In 1996 the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality, or AHRQ) issued an evidence-based clinical practice guideline on urinary incontinence (UI). A multidisciplinary panel of experts, cochaired by a nurse (Diane Newman), developed them. Unfortunately, there’s little evidence suggesting that nurses and other clinicians have used the guidelines. As the AHRQ and other professional organizations have discovered, changing clinical practice is easier said than done.
While progress in the clinical management of UI has stalled, the prevalence of UI is rising. At least 17 million Americans have UI; it’s the second leading cause of institutionalization of the elderly and occurs in more than 50% of nursing home residents. According to a 1987 survey, as many as 53% of people living in their own homes may have UI. It’s estimated that a majority of people with UI never mention the condition to a physician or nurse.
Nursing research has provided substantial evidence that noninvasive toileting programs can be effective in long-term—care settings. But clinicians in these settings remain unfamiliar with the research and largely don’t use innovative techniques. Some nursing homes maintain that their lack of staff means all they can do is contain the problem through the use of absorbent products, but demonstration projects have disputed this assertion. For some people with incontinence, use of absorbent products is the most appropriate intervention; for others, a restorative intervention such as bladder retraining or prompted voiding is more appropriate. Nonetheless, use of absorbent products is often the intervention applied to everyone. Individualized care for UI isn’t provided.
On July 12 and 13, 2002, 41 nurses and others interested in incontinence gathered in Philadelphia to analyze the state of the science of UI management and to develop recommendations for research, practice, education, and public policy. This supplement to the American Journal of Nursing constitutes the report of this invitational symposium and includes an executive summary; four papers reviewing the research in specific areas, the highlights of which were presented at the symposium; a summary of the group’s delineation of barriers to improved management of UI; brief reports developed after the symposium, relaying information that was mentioned in passing at the meeting; and a list of participants and sponsors.
Although nursing care of people with UI involves the use of various devices and products, those presenting at the symposium did not say much about these approaches. Similarly, little mention was made of drug therapies, even though nurses prescribe, administer medication, assess for adverse effects, monitor responses, and teach patients about drugs. Nurses seldom lead research in these areas, but why? And why aren’t nurses designing research into complementary and behavioral approaches to managing UI? Other unanswered questions remain. Are some nurses merely uninterested in evidence-based practice? Are research findings making their way into clinical practice where they need to be put into action? Is the research that’s being conducted inapplicable to complex clinical settings? What are the institutional factors that prohibit or facilitate evidence-based changes in practice? Are federal and state regulations insufficient to ensure that promotion of continence becomes a priority? To what extent is the lack of universal reimbursement by third-party payers for behavioral approaches and patient teaching a factor in continued incontinence? Why has so little attention been accorded to preventing UI, and why does virtually no research address prevention?
The biggest question of all may be: Why aren’t nurses doing a better job of preventing and managing UI? It’s time to move beyond pat answers. The symposium participants identified “lack of knowledge” as a primary barrier, but simply disseminating information to nurses and the public won’t go very far. The group recognized this and recommended a social marketing approach (applying advertising and marketing principles to sell positive health behaviors) to change values, attitudes, beliefs, and behaviors related to UI.
The patient’s voice must be heard and must determine our priorities. The symposium began with selected readings from writer Michael Korda’s elegant and articulate account of living with incontinence. To understand how UI can change one’s life, read his book, Man to Man: Surviving Prostate Cancer (1997, Vintage Books).
Continence remains undervalued, and UI remains underassessed. Even though UI is a basic nursing care issue, nurses are not claiming it as one. Nurses must be more creative, inventive, and bold in developing new approaches to preventing and managing UI. The symposium and this report constitute first steps in ensuring that the profession is living up to its responsibility to support nurses as patient advocates, expert clinicians, researchers, educators, policy activists, and leaders. In all clinical settings, people have the right to be continent.
We urge you to read this document and to share it with colleagues. It is available online at http://www.NursingCenter.com/UI.