Step 3: Time-Saving Management
Choose between two options that yield reliable, accurate estimates of residents' food and fluid intake at mealtimes. Our Mealtime Observational Protocol helps standardize consumption calculations.
Click on one of the following topics to skip to that section:
Work Smarter Not Harder to Offer Prompted Voiding Programs
Lack of staff time is one of, if not THE biggest barrier to implementing prompted voiding programs. The problem is not that prompted voiding consumes more time per episode than regular toileting assistance. We timed both interventions; on average, the first took just 12 seconds longer per episode to implement than the second (1). But toileting assistance in any form is more time-consuming to provide than checking and changing (5.5 minutes per episode), the usual care given to incontinent residents. In addition, prompted voiding must be offered every two hours, preferably between 7 am and 7 pm every day, if residents are to stay dry. By comparison, most nursing home staff provide toileting assistance less than twice a day to residents (1, 2).
We estimate that nursing homes need a staffing ratio of five residents to one nurse aide to effectively provide prompted voiding to all responsive residents (1). But the ratio in most facilities is 10 or more residents to one nurse aide. With such severely restricted staff resources, nursing homes must work smarter in order to wring the most out of what they have. The recommendations that follow can help.
Keep in mind that not every recommendation will work well in every facility. You should decide which to implement based on your residents’ needs and your facility’s staff resources. And please note: We’ve started our list with the least restrictive recommendations. You should consider implementing these first.
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Consistently Assign Nurse Aides to the Same Residents
Nurse aides who consistently work with the same residents each day grow familiar with the residents’ daily routines and preferences. Such knowledge can make it easier to offer timely toileting assistance that helps keep residents drier.
Integrate Prompted Voiding with Interventions that Enhance Residents' Mobility
An integrated intervention—one that combines prompted voiding with a low-intensity exercise program—offers two major advantages:
Forego Evening and Nighttime Prompted Voiding
In the only study of its kind to date, we showed that prompted voiding does not improve continence at night (3). So don’t bother to offer it. Instead, nighttime care should be individualized, with the goals of minimizing sleep disruption and protecting at-risk incontinent residents from skin problems. Prompted voiding and other toileting assistance interventions should be reserved for those residents who are bothered by nighttime incontinence and who demonstrate their willingness to toilet at night. In our study, we attempted a nighttime toileting assistance program with 61 incontinent nursing home residents. Wetness rates remained relatively high at night—49%--while appropriate toileting rates were low—18%. Ideally, wetness rates should drop below 20% and appropriate toileting rates should be above 66%. The poorest response rate was primarily observed between 10 pm and 6 am. Even residents who responded well to daytime prompted voiding showed poor results at night.
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Reduce Nurse Aide Workloads in Other Areas
Assign time-consuming tasks that are typically the responsibility of nurse aides to non-traditional care providers, including volunteers, social service staff, even administrative personnel, so that nurse aides have more time to provide prompted voiding. Some mealtime chores and between-meal snack deliveries, for example, can be handled by non-traditional staff. See our weight loss preventions, especially Step 3 , for tips on redeploying staff at mealtimes.
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Reduce the Number of Hours During Which Staff Provide Prompted Voiding
Ideally, incontinent residents should be offered prompted voiding every two hours between 7 am and 7 pm. Realistically? Between 8 am to 4 pm will do. With this schedule, residents will receive toileting assistance four times a day, enough to stay dry for the period. They are also more likely to receive the assistance they need because nursing homes are typically better staffed during the day shift than the evening and graveyard shifts.
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Raise the Appropriate Toileting Rate to More Narrowly Target Services
As a last resort, use more restrictive criteria to target the prompted voiding intervention to the most responsive residents. Instead of using an appropriate toileting rate of 66% or higher, raise the rate to above 75%, for example. Step 2 explains how to calculate this rate. This targeting approach, unfortunately, will exclude some residents who could benefit from prompted voiding. Nevertheless, despite this serious drawback, it is ethically and clinically preferable to providing sub-optimal assistance to all incontinent residents or targeting assistance based on invalid resident characteristics such as cognitive status, both of which are common practices in nursing homes.
Back to Top
A Word of Caution: Do Not Restrict Fluids to Improve Continence
Some residents will purposely restrict their fluid intake in an attempt to improve their continence. For the same reason, some nursing homes will do the same for residents. In both cases, it’s a bad idea, potentially harmful to a resident’s health. Studies show that the majority of nursing home residents are at high risk for dehydration, a condition associated with numerous adverse clinical outcomes for residents, including the ultimate: death (4).
Far from an opportune time to limit fluids, the start of a prompted voiding program is the ideal time to offer extra fluids to residents. Incontinent residents may be more likely to drink more if they know they can count on help to the toilet. And it will take staff next to no extra time to offer the extra care because they have to attend to the residents in any case.
Experts recommend that nursing home staff offer all residents extra fluids between meals, as many as 4-8 times a day. For more information about strategies to increase residents’ fluid intake, visit our training module on weight loss preventions , especially the FAQs .
Back to Top or proceed to Step 4
Click on one of the following topics to skip to that section:
- Work Smarter Not Harder to Offer Prompted Voiding Programs
- Consistently Assign Nurse Aides to the Same Residents
- Integrate Prompted Voiding with Interventions that Enhance Residents' Mobility
- Forego Evening and Nighttime Prompted Voiding
- Reduce Nurse Aide Workloads in Other Areas
- Reduce the Number of Hours During Which Staff Provide Prompted Voiding
- Raise the Appropriate Toileting Rate to More Narrowly Target Services
- A Word of Caution: Do Not Restrict Fluids to Improve Continence
Work Smarter Not Harder to Offer Prompted Voiding Programs
Lack of staff time is one of, if not THE biggest barrier to implementing prompted voiding programs. The problem is not that prompted voiding consumes more time per episode than regular toileting assistance. We timed both interventions; on average, the first took just 12 seconds longer per episode to implement than the second (1). But toileting assistance in any form is more time-consuming to provide than checking and changing (5.5 minutes per episode), the usual care given to incontinent residents. In addition, prompted voiding must be offered every two hours, preferably between 7 am and 7 pm every day, if residents are to stay dry. By comparison, most nursing home staff provide toileting assistance less than twice a day to residents (1, 2).
We estimate that nursing homes need a staffing ratio of five residents to one nurse aide to effectively provide prompted voiding to all responsive residents (1). But the ratio in most facilities is 10 or more residents to one nurse aide. With such severely restricted staff resources, nursing homes must work smarter in order to wring the most out of what they have. The recommendations that follow can help.
Keep in mind that not every recommendation will work well in every facility. You should decide which to implement based on your residents’ needs and your facility’s staff resources. And please note: We’ve started our list with the least restrictive recommendations. You should consider implementing these first.
Back to Top
Consistently Assign Nurse Aides to the Same Residents
Nurse aides who consistently work with the same residents each day grow familiar with the residents’ daily routines and preferences. Such knowledge can make it easier to offer timely toileting assistance that helps keep residents drier.
Integrate Prompted Voiding with Interventions that Enhance Residents' Mobility
An integrated intervention—one that combines prompted voiding with a low-intensity exercise program—offers two major advantages:
- By improving or preventing decline in residents’ ability to walk or wheel themselves, it helps enhance their ability to use the toilet independently or with minimal staff assistance. This, in turn, can reduce the amount of staff time needed to provide toileting assistance while it also improves residents’ continence.
- Combining programs uses staff time more efficiently. For starters, it cuts in half the travel time needed to locate residents (an estimated 3.4 minutes for a single trip), because only one (integrated) intervention is being provided, not two separate programs. For the same reason, it also reduces orientation time—the time it takes to introduce the service to a resident whenever it is provided.
Forego Evening and Nighttime Prompted Voiding
In the only study of its kind to date, we showed that prompted voiding does not improve continence at night (3). So don’t bother to offer it. Instead, nighttime care should be individualized, with the goals of minimizing sleep disruption and protecting at-risk incontinent residents from skin problems. Prompted voiding and other toileting assistance interventions should be reserved for those residents who are bothered by nighttime incontinence and who demonstrate their willingness to toilet at night. In our study, we attempted a nighttime toileting assistance program with 61 incontinent nursing home residents. Wetness rates remained relatively high at night—49%--while appropriate toileting rates were low—18%. Ideally, wetness rates should drop below 20% and appropriate toileting rates should be above 66%. The poorest response rate was primarily observed between 10 pm and 6 am. Even residents who responded well to daytime prompted voiding showed poor results at night.
Back to Top
Reduce Nurse Aide Workloads in Other Areas
Assign time-consuming tasks that are typically the responsibility of nurse aides to non-traditional care providers, including volunteers, social service staff, even administrative personnel, so that nurse aides have more time to provide prompted voiding. Some mealtime chores and between-meal snack deliveries, for example, can be handled by non-traditional staff. See our weight loss preventions, especially Step 3 , for tips on redeploying staff at mealtimes.
Back to Top
Reduce the Number of Hours During Which Staff Provide Prompted Voiding
Ideally, incontinent residents should be offered prompted voiding every two hours between 7 am and 7 pm. Realistically? Between 8 am to 4 pm will do. With this schedule, residents will receive toileting assistance four times a day, enough to stay dry for the period. They are also more likely to receive the assistance they need because nursing homes are typically better staffed during the day shift than the evening and graveyard shifts.
Back to Top
Raise the Appropriate Toileting Rate to More Narrowly Target Services
As a last resort, use more restrictive criteria to target the prompted voiding intervention to the most responsive residents. Instead of using an appropriate toileting rate of 66% or higher, raise the rate to above 75%, for example. Step 2 explains how to calculate this rate. This targeting approach, unfortunately, will exclude some residents who could benefit from prompted voiding. Nevertheless, despite this serious drawback, it is ethically and clinically preferable to providing sub-optimal assistance to all incontinent residents or targeting assistance based on invalid resident characteristics such as cognitive status, both of which are common practices in nursing homes.
Back to Top
A Word of Caution: Do Not Restrict Fluids to Improve Continence
Some residents will purposely restrict their fluid intake in an attempt to improve their continence. For the same reason, some nursing homes will do the same for residents. In both cases, it’s a bad idea, potentially harmful to a resident’s health. Studies show that the majority of nursing home residents are at high risk for dehydration, a condition associated with numerous adverse clinical outcomes for residents, including the ultimate: death (4).
Far from an opportune time to limit fluids, the start of a prompted voiding program is the ideal time to offer extra fluids to residents. Incontinent residents may be more likely to drink more if they know they can count on help to the toilet. And it will take staff next to no extra time to offer the extra care because they have to attend to the residents in any case.
Experts recommend that nursing home staff offer all residents extra fluids between meals, as many as 4-8 times a day. For more information about strategies to increase residents’ fluid intake, visit our training module on weight loss preventions , especially the FAQs .
Back to Top or proceed to Step 4
