**6.4 Dispelling ageism in LTC**

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

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

Elderly Women and Urinary Incontinence in Long-Term Care 105

in planning, implementing, and evaluating such a program for it to be successful (Palmer, 1995). Administrators, managers, and owners of LTC facilities must be educated about the negative implications that short staffing and budgeting has on elderly women's experiences with UI in LTC. It is fundamental that management and staff attend educational conferences and in-services pertaining to UI to ensure that their knowledge is current, evidence-based

Staff and managers of LTC facilities must lobby governments to formalize initiatives to educate and recruit new staff to the field of Gerontology and long-term care, so that caring for the elderly will be viewed as a valuable and a respected place for employment. Advanced Nursing Practice in Gerontology and nurse-led continence clinics must be encouraged, and financially supported to optimize health promotion and standards of care

Research is required to improve and advance evidence-based continence care practices. From the literature it is evident there are areas where further research is recommended. One potential area for further research is the impact of culture, economic and social factors associated with elderly women's experiences and perceptions of UI in LTC. This research would provide healthcare providers with the knowledge to understand the implications of UI on the QoL of elderly women, and assist in implementation strategies to ensure individualized continent care. With regards to cultural factors affecting women's perceptions of UI, it would be interesting to complete a research study with extended families where long- term care would not be considered an option, and to explore how significant an impact ageism has on a women's experience with UI. Also, to complete a comparative study of for profit and non-profit LTC facilities to determine differences and similarities in the experiences women have with UI. Further, conduct research on the prevention of UI in elderly women, design and test interventions that are based on evidence, and research that supports the implementation of nurse-led continence clinics that are costeffective. More research that improves the diagnosis, treatments and management strategies, and outcomes is necessary to guide evidenced-based clinical practice for elderly women with UI in LTCis needed (Borrie et al., 2002; MacDonald & Butler, 2007; Du Moulin et al., 2009). Du Beau et al (2007) suggested that more research is required that determines residents' and families' definitions and values of "quality" UI care and how to incorporate them into quality improvement strategies. More research that address nurses' attitudes, and their cultural and ethnic perspectives about UI are imperative to advancing continence care

A comparative study to explore similarities and differences between younger women experiencing UI and older women experiencing UI in LTC could be conducted. The knowledge attained from this type of study would be fundamental to care of all women experiencing UI in LTC. This research could assist healthcare providers to understand the impact of ageing, which potentially may optimize the quality of incontinent care. Also, a research study that developed and implemented an individualized continence care program in LTC is essential given the current state of knowledge about continence care. Such a study could combine quantitative and qualitative methods. Further, more research that considers

and without bias from incontinent companies seeking considerable profits.

for the elderly living in LTC (Borrie et al., 2002).

**8. Implications for future research** 

practices (Zeznock et al., 2009).

nurses and other healthcare providers can bring forth institutional ageist practices, and injustices without fear of reprisal. Healthcare professional licensing bodies must lobby governments and public policy-makers to incorporate positive awareness of the aging in developing health policies and the allocating of resources to caring for elderly with UI in LTC. Further, nurses and other healthcare providers should actively lobby governments for more healthcare programs and funding for LTC facilities, so that staffing and supplies are adequate to ensure provision of individualized, competent incontinent care. Existing national and provincial continence organizations need to be more vocally active about practice continence care guidelines, which in turn could assist in dispelling myths about incontinence, and potentially decrease ageist attitudes. Healthcare providers must be encouraged to participate in continence care committees within the LTC facilities locally, provincially, and internationally in order to attain knowledge about current evidencedbased continence care practices.

#### **7. Implications for education**

Nurses, physicians, and other healthcare providers must be educated about the implications of UI on the QoL of elderly women, a topic that is still rarely discussed, poorly understood, and considered taboo in some cultural groups. Lack of knowledge regarding UI, and the elderly perpetuates ageist attitudes of healthcare providers and consequently, negatively impacts the provision of quality and sensitive continence care. It was evident from research that healthcare providers lacked knowledge regarding assessment of UI, provision of individualized continent care, and physical and psychosocial implications of UI. Furthermore, there was little knowledge regarding assisting elderly women with UI or the influence of staff on the UI experience. Therefore, it is imperative to incorporate knowledge regarding UI into core curriculum of Nursing Undergraduate and Graduate programs, LPN programs, PCW programs, Medical Schools, and other health care professionals' education. This would help dispel the myth that UI is a normal part of ageing, while assisting healthcare providers to reflect on their own beliefs and bias regarding the elderly and UI. Furthermore, healthcare providers must be educated to initiate conversations and be confident in dialoguing about UI with elderly women, as it is a sensitive topic rarely discussed by the individual experiencing UI. While dialoguing about UI, healthcare providers should be cognisant of the ageist terminology that maybe barriers to communication and empowering women. Healthcare providers ought to be advocates and educate elderly women in LTC that experiencing UI is not normal, and there are treatment options and methods to assist in controlling UI other than incontinent products.

It is essential that mandatory continence care programs be incorporated into the orientation of new staff to LTC facilities, as nurses are often the first contact of elderly experiencing incontinent problems. A continence care program could include tools to assess, implement, and evaluate continence care and include strategies to prevent episodes of incontinence that are individualized. Another component of the educational program for healthcare providers in LTC could involve role playing, whereby each of the staff must wear an incontinent product that has been saturated with water over gym clothing, or have them lying in a bed with another staff member changing their incontinent product. Role playing is a unique interactive learning method whereby staff may appreciate what it is like to experience UI first hand. Additionally, management in LTC facilities must form partnerships with the staff

nurses and other healthcare providers can bring forth institutional ageist practices, and injustices without fear of reprisal. Healthcare professional licensing bodies must lobby governments and public policy-makers to incorporate positive awareness of the aging in developing health policies and the allocating of resources to caring for elderly with UI in LTC. Further, nurses and other healthcare providers should actively lobby governments for more healthcare programs and funding for LTC facilities, so that staffing and supplies are adequate to ensure provision of individualized, competent incontinent care. Existing national and provincial continence organizations need to be more vocally active about practice continence care guidelines, which in turn could assist in dispelling myths about incontinence, and potentially decrease ageist attitudes. Healthcare providers must be encouraged to participate in continence care committees within the LTC facilities locally, provincially, and internationally in order to attain knowledge about current evidenced-

Nurses, physicians, and other healthcare providers must be educated about the implications of UI on the QoL of elderly women, a topic that is still rarely discussed, poorly understood, and considered taboo in some cultural groups. Lack of knowledge regarding UI, and the elderly perpetuates ageist attitudes of healthcare providers and consequently, negatively impacts the provision of quality and sensitive continence care. It was evident from research that healthcare providers lacked knowledge regarding assessment of UI, provision of individualized continent care, and physical and psychosocial implications of UI. Furthermore, there was little knowledge regarding assisting elderly women with UI or the influence of staff on the UI experience. Therefore, it is imperative to incorporate knowledge regarding UI into core curriculum of Nursing Undergraduate and Graduate programs, LPN programs, PCW programs, Medical Schools, and other health care professionals' education. This would help dispel the myth that UI is a normal part of ageing, while assisting healthcare providers to reflect on their own beliefs and bias regarding the elderly and UI. Furthermore, healthcare providers must be educated to initiate conversations and be confident in dialoguing about UI with elderly women, as it is a sensitive topic rarely discussed by the individual experiencing UI. While dialoguing about UI, healthcare providers should be cognisant of the ageist terminology that maybe barriers to communication and empowering women. Healthcare providers ought to be advocates and educate elderly women in LTC that experiencing UI is not normal, and there are treatment

options and methods to assist in controlling UI other than incontinent products.

It is essential that mandatory continence care programs be incorporated into the orientation of new staff to LTC facilities, as nurses are often the first contact of elderly experiencing incontinent problems. A continence care program could include tools to assess, implement, and evaluate continence care and include strategies to prevent episodes of incontinence that are individualized. Another component of the educational program for healthcare providers in LTC could involve role playing, whereby each of the staff must wear an incontinent product that has been saturated with water over gym clothing, or have them lying in a bed with another staff member changing their incontinent product. Role playing is a unique interactive learning method whereby staff may appreciate what it is like to experience UI first hand. Additionally, management in LTC facilities must form partnerships with the staff

based continence care practices.

**7. Implications for education** 

in planning, implementing, and evaluating such a program for it to be successful (Palmer, 1995). Administrators, managers, and owners of LTC facilities must be educated about the negative implications that short staffing and budgeting has on elderly women's experiences with UI in LTC. It is fundamental that management and staff attend educational conferences and in-services pertaining to UI to ensure that their knowledge is current, evidence-based and without bias from incontinent companies seeking considerable profits.

Staff and managers of LTC facilities must lobby governments to formalize initiatives to educate and recruit new staff to the field of Gerontology and long-term care, so that caring for the elderly will be viewed as a valuable and a respected place for employment. Advanced Nursing Practice in Gerontology and nurse-led continence clinics must be encouraged, and financially supported to optimize health promotion and standards of care for the elderly living in LTC (Borrie et al., 2002).
