An Exercise Intervention
Follow these five steps to implement an exercise program aimed at the 50-60% of long-stay residents who are incontinent. The program is designed to work with varying degrees of cognitive impaired residents.
Click on one of the following topics to skip to that section:
Step 1: Understand Your Choices
Step 2: Provide Incontinence Care
Step 3: Offer Exercise
Step 4: Implement Time-Saving Strategies
Step 5: Monitor the Program
Step 1: Understand Your Choices
Learn about your options for offering regular exercise opportunities to very frail nursing home residents.
"FIT" for Frail Residents
For ambulatory residents there’s our walking program. For almost everyone else, especially incontinent residents, there’s FIT. “FIT” stands for Functional Incidental Training, and it combines low intensity exercise with scheduled toileting as a means of improving continence as well as mobility, strength, and endurance among frail, incontinent nursing home residents.
The special features of FIT are several:
But we’ll be honest with you: Notwithstanding its benefits and cost-efficient design, FIT still takes considerably more time to administer than usual care, and this can be a big barrier to its implementation.
Let’s look briefly at how FIT works, then discuss time management.
FIT is designed to be implemented four times daily, approximately every two hours, between 8:00 a.m. and 4:00 p.m., five days a week. The procedure is as follows:
How long does all this take? Approximately 20 minutes per resident per care episode when we count travel time plus the time needed to provide both exercise and incontinence care (1,2). Here’s the breakdown: 3 minutes to locate the resident and transport them to/from their room for incontinence care, 7 minutes for incontinence care (if the resident uses the toilet); 10 minutes for exercise. We also know, from an eight-month evaluation during which we implemented FIT in four nursing homes, that on average, residents participate in three of the four FIT sessions per day (1,2). So, it takes about an hour a day per resident to implement FIT.
FIT Versus Group Exercise
An hour per resident per day! That’s too much, you balk. And we agree, it’s a lot. But we can’t figure out how to reduce the time costs any further, and as we stated earlier, we know of no other exercise intervention that works as well, or just plain works at all, with such a frail, cognitively impaired population.
On the bright side, consider that FIT offers residents not only exercise, but also incontinence care, which your CNAs need to provide in any case. As a result, it not only increases mobility and physical activity, but also keeps residents drier.
On the alternative side, it’s worth considering group exercise programs. Some of these have been shown to work with more ambulatory, less cognitively impaired residents (4). In our experience, however, “group exercise” for residents with severe cognitive impairments is a misnomer. Yes, you can gather these residents in a group, but they are unlikely to accomplish much unless you work one-on-one with each person.
Bear in mind that, while group exercises are more time-efficient than FIT, they are still time-consuming. Figure that sessions for groups of about 10 fairly ambulatory residents should be offered 3-5 times per week, with each session lasting 30-45 minutes. This does not include time to get residents to/from the place they need to be for exercise, which as we’ve seen in the FIT breakdown, can add up quickly. Also consider that these exercise-only sessions do not include toileting assistance for incontinent residents.
An Ongoing Industry Challenge
That we and other long-term-care researchers have met with only qualified success in designing effective and feasible exercise programs for frail residents reflects two ongoing challenges in the nursing home industry.
The first is the very frailty of this population. Even when offered FIT, many of these impaired residents will not regain their ability to function independently and safely. Most will continue to need staff assistance and supervision. Thus, this program, and probably others similar to it, cannot be expected to pay for themselves down the line through offsets in labor costs.
Second, understaffing in many nursing homes presents an almost insurmountable barrier to translating many efficacious clinical interventions into everyday care practice. We as a nation need to take into careful consideration the resources needed to meet the standards of care we expect for our rapidly growing, frail older population.
That said, we’re left with doing the best we can in an imperfect long-term-care system. The pages that follow present instructions for implementing FIT. Along the way, we’ll identify trade-offs you can choose between to provide the best care possible given your facility’s resources.
Your Assignment
Consider the pros and cons of group exercise versus the FIT intervention. Now consider your facility’s resident case mix. Which type of exercise program seems most feasible to implement with the residents in your facility? Would it work to offer both types for different groups of residents?
Share your thoughts with us so we can share them with others through this website. Please contact us.
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Step 2: Provide Incontinence Care
Learn how to conduct the incontinence care component of the FIT program.
Identify Incontinent Residents
FIT is designed for residents who are incontinent of urine. More specifically, it’s for incontinent residents who receive some type of staff toileting assistance to help them stay dry. This means, of course, that these residents already have been, or should have been, assessed and treated for any transient causes of urinary incontinence.
If any incontinent residents haven’t yet been assessed by a physician, they should be, for it is possible that their incontinence can be treated. Step 1 of our incontinence management training module outlines the assessment process. You may want to review this section to make sure your facility is covering all the bases:
Click here to review Step 1 of the incontinence care module.
From this point on, we’ll assume that you’ve identified all incontinent residents who need some type of staff assistance to stay dry (or drier).
Provide Regular Toileting Assistance, Preferably Prompted Voiding
FIT follows best practice guidelines for incontinence care in that it calls on nursing home staff to provide incontinent residents with toileting assistance every two hours during the daytime (roughly 8:00 a.m. to 4:30 p.m.). Toileting assistance can take a number of different forms. It can mean checking and changing adult garments; habit training; scheduled toileting; or prompted-voiding.
Of these various management options, only prompted-voiding has been shown to significantly improve continence in long-stay nursing home residents with varying levels of cognitive impairment. This is one reason we strongly recommend that you provide prompted-voiding as part of the FIT program.
You can review prompted-voiding procedures in Step 2 of our incontinence management training module.
Prompted Voiding Versus Other Options
Yes, you can use FIT with the other toileting care routines, as long as that care is offered every two hours. But while you’re at it, why not take advantage of the opportunity to provide the most effective care available to your residents?
If you’re concerned about how much time prompted-voiding takes, we can offer some assurances. On average, it takes about 7 minutes to provide prompted-voiding to a single resident. That’s about 12 seconds longer than it takes to provide scheduled-toileting. And it’s about a minute and a half longer than it takes to check-and-change a resident without toileting assistance. In other words, you won’t save much time per episode of care by implementing one of the less effective toileting interventions.
Prompted-Voiding (PV) Advantage: Targeting Procedures
And there are additional advantages to offering prompted-voiding (PV). One is that we have developed a simple, valid procedure for identifying residents who are responsive to prompted-voiding. You can review it in Step 2 of our incontinence management training module.
Here’s the synopsis: Provide prompted-voiding to incontinent residents for a few days, and then analyze the results. Those who use the toilet (or bedpan or urinal) appropriately at least two-thirds of the time are “responsive” to PV and should continue to receive it every two hours during the day; those who don’t are “unresponsive” and can be placed on check-and-change programs. The rationale behind this “trial run” approach is simple common sense: Residents either respond to prompted-voiding, or they don’t, and there is no reason to expect different results unless there is a significant change—for better or worse—in the resident’s condition (e.g, acute illness, hospitalization, urinary tract infection, constipation).
Our studies show that between 25% and 40% of incontinent residents will respond to prompted-voiding, with a reduction in their incontinence frequency from three to four episodes per day to one per day (1,2).
This ability to identify responders and non-responders enables staff to use their time more effectively and efficiently. They don’t waste time trying to toilet some residents who are unresponsive to their help while better candidates go without consistent, daily assistance.
To the best of our knowledge, comparable valid targeting procedures do not exist for any of the other incontinence management strategies.
Prompted-Voiding (PV) Advantage: Program Monitoring Procedures
Another advantage to prompted-voiding is that there is a tested procedure for monitoring its results. We discuss this in more detail later on (see Step 4), but basically, if you don’t continuously monitor program implementation, there is a good chance that the program procedures will be compromised and its positive effects diluted. As a general rule, nursing home programs that are implemented in residents’ rooms at various times throughout the day are difficult to monitor through objective means. It’s not feasible, for example, for supervisors to conduct regular observations of care provision. Prompted-voiding programs, however, are the exception to this rule.
With prompted-voiding programs, supervisors can conduct periodic control checks that allow them to continuously monitor care provision. We tell you how to conduct these quality control checks and analyze the results in Step 4 of our incontinence management module.
These control checks won’t tell you whether or how well nurse aides are carrying out the exercise component of FIT. But they do allow you to assess the other key component (toileting assistance). And if this care activity is (or is not) being accomplished, then that’s some small assurance that the other component, exercise, also is (or is not) being accomplished.
One Last Time...
Going forward, we will assume that your facility is committed to providing FIT participants with some form of toileting assistance every two hours during the daytime on at least five days per week. We’ve said it various ways throughout this section, but it bears repeating one last time: There are distinct advantages to choosing prompted-voiding as the form of toileting assistance your program provides. (Remember: most residents who are not responsive to prompted-voiding are placed in check-and-change programs). You can read more about this toileting strategy in our incontinence management module.
Your Assignment
Take a few minutes to review our prompted-voiding protocol and the incontinence management training module.
Step 3: Offer Exercise
Learn how to conduct the exercise component of the FIT program.
Fit's Exercise Component
Let’s review. We now know that FIT targets incontinent residents and is intended to be implemented by certified nurse aides (CNAs) every two hours, roughly between 8:00 a.m. and 4:30 p.m., five days per week. This schedule allows for four care “episodes” each day. During each episode, CNAs provide residents with toileting assistance, preferably prompting residents to toilet and changing those need it. That’s the incontinence care component of FIT.
The exercise component includes the following:
These exercises emphasize specific functional skills involved with toileting and other activities of daily living.
Let’s discuss procedures for each exercise, starting with walking and wheeling.
Walking or Wheeling
Sit-To-Stands
Before and after each care episode, CNAs should offer residents beverages such as water or juices. This twice-per-session fluid prompting is very effective in significantly increasing fluid intake and improving hydration status in this frail population. So, if done correctly, the FIT intervention improves: urinary continence, hydration AND physical functioning.
For best results, offer residents a choice from a variety of beverages, ideally beverages not typically served during meals (e.g, cranapple, cranraspberry). This strategy results in fewer refusals to drink and increases fluid consumption (1).
Studies show that, while the majority of nursing home residents are at high risk for dehydration, few facilities offer fluids between meals. In two separate studies, we found that staff offered residents between-meal beverages less than once per day on average, including oral liquid nutrition supplements (2,3).
Many workers erroneously believe that residents will request fluids, if thirsty, or retrieve a glass of water for themselves from their bedside pitcher. But few residents do this. One reason they don’t is that the thirst sensation declines with age, so many older adults may not recognize that they are thirsty even when they are. In addition, cognitive impairment and depression can impair a resident’s ability and motivation to seek out fluids. As a result, it is critical that staff not only offer fluids but also provide encouragement to residents to drink.
For more information about increasing residents’ fluid and food intake, see our weight loss prevention training module.
Causes for Concern
Special circumstances warrant special attention:
Your Assignment
Step 4: Implement Time-Saving Strategies
Implement these time-saving strategies to help your facility maintain the FIT program and maximize benefits for frail nursing home residents.
Lack of Staff Can Hamper Implementation
Having reviewed Step 1 (Identify the problem, the solution), Step 2 (Provide incontinence care), and Step 3 (Offer exercise), you are now in a position to make informed decisions about how to deploy the one resource that can make or break the FIT program: your staff.
Lack of staff time is THE biggest barrier to implementing the FIT program. How big? We estimate that in a nursing home with a staffing ratio of 10 residents to one certified nurse aide (CNA), the CNAs would need 60 minutes of every daytime hour to provide FIT to all eligible incontinent residents. In other words, they wouldn’t have time for any other duties. Given that this resident-to-CNA ratio is typical of the industry, FIT clearly is not going to work in the majority of facilities without modification.
Below, we offer two suggestions. The first will make the biggest difference in nursing homes with staffing levels that approach an ideal: five residents to one CNA. This first suggestion will also help in lower-staffed facilities, where the daytime ratio reaches seven or more residents to one CNA, but is unlikely to be sufficient. In these facilities, consider also the more drastic change outlined in our second suggestion.
This may sound like an insignificant number but it adds up. Consider this scenario: In a 40-bed facility, an estimated 20 residents will be incontinent and thus eligible for FIT. If the facility is staffed at 10 residents to one CNA during the day, then four CNAs are available to provide FIT to four residents, or one-fifth of all eligible residents. Yes, this approach excludes residents who could benefit from FIT. But despite this serious drawback, it is ethically and clinically preferable to foregoing the intervention altogether, a strategy that in most facilities means none of these frail residents will get exercise to prevent further decline.
How do you decide who makes the cut? There are no hard and fast rules to follow here, so we let reason guide us to this recommendation: Target services first to those residents who stand to lose the most functionality if denied regular exercise. In our clinical judgment, these are residents who are on the verge of losing their ability to walk. “They’re wobbly,” one of our researchers observed. “They can still bear weight, but they can’t walk safely without assistance.” They’re not the most impaired residents, nor the least impaired; they’re between these two extremes.
For these residents, their FIT-ness goal should be to maintain their walking ability.
You can use our standardized walking performance assessment to objectively select these participants.
Click here to view or print the assessment form.
Your Assignment
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Step 5: Monitor the Program
Learn three methods for monitoring the FIT program so that its beneficial results are sustained.
Failure to Monitor can Undermine the Program
The procedures for monitoring the FIT program are similar to those for monitoring our walking program (see Step 4 of the walking program). The rationale for ongoing program assessment is virtually the same as well: That is, in its absence, certified nurse aides (CNAs) may backslide and fail to consistently implement the FIT protocols.
Studies in other fields have shown that old habits are hard to break and new ones are hard to maintain if you don’t get timely feedback about how you’re doing, including reinforcement for doing things right and recommendations for improvement if you’re doing things wrong. This feedback loop is a hallmark of continuous quality improvement programs. Creating such a feedback loop is the purpose of this step.
Use But Don't Rely Soley on CNA Reports
Start by collecting program assessment data.
The FIT logs completed by CNAs should tell you almost at a glance whether residents are improving their mobility, strength, and endurance with the FIT program. Our log includes columns for tracking daily performance: the total minutes each resident walks or wheels, the number of sit-to-stands, and the number of arm curls or raises completed, as well as refusal rates.
Click here to view and print a sample log.
We recommend collecting and reviewing FIT logs every two weeks. A licensed nurse / supervisory-level staff member should scan the logs to see whether the numbers for a particular resident are gradually increasing; holding steady; or declining, which would signal the need for a reassessment.
Data from the FIT logs can also be used to calculate compliance rates. On what percentage of days in a given period did residents walk? Complete sit-to-stands? Do arm curls or raises? On what percentage of sessions in a given day did residents do some form of exercise? Information about compliance gives you insight into whether residents value the program.
As informative as they may be, DO NOT solely rely on the CNAs’ written logs of exercise and incontinence activity to evaluate the FIT program. In several studies, we found that nurse aide documentation of care provision was inconsistent with the care residents actually received (1). In fairness to the CNAs, we believe they did this largely because they truly lack the time required to provide the multitude of services that we—employers, regulators, family, and friends—ask them to deliver. But with performance expectations continuing to exceed most nursing homes’ staff resources, it’s best to use CNA reports only in conjunction with data gleaned from other assessment strategies such as resident reports, direct observations, or, in the case of prompted voiding, control checks.
Conduct Wetness Control Checks
We developed, tested, and validated a standardized procedure that you can use to conduct continuous quality control checks of your prompted-voiding program.
Click here to review these procedures.
The control checks (which require about 15 minutes a week to complete) allow you to compare the percentage of incontinent residents found wet at any given point in time to the percentage who should be wet if the prompted-voiding program is working as expected. If the “actual” percentage exceeds the “expected” percentage, there’s a problem, and it needs further analysis if you intend to resolve it. Typical problems stem from changes in a resident’s status or break-downs in the prompted-voiding work process.
If your facility offers prompted-voiding to FIT participants, then a staff nurse should take the time to conduct weekly control checks. These weekly control checks are the best method for ensuring the integrity of incontinence care.
Conduct Resident Interviews
You can also monitor the FIT program through periodic interviews with participating residents. Many residents, even those with cognitive impairment, can reliably report on their care (2-4). They can tell you whether in fact they received it, they can tell you if they liked it, and often they can tell you how to improve it. All you have to do is ask them.
Resident interviews, even short ones, are more time-consuming to conduct than quality control checks. Thus, we recommend that a supervisor should try to interview all participating residents individually at some point in the first month of the FIT program. This will allow each resident to give feedback that will help you create a more responsive program. We also recommend repeating interviews during the residents’ MDS reassessments.
Keep the interview short and simple. Follow our protocol for conducting resident interviews, presented in the Quality-of-Life Assessment Module.
Click here to view the interview protocol.
Sample interview questions include:
Be sure to record responses. Our resident interview protocol includes suggestions for interpreting and reporting results.
Compare Results to CNA Reports
You can compare results from the resident interviews with information in the CNAs’ written FIT logs to identify any reporting discrepancies. These may indicate areas for improvement or further training. A CNA’s log may also explain why FIT was not provided on particular days/times (e.g., resident did not feel well or was out with family).
Analyze Results
With all your program assessment data in hand, ask yourself this question: Is the FIT program working as expected? This, of course, raises several related questions:
If you identify a problem in any of these areas (look for the “no” answers) you may need to investigate further before you can resolve it. Often a meeting with the CNAs can help clarify and correct problems.
Share Results with Staff
For best results, complete the feedback loop by sharing results from the FIT logs, wetness control checks, and resident interviews with the CNAs who perform the lion’s share of the work in this program. As we noted earlier, staff members need feedback—both good and bad—to help them establish new work routines. Simply posting the wetness control checks each week, for example, will enable nurse aides to make connections between their work and the impact it has on their residents.
If these direct care providers can see tangible evidence of the benefits of the FIT program, they will be less likely to view the intervention as an extra burden and more likely to work to sustain its positive effects.
Sharing performance results also gives CNAs the opportunity to help supervisors correct any problems that arise. Often the CNAs are the first to know if a resident’s functional status has changed or if there’s been a break-down in the work process. Involving these staff members in improvement efforts will also help strengthen their commitment to the program.
Another way to complete the “circle of communication” is by presenting and discussing program performance results at in-service trainings and during regular staff meetings and care planning efforts. We’ve found in our recent work that brief (less than 15 minutes), weekly meetings focused specifically on a new program are effective for training and management purposes.
And finally, here’s a recommendation that bears repeating: Reward CNAs for consistently good results. Recognition as employee of the month, a staff pizza party for outstanding performance, a gift certificate to a local restaurant—they can’t hurt.
Your Assignment
Browse through our protocol for designing and conducting quality-of-life assessment interviews with nursing home residents so that you are better prepared to implement this fifth step in your FIT program.
Click here to view the interview protocol.
Back to Top or Proceed to Mobility Assessment Forms
Click on one of the following topics to skip to that section:
Step 1: Understand Your Choices
Step 2: Provide Incontinence Care
Step 3: Offer Exercise
Step 4: Implement Time-Saving Strategies
Step 5: Monitor the Program
Step 1: Understand Your Choices
Learn about your options for offering regular exercise opportunities to very frail nursing home residents.
"FIT" for Frail Residents
For ambulatory residents there’s our walking program. For almost everyone else, especially incontinent residents, there’s FIT. “FIT” stands for Functional Incidental Training, and it combines low intensity exercise with scheduled toileting as a means of improving continence as well as mobility, strength, and endurance among frail, incontinent nursing home residents.
The special features of FIT are several:
- Targets the very frail. It is designed for the more than 50% of nursing home residents who are incontinent of urine, many of them with severe cognitive impairment, and all of them physically inactive and deconditioned, with a high risk for hospitalization. We know of no other exercise program that has proven effective with such an impaired population.
- CNAs implement it. It is designed to be implemented by certified nurse assistants (CNAs), rather than higher-cost professionals such as physical therapists, although restorative nurse aides could supplement CNAs in the delivery of FIT.
- Combines daily activities. To further reduce time costs, it maximizes efficiency by integrating one daily care routine with another. CNAs are normally in contact with incontinent residents throughout the day to provide toileting assistance. This daily care activity offers a time-efficient opportunity for residents to practice other functional daily activities such as walking, standing, and transferring—activities featured in FIT.
- Distributes exercise. FIT spreads exercise over the course of a day, as opposed to offering it in a single session. Providing several brief opportunities to exercise reduces the risk of injury for these frail residents, many of whom would not be able to sustain increased activity during more traditional, single exercise sessions of 30-45 minutes in the context of physical therapy sessions. Brief sessions throughout the day coupled with other care routines (standing, transferring, toileting, walking) also make FIT more manageable in terms of staff time.
- Proven effective. Perhaps most importantly, it has been shown to improve or maintain both physical activity and mobility endurance in extremely frail residents. These findings come from two randomized controlled trials—the gold standard for research studies—which also found that the comparison group, which did not receive FIT, declined in their functional abilities (1,2). Did we also mention that FIT participants improved their continence status too?
But we’ll be honest with you: Notwithstanding its benefits and cost-efficient design, FIT still takes considerably more time to administer than usual care, and this can be a big barrier to its implementation.
Let’s look briefly at how FIT works, then discuss time management.
FIT is designed to be implemented four times daily, approximately every two hours, between 8:00 a.m. and 4:00 p.m., five days a week. The procedure is as follows:
- During each of the four daytime care episodes, CNAs prompt incontinent residents to toilet, and provide the necessary care for incontinent episodes (changing). During incontinence care and toileting activities, CNAs encourage residents to sit-to-stand and transfer as independently as possible (providing supervision, verbal instruction, minimum physical assistance).
- Before or after this incontinence care, CNAs encourage residents to walk, or if nonambulatory, to wheel their chairs and to repeat sit-to-stands up to eight times.
- During one episode per day, each resident, usually while in bed, is given upper body resistance training (arm curls or arm raises) and/or range-of-motion exercises.
- Before and after each care episode, residents are offered beverages to increase their daily intake of fluids, preferably a choice among a variety of fluids, such as assorted juices (3).
How long does all this take? Approximately 20 minutes per resident per care episode when we count travel time plus the time needed to provide both exercise and incontinence care (1,2). Here’s the breakdown: 3 minutes to locate the resident and transport them to/from their room for incontinence care, 7 minutes for incontinence care (if the resident uses the toilet); 10 minutes for exercise. We also know, from an eight-month evaluation during which we implemented FIT in four nursing homes, that on average, residents participate in three of the four FIT sessions per day (1,2). So, it takes about an hour a day per resident to implement FIT.
FIT Versus Group Exercise
An hour per resident per day! That’s too much, you balk. And we agree, it’s a lot. But we can’t figure out how to reduce the time costs any further, and as we stated earlier, we know of no other exercise intervention that works as well, or just plain works at all, with such a frail, cognitively impaired population.
On the bright side, consider that FIT offers residents not only exercise, but also incontinence care, which your CNAs need to provide in any case. As a result, it not only increases mobility and physical activity, but also keeps residents drier.
On the alternative side, it’s worth considering group exercise programs. Some of these have been shown to work with more ambulatory, less cognitively impaired residents (4). In our experience, however, “group exercise” for residents with severe cognitive impairments is a misnomer. Yes, you can gather these residents in a group, but they are unlikely to accomplish much unless you work one-on-one with each person.
Bear in mind that, while group exercises are more time-efficient than FIT, they are still time-consuming. Figure that sessions for groups of about 10 fairly ambulatory residents should be offered 3-5 times per week, with each session lasting 30-45 minutes. This does not include time to get residents to/from the place they need to be for exercise, which as we’ve seen in the FIT breakdown, can add up quickly. Also consider that these exercise-only sessions do not include toileting assistance for incontinent residents.
An Ongoing Industry Challenge
That we and other long-term-care researchers have met with only qualified success in designing effective and feasible exercise programs for frail residents reflects two ongoing challenges in the nursing home industry.
The first is the very frailty of this population. Even when offered FIT, many of these impaired residents will not regain their ability to function independently and safely. Most will continue to need staff assistance and supervision. Thus, this program, and probably others similar to it, cannot be expected to pay for themselves down the line through offsets in labor costs.
Second, understaffing in many nursing homes presents an almost insurmountable barrier to translating many efficacious clinical interventions into everyday care practice. We as a nation need to take into careful consideration the resources needed to meet the standards of care we expect for our rapidly growing, frail older population.
That said, we’re left with doing the best we can in an imperfect long-term-care system. The pages that follow present instructions for implementing FIT. Along the way, we’ll identify trade-offs you can choose between to provide the best care possible given your facility’s resources.
Your Assignment
Consider the pros and cons of group exercise versus the FIT intervention. Now consider your facility’s resident case mix. Which type of exercise program seems most feasible to implement with the residents in your facility? Would it work to offer both types for different groups of residents?
Share your thoughts with us so we can share them with others through this website. Please contact us.
Back to Top
Step 2: Provide Incontinence Care
Learn how to conduct the incontinence care component of the FIT program.
Identify Incontinent Residents
FIT is designed for residents who are incontinent of urine. More specifically, it’s for incontinent residents who receive some type of staff toileting assistance to help them stay dry. This means, of course, that these residents already have been, or should have been, assessed and treated for any transient causes of urinary incontinence.
If any incontinent residents haven’t yet been assessed by a physician, they should be, for it is possible that their incontinence can be treated. Step 1 of our incontinence management training module outlines the assessment process. You may want to review this section to make sure your facility is covering all the bases:
Click here to review Step 1 of the incontinence care module.
From this point on, we’ll assume that you’ve identified all incontinent residents who need some type of staff assistance to stay dry (or drier).
Provide Regular Toileting Assistance, Preferably Prompted Voiding
FIT follows best practice guidelines for incontinence care in that it calls on nursing home staff to provide incontinent residents with toileting assistance every two hours during the daytime (roughly 8:00 a.m. to 4:30 p.m.). Toileting assistance can take a number of different forms. It can mean checking and changing adult garments; habit training; scheduled toileting; or prompted-voiding.
Of these various management options, only prompted-voiding has been shown to significantly improve continence in long-stay nursing home residents with varying levels of cognitive impairment. This is one reason we strongly recommend that you provide prompted-voiding as part of the FIT program.
You can review prompted-voiding procedures in Step 2 of our incontinence management training module.
Prompted Voiding Versus Other Options
Yes, you can use FIT with the other toileting care routines, as long as that care is offered every two hours. But while you’re at it, why not take advantage of the opportunity to provide the most effective care available to your residents?
If you’re concerned about how much time prompted-voiding takes, we can offer some assurances. On average, it takes about 7 minutes to provide prompted-voiding to a single resident. That’s about 12 seconds longer than it takes to provide scheduled-toileting. And it’s about a minute and a half longer than it takes to check-and-change a resident without toileting assistance. In other words, you won’t save much time per episode of care by implementing one of the less effective toileting interventions.
Prompted-Voiding (PV) Advantage: Targeting Procedures
And there are additional advantages to offering prompted-voiding (PV). One is that we have developed a simple, valid procedure for identifying residents who are responsive to prompted-voiding. You can review it in Step 2 of our incontinence management training module.
Here’s the synopsis: Provide prompted-voiding to incontinent residents for a few days, and then analyze the results. Those who use the toilet (or bedpan or urinal) appropriately at least two-thirds of the time are “responsive” to PV and should continue to receive it every two hours during the day; those who don’t are “unresponsive” and can be placed on check-and-change programs. The rationale behind this “trial run” approach is simple common sense: Residents either respond to prompted-voiding, or they don’t, and there is no reason to expect different results unless there is a significant change—for better or worse—in the resident’s condition (e.g, acute illness, hospitalization, urinary tract infection, constipation).
Our studies show that between 25% and 40% of incontinent residents will respond to prompted-voiding, with a reduction in their incontinence frequency from three to four episodes per day to one per day (1,2).
This ability to identify responders and non-responders enables staff to use their time more effectively and efficiently. They don’t waste time trying to toilet some residents who are unresponsive to their help while better candidates go without consistent, daily assistance.
To the best of our knowledge, comparable valid targeting procedures do not exist for any of the other incontinence management strategies.
Prompted-Voiding (PV) Advantage: Program Monitoring Procedures
Another advantage to prompted-voiding is that there is a tested procedure for monitoring its results. We discuss this in more detail later on (see Step 4), but basically, if you don’t continuously monitor program implementation, there is a good chance that the program procedures will be compromised and its positive effects diluted. As a general rule, nursing home programs that are implemented in residents’ rooms at various times throughout the day are difficult to monitor through objective means. It’s not feasible, for example, for supervisors to conduct regular observations of care provision. Prompted-voiding programs, however, are the exception to this rule.
With prompted-voiding programs, supervisors can conduct periodic control checks that allow them to continuously monitor care provision. We tell you how to conduct these quality control checks and analyze the results in Step 4 of our incontinence management module.
These control checks won’t tell you whether or how well nurse aides are carrying out the exercise component of FIT. But they do allow you to assess the other key component (toileting assistance). And if this care activity is (or is not) being accomplished, then that’s some small assurance that the other component, exercise, also is (or is not) being accomplished.
One Last Time...
Going forward, we will assume that your facility is committed to providing FIT participants with some form of toileting assistance every two hours during the daytime on at least five days per week. We’ve said it various ways throughout this section, but it bears repeating one last time: There are distinct advantages to choosing prompted-voiding as the form of toileting assistance your program provides. (Remember: most residents who are not responsive to prompted-voiding are placed in check-and-change programs). You can read more about this toileting strategy in our incontinence management module.
Your Assignment
Take a few minutes to review our prompted-voiding protocol and the incontinence management training module.
- Click here to view or print the prompted voiding protocol.
- Click here to access the incontinence management training module.
Step 3: Offer Exercise
Learn how to conduct the exercise component of the FIT program.
Fit's Exercise Component
Let’s review. We now know that FIT targets incontinent residents and is intended to be implemented by certified nurse aides (CNAs) every two hours, roughly between 8:00 a.m. and 4:30 p.m., five days per week. This schedule allows for four care “episodes” each day. During each episode, CNAs provide residents with toileting assistance, preferably prompting residents to toilet and changing those need it. That’s the incontinence care component of FIT.
The exercise component includes the following:
- Walking or wheeling
- Sit-to-stands and tranfers
- Arm curls, arm raises or range-of-motion
These exercises emphasize specific functional skills involved with toileting and other activities of daily living.
Let’s discuss procedures for each exercise, starting with walking and wheeling.
Walking or Wheeling
- Use our walking performance test to identify residents capable of walking. A licensed nurse should conduct this assessment during the resident’s first FIT session and share results with the appropriate CNAs, letting them know which residents can walk (and what level of assistance they require to do so) and which are completely non-ambulatory (unable to walk at all).
- Based on the nurses’ assessment findings, CNAs should encourage residents to walk with the appropriate level of assistance (e.g., supervision, verbal instructions, some physical help and assistive devices) or, if non-ambulatory, to wheel their chairs during each of the four care episodes.
- Residents may walk or wheel their chairs either before or after receiving incontinence care. Ask the resident for his or her preference.
- To start, encourage residents to walk or wheel their chairs for one to five minutes per session. Prompt them to gradually (over several weeks) increase their mobility time until they reach a maximum of 10 minutes per session.
- See Step 3 of our walking program for tips on motivating residents to stay mobile. These suggestions are geared toward encouraging residents to walk, but most apply equally well to encouraging residents to wheel their chairs. See also our tips for improving wheelchair mobility.
- Record the results of each session in our FIT log.
Sit-To-Stands
- CNAs should encourage all FIT participants to repeat sit-to-stands during each care episode (moving from a complete sitting position to a full standing position with minimum staff assistance to build lower body strength and maintain ability to stand).
- Residents may engage in this exercise either before or after receiving incontinence care, and before or after walking or wheeling. Ask the resident for his or her preference.
- To start, encourage residents to repeat 1-4 sit-to-stands. Prompt them to gradually (over several weeks) increase the number of repetitions until they reach a maximum of eight sit-to-stands per session.
- Offer residents the minimal physical assistance needed to complete each sit-to-stand. Follow the procedure described in our graduated sit-to-stand protocol.
- Record results in the FIT log.
- During one session per day, CNAs should prompt participating residents to repeat either arm curls or arm raises.
- This upper body resistance training is usually best accomplished while the resident is in bed. Thus, CNAs should encourage residents to do these exercises either before or after incontinence care and the other exercises are completed.
- Arm curls or raises can be done during any of the day’s four sessions. We recommend that CNAs gently prompt each resident during the first session and at each subsequent session in turn until the resident completes the exercise. Light hand-held weights can be used for this exercise or therabands (rubber bands that stretch). Ask physical therapy and restorative nurse aides for available equipment and initial help in assessing the resident’s abilities. Each week, try to increase their goal for number of repetitions and resistance. For example, start with 4-8 repetitions each session and increase to 8-12 repetitions each session. Begin with the lightest hand-held weight(s) or the theraband with the least resistance and increase modestly (2-5 pounds) each week once the resident can do the maximum number of repetitions (12 per arm/session) comfortably.
Before and after each care episode, CNAs should offer residents beverages such as water or juices. This twice-per-session fluid prompting is very effective in significantly increasing fluid intake and improving hydration status in this frail population. So, if done correctly, the FIT intervention improves: urinary continence, hydration AND physical functioning.
For best results, offer residents a choice from a variety of beverages, ideally beverages not typically served during meals (e.g, cranapple, cranraspberry). This strategy results in fewer refusals to drink and increases fluid consumption (1).
Studies show that, while the majority of nursing home residents are at high risk for dehydration, few facilities offer fluids between meals. In two separate studies, we found that staff offered residents between-meal beverages less than once per day on average, including oral liquid nutrition supplements (2,3).
Many workers erroneously believe that residents will request fluids, if thirsty, or retrieve a glass of water for themselves from their bedside pitcher. But few residents do this. One reason they don’t is that the thirst sensation declines with age, so many older adults may not recognize that they are thirsty even when they are. In addition, cognitive impairment and depression can impair a resident’s ability and motivation to seek out fluids. As a result, it is critical that staff not only offer fluids but also provide encouragement to residents to drink.
For more information about increasing residents’ fluid and food intake, see our weight loss prevention training module.
Causes for Concern
Special circumstances warrant special attention:
- Forego exercise if the resident feels sick or is in pain. When this happens, CNAs should report their findings to a registered nurse so he or she can assess the resident for possible treatment. CNAs should still provide the resident with toileting assistance and offer fluids.
- Report to the nurse any resident whose performance declines consistently over a period of days. CNAs should report a consistent decline, or repeat refusals, in any of the exercises: walking, wheeling, sit-to-stands, arm raises, or arm curls. The nurse or a physician should assess the resident to determine possible causes for the decline in function.
Your Assignment
- Print our walking performance assessment and use it to assess a handful of incontinent residents. Which of these residents are ambulatory enough to walk in the FIT program? Which should be encouraged to propel their wheelchairs?
- Print our graduated sit-to-stand protocol and use it to prompt a few residents to repeat this exercise. Were residents able to complete the exercise? How many repetitions were they able to complete?
- Share results of these assessments with us. Please contact us, and we’ll report your feedback in updates to this site.
Step 4: Implement Time-Saving Strategies
Implement these time-saving strategies to help your facility maintain the FIT program and maximize benefits for frail nursing home residents.
Lack of Staff Can Hamper Implementation
Having reviewed Step 1 (Identify the problem, the solution), Step 2 (Provide incontinence care), and Step 3 (Offer exercise), you are now in a position to make informed decisions about how to deploy the one resource that can make or break the FIT program: your staff.
Lack of staff time is THE biggest barrier to implementing the FIT program. How big? We estimate that in a nursing home with a staffing ratio of 10 residents to one certified nurse aide (CNA), the CNAs would need 60 minutes of every daytime hour to provide FIT to all eligible incontinent residents. In other words, they wouldn’t have time for any other duties. Given that this resident-to-CNA ratio is typical of the industry, FIT clearly is not going to work in the majority of facilities without modification.
Below, we offer two suggestions. The first will make the biggest difference in nursing homes with staffing levels that approach an ideal: five residents to one CNA. This first suggestion will also help in lower-staffed facilities, where the daytime ratio reaches seven or more residents to one CNA, but is unlikely to be sufficient. In these facilities, consider also the more drastic change outlined in our second suggestion.
- Reduce Nurse Aide Workloads in Other Areas: Assign time-consuming tasks that are typically the responsibility of CNAs to non-traditional care providers such as volunteers, social service staff, even administrative personnel, so that CNAs have more time to implement FIT. For example, some mealtime tasks and between-meal snack deliveries can be handled by non-traditional staff. See our weight loss prevention module, especially step 3, for tips on redeploying staff at mealtimes.
- Reduce the Number of "FIT" Participants: If, after shifting some of their duties, CNAs still lack sufficient time to implement FIT, then reduce the number of residents who participant in the program. If necessary, reduce the number of participants one by one until each CNA on the daytime shift is responsible for only one FIT participant.
This may sound like an insignificant number but it adds up. Consider this scenario: In a 40-bed facility, an estimated 20 residents will be incontinent and thus eligible for FIT. If the facility is staffed at 10 residents to one CNA during the day, then four CNAs are available to provide FIT to four residents, or one-fifth of all eligible residents. Yes, this approach excludes residents who could benefit from FIT. But despite this serious drawback, it is ethically and clinically preferable to foregoing the intervention altogether, a strategy that in most facilities means none of these frail residents will get exercise to prevent further decline.
How do you decide who makes the cut? There are no hard and fast rules to follow here, so we let reason guide us to this recommendation: Target services first to those residents who stand to lose the most functionality if denied regular exercise. In our clinical judgment, these are residents who are on the verge of losing their ability to walk. “They’re wobbly,” one of our researchers observed. “They can still bear weight, but they can’t walk safely without assistance.” They’re not the most impaired residents, nor the least impaired; they’re between these two extremes.
For these residents, their FIT-ness goal should be to maintain their walking ability.
You can use our standardized walking performance assessment to objectively select these participants.
Click here to view or print the assessment form.
Your Assignment
- Find out your facility’s resident-to-CNA ratio during daytime hours (7am to 3pm shift). Then estimate the percentage of residents in your facility who are incontinent of urine.
- If both the staffing ratio and percentage of incontinent residents are at or above industry standards (that is, about eight residents to one CNA and an incontinence prevalence rate of 50%), then your facility should reduce the number of FIT participants. With a better staffing ratio and/or a lower percentage of incontinent residents, a cutback in the number of FIT participants is less necessary.
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Step 5: Monitor the Program
Learn three methods for monitoring the FIT program so that its beneficial results are sustained.
Failure to Monitor can Undermine the Program
The procedures for monitoring the FIT program are similar to those for monitoring our walking program (see Step 4 of the walking program). The rationale for ongoing program assessment is virtually the same as well: That is, in its absence, certified nurse aides (CNAs) may backslide and fail to consistently implement the FIT protocols.
Studies in other fields have shown that old habits are hard to break and new ones are hard to maintain if you don’t get timely feedback about how you’re doing, including reinforcement for doing things right and recommendations for improvement if you’re doing things wrong. This feedback loop is a hallmark of continuous quality improvement programs. Creating such a feedback loop is the purpose of this step.
Use But Don't Rely Soley on CNA Reports
Start by collecting program assessment data.
The FIT logs completed by CNAs should tell you almost at a glance whether residents are improving their mobility, strength, and endurance with the FIT program. Our log includes columns for tracking daily performance: the total minutes each resident walks or wheels, the number of sit-to-stands, and the number of arm curls or raises completed, as well as refusal rates.
Click here to view and print a sample log.
We recommend collecting and reviewing FIT logs every two weeks. A licensed nurse / supervisory-level staff member should scan the logs to see whether the numbers for a particular resident are gradually increasing; holding steady; or declining, which would signal the need for a reassessment.
Data from the FIT logs can also be used to calculate compliance rates. On what percentage of days in a given period did residents walk? Complete sit-to-stands? Do arm curls or raises? On what percentage of sessions in a given day did residents do some form of exercise? Information about compliance gives you insight into whether residents value the program.
As informative as they may be, DO NOT solely rely on the CNAs’ written logs of exercise and incontinence activity to evaluate the FIT program. In several studies, we found that nurse aide documentation of care provision was inconsistent with the care residents actually received (1). In fairness to the CNAs, we believe they did this largely because they truly lack the time required to provide the multitude of services that we—employers, regulators, family, and friends—ask them to deliver. But with performance expectations continuing to exceed most nursing homes’ staff resources, it’s best to use CNA reports only in conjunction with data gleaned from other assessment strategies such as resident reports, direct observations, or, in the case of prompted voiding, control checks.
Conduct Wetness Control Checks
We developed, tested, and validated a standardized procedure that you can use to conduct continuous quality control checks of your prompted-voiding program.
Click here to review these procedures.
The control checks (which require about 15 minutes a week to complete) allow you to compare the percentage of incontinent residents found wet at any given point in time to the percentage who should be wet if the prompted-voiding program is working as expected. If the “actual” percentage exceeds the “expected” percentage, there’s a problem, and it needs further analysis if you intend to resolve it. Typical problems stem from changes in a resident’s status or break-downs in the prompted-voiding work process.
If your facility offers prompted-voiding to FIT participants, then a staff nurse should take the time to conduct weekly control checks. These weekly control checks are the best method for ensuring the integrity of incontinence care.
Conduct Resident Interviews
You can also monitor the FIT program through periodic interviews with participating residents. Many residents, even those with cognitive impairment, can reliably report on their care (2-4). They can tell you whether in fact they received it, they can tell you if they liked it, and often they can tell you how to improve it. All you have to do is ask them.
Resident interviews, even short ones, are more time-consuming to conduct than quality control checks. Thus, we recommend that a supervisor should try to interview all participating residents individually at some point in the first month of the FIT program. This will allow each resident to give feedback that will help you create a more responsive program. We also recommend repeating interviews during the residents’ MDS reassessments.
Keep the interview short and simple. Follow our protocol for conducting resident interviews, presented in the Quality-of-Life Assessment Module.
Click here to view the interview protocol.
Sample interview questions include:
- Did someone help you to walk today?
- How many times did you walk today?
- Did someone help you to the toilet today?
- How many times were you helped to the toilet today?
Be sure to record responses. Our resident interview protocol includes suggestions for interpreting and reporting results.
Compare Results to CNA Reports
You can compare results from the resident interviews with information in the CNAs’ written FIT logs to identify any reporting discrepancies. These may indicate areas for improvement or further training. A CNA’s log may also explain why FIT was not provided on particular days/times (e.g., resident did not feel well or was out with family).
Analyze Results
With all your program assessment data in hand, ask yourself this question: Is the FIT program working as expected? This, of course, raises several related questions:
- Are CNAs consistently offering FIT participants incontinence care and exercise every two hours?
- Are residents complying with the exercise?
- Is resident performance improving or at least holding steady?
- Are CNAs accurately completing the FIT logs?
If you identify a problem in any of these areas (look for the “no” answers) you may need to investigate further before you can resolve it. Often a meeting with the CNAs can help clarify and correct problems.
Share Results with Staff
For best results, complete the feedback loop by sharing results from the FIT logs, wetness control checks, and resident interviews with the CNAs who perform the lion’s share of the work in this program. As we noted earlier, staff members need feedback—both good and bad—to help them establish new work routines. Simply posting the wetness control checks each week, for example, will enable nurse aides to make connections between their work and the impact it has on their residents.
If these direct care providers can see tangible evidence of the benefits of the FIT program, they will be less likely to view the intervention as an extra burden and more likely to work to sustain its positive effects.
Sharing performance results also gives CNAs the opportunity to help supervisors correct any problems that arise. Often the CNAs are the first to know if a resident’s functional status has changed or if there’s been a break-down in the work process. Involving these staff members in improvement efforts will also help strengthen their commitment to the program.
Another way to complete the “circle of communication” is by presenting and discussing program performance results at in-service trainings and during regular staff meetings and care planning efforts. We’ve found in our recent work that brief (less than 15 minutes), weekly meetings focused specifically on a new program are effective for training and management purposes.
And finally, here’s a recommendation that bears repeating: Reward CNAs for consistently good results. Recognition as employee of the month, a staff pizza party for outstanding performance, a gift certificate to a local restaurant—they can’t hurt.
Your Assignment
Browse through our protocol for designing and conducting quality-of-life assessment interviews with nursing home residents so that you are better prepared to implement this fifth step in your FIT program.
Click here to view the interview protocol.
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