168 Research in Brief

The Unit is funded by the Chief Scientist Office of theScottish Office Home and Health Department. The viewsand conclusions are those of the author and do notnecessarily represent the views of SOHHD.

References

Hughes D.J.F. & Goldstone L. (1989) Frameworks for midwiferyeare in Great Britain: an exploration of quality assurance. Mid-wifery 5(4), 163-171.

Murphy-Black T. (1992) A Survey of Systems of Midwifery Care inScotland. Nursing Research Unit Report. University of Edin-burgh.

Case studies in the nursing managementof urinary incontinence in confused,elderly patients

JOAN ANDERSON BA, PhD, RGNResearch Fellow, Nursing Research Unit, Department of NursingStudies, University of Edinburgh, 12 Buccleuch Place, Edinburgh EIIH9LW, UK

Introduction

Levels of urinary incontinence (UI) of between 40 and80% have been recorded in studies in British hospitals andin American Nursing homes (Donaldson, 1984; Ramphal,1987). A review of 12 consecutive annual visits conductedby the Health Advisory Service for England and Wales(Health Advisory Service, 1987) identified the lack ofeffective management of UI as a persistent problem. Aneed for studies to explore the complex relationshipsbetween the social and physical environment, patientcharacteristics and the organization and delivery of care,was identified.

Objectives of the study

The objectives of the study were:• to explore the ways in which nursing staff approached

the problem of UI in the elderly, confused patient;• to examine the effect of the organization of care on the

management of UI;• to examine the application of principles derived from

behavioural psychology to nursing practice.

Study design and methods

Biomedical explanations of UI and the nature of thedementing illnesses were examined in an extensive review

of literature. Models derived from behavioural psychologywere found to be inadequate for an undetstanding ofbebavioural problems associated with a dementing illness,and an alternative model based on a contextual-dialecticframework was proposed. This framework which wasconsistent with the evolution of thinking in nursing theory,also provided the rationale for the study design andmethods.

A combination of action research using case studies andembedded single-case experimental studies provided tbebest means of examining complex issues. Two propositionsderived from nursing literature, stated that (i) under theconditions of a routine geriatric model of nursing care,the level of UI in a ward would be high; and (ii) under theconditions of an intervention model in which the nursesought to actively manage the interaction between personand environment, levels of UI would be reduced.

Findings

Comparisons from preliminary studies in two psychogeri-atric wards and one residential home provided insights thatwere applied in the two main studies. By using the conceptof'accident' to categorize UI as fundamental, predisposingand precipitating factors, two frames of reference, thebiological and the social, were linked. Nursing staff wereencouraged to reframe the problem of UI through thisperspective, and to assist in the development and testing ofnursing interventions.

In a residential home the legibility of the environmentwas improved by the use of signposts as recommended bythe Department of Health. The assumption was that thiswould make the toilets easier to find and hence reduce thenumber of episodes of UI. Rapid and marked improve-ment was shown in only one of four cases over a period of4 weeks following a programme of guided orientation. In apsychogeriatric ward, systematic and sustained interactionbetween nurses and patient was improved when theorganization of nursing was altered to limit the number ofnurses caring for a small group of elderly confused andincontinent men. Interactions between nurse and patientswere improved also by alterations in tbe arrangement offurniture. Tbis simple adaptation of the environmentserved also to facilitate prompted voiding. The findingsshowed a reduction in UI of one-third of the baselinefigure and a commensurate increase in the appropriate useofthe toilet. ; '•' ' •<

It was concluded that to be effective, an intervention,such as prompted voiding, requires a shift from a routine,geriatric model of care to an interventiotiist model inherent

in an integrated code of primary nursing practice. Al-though nurses are exhorted to adopt a patient-centred andindividualized approach to patient care, in practice apowerful conflict exists in caring for an individual withina collective setting that can be countered only by overtstrategies. While alterations in the environment are neces-sary, these are alone insufficient to affect UI in theconfused, elderly patient: the active and available presenceof a nurse is required. Recommendations for nursingpractice, management, education and research are made.

R e f e r e n c e s , i..,;:,|,-,,vj •-MUn.' iya -

Anderson M.J. (1991) Case Studies in the nursing management ofurinary incontinence in confused, elderly patients. PhD. thesis.University of Kdinburgh.

Donaldson f,. (1984) Longitudinal changes in functional capacityamong surviving old people continuously resident in hospitals andold people's hotncs. Journal of Epidemiology and CommunityHealth 38, 240-246.

Health Advisory Service (1987) Annual Report, June 1987. NHSAdvisory Service, Sutton, Surrey.

Ramphal M. (1987) Urinary incontinence among nursing homeresidents: issues in research. Geriatric Nurung (U.S.) September/October, 249-254.

An evaluation of bodyworn incontin-ence pads used in the management ofintractable urinary incontinence in agroup of confused, elderly womenL.M. PROUDFOOTRUN, 1!A,E.S. FARMKR RGN, SCM, U.N., PhD. ANDJ. McINTOSH RGN, PhD.Department of Health and Nursing Studies, Glasgow Polytechnic,Cowcaddens Road, Glasgow G4 OB A, UK

Correspondence: Dr E. Farmer. ' " ' ^ ' '

Introduction and study a ims

A study ofthe cost-cffcctivcness of four ranges of bodywornincontinence pads used by elderly, confused women suffer-ing from intractable urinary incontinence was carried out intwo clinical areas in Scotland. The study was funded by theAdvisory Panel on Evaluation of Medical and ScientificEquipment and Health Service Supplies, Scottish HealthService Common Services Agency. The 1-year study wascompleted in December 1991 and had the following aims:• to test the cost-effectiveness of a range of bodyworn

incontinence pads used by confused elderly women inhospital and community settings;

• to test a tnclhod of continuously providing low-cost,reliable, valid data for the evaluation and specification ofequipment and products used in nursing;

Research in Brief 169

• to develop a data-base system for accessing informationon product trials for use at the point of care delivery.

Background of the study

Between 12 and 34% of people in the UK suffer a degreeof urinary incontinence (Brink, 1990). Prevalence studiesare limited by the difficulties in defining incontinence.Increasing in severity with age, urinary incontinence hasbeen closely linked with confusion and dementia (Ous-lander ct al., 1990) and women are twice as likely to sufferthan men (Herzog & Fultz, 1990). Incontinence pads arethe most common form of management of irreversibleintractable urinary incontinence. The purchase of theseproducts represents a major item of expenditure in sup-plies budgets. Studies of the clinical effectiveness of padshave concentrated on the 'average' response for the 'aver-age' patient, thus generating results which seldom transferto the individual person.

Study methods and data analysis

A multiple-baseline single-case research design was usedin the context of quality assurance processes to study padperformance in 14 elderly, confused women in two clinicalsettings. Classical experimental research designs attemptto control variables and produce 'average' results for the'average' person. Single-case designs permit the manage-ment of variables by nursing intervention and subsequentmonitoring of the effects of the intervention in the pheno-mena of interest, ji xl^-i JH.i

In the study of incontinence pads, criterion measures ofthe efffectiveness of nursing interventions were generatedby expert nurses. Proxy measures of effectiveness wereidentified for less tangible indicators of quality such asdignity and comfort. The criterion measures of the effect-iveness of nursing intervention were tested for clinical andstatistical assessment through the use of visual inspectionof data, and clinical judgement combined with multinom-inal probability testing (le Roux, 1990).

The study methods were incorporated into a system ofnursing audit based upon the accumulation of clinicallyand statistically significant single-case data on particularpatient problems. The system makes innovative use ofinformation technology which includes analysis of nursingnarrative used in combination with single-case data in afeedback loop to refine quality indicators.

Results

Reliable, valid data were generated which enabled nursesto make rational, cost-effective choices of incontinence