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Development and Validation of the Role Profile of the Nurse Continence Specialist
Abstract
Although nurses have specialized in the management of incontinence, bladder, bowel, and pelvic fl oor dysfunction for more than 30 years, there is a lack of awareness and underutilization of their role. This article describes a 6-year project to defi ne, characterize, and validate a role profi le of the Nurse Continence Specialist. Data collection used a 2-phase, mixed-methods design. Phase 1 of the project resulted in a draft Nurse Continence Specialist role profi le and Phase 2 led to validation of the draft profile. The result was a broad consensus about what constitutes the specifi c skill set for Nurse Continence Specialist specialization within nursing.
... In their 2009 position statement, the USA-based Wound, Ostomy and Continence Nurses Society described the continence nurse as having an in-depth knowledge of normal voiding and defecation and common bladder and bowel Hunter and wagg function alterations, undertaking focused assessment with development of a nursing diagnosis and providing education on conservative management, including behavioral therapies, containment products, skin care and pelvic floor rehabilitation. 53 A role profile of the nurse continence specialist was developed and validated internationally under the auspices of the International Continence Society in 2016, 54 identifying that these clinicians hold specialized theoretical as well as experiential knowledge in bladder, bowel and pelvic floor dysfunction, providing continence services to a wide range of patient populations in diverse settings. Specialist continence nurses have the ability to undertake initial assessment and management of continence-related issues, as well as assume a case coordinator role. ...
... A multipronged intervention, across health care settings, therefore appears appropriate, ranging from education at all levels of provision for all levels of nurses, ongoing professional development and the use of continence specialist practitioners as champions of care, working within multiprofessional teams in order to set acceptable ethos. Data suggest that continence specialists, unsurprisingly, deliver a higher standard of care, 48,54,63 but the high degree of specialization is unaffordable, and perhaps inappropriate, for many patients. Continence (either independent continence or dependent continence, depending upon the target population) 75 needs to be seen as a normal state, and efforts need to be focused on appropriate initial assessment and management as this is where the gains will be made. ...
Kathleen F Hunter,1 Adrian S Wagg2 1Faculty of Nursing, University of Alberta, Edmonton, AB, Canada; 2Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada Abstract: Urinary (UI) and fecal incontinence (FI) are troublesome conditions for many in society; both UI and FI increase in prevalence with increasing age. Despite well-recognized effects on health, well-being and quality of life, incontinence is often seen by care providers and payers as a social problem, rather than a health related one. Nurses are in a key position to assist those affected by UI. Nurses have the potential to identify people with incontinence, establish appropriate interventions and provide valuable education to empower patients. Indeed, nurses are ideally placed to perform the initial assessment and management of incontinence, that portion of the care pathway which is crucial, but often poorly done. Unfortunately, this is not always easily implemented; nursing staff have identified environmental barriers, such as lack of time at work, and consider UI a low priority that prevents the facilitation of interventions. This article reviews the evidence on nursing involvement, or lack of it, in continence care and suggests a strategy to improve the situation, involving a complex intervention of knowledge translation. Keywords: nursing, continence, knowledge transfer, continence specialist nurses
... Unlike research in other settings, where the majority of health-care providers did not know how to manage UI, participants in this study either had that expertise themselves or were aware of nurses with that expertise that they could consult with (i.e., requested a referral to a nurse continence advisor; French et al., 2017;Sui et al., 2001). These specialist roles exist internationally in home-care programs for example, in Australia, the United States, and the United Kingdom (Paterson et al., 2016). The generalist home-care nurses in this study self-identified learning needs regarding continence promotion strategies. ...
Introduction:
A third of older adults with diabetes receiving home-care services have daily urinary incontinence. Despite this high prevalence of urinary incontinence, the condition is typically not recognized as a complication and thereby not detected or treated. Diabetes and urinary incontinence in older adults are associated with poorer functional status and lower quality of life. Home-care nurses have the potential to play an important role in supporting older adults in the management of these conditions. However, very little is known about home-care nurses' care of this population.
Objective:
The objective of this study was to explore how nurses care for older home-care clients with diabetes and incontinence.
Methods:
This was an interpretive description study informed by a model of clinical complexity, and part of a convergent, mixed methods research study. Fifteen nurse participants were recruited from home-care programs in southern Ontario, Canada to participate in qualitative interviews. An interpretive description analytical process was used that involved constant comparative analysis and attention to commonalities and variance.
Results:
The experiences of home-care nurses caring for this population is described in three themes and associated subthemes: (a) conducting a comprehensive nursing assessment with client and caregiver, (b) providing holistic treatment for multiple chronic conditions, and (c) collaborating with the interprofessional team. The provision of this care was hampered by a task-focused home-care system, limited opportunities to collaborate and communicate with other health-care providers, and the lack of health-care system integration between home care, primary care, and acute care.
Conclusion:
The results suggest that nursing interventions for older adults with diabetes and incontinence should not only consider disease management of the individual conditions but pay attention to the broader social determinants of health in the context of multiple chronic conditions. Efforts to enhance health-care system integration would facilitate the provision of person-centred home care.
... Exemplos de tais ações incluem: controle de intervalo miccional, ingestão de água e treinamento dos músculos do assoalho pélvico (PATERSON et al., 2016). ...
... Although the nurses have specialized in the management of incontinence for more than 30 years their role has been underutilized due to lack of awareness [37]. Klay and Marfyak performed a study that utilized a continence nurse specialist in an extended care facility to design a continence program. ...
There is a misconception that urinary incontinence (UI) in older adults, usually above the age of 65 is a part of aging. More than 50% of residents in long-term care (LTC) settings are affected by UI and it is associated in many cases with markedly reduced quality of life. It has become evident that incontinence can be cured or successfully managed. However, many nurses lack sufficient knowledge to intervene appropriately. The purpose of this review is to share how the collaborative efforts of nurses at all levels may lead to increased assessment and interventions of UI in this population.
... As unqualified staff are generally not recognised as dealing with FI they are not likely to receive much training around management. Much of the training in continence care is aimed at qualified nursing staff (Ostaszkiewicz, 2006, Paterson et al., 2016. There is a gap in research and training for formal carers in continence management. ...
Purpose
This paper aims to raise awareness of the ways in which faecal incontinence can impact the provision of dementia care by examining this through the lens of stigma.
Design/methodology/approach
This paper contains a scoping review of available literature relating to faecal incontinence, dementia and stigma.
Findings
Literature was organised into three themes: the origins of the stigma, the purpose of stigma and the care context.
Research limitations/implications
Limitations of this paper include the lack of literature discussing faecal incontinence and dementia in relation to stigma.
Practical implications
Stigma regarding faecal incontinence has the potential to impact quality of life of people with a dementia and contributes towards the invisible work of unqualified care workers.
Originality/value
Stigma and faecal incontinence have only a small amount of research around them in residential dementia care.
... Specialist nurses, in the UK are registered nurses who practice at an advanced level to manage and improve patient care, satisfaction and outcomes, have a similar and broad spectrum of roles regardless of the specialty in which they work [20][21][22][23][24][25] Subsequently, the concept of competencies was introduced to provide a standard to support individuals to maintain fitness for practice and encourage professional and personal development. [26][27][28] In 2014, a working party of experienced nurses agreed a consensus statement on a core competency framework that would enable haemophilia nurse specialists to carry out their roles effectively. ...
Introduction
Nurses play a central co‐ordinating role in delivering comprehensive care for people with haemophilia and allied bleeding disorders, for which they need a broad range of competencies. The UK Haemophilia Nurses Association (HNA) published a role description in 1994 which was developed into a competency framework in 2014. This has now been updated to reflect current educational and clinical practice.
Aim
To summarize the evidence supporting the nurse's advanced role within haemophilia care and develop new competencies to deliver comprehensive care within a multidisciplinary team.
Methods
Systematic reviews were identified by PubMed literature search. The HNA conducted workshops to consult its membership, and the authors incorporated this input to update its competency framework within the structure outlined by Health Education England in multiprofessional framework for advanced clinical practice in England (2017).
Results
The proposed framework includes five domains (Clinical knowledge, Clinical/direct care, Communication and support, Collaborative practice and Research) supported by indicators for four levels of practice (beginner, competent, proficient and expert). The framework is a tool which nurses and their managers can use to assess skills and knowledge, and identify learning needs appropriate to personal development and improve patient care and outcomes.
Conclusion
The HNA has developed a new competency framework to provide a strong foundation for haemophilia specialist nurses to continue improving services for people living with bleeding disorders and their families, as well as supporting personal development alongside new therapeutic options, models of care and follow‐up.
... Quando, por um lado, deparo-me com a realidade do sistema de saúde, por outro percebo o quanto nós, enfermeiros, podemos fazer por essas pessoas. Podemos atuar na prevenção por meio da divulgação de medidas simples que evitariam a manifestação da incontinência ou de suas complicações, agir precocemente nos sintomas por meio de orientação de medidas comportamentais simples (controle de intervalo miccional, posicionamento para eliminações, ingestão de água, treinamento muscular de assoalho pélvico), contribuir para o resgate da autonomia e da qualidade de vida à mulher com prolapsos de órgão pélvicos pela inserção de pessários vaginais ou à pessoa com disfunção neurológica de trato urinário inferior pela capacitação para o cateterismo intermitente limpo 3 ...
Quero convidá-lo à uma reflexão sobre a atuação da nossa estimada estomaterapia na área de incontinências. Ou, como prefiro me referir a ela, a área das disfunções miccionais e evacuatórias, compreendendo que as disfunções vão além da perda urinária ou fecal, contemplando também a retenção urinária e a constipação intestinal.
... When, on the one hand, I encounter the reality of the health system, on the other I realize how much we, nurses, can do for these people. We can act in prevention through the dissemination of simple measures that would prevent the manifestation of incontinence or its complications, acting early in the symptoms through guidance of simple behavioral measures (control of urinary interval, positioning for eliminations, water intake, muscle training of the pelvic oor), contribute to the recovery of autonomy and quality of life to women with pelvic organ prolapses by the insertion of vaginal pessaries or to the person with inferior urinary tract neurological dysfunction by the capacity for clean intermittent catheterization 3 . e nurse's specialized actions prevent and treat urinary and evacuation dysfunctions ee ectively. ...
I would like to invite you to reflect on the work of our estimated stomatherapy, in the area of incontinence. Or, as I prefer to refer to it, the area of urinary and evacuation dysfunctions, understanding that dysfunctions go beyond urinary or fecal loss, also contemplating urinary retention and intestinal constipation.
... Practice standards are authoritative guidelines that describe the responsibilities and accountability of practitioners, reflect the profession's values and priorities and provide a framework for evaluation of clinical practice and are considered the baseline requirement for quality clinical care 11,12 . They are also a means to communicate the role and scope of practice of a nursing speciality to consumers, other nurses and health professionals, stakeholders such as employers and policy makers 1,[13][14][15] . The development and publication of standards for specialist nursing practice is well established in Australia; for example, nurses in general practice 16 , professional school nursing 17 and cancer nursing 18 . ...
Practice standards are authoritative guidelines that: describe the responsibilities and accountability of practitioners; reflect the profession's values and priorities; provide a framework for evaluation of clinical practice; and are a means of communicating a specific role and scope of practice to consumers and other health professionals. The aim of this project was to revise, update and determine the face validity of the draft Practice Standards for the Nurse Continence Specialist in Australia. A mixed-method approach using questionnaires, repeated expert opinion, content analysis and consensus was used to validate the draft versions of the practice standards. The project was undertaken in two interrelated stages. In stage one a purposive sample of 33 registered nurses participated in a workshop and completed an anonymous questionnaire. Data were primarily quantitative and analysed using descriptive statistics. Narrative comments were analysed using content analysis. In stage two 165/287 Continence Nurses Society Australia members completed an online questionnaire related to the application and relevance of the proposed standards. Following each stage, the draft standards document was refined and redrafted. In stage one, 33 workshop attendees completed the questionnaire. Quantitative responses indicated very high levels of agreement (> 94%) with the draft standard statements. In stage two, 165 (57%) members completed the online questionnaire. Quantitative responses indicated very high levels of agreement (97-100%). This iterative and consensus approach resulted in the development and validation of the Continence Nurses Society Australia Practice Standards for the Nurse Continence Specialist in Australia.
Introduction:
Lower Urinary Tract Symptoms(LUTS) are a complication of Diabetes Mellitus (DM) and although it negatively impactsthe quality of life, it is not considered in care programs for this population.
Objective:
To survey the occurrence of LUTS in a population with Type 2 DM and assess its association with clinical history.
Method:
Cross-sectional study. Interview with 60 patients from a private DM clinic using a tool with sociodemographic and clinical data and symptoms of bladder storage and voiding in the last 30 days. Statistical analysis was performed using the computer program IBM SPSS Statistics, v20.0.
Results:
Most of the participants were retired with high education, good dietary, and intestinal pattern, sedentary, obese, or overweight, with high glycated hemoglobin rates. Of the total, 25% had stress urinary incontinence, 60% had at least one symptom of overactive bladder, 41.7% had at least one symptom of incomplete bladder voiding, 70.1% had at least one LUTsymptom. An association was found between urinary symptoms and time since DM diagnosis.
Conclusion:
The population with type 2 DM has a high occurrence of LUTS, with a predominance of symptoms of overactive bladder, associated with the time of DM diagnosis.
Introdução: A Disfunção do Trato Urinário Inferior (DTUI) é uma complicação do Diabetes Mellitus (DM) e embora cause impacto negativo na qualidade de vida, não é contemplada nos programas de atenção a essa população. Objetivo: Levantar a ocorrência de DTUI em uma população com DM Tipo 2e avaliar sua associação com a história clínica. Método: Estudo transversal. Entrevista com 60 pacientes de um centro privado de DM por meio de instrumento contendo dados sociodemográficos, clínicos e sintomas de armazenamento e esvaziamento vesical apresentados nos últimos 30 dias. Análise estatística por meio do programa computacional IBM SPSS Statistics, v20.0. Resultados: Amostra predominantemente aposentada com alta escolaridade, bom padrão alimentar e intestinal, sedentária, obesa ou em sobrepeso, com taxas de hemoglobina glicada elevadas. Do total, 25% apresentavam incontinência urinária aos esforços, 60% pelo menos um sintoma de bexiga hiperativa, 41,7% pelo menos um sintoma de esvaziamento vesical incompleto, 70,1% pelo menos um sintoma de DTUI. Foi encontrada associação entre os sintomas urinários e o tempo de diagnóstico de DM. Conclusão: A população com DM tipo 2 apresenta alta ocorrência de DTUI, com predominância de sintomas de bexiga hiperativa, associada ao tempo de diagnóstico de DM.
Objective:
To critically appraise peer-reviewed evidence concerning the value, or implied sense of worth or benefit, of nurses specialized in wound, ostomy, and continence (WOC) care.
Data sources:
The Preferred Reporting Items for Systematic Reviews and Meta-analyses was used to systematically review current literature in a single database from 2009 to the date of search (July 2019).
Study selection:
The initial search retrieved 2,340 elements; 10 studies were retained following removal of duplicate records, title and abstract reviews, and application of the inclusion/exclusion criteria.
Data extraction:
Literature was graded and critiqued with regard to design and research quality and then synthesized using a narrative approach.
Data synthesis:
Nine values that WOC nurses demonstrate were identified: improved quality of life for patients, teaching and mentoring, cost reduction, improved efficiency, improved wound outcomes, improved incontinence outcomes, advanced treatments, research, and leadership.
Conclusions:
Although current studies suggest that there is value in the WOC nurse role, in all areas of the trispecialty, there is a need for high-quality literature with higher-level designs focused on bias reduction.
The Wound, Ostomy and Continence Nurses Society believes the tri-specialty certified nurse (Certified Wound Ostomy Continence Nurse [CWOCN]) or advanced practice tri-specialty certified nurse (Certified Wound Ostomy Continence Nurse-Advanced Practice [CWOCN-AP]) possesses unique knowledge, expertise for assessment, and first-line management of incontinence as well as for prevention of incontinence. The CWOCN or CWOCN-AP provides care and consultation in the treatment of potential and actual skin complications through absorption, and containment, in persons with urinary, fecal, or dual incontinence. This executive summary describes the role of the CWOCN or CWOCN-AP in the delivery of continence care across care settings. The original statement is available at https://cdn.ymaws.com/www.wocn.org/resource/collection/6D79B935-1AA0-4791-886F-E361D29F152D/Role_of_Continence_Nurse__2018_.pdf.
The focus of this chapter is to explain the management of fecal incontinence in adult patients who are admitted to an acute care hospital who have either chronic (pre-existing) or transient (reversible, short-term) fecal incontinence. Effective management can minimize or eliminate adverse patient outcomes such as skin breakdown, infections, and patient discomfort from fecal leakage. Included in the care approaches will be containment/collection products that are currently used for fecal incontinence in acute care and critical care. This chapter will also describe efforts toward prevention of fecal incontinence in this population.
This chapter explains the concepts of advanced practice nursing and advanced practice continence nursing. It describes advanced practice nursing and advanced practice continence nursing practice in four countries. It distinguishes between specialist and advanced nursing practice, introduces the reader to the global development of continence nursing as a specialization, describes the role profile of the nurse continence specialist, and proposes a set of competences and education from basic to advanced practice continence nursing care. This chapter includes information about the advanced practice approach to continence care for people with fecal incontinence and concludes with research about the effectiveness of nurses with advanced practice skills in continence care for people with fecal incontinence.
The purpose of this study was to determine the effect on clinical outcomes for newly admitted nursing home residents when advanced practice gerontological nurses (APNs) worked with staff to implement scientifically based protocols for incontinence, pressure ulcers, depression, and aggressive behavior. Use of APNs in this manner differs from the usual way APNs have been used in nursing homes, in which their primary focus has been to augment the physician's role. The APN treatment was randomly assigned to two nursing homes and usual care was assigned to a third. Trajectories from admission to 6 months revealed that residents with APN input into their care (n = 86) experienced significantly greater improvement or less decline in incontinence, pressure ulcers, and aggressive behavior, and they had higher mean composite trajectory scores compared with residents receiving usual care (n = 111). Significantly less deterioration in affect was noted in cognitively impaired residents in the treatment group. Findings suggest that APNs can be effective links between current scientific knowledge about clinical problems and nursing home staff.
The short-term efficacy of combined lifestyle and behavioural interventions led by nurses in the management of urinary incontinence has not been rigorously evaluated by randomized controlled trial. We conducted a 6-month randomized controlled trial to determine whether a model of service delivery that included lifestyle and behavioural interventions led by "nurse continence advisers" in collaboration with a physician with expertise in continence management could reduce urinary incontinence and pad use in an outpatient population. We also aimed to evaluate the impact of this approach on subjects' knowledge about incontinence and their quality of life.
We used advertising in the mainstream media, newsletters to family physicians and community information sessions in 1991 to invite volunteers who were 26 years of age or older and suffered from incontinence to participate in a randomized controlled trial. Men and women who met the eligibility criteria were randomly allocated to receive either counselling from specialized nurses to manage incontinence using behavioural and lifestyle modification sessions every 4 weeks for 25 weeks or usual care. Symptoms of incontinence and the use of incontinence pads were the primary outcome measures.
Using sealed envelopes, 421 patients were randomly allocated to the treatment or control groups. On average, patients in the treatment group experienced 2.1 "incontinent events" per 24 hours before treatment and 1.0 incontinent event per 24 hours at the end of the study. Control patients had an average of 2.4 incontinent events per 24 hours before the study and 2.2 incontinent events per 24 hours at the end of the study. The mean decrease in events in the treatment group was 1.2 and in the control group 0.2 (p = 0.001). Pad use declined from a mean of 2.2 per 24 hours before randomization in the treatment group to 1.2 per 24 hours at the end of the study, compared with 2.6 pads per 24 hours in the control group at the start of the study and 2.4 per 24 hours at the end. Pad use per 24 hours decreased on average by 0.9 pads in the treatment group and 0.1 in the control group (p = 0.021).
Behavioural and lifestyle counselling provided by specialized nurses with training in managing incontinence reduces incontinent events and incontinence pad use.
Previous research on urge urinary incontinence has demonstrated that multicomponent behavioral training with biofeedback is safe and effective, yet it has not been established whether biofeedback is an essential component that heightens therapeutic efficacy.
To examine the role of biofeedback in a multicomponent behavioral training program for urge incontinence in community-dwelling older women.
Prospective, randomized controlled trial conducted from April 1, 1995, to March 30, 2001.
University-based outpatient continence clinic in the United States.
A volunteer sample of 222 ambulatory, nondemented, community-dwelling women aged 55 to 92 years with urge incontinence or mixed incontinence with urge as the predominant pattern. Patients were stratified by race, type of incontinence (urge only vs mixed), and severity (frequency of accidents).
Patients were randomly assigned to receive 8 weeks (4 visits) of biofeedback-assisted behavioral training (n = 73), 8 weeks (4 visits) of behavioral training without biofeedback (verbal feedback based on vaginal palpation; n = 74), or 8 weeks of self-administered behavioral treatment using a self-help booklet (control condition; n = 75).
Reduction in the number of incontinence episodes as documented in bladder diaries, patients' perceptions and satisfaction, and changes in quality of life.
Intention-to-treat analysis showed that behavioral training with biofeedback yielded a mean 63.1% reduction (SD, 42.7%) in incontinence, verbal feedback a mean 69.4% reduction (SD, 32.7%), and the self-help booklet a mean 58.6% reduction (SD, 38.8%). The 3 groups were not significantly different from each other (P =.23). The groups differed significantly regarding patient satisfaction: 75.0% of the biofeedback group, 85.5% of the verbal feedback group, and 55.7% of the self-help booklet group reported being completely satisfied with treatment (P =.001). Significant improvements were seen across all 3 groups on 3 quality-of-life instruments, with no significant between-group differences.
Biofeedback to teach pelvic floor muscle control, verbal feedback based on vaginal palpation, and a self-help booklet in a first-line behavioral training program all achieved comparable improvements in urge incontinence in community-dwelling older women. Patients' perceptions of treatment were significantly better for the 2 behavioral training interventions.
Continence services in the UK have developed at different rates within differing care models, resulting in scattered and inconsistent services. Consequently, questions remain about the most cost-effective method of delivering these services.
To evaluate the impact of a new service led by a continence nurse practitioner compared with existing primary/secondary care provision for people with urinary incontinence and storage symptoms.
Randomised controlled trial with a 3- and 6-month follow-up in men and women (n = 3746) aged 40 years and over living in private households (intervention [n = 2958]; control [n = 788]).
Leicestershire and Rutland, UK.
The continence nurse practitioner intervention comprised a continence service provided by specially trained nurses delivering evidence-based interventions using predetermined care pathways. They delivered an 8-week primary intervention package that included advice on diet and fluids; bladder training; pelvic floor awareness and lifestyle advice. The standard care arm comprised access to existing primary care including GP and continence advisory services in the area. Outcome measures were recorded at 3 and 6 months post-randomisation.
The percentage of individuals who improved (with at least one symptom alleviated) at 3 months was 59% in the intervention group compared with 48% in the standard care group (difference of 11%, 95% CI = 7 to 16; P<0.001) The percentage of people reporting no symptoms or 'cured' was 25% in the intervention group and 15% in the standard care group (difference of 10%, 95% CI = 6 to 13, P = 0.001). At 6 months the difference was maintained. There was a significant difference in impact scores between the two groups at 3 and 6 months.
The continence nurse practitioner-led intervention reduced the symptoms of incontinence, frequency, urgency and nocturia at 3 and 6 months; impact was reduced; and satisfaction with the new service was high.
Context.— Urinary incontinence is a common condition
caused by many factors with several treatment options.Objective.— To compare the effectiveness of
biofeedback-assisted behavioral treatment with drug treatment and a
placebo control condition for the treatment of urge and mixed urinary
incontinence in older community-dwelling women.Design.— Randomized placebo-controlled trial conducted from
1989 to 1995.Setting.— University-based outpatient geriatric medicine
clinic.Patients.— A volunteer sample of 197 women aged 55 to 92
years with urge urinary incontinence or mixed incontinence with urge as
the predominant pattern. Subjects had to have urodynamic evidence of
bladder dysfunction, be ambulatory, and not have dementia.Intervention.— Subjects were randomized to 4 sessions (8
weeks) of biofeedback-assisted behavioral treatment, drug treatment
(with oxybutynin chloride, possible range of doses, 2.5 mg daily to 5.0
mg 3 times daily), or a placebo control condition.Main Outcome Measures.— Reduction in the frequency of
incontinent episodes as determined by bladder diaries, and patients'
perceptions of improvement and their comfort and satisfaction with
treatment.Results.— For all 3 treatment groups, reduction of
incontinence was most pronounced early in treatment and progressed more
gradually thereafter. Behavioral treatment, which yielded a mean 80.7%
reduction of incontinence episodes, was significantly more effective
than drug treatment (mean 68.5% reduction;
P=.04) and both were more effective than the
placebo control condition (mean 39.4% reduction; P<.001 and
P=.009, respectively). Patient-perceived
improvement was greatest for behavioral treatment (74.1% "much
better" vs 50.9% and 26.9% for drug treatment and placebo,
respectively). Only 14.0% of patients receiving behavioral treatment
wanted to change to another treatment vs 75.5% in each of the other
groups.Conclusion.— Behavioral treatment is a safe and effective
conservative intervention that should be made more readily available to
patients as a first-line treatment for urge and mixed
incontinence.
Objective: We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes. Study Design: A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and χ2 tests. Results: The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site. Conclusions: Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact. (Am J Obstet Gynecol 1998;179:999-1007.)
To determine the 12-month, societal cost-effectiveness of involving urinary incontinence (UI) nurse specialists in primary care compared to care-as-usual by general practitioners (GPs).
From 2005 until 2008 an economic evaluation was performed alongside a pragmatic multicenter randomized controlled trial comparing UI patients receiving care by nurse specialists with patients receiving care-as-usual by GPs in the Netherlands. One hundred eighty-six adult patients with stress, urgency, or mixed UI were randomly allocated to the intervention and 198 to care-as-usual; they were followed for 1 year. Main outcome measures were Quality Adjusted Life Year (QALY(societal) ) based on societal preferences for health outcomes (EuroQol-5D), QALY(patient) based on patient preferences for health outcomes (EuroQol VAS), and Incontinence Severity weighted Life Year (ISLY) based on patient-reported severity and impact of UI (ICIQ-UI SF). Health care resource use, patient and family costs, and productivity costs were assessed. Data were collected by three monthly questionnaires. Incremental cost-effectiveness ratios were calculated. Uncertainty was assessed using bootstrap simulation, and the expected value of perfect information was calculated (EVPI).
Compared to care-as-usual, nurse specialist involvement costs € 16,742/QALY(societal) gained. Both QALY(patient) and ISLY yield slightly more favorable cost-effectiveness results. At a threshold of € 40,000/QALY(societal,) the probability that the intervention is cost-effective is 58%. The EVPI amounts to € 78 million.
Based on these results, we recommend adopting the nurse specialist intervention in primary care, while conducting more research through careful monitoring of the effectiveness and costs of the intervention in routine practice.
Fecal incontinence affects up to 11% of Australian community-dwelling adults and 72% of nursing home residents. Biofeedback is a recommended conservative therapy when medication and pelvic floor exercises have failed to improve patient outcomes.
This study aimed to investigate the impact of a new exercise regimen on the severity of fecal incontinence and the quality of life of participants.
This was a randomized clinical study.
This study was conducted at the Anorectal Physiology Clinic, Townsville Hospital, Queensland, Australia.
Seventy-two participants (19 male), with a mean age of 62.1 years, attended 5 clinic sessions: 4 weekly sessions followed by 4 weeks of home practice and a follow-up assessment session. A postal survey was conducted 2 years later.
Thirty-seven patients (12 male) were randomly assigned to the standard clinical protocol (sustained submaximal anal and pelvic floor exercises) and 35 patients (7 male) were randomly assigned to the alternative group (rapid squeeze plus sustained submaximal exercises).
The main outcomes were measured by use of the Cleveland Clinic Florida Fecal Incontinence score and the Fecal Incontinence Quality of Life Scale survey tool.
No significant differences were found between the 2 exercise groups at the beginning or at the end of the study or as a result of treatment in objective, quality-of-life, or fecal incontinence severity measures. Sixty-nine participants completed treatment. The severity of fecal incontinence decreased significantly (11.5/20 to 5.0/20, P < .001). Eighty-six percent (59/69) of participants reported improved continence. Quality of life significantly improved for all participants (P < .001). Results were sustained 2 years later. Patients who practiced at least the prescribed number of exercises had better outcomes than those who practiced fewer exercises.
This study was limited because it involved a heterogeneous sample, it was based on subjective reporting of exercise performance, and loss to follow-up occurred because of the highly mobile population.
Patients attending this biofeedback program attained significant improvement in the severity of their fecal incontinence and in their quality of life. Although introduction of rapid muscle squeezes had little impact on fecal incontinence severity or patient quality of life, patient exercise compliance at prescribed or greater levels did.
Urinary incontinence (UI) primary care management is substandard, offering care rather than cure despite the existence of guidelines that help to improve cure. Involving nurse specialists on incontinence in general practice could be a way to improve care for UI patients.
We studied whether involving nurse specialists on UI in general practice reduced severity and impact of UI.
Between 2005 and 2008 a pragmatic multicentre randomised controlled trial was performed comparing a 1-year intervention by trained nurse specialists with care-as-usual after initial diagnosis and assessment by general practitioners in adult patients with stress, urgency or mixed UI in four Dutch regions (Maastricht, Nijmegen, Helmond, The Hague). Simple randomisation was computer-generated with allocation concealment. Analysis was performed by intention-to-treat principles. Main outcome measure was the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) severity sum score.
A total of 186 patients followed the intervention and 198 received care-as-usual. Patients in both study groups improved significantly in UI severity and impact on health-related quality of life. After correction for effect modifiers [type of UI, body mass index (BMI)], we found significant differences between groups in favour of the intervention group at 3 months (p = 0.04); no differences were found in the 1-year linear trend (p = 0.15). Patients in the intervention group without baseline anxiety/depression improved significantly better compared with care-as-usual after 1 year (p = 0.03).
Involving nurse specialists in care for UI patients supplementary to general practitioners can improve severity and impact of UI, after correction for effect modifiers. This is also the case in specific situations such as anxiety/depression.
Incontinence is recognized as a health problem of sizeable proportions affecting a wide age range of the population. This paper compares the nursing approaches for the promotion and management of continence within the U.K. and Denmark. Semi-structured interview of key health professionals within Denmark was undertaken. The information collected forms the basis for a comparison of prevalence of incontinence, clinical practice, management, education and research.
Continence advice in England and Wales is a relatively new specialism within nursing and, over the past 20 years, the number of continence advisers has grown substantially. There are, however, no formal qualifications for the role and the service has grown up in a piecemeal fashion. A study carried out by the Social Policy Research Unit of the University of York sought to answer basic quantitative questions about: (1) the number of continence advisers in post, their professional backgrounds and so on; (2) the structures within which continence advisers work; and (3) the nature of their current practice; as well as more attitudinal and developmental questions about the history and future development of continence advisers' work.
This survey is the first report on the characteristics, functions, and barriers to practice reported by continence care nurses in the United States. The data obtained provide valuable information regarding a new subspecialization in nursing.
Urinary incontinence remains a hidden and inadequately treated problem in a high proportion of women.
Ninety women 50-74 years of age were recruited to a population-based, randomized, controlled clinical trial of conservative treatment for urinary incontinence, with delayed treatment for the control group. The study was performed in general practice in three north-Norwegian municipalities, in cooperation with two local departments of gynecology. Three patients were found protocol deviant and analysis was based on 87 patients.
Local estrogen, physiotherapy and electrostimulation combined with close follow-up.
1. Change in severity of incontinence from start of treatment (index range 0-8). 2. Change in impact from start of treatment (index range 0-4). 3. Quantitative measures in relation to micturition. 4. Criteria based classification into cured, improved, unchanged, worse.
Treatment reduced severity (index change 1.8 in the intervention group vs. 0.1 in the control group at six months) and impact (index change 0.8 vs. 0.0) of leakage. Almost one third of the patients did not complete all micturition tests, but in those who did, average number of wet episodes per 24 hours decreased with treatment, and so did average number of micturitions in urge and mixed incontinence. Forty-nine patients (56%) were cured or improved after one year.
Women 50 to 74 years of age with urinary incontinence may improve considerably through conservative treatment in general practice.
We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes.
A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and chi2 tests.
The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site.
Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact.
Urinary incontinence is a common condition caused by many factors with several treatment options.
To compare the effectiveness of biofeedback-assisted behavioral treatment with drug treatment and a placebo control condition for the treatment of urge and mixed urinary incontinence in older community-dwelling women.
Randomized placebo-controlled trial conducted from 1989 to 1995.
University-based outpatient geriatric medicine clinic.
A volunteer sample of 197 women aged 55 to 92 years with urge urinary incontinence or mixed incontinence with urge as the predominant pattern. Subjects had to have urodynamic evidence of bladder dysfunction, be ambulatory, and not have dementia.
Subjects were randomized to 4 sessions (8 weeks) of biofeedback-assisted behavioral treatment, drug treatment (with oxybutynin chloride, possible range of doses, 2.5 mg daily to 5.0 mg 3 times daily), or a placebo control condition.
Reduction in the frequency of incontinent episodes as determined by bladder diaries, and patients' perceptions of improvement and their comfort and satisfaction with treatment.
For all 3 treatment groups, reduction of incontinence was most pronounced early in treatment and progressed more gradually thereafter. Behavioral treatment, which yielded a mean 80.7% reduction of incontinence episodes, was significantly more effective than drug treatment (mean 68.5% reduction; P=.04) and both were more effective than the placebo control condition (mean 39.4% reduction; P<.001 and P=.009, respectively). Patient-perceived improvement was greatest for behavioral treatment (74.1% "much better" vs 50.9% and 26.9% for drug treatment and placebo, respectively). Only 14.0% of patients receiving behavioral treatment wanted to change to another treatment vs 75.5% in each of the other groups.
Behavioral treatment is a safe and effective conservative intervention that should be made more readily available to patients as a first-line treatment for urge and mixed incontinence.
To examine the (1) short-term effectiveness of behavioral therapies in homebound older adults and (2) characteristics of responders and nonresponders to the therapies.
Prospective, controlled clinical trial with cross-over design.
Adults aged 60 and older with urinary incontinence and who met Health Care Financing Administration criteria for being homebound were referred to the study by homecare nurses from two large Medicare-approved home health agencies in a large metropolitan county in southwestern Pennsylvania.
Structured continence and medical history, OARS Physical and Instrumental Activities of Daily Living scales, Folstein Mini-Mental State Examination Score, Clock Drawing Test, Geriatric Depression Scale, Performance-Based Toileting Assessment, bladder diaries, and physical examination.
One hundred five subjects were randomized to biofeedback-assisted pelvic floor muscle training (53 to the treatment group and 52 to the control groups). Control subjects with complete pre- and post-control data (n = 45) experienced a median 6.4% reduction in urinary accidents in contrast to a median 75.0% reduction in subjects with complete pre- and post-treatment data (n = 48, P < .001). Following the control phase, subjects crossed over to the treatment protocol. Eighty-five subjects completed treatment, achieving a median 73.9% reduction in UI. Exercise adherence was the most consistent predictor of responsiveness to the behavioral therapy.
Clinically significant reductions in urinary incontinence are achievable with behavioral therapies in many cognitively intact homebound older adults despite high levels of co-morbidity and functional impairment.
To describe changes in bladder function and voiding frequency associated with behavioral and drug treatment for urge incontinence and to examine whether these variables mediate the positive effects of treatment on the frequency of incontinence.
Randomized, double-blinded, placebo-controlled, clinical trial. Eligible patients were stratified according to type of incontinence (urge only vs mixed urge and stress) and severity of incontinence (frequency of accidents as documented in bladder diary).
University-based outpatient geriatric medicine clinic.
One hundred five ambulatory, nondemented, community-dwelling women; mean age 67.0 (range 55-91); 98% white, 2% African American.
Four sessions (over 8 weeks) of biofeedback-assisted behavioral training, drug treatment with individually-titrated oxybutynin chloride, or a placebo control condition.
Two-channel cystometry was performed to determine threshold volumes for first desire to void (FDV), strong desire to void (SDV), bladder capacity, and the volume at which detrusor instability (DI) or leakage occurred, before randomization and after completion of treatment. Two-week bladder diaries were used before and after treatment to document episodes of incontinence and voiding frequency.
Bladder capacity increased by 68.9 mL in the oxybutynin group (P <.001) and 17.3 mL in the behavior group and decreased 6.0 mL in the control group. SDV increased 69.9 mL in the oxybutynin group (P <.001), 40.5 in the behavior group (P <.05), and 7.8 mL in the control group. FDV increased by 44.4 mL in the oxybutynin group (P <.001), 18.8 mL in the behavior group, and 8.9 mL in the control group. One of seven patients who presented with DI (12.0%) resolved in the behavior group, seven of eight (87.5%) resolved in the oxybutynin group, and seven of 12 (58.3%) resolved in the control group. These differences were not statistically significant. Voiding frequency was significantly reduced after treatment in both the behavior and the oxybutynin group. Behavioral training resulted in a mean 82.3% reduction in frequency of accidents, oxybutynin (final doses 2.5 mg daily to 5 mg three times a day) resulted in a mean 78.3% reduction, and the control condition resulted in a mean 51.5% reduction (P =.002). Although oxybutynin and behavioral treatment were both effective, and oxybutynin increased SDV and bladder capacity, the structural equation modeling did not demonstrate that the clinical improvement was mediated through the effects of these treatments on urodynamic or voiding frequency measures.
Studies using more-complex urodynamics and studies with larger sample sizes are needed to better characterize changes in bladder function and explore other urodynamic changes that may accompany treatment. In addition, other factors, both physiological and behavioral, need to be explored as mechanisms by which conservative therapies improve urge incontinence.
To evaluate the effect of a low-intensity behavioral therapy program on urinary incontinence in older women.
A randomized clinical trial for community-dwelling women at least 55 years reporting at least one urinary incontinent episode per week was conducted. Women were randomly assigned to a behavioral therapy group (n = 77) or a control group (n = 75). The treatment group had six weekly instructional sessions on bladder training and followed individualized voiding schedules. The control group received no instruction but kept urinary diaries for 6 weeks. After this period, the control group underwent the behavioral therapy protocol. Using per-protocol analyses, t and chi(2) tests were used to compare the treatment and control groups, and paired t tests were used to evaluate the efficacy of behavioral therapy for all women (treatment and control groups before and after behavioral therapy).
Women in the treatment group experienced a 50% reduction in mean number of incontinent episodes recorded on a 7-day urinary diary compared with a 15% reduction for controls (P =.001). After behavioral therapy, all women had a 40% decrease in mean weekly incontinent episodes (P =.001), which was maintained over 6 months (P <.004). Thirty (31%) women were 100% improved (dry), 40 (41%) were at least 75% improved, and 50 (52%) at least 50% improved. There were no differences in treatment efficacy by type of incontinence (stress, urge, mixed) or group assignment (treatment, control).
A low-intensity behavioral therapy intervention for urinary incontinence was effective and should be considered as a first-line treatment for urinary incontinence in older women.
This study compared the effectiveness of bladder training versus pelvic muscle exercises in the treatment of urinary incontinence in women. It was revealed that the two intervention groups showed improvement compared with the control group, but differed in their effects on outcome measures. The pelvic muscle exercise group was more effective in increasing the peak and the average pressures of pelvic muscle contraction. The bladder-training group was more effective in reducing urinary frequency and in increasing voided volume. Further research is needed to explore the relationship among the various outcome measures of urinary incontinence.
Urinary incontinence (UI) is a complex symptom of underlying disorders that affects over one and a half million Canadians. Although there is good evidence that incontinence can be treated effectively, the most efficient and cost-effective method for delivery of treatment is uncertain. The purpose of this study was to explore and describe the continence services that exist internationally and in Canada in order to provide the background for a Canadian model of continence service. Data were collected by communication with international health care professionals with expertise in UI, and distribution of a questionnaire to international and Canadian continence care providers. Findings suggest that although physicians, nurses, and/or physiotherapists currently provide continence care, services are scattered and inconsistent and discrepancies exist in how they are funded. The major themes that emerged are the need for enhanced accessibility of continence care and the importance of multidisciplinary teamwork.
Urinary incontinence among community-dwelling frail elderly is estimated to affect 6.23 million people at an annual cost of over $7 billion. Overwhelmed caregivers may seek institutional placement of their incontinent family member. Results from this study of 78 subjects demonstrate that even in physically and cognitively impaired persons a behavioral treatment program can reduce incontinence, lower costs, and relieve caregiver burden.
Behavioral treatment (biofeedback) has been reported to improve fecal incontinence but has not been compared with standard care.
A total of 171 patients with fecal incontinence were randomized to 1 of 4 groups: (1) standard care (advice); (2) advice plus instruction on sphincter exercises; (3) hospital-based computer-assisted sphincter pressure biofeedback; and (4) hospital biofeedback plus the use of a home electromyelogram biofeedback device. Outcome measures included diary, symptom questionnaire, continence score, patient's rating of change, quality of life (short-form 36 and disease specific), psychologic status (Hospital Anxiety and Depression scale), and anal manometry.
Biofeedback yielded no greater benefit than standard care with advice (53% improved in group 3 vs. 54% in group 1). There was no difference between the groups on any of the following measures: episodes of incontinence decreased from a median of 2 to 0 per week (P < 0.001). Continence score (worst = 20) decreased from a median of 11 to 8 (P < 0.001). Disease-specific quality of life, short-form 36 (vitality, social functioning, and mental health), and Hospital Anxiety and Depression scale all significantly improved. Patients improved resting, squeeze, and sustained squeeze pressures (all P < 0.002). These improvements were largely maintained 1 year after finishing treatment.
Conservative therapy for fecal incontinence improves continence, quality of life, psychologic well-being, and anal sphincter function. Benefit is maintained in the medium term. Neither pelvic floor exercises nor biofeedback was superior to standard care supplemented by advice and education.
Urinary incontinence (UI) is a condition that is associated with decreased quality of life. Apart from this impact on quality of life, UI is also a very costly problem. It is recognised that 'usual care' for patients suffering from UI is not optimal. Specialised nurses can play an important role in the care for community-dwelling incontinent patients, as they have the appropriate interpersonal and technical skills to provide patient-tailored care. This systematic review analyses the effect of treatment by nurses on clinical and economic outcomes. A total of 12 randomised controlled trials (RCTs) were found, varying in terms of population, setting, outcome measurement and control/intervention. There is limited evidence that treatment by nurses results in a decrease in incontinence. No evidence was found for cost reduction. Recommendations are made for future studies.
To assess if an integrated care pathway improves the services provided for continence care.
This was a prospective cohort study. At Worcester Royal Hospital, a UK district general hospital, an integrated care pathway was developed for the management of women presenting in primary care with continence problems. Sixty-five women referred through this pathway were compared to women referred directly to outpatients with similar problems. The outcomes compared were the time in days from referral to (1) the first medical contact, (2) diagnosis (3) physiotherapy/continence advisory review and (4) surgery or discharge. Statistical significance of the difference in outcomes was established using the Mann-Whitney U-test.
The mean time from referral to first medical contact, urodynamic studies, physiotherapy/continence advisory team review and to surgery or discharge for the direct access patients compared to clinic patients was significantly less (p<0.05). Thirty-five percent (7/20) patients were discharged without seeing a doctor.
The implementation of integrated care pathways enables a more efficient service provision for patients with incontinence problems. Thirty-five percent of women attending gynaecology outpatient department with incontinence problems could be effectively managed by urogynaecology specialist nurses.
Urinary incontinence (UI) often remains inadequately treated. In the literature, there are indications that continence nurses' diagnoses and treatment advices are beneficial in terms of clinical outcomes. However, the precise short-term and long-term effects are unclear. This study investigates the short-term and long-term effects of the introduction of a continence nurse in the care of community-dwelling women suffering from UI.
In a cluster randomized study, 38 women were referred to the continence nurse who, guided by a protocol, assessed and advised the patients about therapy, lifestyle, or medication. If progress was disappointing, therapy was revised. Results were compared to a group of 13 women who received "usual care" by the general practitioner. Data on frequency and volume of incontinence, quality of life, and patient satisfaction were collected at baseline and after 3, 6, and 12 months.
After 6 months, women in the intervention group reported a greater reduction in "moderate" incontinent episodes when compared to women in the control group. No treatment effect was found after 12 months. Although there was a stronger improvement in scores as regards to quality of life in the intervention group, with the exception of the dimension "physical," no treatment effect was found.
The introduction of a continence nurse demonstrates short-term benefit to community-dwelling women suffering from UI. However, the long-term effects should be further explored with larger study populations. Trial registration number: ISRCTN15553880.
Preparing for the future
- Stewart