pelvic floor care. Study findings suggested that pelvic floor dysfunction was not reported to play a central role in general QOL in these elderly women with multiple co- morbidities. The women discussed the value of comfort, containment, restful sleep, and making do, and were opposed to evaluation or interventions or citing risks of discomfort and ineffectiveness. Further, these elderly women living in LTC may prefer to live with pelvic floor dysfunction, than to access evaluation and treatment, even though it is available in their LTC facility. The authors concluded that residents in LTC

Another qualitative study using one-to-one interviewing by MacDonald & Butler (2007), explored the experiences of elderly women living in LTC with UI. Findings revealed that UI had a dramatic impact on the QoL of elderly women residing in LTC. There existed physical costs of UI that included; skin irritation and breakdown, bladder inflammation, physical discomfort, and feelings of being wet and soggy. Women expressed feelings of being dependant on staff for care and therefore, felt like they were losing control of their body, losing dignity, losing their independence, and losing the ability to maintain active lives, which directly impacted their QoL. The study suggested opportunities for improving healthcare education related to QoL of women who experience UI, and the need to make the UI experience more visible and openly discussed as a healthcare issue. Therefore, more research studies need to be conducted to determine the effects of UI on the QoL of elderly

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

ought to be part of planning care if improved QoL is the primary goal.

women in LTC from their lived experiences.

**6. Implications for clinical practice 6.1 A comprehensive UI assessment** 

having no training in the management of UI. However, most of the education was agency in-services, followed by classroom instruction in a school of nursing. Notably, less than half the participants acknowledged having formal clinical educational in the management of UI. According to the study, LTC facilities generally have positive attitudes toward UI in the elderly, but they have a limited knowledge regarding application to specific clinical situations or insight into the current research relating to UI. This lack of knowledge has dramatically impacted the manner in which UI care is provided to the elderly in LTC.

Vinsnes et al (2001) completed a study to understand Norwegian nurse's attitudes towards clients with UI by place of work, age, and educational levels of staff. Five hundred thirtyfive responded to the questionnaire including five nursing facilities, three home care districts and medical surgical wards at a university hospital. Findings reported that staff members working in the long- term care were older than staff working in acute care units. Further, most of the registered nurses worked in the acute care, while most of the nursing assistants worked in long- term care. Findings also indicated that working on a medical surgical unit predicted more negative reactions and feeling towards UI than working in a nursing home. Also, nursing assistants working in medical units were more positive towards UI than registered nurses in LTC. Overall, the study indicated that attitudes toward UI were positive, but did not address how this translated to practice.

#### **5.4 Elderly women managing UI in LTC**

The literature suggests that elderly women practice a multitude of psychological and behavioural strategies to manage UI in long- term care. Many elderly women view UI as an inevitable part of aging, and often develop their own coping strategies rather than seeking help for their incontinence (Beji et al., 2010; MacDonald & Butler, 2007; Porrett & Cox, 2008; Stewart, 2010; Zeznock et al., 2009). Even earlier on, Skoner and Haylor (1993) suggested that elderly women prefer to normalize UI into their daily routines in an attempt to maintain their self-esteem. Time is measured in intervals between trips to the toilet in an attempt to minimize negative social sanctions from others due to visible soiling or smell thus, preventing shame and embarrassment (Mitteness, 1990). Psychological management strategies often include secrecy and social isolation (MacDonald & Butler, 2007). Elderly women keep incontinence a secret to minimize social ostracism or gossip, which in turn leads to social isolation (Mitteness, 1990; MacDonald & Butler, 2007). Some behavioural management strategies practiced by elderly women were reported to include; reducing fluid intake, voiding frequently, modifying activities that cause urine leakage, using pads and incontinent products, wearing perfume and deodorants to hide scents of urine, and altering clothing (Brink, 1990; Dowd, 1991; Hagglund & Ahlstrom, 2007; Hu et al., 1990; Mitteness, 1990; Skoner & Haylor, 1993; Whyman et al., 1987; Wilson, 2003; Zeznock et al., 2009). In addition to behavioural management, it has also been documented that the elderly implement dietary and environmental managements as a way to cope with UI (Wilson, 2003).

Routines in LTC facilities may not be supportive in assisting incontinent elderly women to practice their psychological and behavioural strategies (MacDonald & Butler, 2007). Maintaining social isolation and secrecy is very difficult as residents share dining areas and attend the same social activities. Scent free policies in long term-care facilities as previously mentioned present challenges for elderly women by preventing the use of fragrances such

having no training in the management of UI. However, most of the education was agency in-services, followed by classroom instruction in a school of nursing. Notably, less than half the participants acknowledged having formal clinical educational in the management of UI. According to the study, LTC facilities generally have positive attitudes toward UI in the elderly, but they have a limited knowledge regarding application to specific clinical situations or insight into the current research relating to UI. This lack of knowledge has dramatically impacted the manner in which UI care is provided to the elderly in LTC.

Vinsnes et al (2001) completed a study to understand Norwegian nurse's attitudes towards clients with UI by place of work, age, and educational levels of staff. Five hundred thirtyfive responded to the questionnaire including five nursing facilities, three home care districts and medical surgical wards at a university hospital. Findings reported that staff members working in the long- term care were older than staff working in acute care units. Further, most of the registered nurses worked in the acute care, while most of the nursing assistants worked in long- term care. Findings also indicated that working on a medical surgical unit predicted more negative reactions and feeling towards UI than working in a nursing home. Also, nursing assistants working in medical units were more positive towards UI than registered nurses in LTC. Overall, the study indicated that attitudes toward

The literature suggests that elderly women practice a multitude of psychological and behavioural strategies to manage UI in long- term care. Many elderly women view UI as an inevitable part of aging, and often develop their own coping strategies rather than seeking help for their incontinence (Beji et al., 2010; MacDonald & Butler, 2007; Porrett & Cox, 2008; Stewart, 2010; Zeznock et al., 2009). Even earlier on, Skoner and Haylor (1993) suggested that elderly women prefer to normalize UI into their daily routines in an attempt to maintain their self-esteem. Time is measured in intervals between trips to the toilet in an attempt to minimize negative social sanctions from others due to visible soiling or smell thus, preventing shame and embarrassment (Mitteness, 1990). Psychological management strategies often include secrecy and social isolation (MacDonald & Butler, 2007). Elderly women keep incontinence a secret to minimize social ostracism or gossip, which in turn leads to social isolation (Mitteness, 1990; MacDonald & Butler, 2007). Some behavioural management strategies practiced by elderly women were reported to include; reducing fluid intake, voiding frequently, modifying activities that cause urine leakage, using pads and incontinent products, wearing perfume and deodorants to hide scents of urine, and altering clothing (Brink, 1990; Dowd, 1991; Hagglund & Ahlstrom, 2007; Hu et al., 1990; Mitteness, 1990; Skoner & Haylor, 1993; Whyman et al., 1987; Wilson, 2003; Zeznock et al., 2009). In addition to behavioural management, it has also been documented that the elderly implement dietary and environmental managements as a way to

Routines in LTC facilities may not be supportive in assisting incontinent elderly women to practice their psychological and behavioural strategies (MacDonald & Butler, 2007). Maintaining social isolation and secrecy is very difficult as residents share dining areas and attend the same social activities. Scent free policies in long term-care facilities as previously mentioned present challenges for elderly women by preventing the use of fragrances such

UI were positive, but did not address how this translated to practice.

**5.4 Elderly women managing UI in LTC** 

cope with UI (Wilson, 2003).

as powders and perfumes to disguise the scent of urine. The lack of opportunity by women to implement the psychological and behavioural strategies they desire contribute to decreased self-esteem and further social isolation (Dowd, 1991). Consequently, it becomes imperative that healthcare providers in LTC shift their thinking of UI as a health and QoL issue, and to understand why elderly women use particular strategies to cope with UI.

### **5.5 The effects of UI on the QoL from the elderly women's lived experiences in LTC**

There is limited literature pertaining to the impact of UI on the QoL of elderly women experiencing UI in LTC from their lived experiences. O'Dell et al. (2008) in a descriptive qualitative study interviewed 25 women aged 65-96 with pelvic floor dysfunction, to increase understanding of the views of frail elderly women in residential care related to QOL, values, and preferences for pelvic floor care. Study findings suggested that pelvic floor dysfunction was not reported to play a central role in general QOL in these elderly women with multiple co- morbidities. The women discussed the value of comfort, containment, restful sleep, and making do, and were opposed to evaluation or interventions or citing risks of discomfort and ineffectiveness. Further, these elderly women living in LTC may prefer to live with pelvic floor dysfunction, than to access evaluation and treatment, even though it is available in their LTC facility. The authors concluded that residents in LTC ought to be part of planning care if improved QoL is the primary goal.

Another qualitative study using one-to-one interviewing by MacDonald & Butler (2007), explored the experiences of elderly women living in LTC with UI. Findings revealed that UI had a dramatic impact on the QoL of elderly women residing in LTC. There existed physical costs of UI that included; skin irritation and breakdown, bladder inflammation, physical discomfort, and feelings of being wet and soggy. Women expressed feelings of being dependant on staff for care and therefore, felt like they were losing control of their body, losing dignity, losing their independence, and losing the ability to maintain active lives, which directly impacted their QoL. The study suggested opportunities for improving healthcare education related to QoL of women who experience UI, and the need to make the UI experience more visible and openly discussed as a healthcare issue. Therefore, more research studies need to be conducted to determine the effects of UI on the QoL of elderly women in LTC from their lived experiences.
