For many long-term care nursing facility residents, urinary incontinence (UI) is a fact of life. Incontinence may have been a long-standing problem prior to admission or the result of recent acute illness or injury such as hip fracture. Urinary incontinence is a sentinel event for the resident creating adverse health consequences and cost burdens. Although multiple chronic illnesses and cognitive and physical frailty affect many residents in long-term care, significant benefits can be attained through restorative interventions directed at improving continence.
Prompted voiding is a scheduled toileting regimen with a communication protocol and social reinforcement component designed to increase the resident's awareness of bladder filling and the social expectation for maintaining continence. As a behavioral therapy, prompted voiding can remind cognitively impaired residents to request or accept toileting assistance and to maintain a higher level of dryness. Prompted voiding may improve incontinence in 25% to 40% of incontinent residents in long-term care facilities and, therefore, has significant implications for quality of life, resource use, and cost of care (Colling, Ouslander, Hadley, Eisch, & Campbell, 1992; Engel et al., 1990; Hu et al., 1989; Schnelle et al., 1989). The efficacy of prompted voiding is hindered by the lack of implementation methodologies that would direct the use of the intervention under realworld circumstances, thus leading to ineffective implementation or discontinuation (Schnelle, Ouslander, & Cruise, 1998).
This article presents a model for implementing a prompted voiding program in a long-term care facility based on Rogers' (1983, 1995) model of diffusion of innovation. Diffusion oí innovation research has studied the reasons why good ideas with obvious advantages are not put into practice. There continues to be a wide gap between what is known and what actually is used. This is particularly true in long-term care settings in which restorative care and behavioral treatment strategies for incontinence are put into practice at a slow pace, on a small scale, or with high discontinuation rates. Diffusion of innovation has practical applications as a model for promoting use of research in practice.
DIFFUSION OF INNOVATION
Diffusion is a process of social change through which an innovation is communicated through certain channels over time among members of a social system (Rogers, 1983, 1995). Diffusion is used to describe both the planned and spontaneous spread of new ideas. An innovation is an idea, practice, or object perceived as new by an individual or social system. The newness of the idea generates a degree of uncertainty as a result of a lack of information regarding the idea. In general, new ideas do not "sell themselves" and will require persuasion on the part of change agents.
The diffusion of innovation model developed by Rogers (1983, 1995) addresses variables of innovations that can either promote or hinder the rate of adoption. Efforts to accelerate the rate of adoption of innovations into practice can narrow the gap between what is known and what is done. The rate of adoption of innovations is influenced by five categories of variables:
Figure 1 . Variables determining rate of adoption of innovations.
* Perceived attributes of innovations.
* Type of innovation decision.
* Communication channels.
* Nature of the social system.
* Extent of the change agent's promotion efforts (Figure 1) (Rogers, 1983, 1995).
Perceived attributes are the characteristics of innovations that make the innovation more or less appealing to individuals (Figure 2).
The relative advantage is the degree to which an innovation is perceived as better than the current idea (or practice). The advantage can be viewed in economic terms, convenience, social status, or satisfaction. Relative advantage is one of the best predictors of the rate of adoption of innovations - the greater the perceived relative advantage of an innovation, the more rapid its rate of adoption.
Compatibility is the degree to which an innovation is perceived as consistent with existing values, beliefs, past experiences, and needs of the group. The adoption of an incompatible innovation requires the prior adoption of a new value system.
Complexity is the degree to which an innovation is perceived as difficult to understand, use, or implement. More complex innovations will be adopted more slowly and are at greater risk for discontinuation.
Trialability is the degree to which an innovation may be altered on a limited basis or implemented on a small scale. Trialability offers the opportunity to modify aspects of the innovation (reinvent) to enhance its implementation.
Observability is the degree to which the results of an innovation are visible to others. Visibility of the innovation increases communication and knowledge regarding the innovation, heightens awareness of its attributes, and promotes acceptance and adoption.
Adopting an innovation is an active process between a change agent and the social system. Most innovations undergo modification, or reinvention, during the adoption or implementation of the innovation. Reinvention underscores that adoption of an innovation is not a passive process of implementing a standard template of the new idea but one of mutual influence (Rogers, 1995). Reinvention may occur when the innovation is complex, when the change agent's knowledge of the innovation is limited or if the change agent encourages modification of the innovation, when the innovation is designed to solve a wide range of problems, and when an organization wishes to personalize or customize an innovation. Therefore, reinvention may risk diminishing the efficacy of the innovation yet can increase the rate of adoption (Rogers, 1995).
TYPE OF INNOVATION DECISION
This process describes the way in which an individual or social group first learns about an innovation and then decides whether to adopt or reject the innovation. The steps in this process include:
* Knowledge, or the gaining of understanding regarding the advantages and disadvantages of the innovation.
* Persuasion, or the formation oí a favorable or unfavorable opinion of the innovation.
* Decision, or the choice to adopt or reject the innovation.
* Implementation, putting the innovation into use.
* Confirmation, or seeking reinforcement that the innovation is effective.
Types of innovation decisions include optional, collective, and authority. Optional innovation decisions are choices made by an individual to adopt or reject an innovation independent of others. Collective innovation decisions are choices to adopt or reject an innovation made by consensus among members of the social system. Authority innovation decisions are choices to adopt or reject an innovation made by a relatively few individuals in a system who possess power, status, and expertise. The more rapid rate of adoption often results from authority decisions, but the innovation can be undermined if there is not collective agreement and action. Authority innovative decisions can set the stage for change, but collective decision-making will be more successful in determining successful implementation.
Two forms of communication include mass media channels and interpersonal channels. Mass media (e.g., radios, television, newspapers, electronic/Internet) enable sources to reach a large authence. Interpersonal channels involve direct face-to-face contact. Interpersonal channels are the most critical component to the diffusion process and strongly influence the adoption or rejection of an innovation.
NATURE OF THE SOCIAL SYSTEM
A social system is a set of individuals or groups engaged in joint problem solving and cooperation to achieve a common goal. Diffusion occurs within the context of social relationships based on power, norms, roles, and public acceptability. Norms that guide behavior patterns for members of the system can be a barrier to change if the innovation contradicts the norms.
Figure 3. Resident and staff outcomes.
EXTENT OF THE CHANGE AGENT'S PROMOTION EFFORTS
Change agents are individuals who wish to influence the decisionmaking process to promote the adoption of an innovation. Change agents help create an intent to change and help translate the innovation into action. Opinion leaders are influential team members who carry the power of persuasion in the acceptance of an innovation. Opinion leaders hold an informal type of leadership earned by the individual's work skill, social accessibility, and conformity to the system's norms. Some opinion leaders may oppose change. Engaging these individuals early in the decision-making process can enhance their social status and sway their opposition through persuasion. Early adopters are those who favor the innovation early in the decision process. It is imperative for change agents to identify opinion leaders and early adopters who will persuade peers to accept and adopt the innovation.
PURPOSE OF THE STUDY
The diffusion of innovation model has a strong applied focus that facilitates the study of strategies that hinder or promote adoption of innovations. The Long-Term Care Continence Demonstration Project used the diffusion of innovation model to design protocols for clinical care, nursing staff education, and staff management and quality monitoring for prompted voiding program implementation. This article describes the application of the diffusion of innovation model in the implementation of a prompted voiding program in a longterm care facility.
Setting and Sample
The project was conducted in a 120-bed not-for-profit long-term care facility in central North Carolina from October 1991 through September 1992. The nursing staff sample included RN, licensed practical nurse (LPN), and certified nursing assistant (CNA) staff who participated in educational workshops. The resident sample was a convenience sample of residents selected by nursing staff for participation in the prompted voiding program according to the following criteria:
* Willing to use the toilet on a regular basis without an observed increase in agitation or disruptive behavior.
* Able to initiate voiding when taken to the toilet.
* Able to verbalize or recognize own name when asked.
* Able to accept toileting assistance when offered and rarely refuse.
* Do not require more than one other individual to transfer.
Education Protocol. The education protocol included consultation and program development, educational workshops, and on-the-job competency training. Prior to implementation of the prompted voiding program, planning and program development was performed for 3 months with managerial nursing staff. After the 6-week prompted voiding program was completed, nursing staff would continue the program independently with monthly telephone and on-site consultation, quality monitoring, and evaluation by the author during the following 6 months.
In general, the educational workshops were designed to raise awareness of the negative physical and psychosocial impact of incontinence, increase empathy for incontinent residents, and counteract myths that adversely affect the care of incontinent residents. Workshops were held during January of 1992. The RN/LPN workshop encompassed 12 hours over 2 days. The RN/LPN workshops focused on medical causes and types of UI, assessment, treatment and management, and roles and responsibilities in the prompted voiding program implementation. The 4hour CNA workshop focused on care routines influencing bladder function (i.e., fluid intake, bowel function, mobility assistance, and positive reinforcement), and their role and responsibilities in the prompted voiding program. Roleplay demonstrations illustrated communication techniques appropriate for residents with varying types of behavioral responses. In-class skill training and on-the-job coaching was conducted by the author with each CNA. Both the RN/LPN and CNA groups received didactic and experiential training related to staff-staff communication. Communication topics included communication styles, giving and receiving feedback, teamwork techniques, and managing conflict. The RN/LPN group received additional content on leadership and management. On-the-job contact with charge nurses encouraged their communication with the CNAs and implementation of quality monitoring procedures.
Nursing staff received premeasurement and postmeasurement of knowledge of incontinence, the prompted voiding program, and staff communication. The RNs and LPNs were administered a 19-item multiple-choice questionnaire. Certified nursing assistants were administered an 11 -item multiple-choice questionnaire. Both questionnaires were developed and reviewed by a panel of gerontological nurse specialists to reflect appropriate knowledge necessary to perform role responsibilities related to continence care. The questionnaires were administered before and after the educational workshops.
Clinical Protocol. The clinical protocol included procedures for resident selection, assessment, documentation, and the prompted voiding procedure. Residents received comprehensive assessment of incontinence including the history, physical examination, functional assessment, psychosocial impact, cognitive assessment (Folstein, Folstein, & McHugh, 1975), post- void residual urine measurement, and simple cystometry (Lekan-Rutledge, 1992). The assessment tool was based on the Minimum Data Set Resident Assessment Protocol from the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) and clinical practice guidelines (UI Guideline Panel, 1992). Assessments were conducted by the author and a staff nurse (RN or LPN).
The prompted voiding procedure was based on work by Schnelle (1991). Residents were provided toileting assistance every 2 hours from 8:00 a.m. to 10:00 p.m. Residents were not disturbed at night but were offered toileting assistance if awake. Night shift personnel offered toileting assistance (and changed wet undergarments if needed) at 6:00 a.m. Wetness and dryness status, voided volumes, fluid intake, and bowl function were recorded on the Prompted Voiding Toileting Form.
Quality Monitoring Protocol. Quality monitoring focused on resident outcomes and staff performance. The quality monitoring protocol included procedures for the Prompted Voiding Toileting Form, the Quality Control Charts, Quality Assurance Nursing Rounds, and guidelines for the Continence Team.
Dryness rates were calculated from the Prompted Voiding Toileting Form by dividing the number of wet episodes by the number of toiletings during the day and evening shift. The staff development nurse recorded daily dryness rates and staff performance rates on the Quality Control Chart. Resident dryness rates and staff performance rates were calculated during a 7-day period for a series of data collection points: first week of implementation of prompted voiding (start up), 6 weeks, 3 months, and 6 months.
Quality Assurance Nursing Rounds were conducted to determine resident wetness or dryness status, review the Prompted Voiding Toileting Form for accuracy and completeness, and elicit feedback from CNAs regarding implementation problems and provide affirmative feedback. Quality Assurance Nursing Rounds were conducted by the author and the staff development nurse on a random basis (daily or at least three times per week) during the day and evening shifts.
The Continence Team included the staff development nurse and nursing staff from all shifts. The Continence Team provided a vehicle for communication and forum for problem solving. The Continence Team convened once 2 weeks prior to start up of prompted voiding and 1 month after the initial implementation date.
Clinical Protocol: Resident Assessment
Nine residents (seven women, two men) were selected for participation in the prompted voiding program. The average age of the residents was 83 (range = 76 to 93). The average length of stay was 8 months (range = 2 to 60 months), and five residents were incontinent on admission to the facility. Six were independent in ambulation, one could ambulate with assistance, and two were wheelchair dependent. The average Mini-Mental State Examination score was 10 (range = 3 to 16), indicating severe intellectual impairment.
Primary medical diagnoses included dementia (all residents), arthritis (3), Alzheimer's disease (2), hypertension (2), pernicious anemia (2), cerebrovascular accident (1), congestive heart failure (1), benign prostatic hypertrophy (1), and diabetes mellitus (1). Two residents had mild pelvic organ prolapse. Atrophic vaginitis was evidenced in five of seven female residents. Two residents had positive urine cultures and were treated with oral antibiotics. Postvoid residual urine measurement and bedside cystometrograms were performed in seven residents. The average bladder capacity was 145, with a range of 90 to 250 cc. Post-void residual urine measurement averaged 45 cc, with a range of 10 to 100 cc. The average voided volume of the two residents in whom cystometrogram could not be completed was 100 cc and 200 cc. In these two residents, post-void residual urine measurement was estimated at 9 cc and 29 cc, respectively, using portable bladder ultrasound. Six residents demonstrated urge incontinence, and two demonstrated stress incontinence with cystometrogram testing.
During the 6-week prompted voiding intervention, all nine residents experienced a reduction in the number of wet episodes (Figure 3). The overall dryness rate increased from 71% at start up to 80% at 6 weeks, 78% at 3 months, and 85% at 6 months. The average number of wet episodes per day during Week 1 (start up) was 2.3, at 6 weeks, 1.57, at 3 months, 1 .79, and at 6 months, 1 .34. Two residents became continent and independent in toileting, needing only occasional verbal reminders. Two residents were transitioned to a less intense toileting regimen (i.e., on arising in the morning, at bedtime, after lunch, or as requested) after the 6 month measurement due to increased agitation and refusal to use the toilet. Both residents had Alzheimer's disease identified as the primary medical problem.
A total of 56 nursing staff (15 RNs and LPNs, and 41 CNAs) participated in educational workshops, representing 80% of full-time and parttime staff. Questionnaire results for RNs/LPNs (n = 10) indicated all RNs achieved passing scores (75%) on premeasurement and postmeasurement. None of the LPNs achieved passing scores on pretesting and posttesting. Certified nursing assistants (« = 21) demonstrated high pass rates on premeasurement (67%) and postmeasurement (86%).
Staff Management and Quality Monitoring Protocol
Staff performance, as measured by documentation on prompted voiding forms, was high throughout the 6-week intervention and at 3-month and 6-month follow up. During the first week of prompted voiding implementation, staff performance was 93%, at 6 weeks, 94%, at 3 months, 81%, and at 6 months, 85% (Figure 3). Although staff performance rates declined slightly from start up, resident wetness rates continued to improve.
STRATEGIES TO INCREASE ADOPTION OF PROMPTED VOIDING PROGRAM (PVP)
Quality monitoring procedures designed to enhance adoption and long-term continuation of prompted voiding included use of the Quality Control Chart and Quality Assurance Nursing Rounds. Both forms were modified to simplify documentation. The quality monitoring forms were modified extensively. The Continence Team convened to identify and solve implementation problems, assist in resident selection, and promote staff communication.
Diffusion of innovation theory guided the implementation of a prompted voiding program in a longterm care facility. After 6 months of implementation, the program showed evidence of successful adoption by nursing staff. Nursing policies and procedures were developed, staff education was incorporated into orientation and inservice programs, a training videotape was developed, quality control charts were computerized, and additional residents were started on prompted voiding. Anecdotal comments from nursing staff indicated prompted voiding was an integral part of daily care routines.
Resident selection criteria in this project were critical in determining the residents likely to be highly responsive to prompted voiding. Initially selecting highly responsive residents facilitated staff adoption of prompted voiding. Resident selection was more difficult in situations in which selection criteria were not met:
* Residents with a high (> 50%) wetness rate who are motivated and mobile or mobility-dependent.
* Residents with high wetness rates (> 50%), small voids (suggesting poor bladder function), or dry runs (inability to initiate voiding reflex when toileted).
* Residents in whom a good continence response was achieved but the behavioral response was worsened.
* Residents who responded poorly to verbal toileting prompts but accepted toileting assistance and maintained good dryness rates when taken on a scheduled toileting regimen.
Criteria for discontinuation from prompted voiding are not well defined in the literature.
Residents with high wetness rates, small voids, or periodic dry runs typically are not responsive to toileting regimens. Impaired cortical function may compromise the voluntary voiding component of the micturition cycle, the net result of which is a neurologically impaired bladder. However, when such residents are motivated and express a preference for toileting, a less intense schedule may be considered using natural opportunities to schedule voiding (i.e., on arising in the morning, at bedtime, after meals). In some residents, bowel continence can be maintained. For residents who do not express preference for toileting, then a check, pad change, skin care regimen is appropriate.
In some residents, significant improvement in continence may be offset by profound deterioration in psychological well-being. Behavioral responses should be considered in evaluating continence outcomes as a proxy for care preference in cognitively impaired residents. Some residents may continue to maintain their baseline level of continence when taken to the toilet but may become agitated or confused when prompted (i.e., "Do you feel wet or dry?", "Would you like me to help you to the toilet now?"). Nursing staff perceived that this subgroup of residents would benefit from a scheduled toileting regimen that omitted the prompts but still delivered praise and social reinforcement. The reinvention of prompted voiding for residents who were not responsive to prompted voiding led to the use of a scheduled toileting program.
Nursing staff education and training should include both in-class and on-the-job components. The benefit of on-the-job coaching not only reinforced correct staff performance but also provided recognition, praise, and affirmation. This seemed to have a profound effect on acceptance and adoption by CNAs and reinforced organizational expectations for performance. The on-thejob component also affirmed cultural values regarding continence care by shifting expectations from incontinence to continence.
Adoption of supervisory functions and staff communication recommendations by LPN charge nurses was limited despite in-class training and on-the-job coaching. In addition, pretest and posttest knowledge scores yielded poor passing rates among LPNs. These findings suggest education and training approaches be identified specifically to address the unique needs of this group.
Initial resident selection focused on more mobile residents. Mobility impairment may be a major factor underlying incontinence, and improving mobility may improve incontinence (Jirovec, 1991). Implementing prompted voiding with mobility-impaired residents requires focused skill training specific to individual resident needs. McCormick, Cella, Scheve, and Engel (1990) describe the use of a mechanical lift. Toileting can be more time consuming than changing pads (Colling et al., 1992). Lifts and other devices to facilitate transfers are more time consuming in mobility-dependent residents but also are safer and easier than hands-on approaches (McCormick et al., 1990). Funher study is needed on the impact of transfer devices on staff performance, resident acceptance, and continence outcomes.
Staff communication skill building can enhance the effectiveness of CNA interactions with cognitively impaired residents when providing continence care. A critical aspect of prompted voiding involves therapeutic communication to engage and motivate the residents to maintain continence.
Education and training alone will not assure adoption of an innovation. Nursing resource use is an important variable relative to implementation. Staff-to-resident ratios should be evaluated further related to efficacy and feasibility of prompted voiding. In one study, CNAs who reported many observed benefits of a prompted voiding program also indicated they had small patient care assignments and low staff turnover and absenteeism (Lekan-Rutledge, Palmer, & Belyea, 1998). Further research exploring nursing staff resource use and models for continence care delivery is needed.
Staff Management and Quality Monitoring Protocol
The adoption of quality monitoring procedures proved to be somewhat difficult for staff. The Quality Control Chart and Quality Assurance Nursing Rounds were implemented on a limited basis as a tool for problem identification and problem solving. Among charge nurses there was the expectation that CNAs would perform their responsibilities as part of their job with little feedback. Among CNAs, there was some concern that charge nurses were not interested in the prompted voiding program or in eliciting feedback from CNAs regarding implementation issues. Efforts to increase communication between CNAs and LPNs had limited success. Staff communication and teamwork has been reported as the key determinant for the long-term success of a prompted voiding program (LekanRutledge et al, 1998). Focused education and training strategies may help develop critical aspects of the charge nurse role. The Table summarizes approaches to increase adoption of prompted voiding.
Experienced clinicians know it is easier - although more expensive, labor intensive, and time consuming - to initiate new care practices than it is to maintain these practices. Effective toileting regimens are the cornerstones of continence care in cognitively impaired and mobilityimpaired residents. There is substantial evidence that toileting programs are not maintained at a level necessary to maintain resident continence, even in those most likely to be highly responsive (Campbell, Knight, Benson, & Colling, 1991; Schnelle, Ouslander, & Cruise, 1998). Strategies that increase the efficacy of prompted voiding need further study, including environmental modifications, documentation and quality monitoring technologies, and other medical or pharmaceutical innovations (Palmer, 1996). Toileting programs are more resource intensive than usual care practices, and efforts to promote adoption of prompted voiding and other continence care interventions must address barriers to acceptance and implementation. Future research using the diffusion of innovation model should address:
* The Innovation: Prompted Voiding. Develop an assessment framework using physiologic determinants of bladder function, behavioral or cognitive response, ethical considerations, resident preferences, and nursing staff resource use with regard to cost-benefit outcomes for continence care delivery in longterm care. Develop a guideline for determining how to best intervene with residents who do not meet clear criteria for prompted voiding. Develop and evaluate technologies that enhance effectiveness of prompted voiding.
* Communication. Identify staffstaff communication skills necessary for optimal adoption of prompted voiding. How will these skills be identified, taught, used, and evaluated? Devise optimal mass media and interpersonal methods for communicating information regarding prompted voiding. Develop education and training strategies most effective for RN, LPN, and CNA staff. Explore the role of the change agent in long-term care settings.
* Adoption. Explore the sociocultural norms and beliefs regarding incontinence and usual continence care practices in long-term care settings. Why is it acceptable to omit toileting in long-term care residents?
* Implementation. Develop strategies that engage staff in problem solving regarding implementation issues. Develop a typology of conditions or strategies that must be present to facilitate implementation. Identify nursing resource use frameworks for implementation of continence interventions. Analyze the costs of implementation of prompted voiding in target populations based on resident dependency. Identify staffing models or assignment-making strategies that enable better management of resident care responsibilities.
* Maintenance. Develop simple, effective quality monitoring procedures. Determine approaches that foster staff performance. How can innovations be maintained in organizations with high staff turnover? What are the consequences of continence care innovations for residents, personnel, organizations, and society?
The Long-Term Care Continence Demonstration Project successfully used strategies for adoption of prompted voiding in a long-term care facility using the diffusion of innovation model. Protocols for implementation of prompted voiding, staff education, and staff management and quality monitoring facilitated adoption by RN, LPN, and CNA nursing staff. Future research exploring technologies that accelerate diffusion of continence care innovations in long-term care facilities would radically impact the quality of care in nursing homes.
- Campbell, E.B., Knight, J., Benson, M., Sc Colling, J. (1991). Effect of an incontinence training program on nursing home staff's knowledge, attitudes, and behavior. The Gerontologist, 31, 788-794.
- Colling, J., Ouslander J., Hadley, B.J., Eisch, J., & Campbell, E. (1992). The effects of patterned urge-response toileting (PURT) on urinary incontinence among nursing home residents. Journal of the American Geriatrics Society, 40, 135-141.
- Engel, B.E., Burgio, L.D., McCormick, K.A., Hawkins, A.M., Scheve, A.A., & Leahy, E. (1990). Behavioral treatment of incontinence in the long-term care setting. Journal of the American Geriatrics Society, 38, 361-363.
- Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). Mint-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
- Hu, T, lgou, J.F., Kaltreider, L., Yu, L.C., Rohner, T.J., Dennis, RJ., Craighead, W.E., Hadley E.C., & Ory, M.G. (1989). A clinical trial of behavioral therapy to reduce urinary incontinence in nursing homes. Journal of the American Medical Association, 261, 2656-2662.
- Jirovec, M.M. (1991). The impact of daily exercise on the mobility, balance, and urine control of cognitively impaired nursing home residents. International Journal of Nursing Studies, 28, 145-151.
- Lekan-Rutledge, D. (1992). Simple cystometry in the evaluation of urinary incontinence. Journal of Urologie Nursing, 11(4), 267-276.
- Lekan-Rutledge, D., Palmer, M.H., & Belyea, M. (1998). In their own words: Nursing assistants' perceptions of barriers to implementation of prompted voiding in long-term care. The Gerontologist, 38, 370-378.
- McCormick, K.A., Cella, M., Scheve, A., & Engel, BT. (1990). Cost-effectiveness of treating incontinence in severely mobilityimpaired long term care residents. Quarterly Review Bulletin, 439-443.
- Palmer, M.H. (1996). A new framework for urinary continence outcomes in long-term care. Urologie Nursing, 16(4), 146-151.
- Rogers, E.M. (1983). Diffusion of innovations (3rd ed.). New York: The Free Press.
- Rogers, E.M. (1995). Diffusion of innovations (4th ed.). New York: The Free Press.
- Schnelle, J.F. Traughber, B., Sowell, M.A., Newman, D.R., Petrilli, CO., & Ory, M. (1989). Treatment of urinary incontinence in nursing home patients. A behavior management approach for nursing home staff. Journal of the American Geriatrics Society, 37, 1051-1057.
- Schnelle, J.F. (1991). Managing urinary incontinence in the elderly. New York: Springer.
- Schnelle, J.F., Ouslander, J.G., & Cruise, P.A. (1998). Policy without technology: A barrier to improving nursing home care. The Gerontologist, 37, 527-532.
- Urinary Incontinence (UI) Guideline Panel. (1992). Urinary incontinence in adults: Clinical practice guideline (AHCPR Publication No. 92-0038). Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, United States Department of Health and Human Services.
STRATEGIES TO INCREASE ADOPTION OF PROMPTED VOIDING PROGRAM (PVP)