Introduction
Learn how the four-step prompted voiding program can individualize incontinence care for nursing home residents, improving outcomes and quality of life without overwhelming staff resources.
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Better Incontinence Care Needed in Nursing Homes
Incontinent nursing home residents are among the frailest of the frail. Most have physical impairments that restrict their mobility and many suffer from dementia. Given the profound functional and cognitive losses they’ve experienced, you might think these residents would be poor candidates for prompted voiding programs that improve continence. Not so. A significant proportion of these severely impaired residents are motivated to stay dry. And that fact, perhaps more so than any other, dramatically demonstrates how important this personal care area is to nursing home residents. It restores a shred of dignity to lives that increasingly are insulted by loss.
Nursing home staff, on the other hand, view incontinence care as one of the most “onerous and difficult” aspects of their job (1). It is also, they say, inordinately time consuming if done properly, which goes a long way—but not all the way—toward explaining why most nursing homes struggle with this care area.
Consider the facts:
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Prompted Voiding Programs Improve Continence
What knowledge do nursing home staff lack? Many seem unaware of key findings from more than 10 years of research on prompted voiding programs, the most extensively evaluated toileting assistance intervention for nursing home residents. Prompted voiding programs are designed to create awareness among residents of their continence status (i.e., whether they are wet or dry) and to encourage them to ask for toileting assistance. When implemented properly, the programs work. Here’s what the findings show:
Effective Programs Lacking in Nursing Homes
One obvious key to program success is assessment of resident responsiveness to the intervention. In the absence of these initial assessments, it is impossible to objectively determine who should receive toileting assistance and who should be managed on a check-and-change program. Nevertheless, in a recent study of 14 nursing homes, we found that all the facilities failed to evaluate incontinent residents’ responsiveness to toileting assistance, a finding in keeping with those from other studies (1, 11).
Without the benefit of a resident assessment, nursing home staff members often attempt to toilet all incontinent residents, but then fall short of recommended care standards due to excessive workloads (11). Observed one nurse aide, “All these people are not going to get the continence care they need because we don’t have enough time or the people we need to get them up every two hours. It’s not fair to the residents (12).” In some facilities, a failure to target toileting assistance discriminates in favor of the most able-bodied, clear-minded residents, reserving the poorest care for the frailest (11).
On the flip side, with better targeting of toileting assistance, not only is improved care more feasible to provide, but it could be easier to sustain, for it allows nursing home staff to “recognize the fruits of their labors, and…use principles of continuous quality improvement to maintain prompted voiding (13).”
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The (many) Benefits of Prompted Voiding Programs
Corrective action is needed. Besides being “the right thing to do,” providing proper toileting assistance to residents makes sense clinically and economically. Urinary incontinence is estimated to cost nursing homes close to $5 billion annually, including costs for laundry, staff time, and supplies (14). Some of these costs are due to staff failure to identify residents responsive to toileting assistance. This oversight often means that staff will waste time trying to toilet some residents who are unresponsive to their help while better candidates go without proper assistance. Urinary incontinence also is associated with a high rate of infection, requiring costly medical treatment both in the hospital and within the nursing home. Prevention programs such as prompted voiding address both problems, enhancing clinical outcomes for residents while possibly improving the facility’s bottom line.
Prompted voiding programs also offer public relations value. In one consumer survey, we asked family members and older board-and-care residents to compare the value of an intervention that improves continence to other nursing home perks such as improved meals or moving from a three- or two-person room to a single. By wide margins, the respondents rated the incontinence prevention program higher than the other, more customary options (5).
Additionally, prompted voiding programs can contribute to better scores on publicly reported quality measures for nursing homes. The Centers for Medicare and Medicaid Services now publish nursing home “report cards” on its consumer website, www.medicare.gov. Among the quality measures reported are the percentage of residents in a facility: 1) with a catheter; 2) with a urinary tract infection; and 3) who lose control of their bowels or bladder. By improving continence among residents, prompted voiding programs may produce better “grades” on a facility’s report card.
Finally, improved incontinence care can improve staff morale. Deborah Lekan-Rutledge at the Duke University School of Nursing writes about the aftereffects of implementing a comprehensive urinary incontinence (UI) management program in one nursing home: “The DON reported that family complaints on Monday mornings went from 20 to virtually none after implementing prompted voiding. Families were ecstatic about the UI program…Additionally, the nurse aides recognized the restorative nature of their role and re-titled themselves ‘Quality Care CNAs,’ reflecting pride and ownership of the program (15).”
Some staff even find prompted voiding, well, inspiring. Consider this little ditty written by DON Fran Bollman at Manor Care in Elgin, Illinois:
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But Before you Start...
Two prerequisites are recommended before you start implementation of a prompted voiding program:
Find out how often incontinent residents in your facility receive incontinence care. Ask between five and ten incontinent residents how often they were checked and changed that day or received help to the toilet from staff. Be sure to interview some residents with moderate to severe cognitive impairments. (We have found that cognitively impaired residents usually give reliable reports of their daily care.)
Were the residents you interviewed on schedule to receive toileting assistance three to four times during the day, the amount needed for them to stay dry? Please contact us to share your findings. We'll report your feedback in updates to this site.
Back to Top or proceed to Step 1
Click on one of the following topics to skip to that section:
- Better Incontinence Care Needed in Nursing Homes
- Prompted Voiding Programs Improve Continence
- Effective Programs Lacking in Nursing Homes
- The (many) Benefits of Prompted Voiding Programs
- But Before you Start...
Better Incontinence Care Needed in Nursing Homes
Incontinent nursing home residents are among the frailest of the frail. Most have physical impairments that restrict their mobility and many suffer from dementia. Given the profound functional and cognitive losses they’ve experienced, you might think these residents would be poor candidates for prompted voiding programs that improve continence. Not so. A significant proportion of these severely impaired residents are motivated to stay dry. And that fact, perhaps more so than any other, dramatically demonstrates how important this personal care area is to nursing home residents. It restores a shred of dignity to lives that increasingly are insulted by loss.
Nursing home staff, on the other hand, view incontinence care as one of the most “onerous and difficult” aspects of their job (1). It is also, they say, inordinately time consuming if done properly, which goes a long way—but not all the way—toward explaining why most nursing homes struggle with this care area.
Consider the facts:
- More than 50% of nursing home residents suffer from urinary incontinence, and most of them have both physical and cognitive problems that prevent them from independently using the toilet (2).
- The vast majority of these residents, 80%-90%, use diapers and some form of staff toileting assistance to manage incontinence (3).
- Incontinent residents need toileting assistance three to four times within a 12-hour period to stay dry (4-6).
- Studies show, however, that they are rarely toileted and are not changed after every wet episode (5,7). Staffs normally change residents an average of 1.34 times per 12 hours and provide toileting assistance an average of .5 times, and very rarely more than twice a day.
Back to Top
Prompted Voiding Programs Improve Continence
What knowledge do nursing home staff lack? Many seem unaware of key findings from more than 10 years of research on prompted voiding programs, the most extensively evaluated toileting assistance intervention for nursing home residents. Prompted voiding programs are designed to create awareness among residents of their continence status (i.e., whether they are wet or dry) and to encourage them to ask for toileting assistance. When implemented properly, the programs work. Here’s what the findings show:
- Prompted voiding results in a 40% to 50% overall reduction in the frequency of daytime urinary incontinence (4, 8).
- 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 (8-9).
- Residents who are most responsive to prompted voiding can be easily identified in a three-day trial of the intervention (10).
- Even residents with severe cognitive and physical impairments have proven responsive to prompted voiding (10).
Effective Programs Lacking in Nursing Homes
One obvious key to program success is assessment of resident responsiveness to the intervention. In the absence of these initial assessments, it is impossible to objectively determine who should receive toileting assistance and who should be managed on a check-and-change program. Nevertheless, in a recent study of 14 nursing homes, we found that all the facilities failed to evaluate incontinent residents’ responsiveness to toileting assistance, a finding in keeping with those from other studies (1, 11).
Without the benefit of a resident assessment, nursing home staff members often attempt to toilet all incontinent residents, but then fall short of recommended care standards due to excessive workloads (11). Observed one nurse aide, “All these people are not going to get the continence care they need because we don’t have enough time or the people we need to get them up every two hours. It’s not fair to the residents (12).” In some facilities, a failure to target toileting assistance discriminates in favor of the most able-bodied, clear-minded residents, reserving the poorest care for the frailest (11).
On the flip side, with better targeting of toileting assistance, not only is improved care more feasible to provide, but it could be easier to sustain, for it allows nursing home staff to “recognize the fruits of their labors, and…use principles of continuous quality improvement to maintain prompted voiding (13).”
Back to Top
The (many) Benefits of Prompted Voiding Programs
Corrective action is needed. Besides being “the right thing to do,” providing proper toileting assistance to residents makes sense clinically and economically. Urinary incontinence is estimated to cost nursing homes close to $5 billion annually, including costs for laundry, staff time, and supplies (14). Some of these costs are due to staff failure to identify residents responsive to toileting assistance. This oversight often means that staff will waste time trying to toilet some residents who are unresponsive to their help while better candidates go without proper assistance. Urinary incontinence also is associated with a high rate of infection, requiring costly medical treatment both in the hospital and within the nursing home. Prevention programs such as prompted voiding address both problems, enhancing clinical outcomes for residents while possibly improving the facility’s bottom line.
Prompted voiding programs also offer public relations value. In one consumer survey, we asked family members and older board-and-care residents to compare the value of an intervention that improves continence to other nursing home perks such as improved meals or moving from a three- or two-person room to a single. By wide margins, the respondents rated the incontinence prevention program higher than the other, more customary options (5).
Additionally, prompted voiding programs can contribute to better scores on publicly reported quality measures for nursing homes. The Centers for Medicare and Medicaid Services now publish nursing home “report cards” on its consumer website, www.medicare.gov. Among the quality measures reported are the percentage of residents in a facility: 1) with a catheter; 2) with a urinary tract infection; and 3) who lose control of their bowels or bladder. By improving continence among residents, prompted voiding programs may produce better “grades” on a facility’s report card.
Finally, improved incontinence care can improve staff morale. Deborah Lekan-Rutledge at the Duke University School of Nursing writes about the aftereffects of implementing a comprehensive urinary incontinence (UI) management program in one nursing home: “The DON reported that family complaints on Monday mornings went from 20 to virtually none after implementing prompted voiding. Families were ecstatic about the UI program…Additionally, the nurse aides recognized the restorative nature of their role and re-titled themselves ‘Quality Care CNAs,’ reflecting pride and ownership of the program (15).”
Some staff even find prompted voiding, well, inspiring. Consider this little ditty written by DON Fran Bollman at Manor Care in Elgin, Illinois:
The Toileting Song
Sung to the tune of “I Will Survive”
At first you were afraid
You were petrified
Kept thinking you could never get it done in just one day.
But then you got into the swing
And toileting became your thing
And you grew strong
And your residents went along.
So just go back.
Take them again.
You’ve got to get them in the habit
If you’re going to win.
You’ve got to get them used to it.
You’ve got to get them in the groove.
It’s just your prompting Q 2 hours that will get them all to move.
So close the door.
Tell them to go.
Just keep them dry
And help prevent their butts from getting sore.
You are the only ones to try
To keep your residents dry.
Did you crumble?
Did you hang it up and lie?
Oh no-no lie.
You will survive
And your residents will be the ones to reap the prize
You’ve got to keep on prompting them.
You’ve got to get them all in line.
And you’ll survive.
And your residents will thrive.
You will survive!
Sung to the tune of “I Will Survive”
At first you were afraid
You were petrified
Kept thinking you could never get it done in just one day.
But then you got into the swing
And toileting became your thing
And you grew strong
And your residents went along.
So just go back.
Take them again.
You’ve got to get them in the habit
If you’re going to win.
You’ve got to get them used to it.
You’ve got to get them in the groove.
It’s just your prompting Q 2 hours that will get them all to move.
So close the door.
Tell them to go.
Just keep them dry
And help prevent their butts from getting sore.
You are the only ones to try
To keep your residents dry.
Did you crumble?
Did you hang it up and lie?
Oh no-no lie.
You will survive
And your residents will be the ones to reap the prize
You’ve got to keep on prompting them.
You’ve got to get them all in line.
And you’ll survive.
And your residents will thrive.
You will survive!
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But Before you Start...
Two prerequisites are recommended before you start implementation of a prompted voiding program:
- Enlist top-level support from administrators and management staff to facilitate acceptance of the new program by direct care staff.
- Allow extra time at the beginning not only to climb the learning curve and but also to assess all eligible residents and get them on board the program; however, the longer you implement the intervention, the less time it will consume.
Find out how often incontinent residents in your facility receive incontinence care. Ask between five and ten incontinent residents how often they were checked and changed that day or received help to the toilet from staff. Be sure to interview some residents with moderate to severe cognitive impairments. (We have found that cognitively impaired residents usually give reliable reports of their daily care.)
Were the residents you interviewed on schedule to receive toileting assistance three to four times during the day, the amount needed for them to stay dry? Please contact us to share your findings. We'll report your feedback in updates to this site.
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