Journal of Gerontological Nursing

Urinary Incontinence : Nursing Home Staff Reaction Toward Residents

Lucy C Yu, PhD; Karen Johnson, BS; D Lynne Kaltreider, MEd; Teh-wei Hu, PhD; Diane Brannon, PhD; Marcia Ory, PhD

Abstract

Nurses usually feel guilty and inadequate when they are unable to meet all of the residents' needs.

Abstract

Nurses usually feel guilty and inadequate when they are unable to meet all of the residents' needs.

A pilot project funded by the National Institute on Aging and conducted at the Pennsylvania State University, University Park, studied the cost-effectiveness of treating urinary incontinent elderly in nursing homes. During the project, an Incontinence Stress Index (ISI) was developed and pilot tested. One component of the ISI, the Incontinence Stress Questionnaire - Staff Reaction (ISQ-SR), measures the reaction of nursing home staff to urinary incontinence among their residents. Yu and Kaltreider have described the ISQ-SR and the results of its use in four nursing homes.1

The current article briefly reviews the development and pilot testing of the ISQ-SR, and then presents the results of its use in six nursing homes participating in a 3-year clinical trial funded by the National Institute on Aging and the National Center for Nursing Research.

Urinary incontinence has become an important topic of discussion and concern among healtii-care providers. Not only is urinary incontinence psychologically stressful to the patient, but it also is increasingly stressful to the nursing home staff who work with these patients. Furthermore, it places financial burdens on the facility housing the patient. The cost of urinary incontinence to nursing homes is estimated to be $2 billion annually, or approximately 10% of nursing home costs.2 Cella reported that nursing homes average approximately two full-time staff members per day who care for urinary incontinent patients.3

The prevalence of urinary incontinence increases with age. Based on current demographic trends, the elderly population can be expected to increase. Therefore, the magnitude of the incontinence problem among the institutionalized elderly is likely to worsen unless effective strategies are found to remedy the situation for both patients and caregivers.

Nursing home administrators are faced with the tasks of first identifying and then eliminating the stressors placed on their employees.4 It is hoped that the ISQ-SR, which examines staff reaction to incontinence, will prove useful to nursing home managers who seek to diminish occupational stressors encountered by those working with urinary incontinent patients.

LITERATURE REVIEW

Urinary incontinence is most often defined as the involuntary loss of bladder control.5 Researchers have identified four major types of urinary incontinence: stress, urge, overflow, and functional incontinence. Stress incontinence, the involuntary loss of urine due to changes in abdominal pressure on the bladder when laughing, coughing, or standing up too quickly, is a common form of the condition, especially among women. Urge incontinence, probably the most common type of urinary incontinence, is characterized by an inability to control the urge to urinate.6,7 Overflow incontinence occurs when the bladder cannot empty completely, resulting in urine leakage. Functional incontinence is urinary leakage that occurs as a result of physical or mental inability of the person to get to the toilet. Environmental factors, such as physical barriers and lack of assistance from a caregiver, also contribute to functional incontinence.5,8

The etiology, symptoms, and management of urinary incontinence have been researched extensively.1·9"13 Although urinary incontinence is prevalent among me elderly at home as well as in institutions, our research focuses on nursing home residents. Estimates of urinary incontinence among nursing home residents range from 30% to 85%. 3·14"18 Some elderly patients (76%) have been found occasionally incontinent, while others (50%) were found always incontinent.3·17 Ouslander et al found that urinary tract infection and skin breakdown were complications in 45% of incontinent patients.16 Urinary incontinence occurs at a higher rate among nursing home patients with physical and mental impairments.14,19

The special care needed by the urinary incontinent patient in the nursing home affects the nursing staff. Care of the patients often involves costly and time-consuming clothing and linen changes, treatment of skin breakdown, and other aesthetically unpleasant tasks.2·3·20 Incontinence can affect staff morale and cause stress.21 The stress brought on by repeated episodes of incontinence with the resultant handling of personal garments, bedclothes, and linens, as well as batìiing the patient, often results in burnout among nursing home personnel.22·23

According to Long, health-care workers who care for urinary incontinent patients view this situation as "an unpleasant and demanding hygienic problem" that is usually handled through functional care rather than attempts to treat the underlying cause.24 Those who care for the elderly often believe that urinary incontinence is part of the aging process; consequentiy, they make no attempt at nursing intervention or medical or surgical treatments to correct the underlying cause.15·25 Instead, caregivers use diapers, extra bedding, and frequent changes of clothes and linens, and they focus on the behavioral aspects of the incontinence, ramer than diagnosing and treating the physical problem. Schnelle et al found that nursing homes minimize the direct cost of incontinence by not changing patients at a level that matches the incontinence frequency.26

One of the problems in dealing with urinary incontinence is the attitudes of health-care providers.27"29 Studies of burnout among nursing home personnel report that nurses usually feel guilty and inadequate when they are unable to meet all of the residents' needs. These feelings of guilt increase with the frequency with which the nursing employee is faced with overwhelming needs of the residents and not enough time or manpower to meet those needs.30

The cost of urinary incontinent patient care has been estimated at 2lh times that of continent patient care. The cost includes extra nursing time, supplies, cleaning and laundry, and absenteeism and turnover rates brought on by the added stress of taking care of urinary incontinent patients.2,31·32

Although the literature suggests that staff stress results from urinary incontinence, no instrument was found to measure this stress prior to the development and pilot testing of the ISQ-SR. The measurement of staff reaction to urinary incontinence provides useful data for nursing home administrators seeking to reduce staff stress. The information serves as a useful prerequisite for planning staff education and staff retention.

Table

FIGUREINCONTINENCE STRESS QUESTIONNAIRE-STAFF REACTION: HISTORY OF DEVELOPMENT

FIGURE

INCONTINENCE STRESS QUESTIONNAIRE-STAFF REACTION: HISTORY OF DEVELOPMENT

Table

TABLE 1STAFF REACTION TO URINARY INCONTINENCE*: FACTOR LOADINGS FOR 30 VARIABLES IN THE PILOT STUDY+F

TABLE 1

STAFF REACTION TO URINARY INCONTINENCE*: FACTOR LOADINGS FOR 30 VARIABLES IN THE PILOT STUDY+F

METHOD

Population and Sample

All of those completing the ISQ-SR were staff members at six long-term care institutions in central Pennsylvania participating in the study, "CostEffectiveness of a Behavior Therapy Program for Urinary Incontinence in Nursing Homes."2

Procedure

In each of the six nursing homes, the ISQ-SR questionnaires were distributed by the director of nursing to all staff, including registered nurses, practical nurses, and nurse's aides. A cover letter accompanying the survey explained its purpose and guaranteed the respondent's anonymity. Participants were asked to return the completed questionnaires to the researchers in the postage-paid envelopes provided, thus ensuring the return of the questionnaires directly to the researchers. In the current study, 291 staff members responded to the ISQ-SR.

Instrument

The ISQ-SR was designed specifically to measure the psychological stress that nursing home staff experience in connection with the urinary incontinence of their patients. Early in die pilot study, using available literature as a guide, a list of words describing possible staff reactions to urinary incontinence was compiled. The list was then put in sentence form, and a five-point Likert format was used. The questionnaire was pretested in a local nursing home not included in the funded study. Staff were asked to provide written feedback about the content, format, and amount of time it took to complete the questionnaire.

The questionnaire was then revised based on the feedback. After the pretests, the questionnaire was reduced fiora 80 items to 40.

The instrument was then pretested with a group of RNs and LPNs in a hospital. One of the investigators met with 20 staff volunteers from different floors. The investigator explained the purpose of the study and asked these individuals to give the researcher their reaction to urinary incontinence. The questionnaire was then distributed to each person along with the request for them to delete, add, modify, and improve the questions. Using this information, the ISQ-SR was again reduced, this time to the final 30-item instrument used in both the pilot and current studies. The Figure summarizes the history of the instrument development.

Table

TABLE 2STAFF REACTION TO URINARY INCONTINENCE*: ACTOR LOADINGS FOR 20 VARIABLES! IN THE CURRENT STUDY*

TABLE 2

STAFF REACTION TO URINARY INCONTINENCE*: ACTOR LOADINGS FOR 20 VARIABLES! IN THE CURRENT STUDY*

Table

TABLE 3REQUENCIES for positive responses in the current study*

TABLE 3

REQUENCIES for positive responses in the current study*

Content analysis was carried out in three steps: frequency distributions of all variables were obtained; Cronbach's alpha, a statistic for determining the internal consistency of multipleitem scales, was computed; and principal component factor analysis with orthogonal rotation was used to explore the underlying dimensions of the factors measured in the instrument.

RESULTS

Principal component factor analysis was used to examine the 30- item questionnaire. Factor analysis is designed to explore the underlying dimensions of scales.33 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 data from the pilot and current studies were analyzed separately using principal component factor analysis with orthogonal rotation. The first four factors in the pilot study accounted for 42% of the variance in the responses for both studies.

In the ISQ-SR pilot study, four factors - positive, negative, ambivalent, and aesthetic reactions - were reported by staff from four nursing homes working with urinary incontinent patients (Table 1). The factor structure in the current study indicates three factors (Table 2).

However, a careful examination of the data reveals that items in the third factor (ambivalent) from the pilot study (ie, guilty, looking for ways to help) loaded under the positive and the negative factors in the current study. Thus, the current study confirmed the factor structure of the pilot study, ie, different samples resulted in an essentially similar factor structure. Factor analysis on the data from the current study (Table 2) indicated that an additional 10 items should be deleted, thus leaving a 20-item instrument. The internal consistency of the ISQ-SR, as a measure of staff stress in relation to urinary incontinence, was .77 (Cronbach's alpha) in the current study.

Table

TABLE 4frequencies for negative responses in the current study*

TABLE 4

frequencies for negative responses in the current study*

Further examination of respondents' reactions (Table 3) shows that staff in the current study reported positive reactions to urinary incontinent patients "all of the time" on the following items: comfortable working with incontinent patients (49%), treat incontinent patients as adults (46%), and treat incontinent patients with respect (57%). These results are similar to those in the pilot study: comfortable working with incontinent patients (48%), treat incontinent patients as adults (53%), and treat incontinent patients with respect (59%).

Table 4 shows that staff reported feeling the following negative reactions "at least some of the time" when caring for urinary incontinent patients: frustrated (63 %\ tired (61%), discouraged and irritable (55%), depressed with their work (38%), guilty about their feelings (39%X and angry (42%).

In the pilot study, the corresponding percentages were frustrated (56%), tired (61%), discouraged (59%), irritable (55%), depressed with their work (35%).

Aesthetic responses varied among staff members. Thirty-five percent of the staff like to work with urinary incontinent patients most of the time, and 29% feel they can help the patients. Forty-six percent of staff like to work in a nursing home, and 58% like to work with elderly all of the time. Forty-two percent state they dislike changing wet beds and clothing some of the time, whereas 45% feel that way none of the time. Forty-nine percent state that they dislike the odor, and 39% dislike working with urinary incontinent patients some of the time. In comparison, data from the pilot study revealed that 55% disliked changing wet clothing and bedding none of the time, and 48% stated that they disliked the odor some of the time.

DISCUSSION AND CONCLUSION

This article has discussed the pilot testing and subsequent development of the ISQ-SR instrument to measure the reactions of nursing home staff who work with urinary incontinent patients and the results of its use in six nursing homes. The results given were compared with those of the pilot study. The ISQ-SR was found to be a reliable and valid tool to measure the psychological stress that nursing home staff associate with working with incontinent patients.

The results suggest that nursing home staff have both positive and negative responses toward urinary incontinent patients, and that staff members experience stress when working with this patient population.

These findings have implications for nursing home administrators for hiring practices and quality of care issues, as well as for staff retention. A tentative solution to dealing with stress is to examine the management systems employed by the administration of the health-care organization and to determine the effectiveness and impact cost of long-term care. Many institutions are interested in finding the most costeffective patient care. However, if a situation is creating a stressful atmosphere for individuals, then this must either be stopped or reversed to achieve objectives and fulfill needs. The key to managing stress in a health-care system is either to identify the stressor and eliminate it, or to reverse the process completely until the stress is reduced to a level considered manageable.34

Previous studies concerning attitudes toward elderly patients have produced conflicting results. Brower found a strong correlation between the educational level of nurses and their positive attitudes toward the elderly.35 Nursing homes are staffed predominantly with LPNs and nurse's aides who are less educated and more functionally oriented than registered nurses. Indifference can be caused by an overpowering sense of frustration due to a lack of knowledge for solving problems of aging clients or to a sense of vulnerability that results from the reality of certain settings.30 Nurses as a group have been inadequately prepared to cope with the multiple problems of the aging institutionalized patient population, and therefore often become frustrated.35 As noted, die data suggest that nursing home staff have both positive and negative responses toward urinary incontinent residents. The negative attitudes may in part be related to the atmosphere of the nursing home.

Another issue related to staff stress is the continuing problem of the nursing shortage and turnover. Therefore, administrators are faced not only with stressed staff, but must also devise methods to retain such caregivers.

NURSING IMPLICATIONS

Administrators need to be aware of the stress to staff caused by working with urinary incontinent patients. Assessing the case mix of patients when making assignments and allocating urinary incontinent patients evenly among staff may be one alternative to alleviate die stress. In-house education should focus on educating staff about the aging processes and encouraging staff to report urinary incontinence to the patient's physician for evaluation of the underlying cause and recommendation for appropriate treatment.

Administrators should attempt to hire staff who are willing to work with and have experience working with urinary incontinent patients. Once willing staff are hired, administrators should attempt to allocate resources, provide continued education, and devise reward systems to retain these valued staff.

What steps can administrators take to deal with the stress associated in caring for urinary incontinent residents? The nursing home administrator may choose to use the ISQ-SR to assess staff reactions. The summary findings can be used to design facilityspecific responses. Such responses might include one or more of the following strategies:

* Hold group discussions. Nursing staff at all levels may benefit from informal group discussions designed to encourage ventilation of feelings about the less pleasant aspects of caregiving work. Feedback from the survey using the ISQ-SR may provide a useful starting point for discussion. Being invited to recount "horror stories" or related chronic negative reactions to incontinence care duties in the presence of supportive administrators may itself be stress-reducing.

* Explore treatment alternatives. Assessment of each resident will facilitate productive treatment approaches. Behavioral approaches have proven successful in treating certain types of urinary incontinence.2·36 The use of such approaches requires an initial investment of staff training, one mat will likely be cost-effective in the long-run.

* Consider job design changes. If alternative treatment approaches are implemented for different categories of urinary incontinent residents, job redesign may be especially helpful. Assignment patterns may need to be altered. Some staff may excel at behavioral treatment of incontinence, for example. In this case, one should consider longterm assignment of these staff members to a particular group of residents who are likely to benefit from such an approach. These staff members could be recognized as in-house experts, thereby providing much-valued recognition and allowing them to serve as models to staff who are less effective.

* Distributing the stress-inducing negative aspects of incontinence care may help minimize the burden. This also requires that residents be assessed and assigned to care programs. By encouraging assessment and treatment, the administration of the nursing facility can demonstrate its commitment to addressing a significant source of stress for residents and staff.

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FIGURE

INCONTINENCE STRESS QUESTIONNAIRE-STAFF REACTION: HISTORY OF DEVELOPMENT

TABLE 1

STAFF REACTION TO URINARY INCONTINENCE*: FACTOR LOADINGS FOR 30 VARIABLES IN THE PILOT STUDY+F

TABLE 2

STAFF REACTION TO URINARY INCONTINENCE*: ACTOR LOADINGS FOR 20 VARIABLES! IN THE CURRENT STUDY*

TABLE 3

REQUENCIES for positive responses in the current study*

TABLE 4

frequencies for negative responses in the current study*

10.3928/0098-9134-19911101-09

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