Guest Editorial: Incontinence Nursing Practice: Is it Evidence-based?

  Evidence-based nursing practice (EBNP) is the integration of the best available research evidence with clinical expertise, patient values, and circumstances.¹ Implementing EBNP can resolve problems in the clinical setting, achieve excellence in care delivery, introduce innovation, reduce variations in nursing care, and assist with efficient and effective decision-making. Urinary incontinence (UI) is one particular area of nursing practice where care needs to be evidence-based, because it involves many aspects of daily nursing care. Although scientific knowledge is growing exponentially and experts are publishing guidelines and recommendations, most practicing nurses are unaware this knowledge exists; there is a considerable gap between evidence-based research and clinical UI nursing practice.   A recent review of current nursing practice for the management of UI for patients at the end of life by Farrington et al² identified this lack of knowledge. The authors’ search revealed this care is guided by common sense and precedent rather than by evidence-based research, especially with regard to the use of indwelling urinary catheters (IUCs). This begs the question: Are nurses caring for patients with UI aware of evidenced-based recommendations? This is especially important in patients where behavioral, drug, and surgical treatments are not indicated or have failed to improve symptoms completely. Many experts in the field have referred to these patients as having “contained incontinence”; this has been described by Fonda and Abrams³ in their Continence Paradigm, as shown in Figure 1.

   Farrington et al’s review² indicated that an IUC is the preferred option for nurses who care for patients with UI. This is of concern because in palliative patient care, a goal is to minimize pain, and IUCs may do the opposite by causing pain and discomfort.⁴ In hospitals, nursing homes, and other healthcare institutions, nurses are the primary provider of contained incontinence, and in the home care setting, they direct informal and formal caregivers in the care of these patients. Therefore, it is imperative that nurses be aware of evidence-based research so bedside nursing care and caregiving are current and appropriate.

  One of the areas of UI care that has experienced guideline development involves catheter-related infections. These urinary tract infections (UTIs) are a patient-safety issue and costly to both the institution and the patient. The majority of these UTIs are caused by instrumentation inserted in the urinary tract, mainly IUCs. The Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC) released the Guideline for Prevention of Catheter-associated Urinary Tract Infections (CAUTIs)⁵; this was followed by an international guideline on diagnosis, prevention, and treatment of CAUTIs.⁶ These guidelines are systematic reviews of the best available evidence with specific recommendations, including new research and technological advancements, to assist in preventing CAUTIs.⁷ Many nurses believe IUCs are the best containment option in patients with UI because these devices contain urine leakage and lessen nursing tasks. This guideline is an essential read for nurses because it provides detailed recommendations for care of IUCs.

   A more recent publication⁸ on recommendations for managing patients with incontinence divides continence products into those intended to assist with toileting (eg, commodes, urinals, absorbent products) and those used to manage urinary retention and/or contain incontinence (eg, internal and external catheters). The authors note that continence products should be considered at each stage of patient assessment and treatment, and if treatment is not successful, subsequent management. These authors use the Fonda and Abrams Continence Paradigm in recommending products and providing levels of evidence for the various products and care algorithms regarding which products might be suitable for a given patient. It is important to note these authors do not recommend an IUC for either urinary retention or UI. This information needs to get to the nurse caring for a patient with UI.

  Care challenges can be daunting in all settings and the practicing nurse often is not aware of the evidence and thus cannot implement it into daily patient care. In order to close the research-to-practice gap, knowledge must be transformed, a difficult and challenging endeavor but one that should be embraced by nurse experts in the field of UI.

Dr. Newman is an Adjunct Associate Professor of Urology in Surgery at the Perelman School of Medicine, University of Pennsylvania, and Co-Director, Penn Center for Continence and Pelvic Health, Division of Urology, University of Pennsylvania Medical Center, Philadelphia, PA. This article was not subject to the Ostomy Wound Management peer-review process.

1. Sackett DL, Straus SE, Richardson WS, Rosenberg WHRB. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd ed. Edinburgh, England: Churchill Livingstone;2000.

2. Farrington N, Fader M, Richardson A. Managing urinary incontinence at the end of life: an examination of the evidence that informs practice. Int J Palliat Nurs. 2013;19(9):449–456.

3. Fonda D, Abrams P. Cure sometimes, help always—a “continence paradigm” for all ages and conditions. Neurourol Urodyn. 2006;25(3):290–292.

4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125–127.

5. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319–326.

6. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625–663.

7. Newman DK, Strauss R. Preventing catheter-associated urinary tract infections. UroToday Int J. 2013;6(5):64.

8. Cottenden A, Bliss DZ, Buckley B, Fader M, Hayder D, Ostaszkiewicz J, et al. Management using continence products. In: Abrams P, Cardozo L, Khoury S, Wein A (eds). Incontinence: Proceedings from the 5th International Consultation on Incontinence. Plymouth, UK: Health Publications; 013:1651–1786.