For many older people in rehabilitation, the promotion, maintenance and restoration of continence is part of working towards regaining independence in activities of daily living. Urinary incontinence is the most common form of incontinence in rehabilitation units for older persons, but a large number also experience mixed urinary and fecal incontinence [1]. While some may have had continence issues prior to hospitalization, there is an increased likelihood they may have become incontinent by virtue of the acute illness that preceded admission to rehabilitation, or simply because of functional loss associated with hospitalization [2]. Although assessment and management of the problem is paramount in enabling creation of a continence care plan, current evidence suggests that specific continence assessment and rationale for treatment may be lacking in this type of setting [1]. Patient engagement in continence care during rehabilitation is not well understood, although this is important in patient centered care and likely influences rehabilitation outcomes. The aim of this study was to understand continence assessment and care in geriatric rehabilitation from the perspective of the older person.

In this qualitative, exploratory study, older people on two geriatric rehabilitation units in a dedicated rehabilitation hospital were recruited using purposive sampling. Participants were identified by nursing staff as requiring assistance for continence care (bladder or bowel) and transfers, with the cognitive ability to participate in an interview a maximum 30 minutes in length. Written informed consent for all interviews was obtained. Using a semi-structured interview guide, open-ended interview questions focused on patient experience with continence assessment and management while on the units. Interviews were digitally recorded and transcribed verbatim. Using a conventional content analysis approach [3], three researchers coded initial interviews independently to develop the coding framework. Two researchers coded the remainder of the interviews, identifying codes subsequently collapsed to categories and themes.

Six women and four men aged 72-90 were interviewed. All participants described urinary incontinence, no participants identified fecal incontinence. From the data, three themes were developed: 1) Assessment: I guess they did, 2) Being continent or incontinent and 3) Gaining control. Under the theme of Assessment there was a single category with three clusters of codes: they haven’t done anything, assessment, and monitoring bowels. The second theme reflected two categories: participant experience of being incontinent, and their perceptions of nursing. The third theme included categories of self-management and management strategies.

Although most of our participants were not aware of a coordinated assessment of continence needs, they were able to describe aspects of assessment, particularly around monitoring bowels. Incontinence for some was a horrible condition due to the embarrassing nature of the problem and the potential for lack of dignity. The nurses’ efforts to minimize their embarrassment was appreciated by patients. Contributors to the negative experience of continence care often centerd around being dependent on nursing staff for continence needs. When nurses were unable to come quickly to assist, it was problematic for participants and some did not wait for assistance. Participants perceived mobility limitations, night time need to use the toilet and access to toilets as barriers to maintaining continence. The nurses and the healthcare aides were identified as the staff members who provided most of the continence care. Participants viewed nursing team as helpful and positive in assisting with bladder and bowel care; the role of other health care professionals was perceived as limited with patients returned from therapy if they needed to use the toilet. Some of the participants described taking on an active role in their own continence management by going to the bathroom before scheduled therapy and treatments. Patient descriptions of staff initiated strategies for their continence needs were limited, with containment strategies via the use of pads dominating, and occasional use of equipment such as commodes identified. A limited understanding as to whether any medications other than laxatives had been used to address continence problems was revealed.

For the older people who participated in this study, incontinence was a negative experience and they were not actively engaged in assessment or collaboration with the interprofessional team on management strategies. Although having to rely on nursing staff for assistance while not independently mobile was challenging, participants could identify strategies they used to help themselves. Healthcare professionals should partner with older people in systematic assessment and shared patient-interprofessional management of continence concerns and challenges.

Coffey, A., et al., Incontinence: Assessment, diagnosis, and management in two rehabilitation units for older people. Worldv Evid-Based Nu, 2007. 4(4): 179-186.
Zisberg, A., et al., Hospital-associated functional decline: the role of hospitalization processes beyond individual risk factors. J Am Geriatr Soc, 2015. 63(1): p. 55-62.
Hsieh H-F., Shannon, S.E., Three approaches to qualitative content analysis. Qual Health Res, 2005. 15(9): p. 1277-1288.