Continence promotion in acute care services - Book Report/Review Example

Continence Promotion in Acute Care Services Introduction: Urinary incontinence has been defined as the complaint of any involuntary leakage of urine. Although by incontinence, it is generally meant involuntary leakage of both urine and stool, for the purpose of this literature review, only urinary incontinence will be considered. It has been mentioned by researchers that, it is very difficult to know the incidence of urinary incontinence in the population, but all the researchers are aware of the social stigma associated with it, and for this reason, this remains an underreported problem (Carr, 2004, 16-18). Other studies have reported earlier that this remains under-reported due to social stigma, and men may be too embarrassed to consult their doctors regarding this. It is known that many cases of urinary incontinence are transient, brought on by infection, immobility or acute disease (Dingwall, 2008, 166-172). However, many other cases result from chronic conditions that persist until intervention through proper treatment and bladder management strategies allowing social continence are instituted. It is also recognised that the prevalence of incontinence increases with age. This is, therefore, a very common problem, which usually does not come into medical attention for the reasons described above. Education, training, support, and voiding training can be effective nonmedical interventions that may help these patients (Cooper and Watt, 2003, 305-313). Since emergency department is an area where these patients frequently present with acute problems associated with urinary tract, this may be an area of health promotion nursing intervention to these patients, which would tend to promote continence. To find out the rationale of this proposal, it was decided that a critical literature review would be done, and a literature search was conducted. Literature Search: For the purpose of the preliminary review of literature to support the rationale, need, and continuation of the project, an exhaustive literature search was conducted. Electronic databases such as CINHAL, Medline and Pubmed along with the Google Scholar Internet Search engine and HigWire Press were looked for. The key words that were used for search were "continence", "incontinence", "urinary incontinence", "nurse practitioner", "promotion", "acute care", "education", "health promotion", "nursing care", and "nursing." The inclusion criteria for these articles were that these would have to be research articles, preferably nursing oriented, but not necessarily, include continence, incontinence, and continence promotion in acute care nursing practice, must be published within last 6 years, and would have some indication about United Kingdom population. Based on these criteria, out of about 150 initial articles, only 6 were narrowed down. In this paper, this author intends to present only the article reviews of 4 articles that are latest and that provide a strong supportive basis for the proposed project research paper including a brief critique of their methodologies, so a comparison is done among the presented studies to arrive at a final conclusion. The articles that studied the fecal incontinence are excluded from this study. Review of Literature: Borrie and colleagues present the results of a randomised controlled trial of management of urinary incontinence by interventions led by nurse continent advisors. This is a very relevant literature since in the acute care settings, the doctors are overloaded, and only a nurse who has adequate knowledge and expertise in incontinence care would be able to discuss and communicate with the potential or established patients and promote incontinence. The authors present a concise review of literature and state that urinary incontinence affects primarily young to middle aged women and both men and women of elderly age group. As previously mentioned, the accurate data of prevalence is extremely variable, ranging from 8% to 30%. The authors reiterate the fact that this problem remains hidden, and due to the shame and embarrassment, the disease goes under or unreported. Literature from other countries indicate that the effective management following a thorough initial assessment would be staged multidisciplinary intervention that should begin with lifestyle and behavioural interventions before commencing on medications or deciding for surgery. These noninvasive interventions highlight the roles of continence advisors or nurse continence advisors; however, even when they participate in care of these patients, it is unknown whether this is evidence based. The authors conducted a randomized controlled trial to know whether the advice of these nurses leads to any short-term efficacy. The authors support the rationale of their study by finding evidence from other studies that demonstrate that since incontinence is multifactorial in the elderly, the strategy of multiple interventions is justified, since each intervention can address separate involved factors. Research has shown that individual components of lifestyle and behavioural interventions are very effective. Behavioural training including pelvic muscle exercise can reduce urinary incontinence up to by 57%. One study has revealed that a combined approach comprising of bladder training, pelvic muscle exercises provided by trained registered nurses can culminate into fewer incontinent episodes than by either approach alone. These exercises are equally effective in women with stress, urge, or mixed incontinence. Intensive exercise training and adherence to exercise can be sustained for up to 5 years in 70% of the women. Other measures, such as decreasing caffeine intake and reducing fluid intake may reduce incontinent episodes. This experimental design was a radomised controlled trial for 6 months to determine a model of service delivery where lifestyle and behavioural modification led by nurses and to see its efficacy in reduction of urinary incontinence and pad use. The secondary end point of this study was whether this type of intervention has any impact on the subjects' knowledge about incontinence and on their quality of life. Data were collected by questionnaire post intervention, and statistical analysis of the data revealed that lifestyle and behavioural interventions led by nurses gave rise to significant improvement in the treatment group. From the end points and outcome measures, it is apparent that after 25 weeks of interventions by the nurses trained in such management would lead to reduction in incontinent events and incontinence pad use (Borrie et al., 2002, 1267). Horrocks et al. in their study, "What prevents older people from seeking treatment for urinary incontinence A qualitative exploration of barriers to the use of community continence services" performs a qualitative study to explore the reasons that promote people in the community not to seek help for problems with incontinence. They conducted in-depth interviews in elderly community dwellers to identify the reasons as well as to find out ways in which they may be assisted. In this article, the authors point to the fact that urinary incontinence is a significant health problem with "potentially serious physical, psychological, and social consequences." The continence promotion is a simple measure that can even be accessed at primary care, and people are seen not to access service. The reasons for which older people refrain from seeking healthcare services are withdrawal, resignation, and low expectations. The authors accept that continence promotion is either a nursing activity or the job of a health visitor, and their work is supported in the community by specialist nurses. An interview questionnaire was designed, and the volunteers were interviewed. The authors graphically present the findings, and this indicates that those who do not seek help, they have reasons. The prime reason is that of attitudes, where the older people believe that with age, incontinence is natural. They believed that ageing can be equated with relaxation of muscles, and with reduction of strength, this is common to occur. With ageing, they had lower expectations about their own health, since most participants accepted the daily restrictions and discomfort with incontinence. The other practical barriers are fear of disclosure and shame associated with that. They commonly described feelings of self consciousness, humiliation, embarrassment, and disgust, and these negative feelings led to "painstaking concealment of problem" (Horrocks et al., 2004, 689-696). Moreover, many participants in this study thought they can independently manage the problem and that gave him a sense of control. Even talking about this to the GP is a problem since they thought this is not a problem worth talking. Moreover, the doctor's gender was an important barrier, but males did not bother about it. The authors concluded that community nurses and other professionals should ask older people routinely about any experience of incontinence, and these practical barriers also indicate that with an opportunity, the trained nurses can best do this (Horrocks et al., 2004, 689-696) (Davison and Philp, 2003, 1300). Cooper and Watt present their findings in their work, "An exploration of acute care nurses' approach to assessment and management of people with urinary incontinence" in order to explore the acute care nurses' approach in assessment and management of people suffering from urinary incontinence. The authors used a qualitative exploratory and descriptive design to study the responses from medical-surgical registered nurses in the acute care setting. The different types of urinary incontinences were represented through different scenarios to these nurses, and the responses of each nurse were thematically analysed. The findings were validated in a focus group where discussions about implications of findings were conducted. It was concluded from these findings that these acute care nurses had limited assessment and management capabilities both in terms of knowledge and experience to manage these cases of urinary incontinence. The authors concluded that acute care nurses have limited abilities to assess and manage varying types of incontinence. Literature suggest the reasons for those, and these include limited ability, lack of knowledge, but more important were their work in the acute care setting, leading to lack of time, lack of support, and a culture that "fails to promote independent practice and holistic care." Moreover, their undergraduate education in the nursing training program lacked specific training on continence education and practice. The authors recommend that they undergo specific continence education following graduation, and acute care settings need to "develop systems, processes, policies, documentations, and role models" so the care of a client with urinary incontinence can be undertaken effectively (Cooper and Watt, 2003, 305-313). Chiarelli and Cockburn in their study "Promoting urinary continence in women after delivery: randomised controlled trial" tested the effectiveness of a physiotherapist delivered intervention for postpartum women, 3 months after the delivery to examine whether this conservative nonmedical intervention leads to prevention of incontinence. It was a prospective randomised controlled trial with pelvic floor exercise training and incorporated strategies that improved adherence. Incontinence is costly in that the yearly economic implications can be equated to 18.5 billion, only in the age group of 65 and older. Lack of research in that area promoted this study, and the authors found that the intervention that promoted urinary continence was successful in reducing incontinence in postpartum women, and this also promoted the performance of adherence to exercise. This study indicates that continence promotion programmes delivered to a selected at risk population proactively prevents urinary incontinence in that population (Chiarelli. and Cockburn, 2002, 1241-1248). Nursing Implications: Continence promotion involves informing and educating the people that incontinence in both males and females and related pelvic organ prolapse in women is not inevitable or shameful, but is very much a treatable or at the least manageable condition. Now, as directed by the research, popular media also spreads the same message, and these campaigns are gradually taking their actions to shape the attitudes and beliefs of people (Lawrence et al., 2007, 2536-3541). For a healthcare professional, such as a nurse, the first important step to be able to deliver continence promotion, is to update knowledge about incontinence, and the second step is to get appropriately trained, one part of which is to be able to gather evidence from current research. Many such health promotional activities have become successful in different parts of the world. Nurses have often been more closely involved in the continence care and management than physicians and other health professionals. Nursing literature in the broader sense did not investigate specifically whether they can execute continence promotion in the busy acute care setting, but it is evident that they recognise their lack of knowledge of incontinence and that they would pursue further education if scope is provided (Shamliyan et al., 2008, 459-473). Thus it indicates that nurses maximally provide continence promotion, yet they have gap in knowledge to a significant level. This is a very positive state of affairs since training can be conducted by the specialist continence nurses, and these trained nurses can provide continence promotion (Chiarelli, Murphy, and Cockburn, 2003, 188-196). Since many patients with incontinence may present to the acute care due to incontinence related complications and since in acute care settings, the patients are more prone to listen, this can be an opportunity to promote incontinence. It is evident from this review that such a study has not been done, and this review can serve as the basis for a future study. Conclusion: There are limitations to this literature review on the specific topic of continence promotion in acute care setting, but this review has highlighted some very useful points. The outlook for incontinent patients is not that grim as it appears. Only conservative, nonmedical and nonsurgical means may be used successfully by the nurses to promote continence, and although evidence is lacking whether it could be implemented in an acute care setting, it is clear that nurses if trained adequately are the best people who can execute this. Reference List Borrie, MJ., Bawden, M., Speechley, M., and Kloseck, M., (2002). Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. Canadian Medical. Association ; 166: 1267. Carr, M., (2004). Continence promotion and management. Nursing British Columbia; 36(2): 16-8. Cooper G, Watt E., (2003). An exploration of acute care nurses' approach to assessment and management of people with urinary incontinence. Journal of Wound Ostomy Continence Nursing. ;30(6):305-13. Chiarelli, P. and Cockburn, J., (2002). Promoting urinary continence in women after delivery: randomised controlled trial. British Medical Journal; 324: 1241-1248. Chiarelli, P., Murphy, B., and Cockburn, J., (2003). Acceptability of a urinary continence promotion programme to women in postpartum. British Journal of Obstetrics and Gynecology; 110(2): 188-96. Dingwall, L., (2008). Promoting effective continence care for older people: a literature review. British Journal of Nursing; 17(3): 166-72. Horrocks, S., Somerset, M., Stoddart, H., and Peters, TJ., (2004). What prevents older people from seeking treatment for urinary incontinence A qualitative exploration of barriers to the use of community continence services. Family Practice; 21: 689 - 696. Davison, S. and Philp, I., (2003). Time to deliver with dignity. British Medical Journal; 326: 1300. Lawrence, JM., Lukacz, ES., Liu, IA., Nager, CW., and Luber, KM., (2007). Pelvic Floor Disorders, Diabetes, and Obesity in Women: Findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care; 30: 2536 - 3541. Shamliyan, TA., Kane, RL., Wyman, J., and Wilt, TJ., (2008). Systematic Review: Randomized, Controlled Trials of Nonsurgical Treatments for Urinary Incontinence in Women. Annals of Internal Medicine; 148: 459 - 473. Read More