Urinary and double (urinary and fecal) incontinence are frequently encountered by nurses on rehabilitation units for older persons [1]. Rehabilitation focuses on the restoration and maintenance of function for the individual to maximize independence and return to the community. Research on continence care in geriatric rehabilitation is scant and suggests limited systematic assessment and management [1], with a reliance on containment rather than proactive management [2]. Our aim was to explore nursing staffs’ experience and perspectives of continence assessment and management in geriatric inpatient rehabilitation.

An exploratory, qualitative design was use to gain understand of how nursing team members addressed continence assessment and management in a geriatric rehabilitation inpatient setting. A purposive sampling approach was used to recruit staff for individual interviews, with written informed consent obtained from all participants. A semi-structured interview guide with open-ended questions focused on the process of continence assessment and management by the nursing team was used to guide the interviews. Interviews were digitally recorded and transcribed verbatim. A conventional content analysis [3] involved a total of four researchers. Two researchers independently coded an initial interview then developed the initial coding framework. A team of three researchers then reviewed the coded interview and framework, coded subsequent interviews using the coding framework and adding additional codes when identified and agreed upon. Codes were collapsed to categories and themes identified.

Results
Ten nursing team members from two geriatric rehabilitation units (3 Registered Nurses, 4 Licensed Practical Nurses and 3 Health Care Aides) participated. Eight were female, two male. Ages ranged from 27-63, years of practice 3-39, with rehabilitation experience from 2 months to 23 years.  Four themes were developed: 1) Getting to know the patient, 2) Working together 3) What works and what doesn’t work and 4) Rehab is a repair shop. Table 1 contains themes, theme descriptions and exemplars under the corresponding categories.

Nursing staff used transfer information and asked patients questions about their continence status at admission and throughout hospitalization. Patients were often asked the same questions by different members of the team. Some nurses undertook limited physical assessment and used bladder diary information in their assessment. Often, initial assessment took up to a week and included routine physician orders for bladder scans, and bladder/bowel diaries. Assessment information was used to create and update an individualized continence care plan.  Nurses saw themselves as a key in gathering information, recording on charts and passing information along to other team members. Nurses communicated verbally or in writing, verbally, and at weekly interprofessional conferences. Gaps in communication existed when information was passed verbally. Regular toileting seen as was the most useful and practical strategy. Other strategies included having access the right containment products (e.g. pull-ups vs mesh panties with a pad) or occasional use of a condom or indwelling catheter, humour, coaxing, getting patients to call for assistance, and ensuring privacy and dignity. The hospital continence service provided positive support. Assisting cognitively impaired patients was seen as the most challenging aspect of continence care. Nurses sought practical approaches to assist patients to gain independence, viewing the rehabilitation mission as improving continence, mobility and skin integrity. They perceived hands on continence care as being left to nursing; patients were brought back from rehab sessions if they needed to use the toilet. Nurses worked around this by trying to toilet patients before therapy. Sometimes being proactive wasn’t possible as they juggled meeting continence needs with other demands on their time.

In contrast to earlier studies, nursing team members in this study described actively trying to toilet patients, with containment a secondary strategy. In spite of some standard assessment practices derived from physician orders, overall assessment and management were not standardized, with some information lost when communicated verbally. Nursing professionals need to further develop systematic approaches to continence assessment and management that engage patients and the interprofessional team.

McCarthy G., McCormack, B., Coffey, A., Wright, J., Slater, P. Incontinence: prevalence, management, staff knowledge and professional practice environment in rehabilitation units, 2009. Int J Older People Nurs. 2009. 4(1):3-11.
Wright, J., McCormack, B., Coffey, A., McCarthy, G.. Evaluating the context within which continence care is provided in rehabilitation units for older people, 2007. Int J Older People Nurs, 2, 9–19.
Hsieh H-F., Shannon, S.E., Three approaches to qualitative content analysis. Qual Health Res, 2005. 15(9): p. 1277-1288.