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Special to OWM: The State of the Science on Urinary Incontinence
The University of North Carolina Chapel Hill School of Nursing; the Penn Center for Continence and Pelvic Health, Division of Urology, University of Pennsylvania Medical Center; and the American Journal of Nursing, in collaboration with the Center for Professional Development, University of Pennsylvania School of Nursing, held an invitational symposium in Philadelphia on July 12 and 13, 2002, to develop research priorities and clinical care and policy recommendations addressing the state of the art and science of continence promotion and the prevention, assessment, treatment, and management of urinary incontinence (UI) in adults, especially in vulnerable groups such as the elderly.
Supported by unrestricted grants from the Agency for Healthcare Research and Quality and companies that manufacture products and pharmaceuticals for urinary incontinence and overactive bladder (OAB), the symposium brought together leading nurse researchers, clinicians, educators, administrators, and industry stakeholders to address the following objectives:
• to critique the current state of urinary incontinence research in various clinical settings
• to review the state of the art of nursing care of incontinent adults • to identify barriers to improved nursing management of UI
• to provide practical and strategic recommendations for future directions in incontinence research, clinical practice, education, and policy
• to disseminate the analysis and recommendations to nurse researchers, nurse educators, healthcare professionals, policymakers, and the public.
Background
Urinary incontinence is one of the most prevalent and costly public health problems in this country. More than 20 million adults have UI or OAB.1 Between 15% and 30% of adult women experience UI, and the prevalence is even greater in the elderly population.2 Urinary incontinence is present in half of older adults in nursing homes and in 13% to 56% of homebound elders.2, 3 In 2000, more than one-third of nursing home residents experienced UI all or most of the time.4 As large segments of the US population enter old age, the absolute numbers of people with incontinence and OAB will increase.
Despite evidence-based guidelines developed and widely disseminated by the Agency for Health Care Policy and Research (AHCPR) in the 1990s (AHCPR is now known as the Agency for Healthcare Research and Quality, or AHRQ), UI remains underreported, underdiagnosed, and consequently, undertreated.1 Some who have been diagnosed with UI do not receive treatment, especially those with cognitive impairment and depression.5 Urinary incontinence affects the quality of a patient's life and may be associated with a greater need for assistance with activities of daily living and the need for formal and informal caregiving.6,7 It also carries a significant financial burden; at least $5.2 billion is spent on incontinence supplies and services in the institutional setting.8
While research on assessing and managing incontinence, especially in adults, has proliferated, gaps remain in what can be applied across clinical settings. Little research on the efficacy of UI interventions in the acute care setting is available, although it is known that the prevalence of UI increases during hospitalization for some conditions (eg, hip fracture repair).9 In the long-term care setting, behavioral interventions have proven effective, but staff compliance with the interventions has been problematic.2,10,11 The Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) is changing the procedure for surveying nursing homes for deficient nursing practices related to UI and indwelling urinary catheters.
Research on gender-specific interventions and on racial and ethnic minority groups also is lacking. Primary prevention research on UI is virtually nonexistent. It is not known whether primary prevention strategies will reduce the incidence of UI. Evidence does exist, however, that consumer UI education programs improve help-seeking behavior and attitudes toward UI.12
Development of theoretical models to help organize data and research results has been slow. A public health perspective has been proposed.13 Because UI has social, psychological, and physical antecedents and consequences, the medical model of a single causative agent and curative approach does not suffice. The Scientific Committee of the Second International Consultation on Incontinence called for randomized controlled trials to answer clinical questions, yet many methodologic challenges hamper such studies, especially among vulnerable populations such as the frail elderly.14,15
Toward the end of the last century, activities of US governmental agencies placed a spotlight on incontinence treatment and management. For example, in 1988 the National Institutes of Health convened a consensus conference involving multiple health professions. One outcome of this conference was that the treatment of UI should include behavioral therapies, medication, and surgery.16 A national clinical practice guideline for UI was developed in 1992 and revised in 1996. This guideline summarized the available evidence and made recommendations about assessment, treatment, and education.2,17 The AHRQ has archived the guideline, and no updates of the document are planned. In 1994, the National Institute of Diabetes and Digestive and Kidney Diseases held a workshop, "Barriers to Rehabilitation of Persons with End-Stage Renal Disease or Chronic UI," and in 1998 sponsored a conference, "Urinary Incontinence: Research Issues and Opportunities," which focused on UI in women. These events provided an opportunity to discuss different modalities of treatment and areas for future research. However, no recent gathering of leading nurse researchers, clinicians, and other interested parties in the prevention, treatment, and management of UI in diverse populations have been held.
A symposium by and for nurses is important because nurses may be the only healthcare professionals who detect and begin assessment and treatment of UI. In most institutional settings, nurses not only provide direct patient care, but they are also responsible for upholding the philosophy and standard of care and policy, as well as supervising the performance of other nursing staff.18 Evidence-based nursing practice, then, is crucial to the delivery of that care.
Although a growing number of nurses in the United States are developing expertise in caring for incontinent patients, no academic or clinical proficiency requirements exist for a continence nurse practitioner or specialist, although such competencies have been advocated.19 The Society of Urologic Nurses and Associates' certification of nurses and advanced practice nurses in urologic nursing includes incontinence care training (www.suna.org). In 1993, the Wound, Ostomy, and Continence Nurses Society developed the first certification program for continence care nurses in the United States. As of December 2002, only 230 nurses had been certified through this process (www.wocncb.org/pdf/newsletter802.pdf).
Most nurses obtain knowledge and skill through self-motivated activities. For example, those attending a national nursing conference in UI care were queried about their educational preparation in UI care. Fewer than half of the respondents (40%) reported receiving academic education related to UI, including course work in accredited postbaccalaureate or graduate programs. However, 76% of the respondents had obtained information and instruction through professional conferences, on-the-job training, self-study, in-service programs, or continence clinics supervised by nurse practitioners or physicians.20
These findings supported an earlier national survey on nursing school curricula.21 Faculty members of schools of nursing agreed that incontinence is an important condition, and 90% of curricula included it specifically, but undergraduate nursing programs devoted an average of just 2.1 hours of lecture time to this topic. In addition, no commitment to require clinical experience in this area had been made, a lack of awareness of available educational resources existed, and few were available to teach. The authors offered evidence that incontinence is not well-managed in clinical practice, suggesting that 2 hours is insufficient for adequate instruction. They recommended investigation into effective instructional methods to teach nurses and nursing students about UI. But practicing nurses may not have positive attitudes toward continence education; in one study, 20% of nurse participants believed that nurses in US nursing homes would be apathetic or resistant to a formal educational program on incontinence.21
Last July's invitational symposium provided a forum for examining past and current incontinence research, developing an agenda for nursing research, and making recommendations for immediate implementation and for future directions in nursing education and practice.
Symposium Methodology
The symposium began with a reception featuring selected readings from Michael Korda's book, Man to Man: Surviving Prostate Cancer, to highlight the consumer perspective on incontinence issues, particularly the humiliation experienced by many with incontinence.
The second day featured four speakers. Each speaker prepared a paper that had been sent to the participants before the symposium. The speakers discussed their papers; summarized the state of the research, including major gaps and future research directions; and responded to questions and issues raised by participants. The papers presented reviews of the research literature on the following topics:
• incontinence in young and middle-age women (Carolyn M. Sampselle)
• gender, social, ethnic, racial, and cultural issues in incontinence research and practice (Mikel L. Gray)
• incontinence treatment in different populations, including older women (Jean F. Wyman)
• incontinence needs in frail elderly populations (Deborah Lekan-Rutledge and Joyce Colling).
Each presentation was followed by small group discussions on the gaps in knowledge, barriers to improved management of UI in the target population addressed in the paper, and strategies for overcoming these barriers. Each group identified barriers to adequate research, education, practice, administration, financing, regulations, and support services (such as products and medications). Subsequently, recommendations and strategies were developed to overcome three of these barriers, and finally, the group reported its work to the large group for discussion and consensus building.
Results
Symposium participants recognized that little discussion of research occurred in several areas. Most of the discussion focused on incontinence in women, despite its occurrence in men. Incontinence among men treated for prostate cancer is an issue that warrants particular attention and study.
In addition, discussion of incontinence products, treatment devices, and medications was absent in all but one of the papers solicited for the symposium, and no papers were solicited to address only these topics. Yet nurses are the healthcare providers who most often recommend products and devices to patients. Many nurses also participate in product selection, although their facilities' bulk purchasing decisions may restrict access to the most effective products available. Such experience enables nurses to identify product deficiencies as well as make informed suggestions about new products. Advanced practice nurses prescribe medications for incontinence; all nurses monitor patients for drug efficacy and side effects and teach patients about self-administration of medications. To begin to address this omission, the symposium report includes information on devices and products that can be found in the National Association for Continence's 12th edition of the Products & Services for Incontinence Resource Guide, 2002-2003, as well as a short review of current UI and OAB drug therapy. In addition, the group made several recommendations that address this issue.
1. Abrams P, et al (eds). Incontinence: Proceedings from the Second International Consultation on Incontinence. Plymouth, UK: Health Publications, Inc.; 2002.
2. Fantl J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; 1996.
3. McDowell BJ, et al. Characteristics of urinary incontinence in homebound older adults. J Am Geriatr Soc. 1996;44(8):963-968.
4. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Nursing Home Data Compendium 2000.
5. Silverman M, et al. To treat or not to treat: issues in decisions not to treat older persons with cognitive impairment, depression, and incontinence. J Am Geriatr Soc. 1997;45(9):1094-101.
6. McCallum TJ, et al. Urinary incontinence after radical prostatectomy: implications and urodynamics. Urol Nurs. 2001;21(2):113-124.
7. Roe B, et al. Help seeking behaviour and health and social services utilisation by people suffering from urinary incontinence. Int J Nurs Stud. 1999;36(3):245-253.
8. Wagner TH, Hu TW. Economic costs of urinary incontinence in 1995. Urology. 1998;51(3):355-361.
9. Palmer MH, et al. Risk factors for hospital-acquired incontinence in elderly female hip fracture patients. J Gerontol A Biol Sci Med Sci. 2002;57(10):M672-677.
10. Palmer MH. Research in long-term care: what do we know, what can we use? Ostomy/Wound Management. 1997;43(10):28-32.
11. Colling J, et al. The effects of patterned urge-response toileting (PURT) on urinary incontinence among nursing home residents. J Am Geriatr Soc. 1992;40(2):135-141.
12. Newman, DK, et al. Promotion, education and organization for continence care. In: Abrams P, et al., (eds). Incontinence: Proceedings from the Second International Consultation on Incontinence. Plymouth, UK: Health Publications, Inc.; 2002:937-964.
13. Palmer MH. A health-promotion perspective of urinary continence. Nurs Outlook. 1994;42(4):163-169.
14. Payne C, et al. Research and outcomes. In: Abrams P, et al., (eds). Incontinence: Proceedings from the Second International Consultation on Incontinence. Plymouth, UK: Health Publications, Inc.; 2002. p. 1045-77.
15. Burns PA. Incontinence research studies: methodologic issues. Urol Nurs. 1994;14(3):113-116.
16. National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases. Urinary incontinence: research issues and opportunities. Abstracts 1998.
17. Department of Health and Human Services. Agency for Healthcare Policy and Research. Urinary Incontinence in Adults: Clinical Practice Guideline. Rockville, MD: Urinary Incontinence Guideline Panel; 1992.
18. Gallo M, et al. The evolution of continence nurse specialists. In: Staskin, D, Cardozo L, (eds). Textbook of Female Urology and Urogynecology. Oxford, UK: Isis Medical Media, Ltd.; 2001:65-80.
19. Jirovec MM, et al. Addressing urinary incontinence with educational continence-care competencies. Image J Nurs Sch. 1998;30(4):375-378.
20. Jacobs M, et al. Continence nurses: a survey of who they are and what they do. Urol Nurs. 1998;18(1):13-20.
21. Morishita L, et al. Education on adult urinary incontinence in nursing school curricula: can it be done in two hours? Nurs Outlook. 1994;42(3):123-129.
