Journal of Gerontological Nursing

Evidence-Based Practice Guideline 

Prompted Voiding for Individuals With Urinary Incontinence

Diane K. Newman, DNP, ANP-BC, FAAN

Abstract

Urinary incontinence (UI) is one of the most common conditions among residents of post-acute and long-term care facilities. UI is seen in at least 55% of nursing home residents and is the second leading cause of institutionalization of older adults. UI has been shown to be an independent risk factor for unplanned hospitalization of home care individuals. Prompted voiding (PV) is a toileting program that combines scheduled voiding with “prompting” from a caregiver and is appropriate for older adults with all types of UI and in individuals who may have impaired cognitive function. The current article summarizes a guideline on the evidence for PV in individuals with UI in reducing the frequency and severity of UI episodes, increasing self-initiated requests to toilet, and preventing complications associated with UI in older adults in their homes and acute and extended care facilities. [Journal of Gerontological Nursing, 45(2), 14–26.]

Abstract

Urinary incontinence (UI) is one of the most common conditions among residents of post-acute and long-term care facilities. UI is seen in at least 55% of nursing home residents and is the second leading cause of institutionalization of older adults. UI has been shown to be an independent risk factor for unplanned hospitalization of home care individuals. Prompted voiding (PV) is a toileting program that combines scheduled voiding with “prompting” from a caregiver and is appropriate for older adults with all types of UI and in individuals who may have impaired cognitive function. The current article summarizes a guideline on the evidence for PV in individuals with UI in reducing the frequency and severity of UI episodes, increasing self-initiated requests to toilet, and preventing complications associated with UI in older adults in their homes and acute and extended care facilities. [Journal of Gerontological Nursing, 45(2), 14–26.]

Urinary incontinence (UI), the involuntary loss of urine, is a common lower urinary tract symptom that affects more women than men. Older adults have the highest known prevalence of UI of any group, other than those with specific neurological disease (e.g., spinal cord injury) (Wagg et al., 2017). UI is seen in at least 55% of nursing home residents and is the second leading cause of institutionalization of older adults (American Medical Directors Association, 2015). The impact of UI in frail older adults extends beyond affected individuals to their caregivers, leading to caregiver stress and an increased likelihood of institutionalization (King, Holliday, & Andrews, 2018). Frail and older individuals are at the highest risk for developing UI (Coyne et al., 2013). UI in frail older adults is normally a result of multiple interacting risk factors, including age-related physiological changes, comorbidity, polypharmacy, functional and cognitive impairments, and common pathways between these conditions (Rose, Thimme, Halfar, Nehen, & Rübben, 2013; Wagg et al., 2017). UI has been shown to be an independent risk factor for unplanned hospitalization of individuals receiving care in their home (Rönneikkö et al., 2017).

Although UI is common in the long-term care (LTC) setting, it is often not a high priority of care; especially in individuals with cognitive impairment. UI may be a marker of an impaired general health condition and an indirect cause of death (e.g., secondary to a fall). UI has been associated with a 24% increased risk of all-cause mortality with a graded relationship across UI severity levels (Damián, Pastor-Barriuso, García López, & de Pedro-Cuesta, 2017). UI has been identified as one of three geriatric syndromes in older adults who transition from ICU to an inpatient acute care unit (Tang, Tang, Hu, & Chen, 2017). Proper assessment and identification of UI is imperative to quality care improvement in UI (Jenkins & Fultz, 2005; Jirovec & Wells, 1990; Ouslander & Johnson, 2004; Resnick, 1990; Skelly & Flint, 1995).

Behavioral interventions improve symptoms through teaching new skills or changing an individual's habits and/or lifestyle choices that are contributing factors or triggers of lower urinary tract symptoms. Behavioral interventions for UI include toileting programs, the mainstay of UI treatment for decades. Toileting programs are usually caregiver dependent, which is defined as the need of a caregiver to assist with toileting. Prompted voiding (PV) is a toileting program that combines scheduled voiding with “prompting” from a caregiver and is appropriate for older adults with all types of UI and in individuals who may have impaired cognitive function.

The current article is a condensed and updated version of the evidence-based guideline, Prompted Voiding for Persons with Urinary Incontinence (Newman, Specht, & Eason, 2018), published by The University of Iowa College of Nursing Barbara & Richard Csomay Center for Gerontological Excellence and provides evidence for PV in individuals with UI in reducing the frequency and severity of UI episodes, increasing self-initiated requests to toilet, and preventing complications associated with UI in older adults in their homes and acute and extended-care facilities (e.g. post-acute care facilities, nursing homes). The full guideline, with graded levels of evidence for assessment; identification of risk factors; recommendations for practice, including evidence-based interventions, assessment tools, and documentation tools; and sample modules for educating staff, is available in electronic format from UIowaCsomayGeroResources.com. The full guideline also includes recommended nursing interventions based on the Nursing Interventions Classification (NIC) (Butcher, Bulechek, Dochterman, & Wagner, 2018) and nursing outcomes based on the Nursing Outcomes Classification (NOC) (Moorhead, Swanson, Johnson, & Maas, 2018).

Purpose

The purpose of this evidence-based guideline is to provide information for implementing a treatment program of PV for individuals with UI. In this guideline, a caregiver may be formal (e.g., extended care professional, allied health) or informal (e.g., family member, companion). PV is appropriate for older adults, both cognitively intact and impaired, with urgency, mixed, or functional UI (Table 1). Nurses, physicians, other providers, support staff, and administrators who are leading and facilitating evidence-based practice changes for UI will find the guideline valuable for the development of assessment, procedures, protocols, education, policies, and documentation tools associated with PV.

Types of Urinary Incontinence (UI)

Table 1:

Types of Urinary Incontinence (UI)

Assessment Prior to Initiating Prompted Voiding

Research has shown that when properly assessed and treated, UI can be corrected in 30% of nursing home residents and suitably controlled and managed in the remainder of residents (Fantl et al., 1996). Thus, given the complex nature of the process of urination, detailed and accurate assessment of older adults is essential to achieve positive outcomes. It is recommended that all adults with UI undergo a basic evaluation that includes history, physical examination, dipstick urinalysis, and measurement of post-void residual (PVR) volume to determine those at risk for incomplete bladder emptying. Additional evaluations include cognitive, functional (i.e., ability to access the toilet), and environmental assessments.

A necessary part of the assessment includes the completion of a bladder record, voiding diary, or other type of monitoring system. The complete guideline includes a 3-day record that can help patients, family members, and health care professionals identify individual patterns of UI (Jeyaseelan, Roe, & Oldham, 2000; van Melick, Gisolf, Eckhardt, van Venrooji, & Boon, 2001; Yap, Cromwell, Brown, Emberton, & van der Meulen 2007). An additional purpose of a voiding record is to gather the necessary data to determine whether an individual is likely to have success (i.e., higher levels of urinary continence) with the PV intervention.

Components of a Prompted Voiding Program

PV is a behavioral intervention that involves prompts to toilet with contingent social approval (Wagg et al., 2017). PV is used to teach caregivers to consistently prompt older adults to attend to the wet/dry status. A prompted voiding program (PVP) is a caregiver-guided program designed to increase patient self-initiated requests (SIR) for toileting with resultant decrease in UI episodes. This program was first used in the late 1980s for incontinent nursing home residents (DuBeau, Kuchel, Johnson, Palmer, & Wagg, 2010). The main requirement of PV is the consistent availability of a caregiver to provide the voiding prompts to incontinent individuals. PV can be used with individuals who have physical or mental impairments or little ability to determine how to best meet their treatment needs. PV is not successful in individuals who need the assistance of more than one person to transfer, cannot follow a one-step command, and have less than a 66% appropriate toileting rate after a 3-day PV trial (Wagg et al., 2017). Table 2 lists the benefits, advantages, and disadvantages of a PVP.

Benefits and Advantages of a Prompted Voiding Program

Table 2:

Benefits and Advantages of a Prompted Voiding Program

PV is based on timely reminders to toilet and positive reinforcement from caregivers to maintain continence. The intervention has been used successfully to treat UI in acute and LTC facilities (Eustice, Roe, & Paterson, 2000; Roe, Ostaszkiewicz, Milne, & Wallace, 2007) as well as in home care settings (Engberg, Sereika, McDowell, Weber, & Brodak, 2002). In addition, some studies have shown a decrease in the number of incontinent voids and an increase in the number of continent voids during the PV intervention. PV has also shown a decrease in the frequency of pressure injury and urinary traction infections using an every 2-hour timed toileting schedule to improve continence.

Caregivers use three primary behaviors each time PV is initiated:

  • Monitoring—Involves asking incontinent individuals, at regular intervals that are established based on their bladder diary, if they need to use the toilet.
  • Prompting—An antecedent to toileting assistance from the caregiver. Prompting includes reminding the individual to use the toilet as well as encouraging maintenance of bladder control between PV sessions.
  • Praising—The consequence to the individual's success with maintaining bladder control. Praising, or feedback, is the positive reinforcing of dryness and appropriate toileting.

The use of respectful communication, no matter the older adult's physical or cognitive capabilities, is an important component of a PVP. Using elderspeak, such as “that's a good girl,” is not acceptable communication. Table A (available in the online version of this article) provides more information on communication techniques when praising and supporting individuals in a PVP.

Prompted Voiding Communication TechniquesPrompted Voiding Communication Techniques

Table A:

Prompted Voiding Communication Techniques

The PV schedule should be individualized to meet the toileting needs of individuals with UI. Identification of individual voiding patterns can promote the highest level of continence for incontinent individuals while minimizing caregiver time required for completion of the intervention. However, individuals who are unable to maintain urinary continence with at least an every 2- to 3-hour toileting schedule after a thorough trial (4 to 7 weeks) of PV are not likely to respond to further use of PV.

As previously mentioned, the completion of a bladder record, voiding diary, or other type of monitoring system can help patients and caregivers identify individual voiding patterns and patterns of UI. Once regular voiding patterns have been identified, caregivers need to be made aware of this pattern (Figure 1).

Prompted voiding (PV) 3-day assessment (Burgio et al., 1994; Colling et al., 1992; Creason et al., 1989; Hu et al., 1989; Jirovec, 1991; Kaltreider et al., 1990; Ouslander & Schnelle, 1995; Schnelle, 1990).

Figure 1.

Prompted voiding (PV) 3-day assessment (Burgio et al., 1994; Colling et al., 1992; Creason et al., 1989; Hu et al., 1989; Jirovec, 1991; Kaltreider et al., 1990; Ouslander & Schnelle, 1995; Schnelle, 1990).

Caregiver adherence to the PV schedule involves toileting the incontinent individual within 30 minutes of the scheduled session and immediately upon seeking a request to toilet. Adherence is essential to achieve maximal continence levels. Once initiated, completion of the PVP must be assessed. If the individual needs to be toileted more frequently than every 2 hours to maintain continence, he/she should not continue using PV. A scheduled toileting plan augmented with incontinence aids (e.g., urinal, bedside commode) and further evaluation for causes of and treatment for UI is then recommended.

Although an individualized PVP is most effective, as it follows the toileting schedule that best meets the needs of the individual, many LTC facilities attempt to toilet residents on an every 2-hour schedule. However, some individuals respond best to an every 3- or 4-hour toileting schedule. Individuals who respond to PV early in the intervention are able to decrease toileting sessions from every 2 to 3 to ≥4 hours (Ouslander et al., 1995b). This longer time period between scheduled PV sessions allows nursing home staff or other caregivers to complete other nursing care (Burgio et al., 1994). Table 3 lists the factors for responsiveness and non-responsiveness to a PVP.

Responsive and Nonresponsive Factors to a Prompted Voiding Program (PVP)

Table 3:

Responsive and Nonresponsive Factors to a Prompted Voiding Program (PVP)

The PV intervention is ideal for caregivers as it needs no prescription by a primary care provider because it is within the scope of nursing practice. The intervention is easy to learn, but requires personal dedication and consistent application of the PV guideline on the part of caregivers to maintain high levels of success (Adkins & Mathews, 1997; Burgio & Burgio, 1986; Colling, Ouslander, Hadley, Eisch, & Campbell, 1992; Colling, Owen, McCreedy, & Newman, 2003; Engel et al., 1990; Fantl et al., 1996; Hu et al., 1989; McCormick, Cella, Scheve, & Engel, 1990; Schnelle, 1990).

Once a regular voiding pattern has been identified, caregivers need to be made aware of this pattern and determine if the individual is aware of the need to void (presence of urge sensation). In the LTC setting, posting individual toileting schedules in convenient locations and having meetings with staff to discuss an individual's response to PV has helped some facilities maintain high levels of continence for extended periods of time. Staff adherence to the PV schedule and toileting individuals with incontinence within 30 minutes of the scheduled session and immediately upon seeking a request to toilet is essential to achieve maximal continence levels.

Evidence to Support Prompted Voiding

PV, like most behavioral techniques for treatment of UI, has no known health risks and can be used in situations where pharmacological or surgical interventions are contra-indicated. PV is one of the least invasive behavioral modification techniques for UI and has a large body of evidence, especially in LTC residents with UI (Burgio, Engel, McCormick, Hawkins, & Scheve, 1988; Burgio et al., 1994; Eustice et al., 2000; Hu et al., 1989; Kaltreider, Hu, Igou, Yu, & Craighead, 1990; Palmer, Bennett, Marks, McCormick, & Engel, 1994; Schnelle et al., 1983). PV has been shown to be effective in the short-term treatment of daytime UI in nursing home residents and home care clients when caregivers comply with the protocol (Wagg et al., 2017). Lai and Wan (2017) conducted a randomized controlled trial to examine the effectiveness of the use of PV by nursing home staff in managing UI among residents in five nursing homes in Hong Kong over a 6-month period. There were significant differences between the two groups in wet episodes per day, incontinence rate per day, and total continent toileting per day at 6 months postintervention, with positive results found in the intervention group. A decrease of 9.1% was observed in the incontinence rate of the intervention group. The PVP delivered by staff was sustainable for a 6-month period (Lai & Wan, 2017).

Although PV has been researched extensively and found to be an effective treatment for UI (Burgio et al., 1988; Burgio et al., 1990; Burgio et al., 1994; Campbell, Knight, Benson, & Colling, 1991; Colling et al., 1992; Creason et al., 1989; Engel et al., 1990; Engberg et al., 2002; Eustice et al., 2000; Hawkins, Burgio, Langford, & Engel, 1993; Kaltreider et al., 1990; Petrilli, Traughber, & Schnelle, 1988; Schnelle et al., 1983), the actual step-by-step procedure has not been examined.

Colling et al. (1992) used an electronic data logger to record exact times of voiding. Eighty-five percent of nursing home residents were found to have regular voiding patterns over the 3-day data collection period. This study was replicated in caregiver-dependent, community-dwelling older adults (n = 43 [experimental group]; n = 35 [control group]) (Colling et al., 2003). Combining PV and data from the electronic logger yielded a 75% improvement of continence status in the experimental group. Another study using a paper monitoring system and an hourly checking schedule was able to identify individual voiding patterns in a significant number of older adult female nursing home residents within 2 weeks of initiating the monitoring system (Schnelle, Newman, Fogarty, Wallston, & Ory, 1991).

Another method to individualize PV is through the use of bladder volume instruments to scan the bladder to determine amount of urine in the bladder. Portable ultrasound scanners (e.g., bladder scans) are used in most clinical settings (e.g., acute care, rehabilitation facilities) to determine urine volume in the bladder pre- and post-void (Newman, Gaines, & Snare, 2005). Ouslander et al. (1994) used a portable ultrasound scanner to determine the accuracy of PVR volumes in nursing home residents. Accuracy of the scanner ranged from 90% to 95% for volumes of 50 to 100 cc to a rate of 69% for volumes >200 cc. Knowledge about bladder volume at any given time may help eliminate unnecessary toileting and allows for accurate assessment of the resident's hydration state. Two non-randomized studies evaluated the feasibility and effect of ultrasound-assisted PV (USAPV) for management of UI in hospitalized Japanese older adults (Iwatsubo, Suzuki, Igawa, & Homma, 2014) and nursing home residents (Suzuki et al., 2016). In a 4-week period evaluating USAPV in 88 hospitalized older adults, statistically significant pre-/posttest improvements in incontinence absorbent pad use and reduction in caregiver stress were noted (Iwatsubo et al., 2014). In a 12-week study involving 77 nursing home residents, incontinence absorbent pad cost decreased in 51.9% of participants, overall costs decreased by 11.8%, and quality of life for care workers in two subscales of the SF-36 Health Survey and mental health were significantly improved (p = 0.02 and p = 0.007, respectively) (Suzuki et al., 2016).

The effective use of a bedside bladder ultrasound device was further shown in a recent publication by Suzuki et al. (2019). They conducted a randomized clinical trial in 13 nursing homes in Japan and compared the efficacy and feasibility between USAPV and conventional prompted voiding (CPV) in decreasing daytime urine loss in residents with UI. Residents were randomized to either the CPV (n = 7) or USAPV group (n = 6). Over an 8-week period, staff conducted PV every 2 to 3 hours in the CPV group, whereas in the USAPV group, staff monitored bladder volume using an ultrasound device and prompted residents to void when the volume reached optimal bladder capacity. Measurement of urine loss was recorded using a frequency–volume bladder chart at baseline and 8 weeks. The change in daytime urine loss was greater in the USAPV (median = −80.0 g) than in the CPV (median = −9.0 g; p = 0.18) group. At the end of 8 weeks, daytime urine loss >25% was seen in 51% of the USAPV group and 26% of the CPV group (p = 0.020). However, quality of life measures were unchanged in both groups, and caregiver burden scale score worsened in the CPV group (Suzuki et al., 2019).

Self-Initiated Requests for Toileting

One outcome of PV is SIRs for toileting, which are any attempts by the individual who is incontinent to notify caregivers of the need to toilet. PV treatment is thought to increase an individual's awareness of the need to void, which in turn will hopefully increase the number of daily SIRs. SIRs for toileting can be successful if the individual is able to delay voiding and cooperate with toileting or has awareness of urge sensation when there is a need to void. There are certain behaviors associated with SIRs, including verbal toileting requests, use of a call light, and attempts to toilet without caregiver assistance.

Although SIRs are desired outcomes, research findings about SIRs are mixed. Some researchers have reported an increase in SIRs during PV treatment ranging from 2.0 to 2.8 SIRs per patient per day. However, other researchers have reported either a decrease or no change in the number of daily SIRs. Studies of LTC residents that reported a decrease or no change in SIRs suggest that PV may promote resident dependence on nursing home staff for maintenance of urinary continence (Burgio et al., 1988; Burgio et al., 1994; Hu et al., 1989; Kaltreider et al., 1990; McCormick, Burgio, Engel, Scheve, & Leahy, 1992; Ouslander & Schnelle, 1995; Schnelle et al., 1983).

Individual SIRs may be related to cognition level. Kaltreider et al. (1990) noted that women in their study who had the greatest increase in the number of SIRs had Mini-Mental Status Examination (Folstein, Folstein, & McHugh, 1975) scores >10 (scale range = 0 to 30) and lived at the LTC facility for <1 year. In addition, SIR is not an expected outcome of PV for individuals with moderate to severe cognitive impairment and/or severe immobility.

Social Feedback for Toileting Behavior

Most PV guidelines have incorporated social feedback into the treatment plan. Social feedback is based on behavioral modification theory; it is used to encourage individuals with UI to continue using the program. Feedback can be either positive or corrective (Table A).

In addition to praise for toileting performance, special attention from the caregiver, such as engaging in conversation unrelated to toileting behavior, offering fluids, or assisting with additional personal grooming, may encourage individuals with UI to continue using the PV program.

Some early studies examined the relationship between social feedback and improvements in continence status. The studies could not determine if participants responded with improved toileting behaviors because of the social rewards related to successful toileting behaviors or because their environment was more supportive of toileting behaviors. Either way, continence experts seem to agree that socializing individuals to appropriate toileting behaviors is necessary for the success of the PV intervention (Azrin & Foxx, 1971; Burgio et al., 1990; Burgio et al., 1988; Campbell et al., 1991; Colling et al., 1992; Engel et al., 1990; Hawkins et al., 1993; Kaltreider et al., 1990; Newman et al., 2014; Petrilli et al., 1988; Schnelle et al., 1983).

Individuals Likely to Benefit from Prompted Voiding

Recommendations about individuals likely to benefit from PV are supported by evidence from properly designed and implemented controlled trials and properly designed and implemented clinical series and guidelines (Burgio et al., 1994; Colling et al., 1992; Creason et al., 1989; Jirovec, 1991; Kaltreider et al., 1990; Ouslander & Schnelle, 1995; Schnelle, 1990).

Most trials of PV have not determined individuals' type of incontinence, but trials that did determine type of incontinence have shown PV to be effective in reducing UI in individuals with urgency, mixed, and functional incontinence. Individuals who responded poorly to PV were those with elevated post-void residuals (e.g., >200 cc) and/or low maximum voided volumes (bladder capacity <100 cc), which are characteristics of overflow UI and/or overactive bladder (Ouslander et al., 1995b). In addition, it was reported that nighttime PV was not effective even though individuals with incontinence responded well to daytime PV (Ouslander, Ai-Samarrai, & Schnelle, 2001). It is important to note that there was no difference in the responsiveness to the intervention based on cognitive ability alone or functional ability alone; therefore, individuals with low cognitive or functional abilities should not be discounted for the intervention (Ouslander et al., 1995b). In fact, a Cochrane review by Eustice et al. (2000) found that PV can be effective in individuals with and without cognitive impairment.

Combining PV toileting with other activities of daily living as part of a multicomponent intervention may be an option in ambulatory older adults with UI (Sackley et al., 2008). Ouslander et al. (2005) used a “designated” versus “integrated” nursing assistant role to combine restorative care including a walking program, exercise therapy, and continence care. Specifically, the Functional Incidental Training (FIT) intervention combined PV with functionally oriented low-intensity endurance and strength-training exercises. Improved physical function and UI in nursing facility residents was noted. Schnelle, MacRae, Ouslander, Simmons, and Nitta (1995) reported a multicomponent program that combined PV with physical activity and fluid management, which improved UI, frequency of bowel movements, and percent of toileted bowel movements.

The best predictor of an individual's response to PV is the individual's success with a therapeutic trial of PV. Many individuals responsive to PV show a clinically significant increase in appropriate toileting behavior and continence levels during a 3-day trial using a Prompted Voiding Record (this tool is available in the full guideline that can be accessed at UIowaCsomayGeroResources.com); however, maximal response to treatment may not be realized until several weeks of PV. Although it is important to consider this predictor, clinicians should not rely on this solely when deciding whether to begin a PV trial.

Caregiver Education and Training

Staff and caregiver education is a key factor for PV treatment success. Due to the physical and/or cognitive decline of individuals needing PV, consistent completion of the guideline by professional or family caregivers is essential for continence maintenance. Higher rates of urinary continence in individuals with UI are noted when caregivers have completed the majority of toileting prompts (Palmer et al., 1994).

Evidence to Support Education and Training Strategies for Prompted Voiding Implementation

Caregiver education is one mechanism for translating evidence into practice; however, there is limited rigorous research on the long-term effectiveness of such strategies (Aylward, Stolee, Keat, & Johncox, 2003; Stolee et al., 2005; Wiener, 2003). Although education may increase knowledge, there is little evidence that knowledge alone adequately prepares staff to implement new care practices, and most research has focused on residents with UI in nursing homes (Aylward et al., 2003; DuBeau, Ouslander, & Palmer, 2007; Jones et al., 2004). Minimal training requirements of certified nursing assistants (CNAs) and licensed practical nurses contrasts with the increasing acuity level and medical complexity of older adults in LTC facilities. Yet, there is no research on the types and amounts of education needed to produce improvements in care (Wiener, 2003). In addition, limited availability of RN expertise in LTC settings further exacerbates difficulties in the acquisition, synthesis, translation, and implementation of new evidence-based practices.

There is evidence that using interactive and informative staff education in combination with other practice-reinforcing strategies is more effective than informative education alone (Bero et al., 1998; Jones et al., 2004; Rahman, Schnelle, Applebaum, Lindabury, & Simmons, 2012; Schneider & Eisenberg, 1998; Stolee et al., 2005). Kohler, Mayer, Battocletti, Kesselring, and Saxer (2016) conducted a 4-hour educational session for nurses and CNAs led by an expert in incontinence and dementia care. Sessions included dementia education (e.g., dementia symptoms, interaction with individuals with dementia, challenging behavior) and incontinence education (e.g., risk factors, assessment, treatment options, optimal care, anatomy, physiology, incontinence types, prevalence, psychosocial consequences), comprising presentations, group work, and discussions. The study by Kohler et al. (2016) indicated that the education session had a considerable positive impact on the quality of life in residents with UI and dementia.

There is a need for emphasis on training and mentoring of unlicensed caregivers who provide the majority of incontinence care (Jones et al., 2004). Training should guard against and address stereotypes such as believing that incontinence is a normal part of aging, incontinence is untreatable and cannot be improved, toileting is an ineffective intervention, incontinence does not have adverse psychological consequences, and older adults do not mind wearing incontinence pads. Experiential learning techniques and learning-by-doing techniques to teach evidence-based practices such as PV have greater likelihoods of changing attitudes and beliefs that constitute a custodial care, illness-oriented perspective.

Educational initiatives are influenced by the variables within organizations that affect clinical and operational routines, management practices, and how individuals provide care. Organizational and system factors should also be taken into consideration when designing continuing education programs. For example, workforce issues such as increased resident acuity and staff's beliefs about incontinence and barriers and resistance to change, management/administrative support, resources such as funding and space, and teaching-learning strategies that address different levels of staff are important (Stolee et al., 2005).

A PVP should involve a multidisciplinary team with designated opinion leaders, change champions, and experts from management and/or a strong nursing leader.

Barriers to Implementing the Prompted Voiding Program

Barriers to the use of current evidence and implementation of evidence-based practices for quality of care are formidable (Penz & Bassendowski, 2006). Although nursing staff in the LTC setting have an important role in incontinence management, their lack of evidence-based knowledge of how to provide UI care is a significant barrier. Park, De Gagne, So, and Palmer (2015) have shown that attitudes and continuing education of nurses are significantly correlated with continence care practices; however, nurses are insufficiently prepared with respect to incontinence management, and their knowledge about caring for individuals with UI is incomplete (Cheater, 2009; Saxer, de Bie, Dassen, & Halfens, 2008, 2009).

Lack of adequate infrastructure to build staff support and provide UI education makes implementing UI programs difficult. These barriers need to be addressed before starting a PVP (Resnick et al., 2006). Assuring sufficient staff to implement the PVP is the most challenging barrier in the LTC setting (Lekan-Rutledge, Palmer, & Belyea, 1998). This perceived barrier may be addressed by limiting the number of individuals started on the intervention at one time and through continuing education to discuss workload tradeoffs of toileting versus time to change wet clothing, beds, or incontinence products.

Monitoring the Prompted Voiding Program

Management systems must be in place if a PVP is to be maintained in a LTC environment. There is a need for ongoing job feedback to maintain quality staff performance of the PVP. Evidence-based guidelines and implementation strategies that are selective to nursing and nursing support staff exclusively will have limited success (Cheater, 2009; Pinkowski, 1996). An approach that combines educational strategies to build knowledge and skill with organizational strategies that focus on the context of care are essential to creating a culture of learning and clinical practice improvement. Factors that reinforce new behaviors associated with evidence-based practices include quality-monitoring tools (e.g., proper documentation and documentation review, audits [self and supervisory], performance feedback [written and verbal]), collaborative relationships across facilities, use of advanced practice RNs/nurse practitioners for clinical care who are also involved in staff education and quality improvement. Techniques used to maintain and increase staff compliance with assigned toileting include determining standard of care, self-monitoring completion of PV assignments, weekly reliability checks of self-monitoring by another individual, and giving verbal feedback on performance of staff as a whole and on individual performance.

Evidence to Support Monitoring the Prompted Voiding Program in Nursing Homes

Several approaches to staff management for implementing and sustaining PV have been tested in nursing homes. Burgio et al. (1994) used and tested a Behavioral Supervision Model. Burgio et al.'s (1994) model focused on change in staff performance, which ultimately affected level of continence of residents by consistently applying the prescribed PV interventions for each resident. Individual feedback from supervisory staff was found to be more effective than group feedback regarding CNAs' compliance with prescribed interventions (Engel et al., 1990). Self-monitoring to increase employees' feelings of self-efficacy is also part of this program, followed up with written formal documentation of staff performance for each employee's personnel record. In Burgio et al.'s (1994) study, PV compliance rates with implementation of the intervention increased by 10% on each of the three study units when the Behavioral Supervision Model was used, with one unit reaching a 90% compliance rate. This method builds on supervisory and leadership roles already in place in most nursing homes to assist staff to meet the expectations for consistently implementing the PVP.

Lekan-Rutledge (2000) suggested a model for implementation of PV in LTC settings using Rogers' (1995) model of diffusion of innovation. According to this model, the rate of adaptation is determined by five categories: (a) perceived attributes, (b) type of innovation, (c) communication channels, (d) nature of the social system, and (e) extent of the change agent's promotion efforts. Lekan-Rutledge (2000) implemented this model for designing nursing policy and nursing procedure of a PVP in a LTC facility and results showed the program was successfully adopted.

Documentation

Documenting residents' continence status is imperative in the PVP to verify resident outcomes and staff performance; however, there are barriers to collecting, documenting, and using these data. The burden of paperwork is further complicated if CNAs are expected to maintain bladder records for individual residents. In addition, even when records are kept, synthesizing and analyzing data are problems for many facilities, as staff do not always have wide access to computers. Innovations in documentation systems offer a solution that can enhance quality monitoring for incontinence programs and other care systems. One innovation, CareTracker by Resource Systems (access http://www.resourcesystems.com), is a documentation system that provides an easy-to-use method for nursing staff to record their care tasks and resident outcomes, while significantly reducing or eliminating paperwork.

Audits and Feedback

Audits and feedback are important components in keeping the PVP and continual process (Pinkowski, 1996). Self-monitoring of completion of PV assignments by caregivers (usually research assistants or nursing assistants) is one strategy used in many studies (Burgio et al., 1990; Engel et al., 1990; Hawkins et al., 1993; Hu et al., 1989; Schnelle et al., 1983). This strategy demonstrates the minimal level of staff management necessary to assure compliance with the guideline.

To monitor the reliability of the self-monitoring reports and PV technique used by caregivers, a weekly performance check by supervisory personnel can be used. This requires supervisory staff to witness a defined number of patient–staff interactions to determine that the technique is being followed as prescribed and that self-monitoring forms are being completed properly (Burgio et al., 1990; Engel et al., 1990; Hawkins et al., 1993; Schnelle et al., 1983).

Verbal feedback on group performance yields high levels of compliance with PV when completed early in the implementation of treatment (Burgio et al., 1990; Engel et al., 1990; Hawkins et al., 1993; Schnelle, Newman, & Fogarty, 1990). During the first 5 months of group feedback, Burgio et al. (1988) reported an average completion rate of 82.8% of all assigned PV sessions. This rate decreased to between 45% and 60% of completed assignments during the sixth month post-intervention. Researchers then tested individual feedback of performance and the completion rate increased to 80% after 1 month. Individual feedback that combined visual representations (e.g., bar graphs) of employee performance (i.e., completed PV) and resident incontinence rates with supervisor verbal feedback was used. Although there were no significant decreases in dry checks during the month when completed assignments decreased, the researchers believed immediate action was needed to maintain high patient continence levels (Burgio et al., 1990; Engel et al., 1990).

Formal letters of praise or reprimand signed by supervisory personnel given biweekly to assistive personnel increase employee compliance more than verbal feedback on individual performance levels (Hawkins et al., 1993). The highest rates of employee compliance were achieved when summary letters of employee performance signed by supervisory and administrative personnel were given to assistive personnel and placed into employee records every 6 months (Engel et al., 1990; Hawkins et al., 1993).

Standard of Care

It is recommended that facilities and/or caregivers using PV determine the standard of care for completion of assigned treatments. Staff compliance with a PVP has been shown in research studies to maintain improved continence rates for at least 3 to 6 months after initiation of treatment (Burgio et al., 1988; Burgio et al., 1990; Burgio, et al., 1994; Schnelle et al., 1993; Schnelle et al., 1983). Noncompliance by staff with PV schedules makes sustained continence or significant improvement of UI impossible to attain. It is recommended that a completion rate of at least 60% to 80% of all assigned PV be achieved. As completion of assigned PV falls below this level, there is a corresponding increase in the number of UI episodes (Ouslander et al., 1995b; Palmer et al., 1994).

One way to check compliance is through weekly wet checks. Once per week, a portion of patients should be randomly selected for wet checks. These checks can be used as a general representation of how a particular organization is doing and can identify employees who may need additional education or non-compliance discipline (Ouslander et al., 1995b). It is also important to set a standard for permissible wetness rates, usually 25% to 50% in nursing homes (Ouslander et al., 1995b). This standard should be a formal policy of the organization.

Supplemental Treatment to Urinary Incontinence with Prompted Voiding

Pharmacological therapy may be prescribed in combination with a PVP. Continence outcomes have been shown to be improved with a combination of drug and behavioral therapy, particularly in cognitively intact patients who are on a toileting program (Ouslander, Maloney, Grasela, Rogers, & Walawander, 2001; Ouslander et al., 1995a). If pharmacological therapy is elected, consideration of side effects (e.g., dry mouth, constipation, dry eyes, increased blood pressure) is a critical part of therapy, especially in older adults with or at risk of cognitive impairment (Zarowitz et al., 2015).

Body-worn incontinence products absorb and contain urine to facilitate social continence. Absorbent pads and garments remain the mainstay for protection against urinary leakage. Absorbent incontinence products should be used only if necessary in combination with PV so that patients do not become reliant on the product and are encouraged to adhere to the PVP.

Handheld containers and devices, often referred to as portable toilet substitutes, can be used by residents to collect urine. There are two general categories: commode seats or bedside commodes and handheld devices (e.g., bedpan, urinal). Teaching residents to use toileting devices may be considered part of a PVP.

Conclusion

PV is indicated for individuals with UI. PV involves three primary caregiver tasks: monitoring the individual's continence status, prompting the individual to void prior to urine loss, and praising appropriate toileting behaviors. PV can be used to improve urinary continence in individuals with and without physical and cognitive impairments. Many individuals residing in LTC facilities may not achieve total continence. Regardless, a substantial improvement in UI can be realized using the PV intervention. An average decrease of one to two incontinent episodes per patient per day can be expected. Over 1 year, 365 to 730 incontinent episodes could be prevented by using PV at least 12 hours per day.

Although PV is easily taught and implemented, it is labor intensive and treatment success requires extensive and continuous staff management techniques. Therefore, staff energies are best used when the intervention is focused on the most responsive incontinent individuals: those who can maintain high levels of urinary continence on an every 2- to 4-hour PV schedule. Nursing assessment of UI is essential for appropriate prescription of the PV intervention. Individual voiding patterns, when monitored over a 3- to 7-day period, can be recognized in most individuals with UI. Once the voiding pattern has been determined, an individualized PV schedule can be developed for the treatment of UI. The most important predictor of an individual's responsiveness to PV is success with a therapeutic trial of the intervention. Regardless of the duration or severity of an individual's UI symptoms, a therapeutic trial of PV is indicated for all individuals who do not exhibit symptoms of overflow, reflex, or total UI.

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Types of Urinary Incontinence (UI)

Stress UIa,b
  Leakage with effort (e.g., with a cough, sneeze; when lifting, changing position; during physical activity)
  UI in small amounts (drops, spurts)
  No urgency, frequency, nocturia
  No UI at night
Urgency UIb
  Strong, uncontrolled urgency prior to UI
  Moderate/large volume of urine loss (gush)
  Frequency of urination
  Nocturia more than two times
  Nocturnal enuresis
Overflow UIa
  Difficulty starting urine stream
  Weak or intermittent stream (dribbles)
  Post-void dribbling
  Prolonged voiding
  Feeling of fullness after voiding
  Voiding small amounts often
Functional UI
  Mobility or manual dexterity impairments
  Lack of toilet or toilet substitute
  Use of restraints
  Use of sedative, hypnotic, central nervous system depressant, diuretic, anticholinergic, alpha-adrenergic antagonist agents
  Depression, delirium, dementia
  Pain associated with toileting activities

Benefits and Advantages of a Prompted Voiding Program

BenefitsAdvantagesDisadvantages

Increased dryness or urinary continence

Decrease in amount of incontinent voids

Increase in amount of continent voids

Decrease in incontinence-associated dermatitis and subsequent pressure injury

Decrease in urinary tract infections

Ideal for formal and non-formal caregivers because a prescription is not required

Easy to learn; however, takes consistency and dedication of formal and informal caregivers

Effective in acute care, home, long-term care, and other settings

Time intensive, which can lead to caregiver burden

Requires a consistent daily caregiver

Can increase caregiver burden

Lack of privacy, embarrassment

Lack of autonomy

Responsive and Nonresponsive Factors to a Prompted Voiding Program (PVP)

Factors Associated With ResponsivenessFactors Associated With Nonresponsiveness

Normal bladder capacity (>200 cc and <450 cc)

More cognitively intact

Recognizes need to void (urge sensation)a

Higher number of SIRs to toilet

Higher completion of assigned PV sessions by formal and informal caregiver

Baseline incontinence <4 times in a 12-hour perioda

Wet percentage <20% during first 3 days of PVP

Appropriate toileting >66% during first 3 days of PVP

At least 50% of voids into toileting receptacle during first day of PVPa

Able to void successfully when given toileting assistance

Able to ambulate independently

Usual voided volume >150 cc

Post-void residual <200 cc

Able to maintain urinary continence levels of less than one wet episode per 12 hours with prompted voidinga

Decreased cognition

Unable to successfully initiate toileting on first day of treatment

Advanced age

No difference in responsiveness to the intervention based on cognitive ability alone or functional ability alone

Elevated post-void residuals (>200 cc)

High frequency (>40%) of “dry runs” (i.e., individual indicated the need to toilet but did not void any urine into appropriate toileting receptacle)

Prompted Voiding Communication Techniques

Approach person at scheduled time.

Reinforces desired toileting behavior.

Establishes trusting relationship.

Greet individual by name, introduce self, and state purpose of interaction.

“Hello, Mr. Roberts. I am Ms. Richards, your nurse. I am here to help you get to the restroom.”

Provide information.

“It's 2:00—the time we agreed to meet so I could help you.”

“I am here to help you keep yourself clean by using the toilet more frequently.”

Provide visual cues in the environment to promote desired toileting behavior.

Use a picture of toilet on bathroom door rather than abstract symbols.

Leave restroom door ajar when not in use.

Use clocks with large numbers near bathrooms to remind people of toileting schedules.

Post toileting schedules near restrooms, bedroom, and nurse stations to remind caregiver of the need to maintain assigned PV schedules.

Determine person's awareness of continence status.

“Can you tell me if you feel wet or dry right now?”

Determine how the person informs others of the need to toilet.

“Your call light is on—do you need to use the toilet?”

Provide for privacy.

“Let's go into the bathroom to check your clothing.”

“I will wait outside the restroom while you empty your bladder.”

Ask for permission prior to performing continence check.

“Can I help you find out if your clothing is still dry?”

“I want to check your underclothes to see if they are wet—is that okay with you?”

“Sometimes it's hard to remember or realize if you've urinated—do you mind if I help you check to see if you're still dry?”

Prompt Person to use toilet (repeat prompt up to 3 times).

“It's time for you to use the bathroom.”

“Your bladder is full—please use the toilet to empty your bladder.”

Ask if person feels the need to void.

Encourages the individual to relearn bladder sensations.

“Does your bladder feel full?”

“Do you feel pressure in your lower abdomen?”

Use familiar language for toileting behavior. Be Consistent with language.

“Do you need to empty your bladder/urinate/pee/pass water/use the toilet/etc.?”

Offer toileting assistance.

“Can I help you on to the toilet/bedpan?”

“I will leave the urinal with you so you can empty your bladder.”

“Can I help you clean up/adjust your clothing?”

Give positive feedback at an adult level, using adult language and terminology.

“Yes, you are dry. You're doing a good job with this new plan.”

“Thanks for reminding me when to help you in the bathroom.”

“You stayed dry all day. It must feel great to be accomplishing your goals.”

Refrain from using negative feedback or treating the individual like a child.

Promotes self-esteem.

Builds trusting relationship.

Provide praising for:

Successful toileting behavior including staying dry between scheduled trips to the toilet

Self-initiating requests to toilet

Responding positively to prompts to void

Accurate reporting of continence status.

Give corrective feedback

Should be informational, not judgmental or punitive

Should be used minimally

Should include things like--correction of inaccurate reporting of continence status; repeating prompts to toilet at least twice; reminders to hold urine until next scheduled toileting; reminders to contact caregiver for toileting assistance; and cleaning of an UI episode without verbal comment to the incontinent individual.

Provide frequent reminders about desired behaviors.

“If you feel the urge to go to the toilet, let me know if you need help.”

“Try to hold your urine until our appointment at 4 o'clock.”

“I will help you to the toilet at 4 o'clock.”

“If you need to use the toilet, please do so and let me know if you need help.”

Inform individual of next scheduled PV session.

“I would like you to hold your urine until 4 o'clock.”

“That is 2 hours from now. I will help you use the toilet at 4 o'clock.”

Authors

Dr. Newman is Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Co-Director, Penn Center for Continence and Pelvic Health, Division of Urology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Diane K. Newman, DNP, ANP-BC, FAAN, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Co-Director, Penn Center for Continence and Pelvic Health, Division of Urology, University of Pennsylvania Medical Center, 3rd Floor, West Pavilion, Perelman Center, 34th & Civic Center Boulevard, Philadelphia, PA 19104; e-mail: diane.newman@uphs.upenn.edu.

10.3928/00989134-20190111-03

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