‘Clinicians must feel able to report errors without fear of recrimination’
Person-centred care initiatives in the management of urinary incontinence in a care home setting can benefit all stakeholders: residents, caregivers and residential care facility administration
This observational study investigated the benefits of adopting a person-centred approach to the management of urinary incontinence and associated hygiene care. A trial was carried out in 12 residential care homes in the Emilia Romagna region of Italy. Toileting, containment product selection, frequency and timing of changes, and personal hygiene routines were tailored to the needs of individual residents. Skin redness improved, there was less leakage and residents’ wellbeing improved. Containment product changes were easier to carry out, fewer containment products were used, and product costs were reduced. The adoption of person-centred care initiatives was seen to benefit all stakeholders – namely, residents, caregivers and the administration of the residential care facility.
Citation: Del Prato C et al (2022) Tailoring continence management to individual needs in residential care. Nursing Times [online]; 118: 4.
Authors: Carlo Del Prato is vice president elect, Liguria regional section, SIGOT, the Italian Geriatric Society, and was, at the time of writing, health director, Coopselios, Reggio Emilia, Italy. Michela Mercanile is clinical nurse specialist; Tania Bedogni is disability process specialist, all at Coopselios, Reggio Emilia, Italy; Helle Wijk is professor, Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Edward Hutt is lead researcher, MEDICA Market Access, Tonbridge, UK.
Urinary incontinence (UI) is a significant challenge for residential care facilities. In 2009, a systematic review of the prevalence rates of UI in nursing home residents found rates ranging from 43% to 77%, with a median of 58% (Offermans et al, 2009).
Incontinence-associated dermatitis (IAD) is a common consideration in patients with faecal and/or urinary incontinence and it has been suggested that it affects as many as 41% of adults in long-term care (Nix and Haugen, 2010) . Frequent IAD is also a risk factor for the development of pressure ulcers (Beeckman et al, 2014) and older adults with UI have been shown to be 2.18 times more likely to experience psychological distress (de Vries et al, 2012). In addition, care staff can find it challenging to manage UI: one study reported that care workers’ self-identity was significantly negatively affected by the stigma associated with this work (Ostaszkiewicz et al, 2016).
Person-centred care has been identified as a means of improving both the quality of care and quality of life for residents (Grabowski et al, 2014; Zimmerman et al, 2014), while also improving the quality of staff members’ working life (Edvardsson et al, 2011). A person-centred approach to the management of UI in residential care facilities showed:
In Edvardsson et al’s (2011) study of job satisfaction among staff caring for older people, the practice of personalising care and the amount of organisational support each received had a statistically significant influence on job satisfaction.
The purpose of our study was to examine the impact of two interventions on the management of containment care, with a particular emphasis on skin health. The interventions were:
The changes were implemented by a community interest, non-profit, social cooperative in the care homes operating in Italy’s Emilia-Romagna region.
An Italian social cooperative is a form of multistakeholder cooperative with its own legal status that brings together providers and beneficiaries of a social service as members to provide either a health service or a social and educational service. Various categories of stakeholder may become members, including paid employees, beneficiaries, volunteers, financial investors and public institutions.
The care home operator wanted to ensure delivery of a uniformly high quality of care across the group’s residential care homes, while increasing the level of staff satisfaction and making best use of available resources. This study set out to measure the impact of a set of person-centred continence care initiatives. Training was carried out on:
Hygiene routines used during the changing of containment products have historically involved the use of soap and water, but several studies demonstrate that a ‘washing without water’ cleansing technique has resulted in improved skin outcomes. Soap- and alcohol-free products are used, mainly for frequent care of the perineal area during changes of absorbent aids, but they can also be used for cleansing the whole body. The technique improves the condition of the skin, contributing to maintaining skin pH and hydration; soap and water, in contrast, can dry out the skin.
The cleansers reduce soap residue and do not require rinsing (Sloane et al, 2004), and also eliminate the risk of cross-infection from wash basins and reusable washcloths (Massa, 2010). A recent systematic review found that washing without water performed better than washing with soap and water in terms of skin abnormalities and bathing completeness, defined as when all body parts were cleaned (Groven et al, 2017).
The social cooperative in which this trial was conducted had seen considerable variation in personal hygiene care practices across its residential homes, as well as within each home. The study started with staff training on the new routine and sought to establish whether a harmonised routine of washing without water would result in improved outcomes for residents, and provide benefits for residential home staff and in terms of administration.
A person-centred approach to UI care involves toileting measures as well as containment strategies (Wijk et al, 2018). Although appropriate toileting care was included in the care plan for each resident with UI, the variability of toileting measures made this aspect less susceptible to quantitative analysis than containment and hygiene care, so the impact of toileting changes was not measured in this study. In addition, residents were often not able to express their needs and the challenge of measuring their expressed needs prevented this from being included as an outcome measure of the study.
The average cost per resident per day for products used in the care routines was calculated at the end of the trial to evaluate the influence of a person-centred approach on this element of costs. The time taken to carry out the UI care routine and associated staff costs were not measured.
“Of the carers, 97% either agreed or strongly agreed that the changed containment routine improved the residents’ overall wellbeing”
The project took the form of a longitudinal observational trial conducted with 485 residents in 12 residential care homes. All residents with UI were included in the trial. Ethical approval was not needed as the study was restricted to observing the effects of implementing accepted care practices. The study was approved by the residential care homes’ management committee.
The trial started with 229.2 hours of training delivered to 323 staff, of whom 244 were professional caregivers and 79 were nurses. All nurses and professional carers had received the usual training on continence management and personal hygiene care included in standard requirements to be licensed in these roles in Italy. Additional training on the use of absorbent products was provided on a periodic basis by the containment product supplier’s continence nurse specialists. Targeted training on person-centred continence care, covering the points highlighted in Box 1 and Box 2, was provided by the same team in March 2017, before the start of the trial.
Box 1. Selecting a containment product
Box 2. Core principles of containment management and hygiene routines
An initial classroom-based training session was followed by training on the ward, with a joint evaluation of the existing hygiene and management for each resident’s containment-care routine. Care routines were then optimised and an individual person-centred care protocol was established for each resident.
The trial lasted for an average of four to six weeks in each care home between July 2017 and October 2018.
The appropriate containment product was selected in line with the principles outlined in Box 1. The care plan was provided in the form of a card to which carers could refer; it summarised the tailored toileting, containment and hygiene care to make sure each member of staff adopted the same care approach that had been individually tailored for that resident.
During the study period, information was collected on:
Performance was regularly monitored and improvements implemented as needed. Increased coordination between the lead nursing and care staff led to improved product selection, as well as improved pad change and hygiene practices.
The results of the existing care routine were assessed before the start of the trial and the results for the optimised routine were collected at the end. The results comprised two elements:
Staff were asked to assess the benefits, for both the resident and the carer, of following the tested containment management approach and hygiene care routines, as set out in Table 2. A Likert scale (‘strongly agree’, ‘agree’, ‘disagree’, ‘strongly disagree’ or ‘don’t know’) was used.
The average cost per resident per day for products used in the care routine – namely, the containment product, underpad and the hygiene products – was calculated at the end of the trial.
The number of residents in each facility ranged from 20 to 65. Skin health was the outcome of principal interest.
Skin damage showed reductions: no resident had skin damage worse than redness at the start of the trial, at which point there was a median number of two patients with redness across the residential facilities. In five facilities, no resident had even the lowest degree of skin damage, and this was maintained during the course of the trial. An additional four residential care facilities were able to reduce skin redness from between two to five residents to zero by the end of the trial. Of the remaining three, two showed improvements, from 15 to 5 and from 7 to 3 residents, and only one had the same number of residents (three) with skin redness at the end of the trial as at the beginning. No facility showed an increase in number of residents with skin redness over the course of the trial. The median reduction in skin redness was 100%.
Table 3 shows, for each residential facility, the reduction in skin redness, number of underpads used, costs, and change in number of pads used per resident per 24-hour period. Variability in continence management practices means that in some residential facilities there is a lower pad use than is ideal, while in others it is greater than necessary. In our study, most residential facilities initially used a greater number of pads than necessary; as a result, that usage decreased. The greatest reduction was 38.7%; one residential care facility increased use, by 5.3%. The median reduction in incontinence pad use over the 12 residential care facilities was 24.6%.
The number of underpads used per resident per day also fell, with the greatest reduction being 76.7%. No residential care facility increased underpad usage, and the smallest reduction was 9.1%. The median reduction in underpad usage was 38.0%.
The costs of the containment and hygiene care products reduced by a median of 18.5% per facility; one residential care facility reduced costs by 40%, while another made no savings. In no residential care facility did the cost for these products increase.
A total of 96% of carers either agreed or strongly agreed that the containment products used in the trial resulted in less leakage, and 88% agreed or strongly agreed that they kept the skin drier. Almost all (99%) agreed or strongly agreed that the containment products were easier to handle during toileting and 93% agreed or strongly agreed that using the containment products resulted in less moving and handling of residents. In total, 97% either agreed or strongly agreed that the changed containment routine improved residents’ overall wellbeing, 98% agreed or strongly agreed that less time was needed for containment management, and 94% agreed or strongly agreed that the new routine was more care efficient.
In terms of personal hygiene care, 89% felt that the hygiene products produced less skin redness, which aligned with the study’s quantitative findings. Of the carers, 91% agreed or strongly agreed that the washing-without-water hygiene routine improved the overall wellbeing of the residents, 96% agreed or strongly agreed that less time was needed for personal hygiene care, and 94% agreed or strongly agreed that the hygiene routine was more care efficient.
This trial demonstrated that adopting a person-centred continence management approach, combined with improved personal hygiene care, provided benefits for residential care facility residents, carers and the administration of the facility.
Using an incontinence pad that had been selected based on individual needs reduced the incidence of skin redness and urine leakage while allowing a reduction in the number of pad changes. Changing the types of incontinence pads used resulted in less moving and handling, thereby benefitting the carers as well as the residents. The carers also judged residents’ overall wellbeing to be improved – both from the change in containment management and the change in the hygiene routine. This was in line with the trend towards beneficial effects of person-centred continence care on residents demonstrated by Wijk et al (2018).
Reduced underpad usage contributed to the reduction in budget spent on containment and hygiene products. It may have been thought that a broader choice of incontinence pads, some of which are more expensive than the traditional all-in-one products, and using a different hygiene product, would have resulted in higher product costs, but this did not happen.
The results showed considerable variability across different residential homes. A key learning from this study was the importance of cross-functional participation in the design and implementation of person-centred continence care, combined with a high level of training and leadership support plus ongoing performance monitoring. This concurs with the conclusions of Sjögren et al (2017) who identified leadership, interdisciplinary collaboration and continuing education as the factors shared by highly person-centred residential aged care units.
While the outcomes recorded in this trial provide evidence of improvements for the residents, the protocol did not include quality of life assessments by the residents themselves or – in the case of residents who were unable to communicate their experience – their relatives. The decision to focus on the experience of the carers was a practical one: the challenge of collecting data on quality of life from individuals with cognitive impairment is widely recognised and the use of proxy measures in such populations is well described (Hendriks et al, 2019).
Similarly, the costs of containment and hygiene products represent only a small proportion of the costs of providing containment and hygiene management, but the practicalities of conducting the trial in 12 working residential homes made it difficult to record the time carers spent on these tasks.
The carers’ judgement that residents’ wellbeing improved, and that both containment and hygiene management required less time to deliver and were more efficient, are positive indications. However, future trials could confirm this by including carers’ time as a measured outcome.
Introducing person-centred continence care, combined with adopting a washing-without-water routine during the containment product change, resulted in several beneficial effects. Skin health improved, as did the residents’ overall wellbeing, as judged by carers. The changes also resulted in benefits for the carers themselves, making the containment product change easier to carry out and resulting in less physical strain when moving and handling patients. It also reduced the time needed for the change and freed up staff to spend time on other aspects of care. These benefits were accompanied by savings in the cost of containment and hygiene products. Adopting person-centred care initiatives in UI management was seen to have benefits for all stakeholders – residents, carers and the administration of the residential facility.
Key success factors in the delivery of the improved care were the cross-functional inclusion in the design and implementation of the care routines, their being tailored to residents’ initial and ongoing needs, high levels of initial and ongoing staff training, and performance monitoring.
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