It is conceivable that nurses practicing in different countries approach similar nursing care problems from their own unique perspective. The perspective may be dictated in part by distinct educational preparation, national values and priorities, and other cultural and demographic variables. It is generally recognized that Great Britain has provided leadership in the medical and nursing care of geriatric patients in hospitals, nursing homes, and in the community. The purpose of this paper is to examine one geriatric nursing care problem as it is discussed in recent British nursing journals and to compare and contrast the approaches with those found in recent journals from the United States. The nursing care problem chosen for comparison is that of urinary incontinence.
The journal articles reviewed for this study were selected from among those listed in the Cumulative Index to Nursing Literature, Vol. 20 (1975) and Vol. 21 (1976), under the heading "Urinary Incontinence." The articles listed in these two volumes represented 18 articles from Great Britain, 10 from the United States, and one from both Canada and Australia. The topics of the articles as suggested by the titles varied widely in both United States and British journals. They included: (a) specific target groups, such as the elderly, spinal cord injured patients, and stroke patients; (b) specific treatments, such as physiotherapy, electrical stimulation, artificial urinary sphincters, and behavioral therapy bladder retraining; and (c) collecting devices, such as portable urinals and external catheters.
For purposes of this paper, articles were selected for comparison that addressed the problem of incontinence in the elderly and chronically ill. The titles and authors of the selected articles are listed in Table I according to the country of publication. These articles were compared and contrasted by the following characteristics: (a) descriptiveness of title; (b) general content overview; (c) basic assumptions about incontinence, nursing attitudes and responsibilities, and rewards of continence; (d) approaches to intervention; and (e) supporting literature.
In general, the titles of both British and United States articles were descriptive of the article's major content. However, it would have been helpful to the reader for information retrieval if the target population of the article had been identified in the title when a specific group of patients was used. Wells did provide such a descriptive title as did Wilson.
As indicated by the titles, the British articles examined incontinence in a more global manner than did the United States articles. British authors discussed the promotion of continence to prevent incontinence as well as provided a comprehensive approach to the understanding and treatment of incontinence. The sixpart series on incontinence contributed greatly to the multifaceted understanding of the incontinence problem. In contrast, the United States article titles indicated concern for specific bladder training programs with the exception of one article which only demonstrated use of male external collection devices.
To gain a clearer understanding of the varied approaches to the problem of incontinence found in this survey, an overview of the British and United States articles will be provided. The articles will be examined by authors beginning with the British journals.
Willington. In his articles, Wellington (1975) stated his attempt to relate the problems of incontinence to the totality of health in the individual. He established incontinence as a major problem to the incontinent person, to families, to nursing staff, and to society. The complexities of incontinence with its physical, psychological, and social variables were discussed. The range of causative factors were explored and the psychological and psychogenic aspects were described.
In articles related to nursing care, Willington purposed to demonstrate that nursing staff contribution to the care of the incontinent patient is the "centre point," He does so through a description of the data collected and organized by nurses relative to the incontinent patient which he considered as essential in the correct diagnosis of the problem. In addition, he outlined ways in which nurses are the vehicles of treatment. Training and retraining for continence was seen as the center of the nurse's expertise in dealing with incontinence. The relationship of the nursing staff to physicians, occupational therapists, physiotherapists, and the community in the treatment and retraining plan were included.
Willington described principles of conditioned reflex training and applied them to retraining for urinary continence. In all considerations, he related treatment components to prevention. He closed the series with a pragmatic discussion of the subject by describing the benefits and limitations including cost effectiveness of devices used for the prevention of soiling. Among those presented were occlusive appliances, conductive appliances, and hygienic aids for both bedfast and ambulant patients.
Hartie and Black. The authors (1975) reported the methods and results of a four-month positive reinforcement program project directed at the problem of nocturnal enuresis in five long-stay psychiatric patients. The reinforcement program was based loosely on operant conditioning principles which were not clearly described in the article. The overall average of wet beds was reduced by approximately 50 percent. The study had no control group and the procedure for reinforcement was abbreviated to the point that the study would be difficult to replicate from the report.
Wells. In the article by Wells (1975) attention was focused on relevant factors which promote continence in the elderly, particularly the hospitalized elderly. She placed the responsibility for reduction of patient incontinence on nursing. She briefly presented knowledge of modern geriatric care as a base for sound intervention. Emphasis was placed on environmental factors and physiological factors that aid continence. Drugs and practical management items were also included.
Kick. The purpose of Kick's article (1972) was to present a realistic and practical approach to bladder training of aged patients confined to nursing homes or extended care facilities. Her emphasis was on the point that incontinence is not inevitable in aged patients and must not be tolerated. Her paper discussed a bladder training program based on communication, fluid intake, and habit formation.
Maney. Maney (1976) presented the incidence and effects of incontinence in the nursing home resident and suggested an approach that would combine concepts of bladder training and contingency management. While she does not use Kick's article as a reference, she based bladder training on the same three factors mentioned by Kick, i.e., communication, fluid intake, and habit. Contingency management is discussed in the context of behavior therapy. A plan is presented for implementing a contingency management program in a nursing home setting. In addition to establishing a reward system for patients, a reward system for staff is discussed.
Wilson. Wilson (1975) described a bladder training program for chronically ill persons who have had urinary catheters for some time and have become catheter dependent. The program consisted of (a) motivating the patient to want to do without the catheter; and (b) closely involving him in the training process that includes fluid intake and output, catheter clamping and release, and a routine for before and after removing the catheter.
Beck. "Helping to make his last dream à reality" is a case presentation of a 62-year-old nursing home cancer patient. He was admitted with a foley catheter which the author described as an object "he hated, because it symbolized complete dependency to him" (Beck, 1975). Beck presented her efforts as a rehabilitation nurse in working with nursing staff and the patient to assist him in a bowel and bladder training program. Their combined efforts resulted in the successful removal of the catheter without incontinence. The victory eventually enabled the patient to realize his dream of visiting in California before his death.
Wkyte and Thistle. The authors (1976) provided an understanding of the advantages and disadvantages of external collectors which they presented as the alternative to catheterization for management of male incontinence. They demonstrated through photography how to avoid skin irritation, circulatory impairment and disconnection with proper application of collecting devices. Alternatives to both catheterization and external were not included among the purposes of the article.
This brief overview demonstrates the diversity of subject matter listed under the general topic of urinary incontinence even when related to a specific population, namely, the elderly or chronically ill. Because of the diversity present even within each country's articles, comparisons between countries were more difficult than had been expected when the study was initially undertaken. Nevertheless, a review of what appeared to be similar and dissimilar basic assumptions provided one area for closer comparison.
The basic assumptions that seemed to underlie the articles will be presented. The assumptions are related to: (a) the problem of incontinence; (b) nursing attitudes about incontinence; (c) nursing responsibility in the care of incontinent patients; and (d) benefits of continence.
The Problem of Incontinence
Both British and United States articles acknowledged that incontinence is a significant problem among the elderly particularly in hospitals and nursing homes. In England, studies have reported a 41 to 44 percent incontinence incidence among new admissions to geriatric units as cited by Wells. United States studies have estimated that 85 percent of incontinence seen in hospitals occurs in persons 65 years and over, as cited by Maney. Incontinence is frequently the reason for hospital or nursing home admission. The harmful effects of incontinence were assumed to be not only physical and psychological, but also social in both cultures. Authors from both countries stress their belief that incontinence is not inevitable in the aged.
Both United States and British authors assumed that nurses have traditionally accepted incontinence as inevitable in aged patients with physical and/or mental limitations. The assumptions related to how nurses cope with incontinent patients seemed to differ. The British journals pointed to a certain acceptance or contentment with nursing "change rounds" during which time dry pads were exchanged for wet ones. In contrast to the British change rounds approach to incontinence, United States articles discussed catheterization as the unsatisfactory nursing attempt to deal with the problem. It is interesting to note that all United States articles addressed the negative effects of bladder catheterization whereas the British articles presented catheterization very briefly if at all, and then, only to indicate its limited usage.
Both countries assumed that nursing staff has the major responsibility for bladder retraining and for the careful preliminary and ongoing assessment of the patient's continent and incontinent status. The British articles assumed nursing responsibility in promoting continence and preventing incontinence in a more direct manner than did the U.S. articles, which spoke more to responsibility after incontinence was present. More detailed nursing responsibilities for intervention will be discussed later in the paper.
Rewards of Continence
Both British and United States articles assumed that rewards were high when bladder retraining was established. The rewards were not only for the patient and family but also for nursing staff and the institution. The same could be understood for maintainance of continence. Rewards for the patient included comfort, sense of accomplishment, dignity, socialization, improved mental acuity, greater sense of well-being and independence. Rewards for staff included a feeling of achievement, greater time for assisting in other care areas, less time needed for "clean-up" aspects of care, and a more pleasant environment within which to work. The institution benefits not only with a better environment of care, but also through the monetary saving of less linen purchased and laundered.
In summary, it appears as though the assumptions underlying the approaches taken by both British and United States authors were quite similar. The British articles included another assumption that was not addressed in the United States articles, namely, some patients may not respond to any types of treatment but management of incontinence extends beyond use of incontinance pads.
Approaches to Intervention
Before a comparison of nursing interventions can be undertaken, it must be recognized that the United States articles were divided in terms of the nature of the incontinence problems addressed. The two United States articles by Wilson and by Beck concentrated more specifically on preparing patients for continence following the removal of catheters. The insertion of the catheter appeared to be primarily for nursing convenience. The nursing intervention prior to removal of the catheter described in these articles may be considered a special circumstance of bladder training. This circumstance is not discussed in the British journals, apparently because catheterization is rare, except ia situations when medically indicated. The British journals concentrated their discussion of intervention on the care of incontinent or potentially incontinent patients without catheters. For this reason, the two United States articles by Kick and Maney that also deal with essentially the same group of patients will be used as a basis for comparison of nursing interventions between countries. The comparisons of interventions will be made in three areas: (a) bladder retraining; (b) behavior therapy; and (c) prevention of soiling.
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Maney and Kick discussed bladder training under the headings of communication, fluid intake, and habit formation. The nature of nursing interventions related to these areas will be contrasted with the British authors' discussion.
Communication for Maney and Kick included verbal and written exchanges between all staff involved in patient care and between the staff and the patient. Communication was related to assessment of the patient's past voiding and intake patterns, problems with incontinence, and the scheduled plan for retraining with its expected outcomes. In addition, patient and staff responsibilities were to be clearly delineated and understood by all. The importance of staff and patient communication was also discussed in each of the British articles. Patient involvement in plan and its implementation was considered crucial by all authors. United States and British authors confronted the problem of lesser prepared staff being most directly related to the patient in rendering care.
The British author, Willington, was much more specific than the other authors in discussing information that should be collected to determine patient's continence profile. He included a sample "nursing incontinence profile chart," an organized, understandable, simple but detailed indicator of nature of the incontinence problem. Environmental restraints, degree of mobility, management of clothing, emotional reactions, and alternative nursing actions were also part of the British profile. Wells spoke to the use of continence charts to determine patient's voiding patterns and individual patient behaviors, but did not present the details of the records. Though not mentioned by Maney and Kick, both Wells and Willington included assessment of bowel regularity, of urinary tract infections, of medication regimes, and of gen i to-urinary and gynecological disturbances having an influence on continence as important to baseline data.
Fluid intake was the second phase of the training program discussed by Maney and by Kick. They emphasized that 2000-3000 cc of fluid should be taken each day by each patient. In addition io amount, importance was given to the spacing of fluids at least every two hours and to the provision of a variety of fluids based on patients' preference. Techniques were offered for making fluid consumption a pleasant experience for patients. Among the suggestions was that of socialization with other patients at beverage times. Wells and Willington also addressed adequate fluid intake of at least two liters daily. They stressed its importance as a physiological factor aiding continence as well as improving mental function through adequate hydration. Neither authors discussed the subject with the detail of the United States authors. All authors warned about problems resulting from limiting fluids during the day to avoid the embarassment of incontinence.
The third phase of the training program described by Kick and Maney was that of habit formation related to fluid intake and regular toileting. Toileting patterns were suggested around the activities of getting up in the morning, eating three meals, and going to bed at night, i.e., eight toileting times a day using both before and after mealtime. Neither Wells nor Willington were as specific as Kick and Maney about toileting patterns. Willington stressed the importance of evaluating bladder capacity to judge what the correct time interval for toileting may be for a given patient. Willington also included planned bowel evacuation as an important part of toileting patterns. He also discussed pelvic floor exercises and use of a kitchen timer as a memory aid to established toileting patterns. Besides the actual toileting timing, Willington suggested that postural evacuation be taught to patients in order to assure complete emptying of the bladder. Postural evacuation consists of bending forward while sitting on the toilet in order to compensate for neuromuscular changes and bladder outlet obstructions that may be present due to normal aging changes.
An area that was not discussed by Kick and Maney in bladder training but is given importance by Willington and Wells was the calculated adjustment of the environment. While Wells was more concerned with providing an opportunity for persons to maintain their own already established bladder programs, her points regarding environmental factors could be applied equally well for retraining incontinent patients in hospitals or nursing homes. The environmental factors included: (a) bed height to encourage mobility; (b) chairs to encourage ease of rising; (c) obstacle free, welllit short distances to labelled, usable toilets; (d) availability of toilet alternatives such as commodes, urinals, and bedpans; (e) provision of signals and privacy; (f) suitable clothing enabling use of toilet in a hurry; and (g) a motivating pleasant environment.
Behavior therapy as a nursing intervention was discussed by Maney as well as by Hartie and Black, and Willington. All three described some principles of conditioning. Social reinforcement and monetary or token reinforcements for continence were used in both the Maney and the Hartie and Black programs. Each stressed the importance of thorough base-line assessments of patients selected for the program, of careful selection of the effective individual reinforcers, and of controlled, consistent, and rapid dispensing of the reinforcement after appropriate behavior. Maney, as well as Hartie and Black, pointed out that the target behavior or urinary incontinence (a nonbehavior) had to be expanded to include not only staying dry, but the appropriate use of the toilet. Neither accounts ottered details of the program that would enable a reader to implement such a program without more information.
On the other hand, Willington described the principles of conditioning as they related to sanitary habits in a much broader context, but in more detail. The usual stimulus in his model was the sensation of a full bladder which leads to the response of micturition. The normal reinforcement was the ''satisfaction" of an empty bladder. Inhibitory stimuli were described as lack of privacy, painful stimuli from sitting on a bedpan, performing in the wrong place or position and others. According to Willington, bladder retraining based on these principles calls for assisting the patient to achieve the ability to void without bladder sensations of fullness when the stimulus of sitting on a toilet seat is added to the situation. In addition, inhibitory stimuli are avoided. Willington spoke briefly of the use of social reinforcement techniques for bladder training, but did not encourage such programs. He raised questions regarding the ethical implications of some of the current programs particularly those that utilize negative reinforcers.
Prevention of Soiling
The final area of nursing intervention discussed was that of prevention of soiling in the incontinent patient who has not responded to training. The United States articles addressed the problem only in the article related to male external appliances (Why te & Thistle, 1976). However, both Willington and Wells spoke to the issue. Wells stated in the closing paragraph of her article that there appeared to be only two practical items to assist in management of incontinence. They are the Gelulose Pad, a colloid-filled absorbent pad, and a marsupial pouch protective garment. Willington devoted the major part of his article on the prevention of soiling to principles underlying the selection of hygienic aids, and the proper selection of aids for bedfast and ambulant patients. The principles included: (a) separate a patient from his excreta by means that have no harmful complications and provide freedom from odor; (b) preserve social independence including management of the aid by the patient; and (c) provide a therapeutic component that includes warmth, dryness, and acceptableness aesthetically. Willington discussed the failure of the common incontinent pads to meet the criteria and suggested the same aids as did Wells for meeting the criteria most satisfactorily to date. He offered the hope that new developments in the technology of materials may enable more satisfactory management in the future.
The United States and British articles discussed in this section were most similar in their emphasis on the importance of communication between staff members and between staff members and the patient. They were also similar in their approaches to involving the patient in the planning and implementation of bladder retraining. Other similarities included importance given to baseline assessments, provision of adequate fluids and use of conditioning principles.
Contrasts appeared in the emphasis placed on specific aspects of bladder retraining. The British articles stressed detailed assessment of the patient and his environment, adjusting the environment, teaching postural evacuation and pelvic exercises, and preventing soiling. The United States articles stressed techniques for increasing fluids and for habit formation in the taking of fluids and in toileting. Differences existed within the British articles on practical application of conditioning principles; both similarities and differences were present when these were compared with the United States article.
The United States and British articles reviewed demonstrated marked differences in their use of references. No references were cited in the three United States articles by Wilson, Beck, and Why te & Thistle to support their particular approaches to patient problems. In most instances, rationales for actions were not presented by these authors. Maney used references to literature on aging, incontinence, and behavioral therapy in order to ground specific aspects of her suggested bladder retraining program. All nine references that she used were taken from United States journals and professional books. Kick included general references at the end of her paper that included books, journals, and an unpublished paper, dealing with incontinence, fluid balance, aging, physiology and rehabilitation. -Two of the nine references were from British nursing journals. Since she did not point out which references were used in developing the particular parts of her paper, it was unclear how supported her ideas were.
In contrast to this rather limited use of references in the United States articles, each British article was well documented. No general references were given. AH références were cited within the body of the article. As might be expected the majority of references were to British journals and books, though Wells and Hartie and Black also cited United States books and journals. The British references included numerous studies by British national groups such as British Standards Institution, National Fund for Crippling Diseases, Disabled Living Foundation, and National Corporation for the Care of Old People. The references provide one cultural clue as to why the British articles differed from the United States articles in the ways they did. The British government has encouraged practical study of the care problems of its elderly and chronically ill.
This paper was an examination of the nursing care problem of incontinence in the elderly and chronically ill as discussed in recent nursing journals published in the United States and England, The articles were compared and contrasted in terms of the titles, content, assumptions, interventions, and supporting literature.
The findings are limited by the fact that the reviewed articles were few in number. In addition, the scope and specific nature of the content were not the same between the two countries. No attempt was made to match the educational levels of the authors, nor to assess the quality and audiences of the nursing journals from which the articles were taken. The fact that nursing journals rather than nursing texts were used for comparison may also account for some of the differences that were found between countries. An interesting follow-up to the present investigation would be a similar analysis of geriatric and rehabilitation nursing textbooks addressing urinary incontinence, its prevention and treatment.
On the basis of the present survey, it can be said that nurses caring for incontinent or potentially incontinent patients could benefit by studying British nursing journals on the subject. It can also be said that United States nurses who are skilled in the care of these patients would do well to publish their knowledge and their successful approaches.
- Cumulative Index to Nursing Literature, Vol, 20-21. Glpndale. California: Seventh Day Adventist Hospital Association, 19751976.
- Beck R: Helping to make his last dream a reality. J Gerontol Nurs 1(2): 10- 12. 1975.
- Hartie A, Black D: A dry bed is the objective. Nurs Times 71:18741876, 1975.
- Kick EM: Rx for incontenance. In ANA Clinical Sessions: American Nurses Association, Detroit, 1972. New York, Appleton-Century-Crofts, 1973.
- Maney JY: A behavioral therapy approach to bladder retraining. Nurs Clin Am 11(1):179-188, 1976.
- Wells T: Promoting urinary continence in the elderly in hospital. Nurs Times 71:1908-1909, 1975.
- Whyte J, Thistle N: Male incontinence: the inside story on external collection. Nurs 76 6:66-67, 1976.
- Willington FL: Incontinence, part 1: significance of incompetence of personal sanitary habits. Nurs Times 71:340-341, 1975.
- Willington FL: Incontinence, part 2: problems in the aetiology of urinary incontinence. Nurs Times 71:378-381, 1975.
- Willington FL: Incontinence, part 3: psychological and psychogenic aspects. Nurs Times 71:422-423, 1975.
- Willington FL: Incontinence, part 4: the nursing component in diagnosis and treatment. Nurs Times 71:464-467, 1975.
- Willington FL: Incontinence, part 5: Training and retraining for continence. Nurs Times 71:500-503, 1975.
- Willington FL: Incontinence, part 6: the prevention of soiling. Nurs Times 71:545-548, 1975.
- Wilson MF: Bladder training for the chronically ill. RN 38:36-37, 1975.
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