In 1983 the NationaJ Institute on Aging (NIA) funded a pilot project at The Pennsylvania State University to study the cost effectiveness of treating urinary incontinent elderly in nursing homes. During that project, an Incontinence Stress Index was developed and pilot tested. This article describes one component of that index - the Incontinence Stress Questionnaire-Staff Reaction (ISQ-SR). This questionnaire measures staff reaction to urinary incontinence.
Urinary incontinence is receiving increased attention from urologisis, nurses, and other healthcare providers. Although urinary incontinence is not a life-threatening condition, it appears to be one of the most psychologically distressing and socially disruptive problems faced by the elderly.1
In general, the prevalence of incontinence increases with advancing age. Given demographic trends that suggest a larger elderly population in the future, the magnitude of the incontinence problem among the institutionalized elderly is likely to increase unless effective strategies or procedures are found to remedy the situation.
Review of the Literature
Substantial research has been carried out on urinary incontinence, its etiology, symptoms, and management.2'5 Although urinary incontinence is a problem faced by the elderly in the community, in nursing homes, in special geriatric units, and in residential homes, the focus of our research is nursing home residents. Estimates of the magnitude of the problem in this setting vary. Wellington6 suggests that approximately 30% of the hospitalized elderly experience some degree of urinary incontinence. Lowenthal7 estimates that incontinence affects 85% of long-term care, institutional populations over the age of 65. In Wells's study of incontinence in a long-term care institution,8 nurses judged that 76% of their elderly patients experienced some degree of incontinence, and 50% were always incontinent. Ouslander, Kane, and Abrass9 found a similar prevalence rate for incontinence among seven nursing homes. They also found that complications, such as urinary tract infection and skin breakdown, occurred in almost 45% of the incontinent patients.
Incontinent residents or patients in institutional settings have special needs that have implications for nursing care givers. According to Spiro,10 the problem is a frustrating one for nursing staff; it entails expensive and time-consuming personal clothing and linen changes, prolonged and painful treatment of decubitus ulcers, and other aesthetically unpleasant assignments. Burnside1 ' has noted that a regular routine of caring for incontinent patients, which includes handling personal garments, bedclothes, and linens, as well as bathing the patient repeatedly, quickly brings on a burn-out of personnel. Anderson12 has observed that incontinence is destructive to staff morale , and he calls on nursing staff to initiate and implement programs to reduce the incidence of urinary incontinence.
More recently, Long13 has noted that those who provide health care to the incontinent often view the situation as "an unpleasant and demanding hygienic problem" that is usually handled via routines aimed at the symptoms rather than the underlying causes. That is, emphasis is placed on keeping the incontinent dry by frequent changes and disposable diapers rather than on diagnosing and treating the incontinent condition. A study by Simons14 supports the claims of earlier researchers (Swaffield,15 and Wells and Brink16) that "the real problem in dealing with urinary incontinence is one of the attitudes of healthcare providers." Simons calls upon gerontological nurses to view urinary incontinence as a major problem for clients in the community and in institutions.
The additional time required of nursing personnel, the need for special supplies, the additional cleaning and laundering, and the increase in absenteeism and staff turnover attributed to urinary incontinence add to the cost of caring for the elderly.17 This increased cost is estimated to be about two-and-one-half times greater than the cost of caring for the continent elderly.18
Although the literature suggests that staff stress results from urinary incontinence, no instrument was developed to measure this stress. This article describes the development and pilot testing of a questionnaire (ISQ-SR) directed specifically at the stress that nursing home staff experience in working with incontinent patients.
Population and Sample - All of the persons completing the staff reaction questionnaire were staff members at long-term care institutions in central Pennsylvania who participated in the pilot study titled, "Cost-Effectiveness of Treating Urinary Incontinent Elderly - A Bladder Training Program in Nursing Homes."19
In each of the four nursing homes for which data were available, the director of nursing was asked to distribute the questionnaire to all staff, including registered nurses, practical nurses, and nurses' aides. A cover letter explained the purpose of the survey and guaranteed the respondents' anonymity. Postage-paid envelopes were provided for participants to return their completed questionnaires directly to the researchers.
Three of the participating nursing homes were proprietary homes, and the fourth was a county home. The combined staff (RNs, LPNs, and aides) of the four nursing homes numbered 308 members. Of these, 156 staff voluntarily responded to the ISQ-SR during the pilot test, for an overall response rate of 51%. The response rate for the county home was 54% and for the three proprietary homes, 25%, 49%, and 100%.
Procedure - The ISQ-SR was designed specifically to measure the psychological stress that nursing home staff experience in connection with urinary incontinence. Initially, we scanned the literature for clues of staff stress. We found that many investigators hinted at staff stress when they talked about the effects of urinary incontinence on patients, but no study was found that empirically examined both urinary incontinence and staff reaction to the condition.
We compiled a list of possible staff reactions, put the list in sentence form, and, using a five-point Likert format, pretested the list in a local nursing home. We asked the staff in that home to provide written feedback about the content, format, and amount of time it took to complete the questionnaire. When the pretests came back, we revised the questionnaire, shortened the sentences, and eliminated inappropriate, ambiguous, and redundant items. The questionnaire was reduced to 40 items.
To give the instrument some content validity, we pretested it with a group of registered nurses and licensed practical nurses in a hospital. One of the investigators obtained permission from the director of nursing services to release two or three staff members from each floor for one hour to go over the items in the questionnaire. Twenty nursing staff from different floors pretested the instrument in two groups. One of the investigators explained the purpose of the study and asked these individuals to give the researcher their reaction to urinary incontinence. She then distributed a questionnaire to each person and asked them to delete, add, modify, and improve the questions. The participants' comments were carefully recorded. The final 30-item ISQ-SR is a composite of our initial effort, the results of the first pretest, and revisions based on suggestions from the 20 staff members who worked with urinary incontinent patients and participated in our feedback session.
Content analysis of the instrument development was carried out in three steps:
1. Frequency distributions of all variables were obtained;
2. Cronbach's alpha, a method for determining the reliability of multiple-item scales, was computed to examine the internal consistency of the instrument; and
3. Principal component factor analysis with verimax rotation was used to explore the underlying dimensions of the factors measured by the instrument as well as to reduce the length of the instrument.
The reliability of the ISQ-SR as a measure of staff stress in relation to urinary incontinence, as indicated by Cronbach's alpha, is 0.84. Alpha levels appear to have no generally accepted criterion of reliability. Sonquist and Dunkelberry2? argue that, for basic research, reliabilities of 0.5 or 0.6 are adequate for most purposes.
Principal component factor analysis was used to examine the 30-item questionnaire further. Factor analysis is designed to explore whether a scale measures more than one concept equally or unequally.2' Usually more than one factor underlies a set of items. The higher the factor loading, the more the particular item contributes to the given factor.
The initial extraction showed 14 factors in this instrument; the first 4 factors accounted for 42% of the variance in the responses. Essentially, the analysis revealed 4 factors in the Staff Reaction Questionnaire: positive, negative, ambivalent, and aesthetic reactions were produced in the staff vis-?-vis urinary incontinence.
Staff reported feeling positive reactions all qe the time to the following items: 48% stated that they felt comfortable working with incontinent patients, 60% said that they like working in a nursing home, 54% said that they treated incontinent patients as adults, and 59% said that they treated incontinent patients with respect.
Staff reported feeling the following negative reactions oí least some of the time: 60% to 70% felt frustrated, tired, discouraged, and irritable, 38% to 43% felt depressed about their work and about the extra work associated with urinary incontinence in particular, and 20% felt like resigning from their job because of patients' urinary incontinence.
A group of indicators in the ambivalent category revealed opposing dimensions of staff reaction to urinary incontinence. On one hand, 60% of the respondents perceived at least some of the time that the situation was hopeless, and 40% to 45% sometimes felt helpless and guilty about their feelings toward urinary incontinent patients.
At the same time, almost all of the respondents (96% and 99%, respectively) reported sometimes feeling sympathetic (sorry) toward these patients and looking for ways to help them. On the aesthetic dimension, 45% of the respondents reported that at least some of the time they disliked changing wet clothes and bedding, and 80% sometimes disliked the odor associated with urinary incontinence.
The respondents were invited to make general comments at the end of the questionnaire. Their comments seemed to fall into three categories. Some staff were upset with the incontinent patients:
* I get frustrated when I feel a patient is doing it purposefully and could control it.
* I get most frustrated (angry) with people (patients) who know when they have to go and wet themselves because they don't feel like getting up to use the toilet.
* I am unable to express my feelings due to negative reaction.
Others viewed the incontinence matterof-factly:
* It is so common in a nursing home you just expect it and clean it up.
Still others blamed nursing care givers or staff shortages:
* I get very frustrated with other staff members because of their negative attitudes toward the problem.
* There wouldn't be any need for studying incontinent residents if there was enough nursing care. It is due to lack of help. I've watched over the years and see how, and why, a resident becomes incontinent: nurses not taking them to the bathroom, not having time if the aides are busy. The patient has no one else to take them to the' bathroom. If the nurses will not take them, what else can they do but wet? It isn't the age; it's the care a lot of times.
Discussion and Conclusions
This article has discussed the construction of an instrument to measure the stress experienced by nursing home staff related to urinary incontinence and has presented the results of its pilot testing.
The results suggest that nursing home staff have both positive and negative feelings toward urinary incontinence, and they document for the first time what the literature has implied - healthcare providers in many homes experience psychological stress in connection with urinary incontinence.
Although the respondents admitted to both positive and negative feelings, we suggest that they probably underreported their negative feelings toward the patients because of the Florence Nightingale Code. Our culture and society expect healthcare providers (RNs, LPNs, and nurses' aides) ?? feel compassion toward the ill and dysfunctional.
Our sample might be biased since the respondents volunteered to participate; however, the response rate leads us to suggest that urinary incontinence creates enough psychological stress in nursing home staff to entice them to volunteer their reaction. Our findings have implications for staff in-service education and for the quality of patient care in long-term care institutions.
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