Patients who require long-term nursing or rehabilitative care may feel they've lost control of many aspects of their lives. If their disease or condition causes them to become incontinent, they may feel they've lost their dignity on top of everything else.

Hallmark House Nursing Center, Pekin, IL, recently participated in a pilot program and study to help these patients address their incontinence and regain a sense of control and dignity in their lives.

The study, "Incontinence Management in Nursing Homes," was coordinated by the Vanderbilt University Center for Quality Aging, Nashville, TN. Hallmark House was one of 14 facilities from nine different states that participated. Cheryl Carlson, RN, clinical compliance coordinator, and Rae Wheeler, RCNA, rehab coordinator, facilitated the project at Hallmark House.

The Vanderbilt study focused on the use of a program called "prompted voiding" that involves teaching residents to become aware of their own bodily functions through consistently timed and repeated reminders from the center's staff.

Data were collected on patients' performance in the program, and staff participated in monthly teleconference education sessions. Patients were tracked for the study from January to August of this year.

Although their participation in the Vanderbilt study began in 2008, Hallmark staff already had been working in collaboration with the Illinois Foundation for Quality Health Care since mid-2007 to improve the incontinence of their patients. According to Carlson, they were pleased to find when they joined the Vanderbilt study that they already had been performing some of its recommended tasks.

A Different Mind-Set
"Unfortunately, there's a long history of patients coming to nursing homes and being put in an adult diaper and in a wheelchair. We need to think differently," Carlson said. She added this is especially true for people who are still mobile.

According to Wheeler, when a new resident arrives at the center, the individual is given 4 or 5 days to settle in after which staff conducts a 2-day tracking assessment of the resident's toileting habits, including when they go, how often and how much. This helps staff determine if the client is a candidate for the prompted-voiding program.

Once on the program, residents are prompted by a CNA every 2 hours to use the bathroom. They are also asked at bed check if they'd like to get up and go to the toilet, and according to Wheeler, many residents do.

The consistent and repeated prompting helps residents become aware of their own bodily functions, especially those residents who are cognitively impaired. "Most of those on the prompted voiding will go when they sit on the toilet, and even if they don't, that's OK. It's like retraining the bladder," Carlson said.

Wheeler praised the Hallmark CNAs' roll in the program. "If we didn't have the CNAs on board, it wouldn't have worked. They're the root of all of this. They are the ones who've made it successful," she said.

The prompted-voiding program is not just for new residents. Assessments of all patients are conducted every 3 months. Anyone who exhibits a change in toileting activity is tracked for 2 days so staff can determine if the individual could benefit from prompted voiding.

According to Carlson, the 70-bed facility has an average census of 65 patients, with approximately 15-20 patients participating in the prompted-voiding program at any given time.

More Than Prompting
Carlson pointed out prompting isn't the only thing done to help residents regain bladder control. Those who are physically able participate in regular exercise classes. "We're training the mind and the body," she said.

Residents are taught an exercise of squeezing a small ball between their legs. "It's actually equivalent to Kegel exercises. However, it can be very hard to train older people to do Kegels properly," Carlson said. The exercise helps strengthen the muscles in the pelvic floor, which can lead to better bladder control.

To help patients be as successful as possible, staff also works to control other contributors to incontinence by serving cranberry juice instead of orange juice and avoiding caffeinated beverages.