A health-promotion perspective of urinary continence

A health-promotion perspective of urinary continence

A Health-Prom.otion Perspective of Urinary Continence Mary H. Palmer, PhD, RN-C, FAAN nence e-transient and establishedhave been identified.f The pr...

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A Health-Prom.otion Perspective of Urinary Continence Mary H. Palmer,

PhD, RN-C, FAAN

nence e-transient and establishedhave been identified.f The process of storing and expelling mine is shaped by social rules for acceptable times and places for elimination. Loss of continence may be a symptom of a disruption in physiologic processes, and in Western culture it is viewed as a violation of social norms. There may be severe psychologic and social consequences for affected perfurther investigation of assessment, sons of all ages. For example, the social treatment, and education for those al- stigma attached to the failure to achieve ready incontinent of urine is needed. or maintain continence has led to osHowever, because of the increasing tracism by peers and taunts of, "You're prevalence of different types of incon- such a baby!" to a young child and to tinence among various subgroups in accusations of incompetence to older the population, effective preventive adults. The loss of control over urinary measures need to be identified, espe- elimination plays a major role in the cially for women who are at risk dur- decision to place older adults in a nursing various stages in their reproductive ing home.? Although it is well known among life, for aging men with prostatic hypertrophy, and for persons with ill- health care professionals and is increasnesses and diseases that affect physical ingly publicized among laypersons that incontinence is not a normal part of and cognitive functioning. The purposes of this article are to aging, there tends to be a societal sense discuss urinary continence from a pub- of denial and, therefore, complacency lic health perspective, to discuss a con- about its prevalence. Isaacs'' discussed ceptual model of urinary continence societal denial of incontinence as a sehealth promotion, and to introduce a rious barrier to the development of matrix for identifying specific areas of comprehensive continence services. He primary prevention nursing research stated, "Dear old ladies do not carry efforts. round collecting boxes for the incontinent, and it is of little use reminding them that they are the future victims BACKGROUND Urinary incontinence is defined as of this disorder." Until recently, wom"involuntary loss of urine sufficient en's groups and publications geared for enough to be a problem." It is a symp- older adults have been reluctant to distom, not a disease. It is not caused by cuss causes of incontinence and treatage. Several types of incontinence ment options, preferring instead to fo(functional, urge, stress, and overflow) cus on the positive aspects of aging. and their causes have been described.' A recent study found that 97 (10.5%) In addition, two patterns of inconti- of 919 recently discharged older adults

There has been a strong interest among nurse researchers in secondary and tertiary prevention strategies for urinary incontinence, but little interest in primary prevention.

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recent review of nursing research on urinary incontinence in adults noted that there has been considerable nursing effort, especially in the last decade, to develop research-based nursing interventions.' Concurrent to these intense nursing research efforts to identify effective assessment and treatment strategies, interest by regulatory and other healthrelated organizations regarding the care of incontinent adults also has increased.' The Clinical Practice Guide-

line for Urinary Incontinence in Adults was released in March 1992 by the Agency for Health Care Policy and Research (AHCPR) for the following purposes: "to improve, reporting, diagnosis, and treatment of urinary incontinence; reduce variations in clinical practice; educate health professionals and consumers about the condition, and, finally, encourage further biomedical, clinical, and cost research on incontinence." 3 Despite increased scientific, regulatory, and clinical efforts, consensus in the health care community exists that

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Table 1. Antecedents and Consequences of Urinary Incontinence Antecedents

Impaired moblllty" Impaired coqnltlorr" Poor pelvic muscle tone 42 Lack of access to bathroornv' Decreased fluid intake 39

Behavior

Consequences

Urinary incontinence

Social lsolatlon-? Embarrassment3 9 Avoidance by others 39 Odor45 Impaired skin lnteqrity? Costs of equipment, pads46 Psychologic stress"? lnstltutionallzatlon?

Medlcatlons'' Lack of knowledge regarding normal functioninql? Abrupt changes in 44 : Sensorium Functional status Physical health Depression and social withdrawal 34

reported they were incontinent before and after their hospitalization.8 Nurses involved in the discharge planning activities identified onl y 19 of 84 persons (23%) in this group as incon tinent dur ing the hospital sta y. The majority of incontinent respondents claimed th ey needed no additional help in managing their incontinence. It is possible that many of these patients would have profited greatly by more aggressive nursing intervention. Jeter and Wagner? found the majority of respondents to a n ational survey viewed their incontinence as a minor problem and reported they did not receive meaningful help from health care professionals. Most respondents resorted -to incontinence management rather than rehabilitative or curative approaches. At the same tim e this survey was reported, however, th e sales for Staying Dry, a book about incontinence written for the layperson, were exceeding the publisher's expectation.10 This gives credence to the idea that incontinent people do not see incontinence as a medical problem,' ! but they do want bett er methods for dealing with it. PUBLIC HEALTH PERSPECTIVE In the face of this apparent contradictory information are areas of agreement between consumers and health care professionals: Incontinence has a negative social impact, people would 164

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rather be dry than wet, self-care methods, especially home devices, are readily used and acceptablel-, and traditional strategies used to encourage people to access medical care - especially in this era of incre ased health care costs to consumers - do not appear to be effective means to achieving comprehensive continence-promotion strategies . As can be seen in Table I, because incontinence has social, psychologic, and physical antecedents and consequences, th e medical model of a single causative agent and of a curative approach to all health problems is insufficient to provide solutions to the many issues facing incontinent adults and their caregivers. Despite intense efforts to develop effective treatments, many people remain incontinent, and as the American population ages, more will become incontinent. A case may be made for viewing urinary incontinence as a significant public health problem. Approximately 10 million Americans report being incontinent.? and over 50% of nursing home residents are incontinent of urine. Kunkel and Applebaum 13 project that by the year 2040, when most baby boomers are in their 80s and 90s, there will be 14.8 to 22.6 million adults aged 65 years an d over with long-term disabilities, indicating a dramatic increased need for long-term care. Projections for an increased number of nursing home beds leads to the conclu-

sian that as the absolute number of nursing home residents increase, so will the number of incontinent residents. The care of incontinent perso ns is expensive; the AHCPR estimation is $10 billion dollars annually.' This figure does not include indirect costs resu lting from psychologic distress and premature withdrawal from work and other activities. Health promotion, including the identification of psychosocial mechanisms underlying the adoption of behaviors leading to healthy lifestyles and taking responsibility for one's health, is a nursing research prioriry.l" Assisting persons to maintain control over urinary elimination, preserving the integrity of the urinary tract and skin, an d helping older adults avoid the social stigma and personal embarrassment of soiling, are appropriate nursing objectives. CONCEPTUAL MODEL Figure 1 presents a conceptual model that was developed earlier to include a health-promotion perspective of continence.P Both conditions, urinary continence and incontinence, are addressed. This model, unlike the medical mod el, accommodates the inclusion of single and multiple causative and associated factors outside the urinary tract and cognitive and functional characteristics of the individual, such as

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Primary Prevention

Environmental Modification Adequate public toiletfacilities thatare hygienic, safe, convenient, and private

Public Education Normalgenitourinary functioning Developmental effects on continence ie,childbirth,menopause, aging. Continence promoting habits: - adequatefluid Intake - treatmentof UTIs, vaginitis, and constipation Health caref'ver Education - personalhygiene Detrimenta effects of - awareness of bodily Institutionalization. sensations Develop strategies to - maintenance of pelvic promoteIndependent floor tonewith weight patientfunctioning management and exercise and decision-making. Theories ofaging and and developmental tasks. Effects of aging on genitourinary function.

EnvIronmental Modification TonetSubstitutes

EquipmentandSupplies Padsand briefs Externalcollection devices Indwelling andsuprapubllc catheters

Behavioral Therapies

Secondary Prevention

Tertiary Prevention

Figure 1. Conceptual model for urinary continence health promotion. (From Palmer M. Nurs Clin North Am 1990;25:929. By permission.)

environmental access to toilet facilities, educational deficits, and attitudes and beliefs of affected adults, families, and caregivers. This model may be used to identify nursing interventions aimed at preventing urinary incontinence from occurring or from becoming more debilitating.

Primary Prevention Strategies The goal of primary prevention strategies is to remove the causes of incontinence before the condition appears. Continent persons, then, are the target population for primary prevention strategies. Public education must be provided about behavioral changes that decrease the probability of incontinence.l'' normal functioning of the genitourinary tract, expected age-related and developmental changes, and how to find the appropriate treatment providers. Primary prevention strategies for specific groups at risk are developed on the basis of the underlying pathologic NURSING OUTLOOK

changes, behaviors, conditions, or systems that increase the likelihood of incontinence. For example, postmenopausal women should receive information about changes to the geni tourinary tract due to menopause, the signs and symptoms of atrophic vaginitis and its treatment, techniques of good perineal hygiene, weight management, fluid intake minimizing fluids containing ingredients with diuretic effects, exercises targeted to strengthen the pelvic muscle, and avoidance of constricting undergarments or clothes. The message that incontinence may be prevented and is treatable should be disseminated through aggressive public education by health care professionals during routine health care visits, in the lay press, at health fairs, health spas, beauty salons, libraries, community centers, and schools. Certainly one expected outcome of primary prevention strategies is increased personal responsibility for health. Persons incapable of taking re-

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sponsibility for their health because of impairments in physical, cognitive, and emotional health are not necessarily excluded from primary prevention interventions, Formaland informal caregivers may act as proxies and assume responsibility to maintain continence. Resources, therefore, must be in place and available to people seeking assistance or information in order for them to make informed decisions. Besides education for the consumer, health caregiver education is essen' tial.'? Education regarding theories of aging, the effects of age, and the detrimental effects of institutionalization should be provided to all caregivers of older adults. Specific information about normal aging and prevalent pathologic changes in the genitourinary tract and methods to maintain or enhance functioning is crucial to primary prevention. The expectation for continent behavior must be fostered as the norm in all health care settings, Caregiver beliefs of, "It's OK for my patients to be wet. It's my job to clean it up"; "Incontinence is due to age"; and "It's easier to change rather than to toilet" must finally be laid to rest. Strategies to promote and enhance independent functioning and decision making on the part of the older adult should be part of every plan of care. In addition to caregiver facilitation of the older adult's autonomy, the administration of each health care facility plays a critical role in articulating the philosophy of promotion and valuation of continence as evidenced by mission statements, policies, and standards of care. Environmental modifications to increase the access to toilet facilities in the community and the institutional setting is critical for the promotion of continence, Respect for privacy; provision of toilet substitutes to those who need them; convenient, clean, well, stocked, and safe facilities; and prompt assistancefor dependent people to transfer and disrobe for toileting are the end products of an operational philosophy of continence promotion, Some factors not included in the Palmer

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original conceptual model include changes in functioning caused by comorbid conditions, diseases, or illnesses. For example, limited mobility and impaired cognition, associated with incontinence, increase with ageand are especially likely to exist among frail elderly over 85 years of age. IB, 19 How' ever, it has been difficult to distinguish the specific effect of these impairments on continence status. Not all older adults with limited mobility and impaired cognition are incontinent. It is also true that not all ambulatory cognitively intact older persons are continent. Therefore factors other than physiological and functional ones may play a role in continence status. Psychologic factors, such as depression, alienation, and anxiety, have been associated with incontinence, although their role is not clearly understood.P Detection and prompt treatment of these disorders or conditions may prevent incontinence from developing.

ments for incontinent frail elderly persons.> Staff compliance to adhering to these interventions is essential to their success. 27 Restoration of function in the nursing home is addressed in federal regulations regarding nursing home care, which read in part, "A resident who is incontinent of bladder receives the appropriate treatment and services to restore as much normal bladder function as possible."2s Yet operational guidelines on how to implement changes in nursing care have not been developed; each facility must devise their own restorative Care program and methods to quantify the results. Evaluation ofthese programs will take on increasing importance as outcome measures for nursing home surveyors arc developed to evaluate the effectiveness of bladderretraining programs and other nursing interventions in the long-term care setting.

Tertiary Prevention Strategies Tertiary prevention involves intervenSecondary Prevention tions designed to minimize the effects Strategies Secondary prevention strategies are of established incontinence that has early interventions designed to allevi- affected the independence and activity ate urinary incontinence or to prevent of the incontinent adult. Nursing init from worsening. Therefore inconti- terventions that may be classified as nent adults are the target population tertiary strategies include management for these strategies. Screening, early measures such as the use of intermitdetection, referral, and prompt treat- tent catheterization, external collecment of incontinence are important tion devices, underpads, and undergarcomponents of secondary prevention. ments designed to prevent leakage and Because not all incontinent people vol- odor, and insertion of an indwelling unteer information about their condi- catheter to prevent further skin breaktion, nurses must incorporate direct down, while promoting psychologic and specific questions into their histo- and physical comfort. Individual need should be the drivries and physical assessments to detect ing force in determining which inconincontinence. Many behavioral interventions de- tinence product to use.29 However in vised, implemented, and investigated actual practice, one type of incontiby nurse researchers and others are nence care product may be purchased secondary prevention strategies. Non- for an entire facility; thus individual invasive behavioral interventions such needs are overlooked because of ecoas biofeedback, prompted voiding, nomic considerations or for ease of use scheduled toileting, bladder retraining, by the staff. and pelvic muscle exercises have As can be seen in Figure I, some inproved effective in the treatment of in- terventions may be either secondary or continence. 21'26 These interventions tertiary prevention. The goal or outare the preferred first choice in treat- come of the strategy determines its

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type. For instance, if surgery is used to restore continence such as a needle bladder neck suspension, it is considered a secondary prevention strategy. However, if surgery, such as a urinary diversion, is performed to contain urine and to prevent skin breakdown, it would be classified as a tertiary prevention. HEALTH·PROMOTION RESEARCH MATRIX Using the urinary continence healthpromotion model helps nurses to conceptualize and classify the focus and intent of nursing interventions and research efforts and to identify groups at risk. The model is inclusive of educational and health -promotion efforts and will accommodate consumer concerns and perspectives and at the same time does not exclude medical and technological interventions. However, it is not particularly helpful in identifying and refining specific research questions to develop research-based practice. Lindeman and Schantz'? recommended a building block, or matrix,

Easy access to toilet facilities is critical for the promotion of continence. approach in reviewing the literature to identify what has been studied, what relationships have been found, and at what level of confidence the relationship has been tested. This approach is useful in identifying areas in which future research is needed and in refining research questions. Table 2 illustrates a matrix that, when completed, provides an overview of the current status of urinary incontinence research conducted by nurses. The variables listed along the horizontal axis representing major categories of primary prevention, secondary prevention, and tertiary prevention strategies. The type

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Table 2. Continence Health Promotion Research Primary

Public education

Secondary

Tertiary

Health caregiver Environmental Behavioral Pharmacologic education modification therapies treatment

Surgery

Equipment devices, supplies

Replication Experimental Quasi-experimental Exploratory Descriptive Survey

of research methodology is listed along the vertical axis. As Lindeman and Schantz noted, research should evolve from hypothesis generating to hypothesis testing methodologies. It is beyond the scope of this article to present a review of the nursing and related health care literature. Therefore only the primary prevention section of the matrix is discussed. However, the reader is referred to McCormick and Palmeri and the AHCPR Guideline for Urinary Incontinence in Adults,2 which provide in-depth discussions of nursing research involving secondary and tertiary prevention interventions. PRIMARY PREVENTION NURSING RESEARCH

Public Education Little research investigating public education to promote continence is available, although surveys of knowledge level and attitudes recently have been conducted.vs! No studies regarding the efficacy of education on the adoption of preventive continence behaviors have been located, and no experimental and replication studies regardhealth ing urinary continence promotion were found in the nursing literature. The AHCPR Urinary Incontinence in Adults Guideline Panel noted that there is a need to provide public education to dispel misconceptions about incontinence, and for research investigat-

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ing the effectiveness of different pa- to form multidisciplinary teams with tient-teaching models that take into economists, psychologists, administraaccount individual needs at different tive scientists, and others to explore developmental stages. Therefore spe- administrative models that are effec cific areas of nursing research interest tive in initiating and maintaining coninclude the characteristics of effective tinence programs. Specific areas for educational programs for different nursing research include the develop' groups (i.e., postmenopausal women, ment and testing of data management men with benign prostatic hypertro- and direct care delivery systems dephy, persons with limited mobility) signed for existing long-term Care perand the efficacy of educational pro- sonnel and fiscal resources. When sysgrams designed to maintain continence tems are found to be effective, further in vulnerable persons with chronic ill- nursing research is needed to investinesses or conditions. gate the methods to adopt the findings into actual practice.

Health Caregiver Education Several articles reported the general level of caregiver knowledge and attitudes regarding incontinence. 17,32-37 The majority of the articles describe or explore the level of knowledge of formal caregivers. No experimental studies investigating the effects of different types of staff education on patient continence outcomes were located. However, evidence exist in the nursing literature that changing knowledge level alone does not change nursing behavior toward incontinence care in the long-term care setting. 36 Schnelle 38 found that the nursing home staff revert back to former behaviors after a behavioral intervention for incontinence is terminated. However, when individualized performance feedback is given to staff members} levels of assigned toiletings completed are maintained.F Nurses need

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Environmental Modifications The environment often is reported as having an effect on continence status, with access to toilets being the most salient feature. 38-4o Continence, though, is rarely an outcome variable in studies exploring the environments of older adults. No nursing quasi-experimental or experimental studies that manipulated the environment to prevent the development of incontinence were located. Therefore exploratory research is needed to identify environmental characteristics in different health care settings that promote continence. The AHCPR Urinary Incontinence in Adults Guideline Panel also recommended investigating the effect of environmental modifications on the incidence (new cases), as well as prevalence, of incontinence. Programs designed to increase cogni-

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tive and physical functioning may improve access to bathroom and continence. N urs ing research focus should include, (1) the efficacy of mobility-enhancement programs on the incidence and remission of incontinence in frail elders, (2) the effect of behavioral management programs on incidence of incont inence in adults with dementi a, (3) the efficacy of estrogen use in postmenop ausal women to reduce th e incidence of incontinence, and (4) the effectiveness of the use of vaginal cones or pelvic muscle exercises to maintain the pelvic muscle tone.

SUMMARY The purposes of this article are to discuss continence in older adults from a pub lic health perspectiv e, to expand a previously reported conceptual model of continence health promotion, and to provide a primary prevention focus to nursing research efforts regarding con' tinence. The conceptual model shows that the re has been a strong interest in secondary and tertiary prevention strategies, but little interest in primary prevention. Use of the matr ix allows the nurse research er identify primary, sec' ondar y, or tertiary prevention research questions and the target population for study. Historically, nurses have had a central role in the care and management of incontinent people. Nurse s will continue to playa critical role in the evolution of research -based practice that inclu des identification of risks, health promotion , and preventive nu rsing str ategies. • REFERENCES 1. Mc Corm ick KA, Palm er MH. Urinary incontinen ce in older adu lts . An nu Rev Nu rs Res 1992;10,25-53. 2. N ation al Institutes of H ealth Consensus Developm ent Conference. Urinary incontinence in adults. I Am Ceriatr Soc I990J 38,265-72. 3. Agency for Heal th Care Policy and Research. Urin ary incontinence in the adult. Rockv ille, Maryland, Dep artment of Healt h and Human Services, 1992. Rep N OdAHCPR92-0038. 4. Int ernational Continence Society. The stan dardiza tion of terminology of lower uri na ry

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tract fu n ction. Br I Ohstet C ynaecol 1990, 6(SupplP- I 6. 5. Ouslander I. Assessment and treatmen t of incontinence in th e nursing home. In: Katz P, Calkins E, eds. Principles and pra ctices of nursi ng home care. New York, Springer, 1989;247-74. 6. Isaacs B. Ge riatric care , wa ter, w ater everywh ere . . . it's tim e we stopped to thi nk . Royal Soc Health I 1979,99,155-7,165. 7. Ousl ander IC, Zarit SH, Orr NK , Muira SA. Incontinence amo ng elderly com mun itydwelli ng dementia patie nt characteristics, managem ent, and impa ct on caregivers. J Am Ceriatr Soc 1990;38.440-5. 8. Palmer MH , Bone LR, Fah ey M, M arnon I, Steinwachs D. Detect ing ur inary incontinence in older adults durin g hospitalization. Appl Nurs Res 1992;174-80. 9. Ieter KF, Wagner Oil. Incontinence in the American home: a survey of 36,500 people. I Am Ger iatr Soc 1990;38 ,379-83. 10. Hancock E. T he making of a best-selle r. [oh ns Hop kins Magazine 1990;12,19-20. II . Holtz K, Wilson D. The prevalence of female u ri nary incontine nce and reasons for not seeki ng treatment. N Z M ed I 1988, 101,756-8. 12. Dowd TT. Discovering old er women's expe rience of ur inary in conti nen ce. Res Nurs Health 1991;14,179-86. 13. Kunkel SR, Appleb aum RA. Estimating the prevalen ce of long-term disability for an aging society. J Gero ntol 1992;47,S253-60. 14. Hinshaw AS, Heinr ich I. Bloch D. Evolvin g clinical nursing research priorities, a na tional end eavor. I Prof Nurs 1988; 4,398,458-9. 15. Palmer M H . Urinary incontine n ce. Nurs Clin North Am 1990;25:919-34. 16. Fried LP, Bush TL. Morb idity as a focus of preventive health care in the eld erly. Epidemiol Rev 1988;10,48'64 . 17. Wellings C. Ageist attitude s promote urinary incontinence in old er people and can lead to the demoralization of nursing staff . Aust J Ageing 1988;7,6-15. 18. Department of Healt h and Hu m an Servi ces. Fun ctional status of the non instirutional ized elderly, estimates of AD L and IADL difficulties. Resear ch findi ngs 4. Wash ington .D: HHS,1990. Report No.,PHS90-3462. 19. Skoog I, Nilsson L, Palmertz 13, Andreassen L, Svanborg A. A popu lat ion-based study of dementia in 85-year-olds. N Engl J Me d 1993;328,153-8. 20. W ells TF. Social an d psycho logical implications of in contin ence . In , Brock lehurst JC, ed. Urology in the elde rly . New York , Chu rchill -Livin gsrone, I984,I 07-26. 21. Fantl A, Wyman /, McClis h D, et aJ. Efficacy of bladde r traini ng in older wo men wi th ur inary in con tin ence. JAMA 1989;265,60913. 22. Burton I, Pearce L, Burgio K, Engel B, Whitehead W. Beh avioral training for urinary incontinenc e in elderly ambulatory patients. J Am Oeriatr Soc 1988;36,693-8. 23. Wells T. Add itional treatm ents for urinary

incontinence. Top Ger iatr Reha bi l 1988; 3:48-57. 24 . CreasonN,Grybows k i /,Burgen erS , Whippo C, Yeo S, Richardson B. Prompted voidin g therapy for urinary incontine nce in aged iejnale nu rsing hom e residen ts. J A dv N urs 1991;14,120-6. 25 . Hu T , Igou I. Kaltreider L, et a!. A clinical trial of a behavioral th erapy on reduc ed urinary incontinence in nursin g ho m es. lA MA 1989,26I,2656-62. 26. Schnelle I, T raughber 13, Sowe ll V, Newm an D, Petrill i C, Dr y M. Prompted VOidi ng treatment of ur inary incontine nce in nursing ho me pat ients, a behavior man agem ent approa ch for nursing home staff. I Am Ceriatr Soc 1989;37,1051-7. 27 . Engel B, Burgio L, McCormick K, Hawkins A, Scheve A , Leahy E. Behavioral treat ment of incont ine nce in the long-term care settin g. rAm C eriatr Soc 1990;38,36 1-3. 28 . Department of Health and Human Services . Rul es and regu latio ns , ur inary inc ontinenc e . Fede ral Register 1989;54(21),5333-34 . 29. Pieper B, Cl el and V, [ohnson 0 , O 'Reill y J. Inventing urine in continence dev ices for wome n. Image J Nurs Sch 1989;21,205-9: 30. Lindeman CA, Scha ntz D . T he researc h questio n. J Nurs Adm 1982;12:6-10. 31. Lagro-Ianssen T LM, Smi ts AJA, Van We e! C. W om en w ith ur inary in contin en ce, selfperceived w orri es and general pra ctitioners' kn owled ge of problem. Br J Ce n Pr act 1990; 40,331,4. 32. Mi tteness L, Woods S. Social workers' responses to in continence, confusion and mobility impa irments in frail clie nts. I Gerontol Soc Work 1986,9(3),63-78. 33. Brocklehurst J. Professional an d pu blic education abou t in con tinence. I Am C er iatr Soc 1990;38,384-6. 34 . We hb J. Hel p for the elderly confused. N urs Times 1990;86(16),64-8. 35. Yu L, Johnson K, Kaltreider L, Hu T, Bran non D, Ory M . Urinary incontinence, nursing home sta ff reacti on toward res idents . J Gero mol Nurs 1991;17(11),34-41. 36. Campbell Ell, Knight M, Ben son M , Colling J. Effect of an incontin ence training program on nursi ng home staff's knowledge, attitudes, and beh avior. Gerontologist 1991; 31,788 -93. 37. Ch eater F. Nurses' educational preparation an d kn owledge concerning continen ce promotion. J Adv Nurs 1992;17,328-38. 38. Schnelle JF. T reatment of urina ry inconti nence in nursin g h ome patients by p rompted voiding. J Am Ccriat r Soc 1990;38,356-60. 39 . Mi tte ness L. The m anagement of urinary inconti nence by communi ty-living elderly . Gerontologist 1987;27,185-93. 40. W ill iams M , Gaylord S. Role of function al assessment in the evalu ation of ur in ar y Am Geria tr Soc 1990; incontinenc e. 38,296-9. 4 1. Palmer MH , German PS,Ousl ander JG. Risk facto rs for urina ry incontinence one year after nursin g home admission. Res Nurs Health 199 I;14:405-I2.

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42, Dougherty MC, Bishop KR, Mooney RA, Gimotty PA, Williams B. Graded exercise. effect on pressures developed by pelvic muscles, In. Funk SG, Tornquist EM, Champagne MT, Weise RA, eds, Key aspects of elder care. New York: Springer, 1992.21424. 43. Wyman I. Nursing assessment of the incontinent geriatric outpatient population. Nurs Clin North Am 1988;23(1).169-87. 44. Resnick NM. Initial evaluation of the in-

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continent patient. I Am Geriatr Soc 1990; 38.311-16. 45. Norberg A, Odelhog SO, Norberg B, Lundbeck K The urine smell around patients with urinary incontinence. laboratory tests of a diaper impregnated with copperacetate, J Clin Exp Gerontol 1983;5J-9. 46. Schnelle IF, SowellVA, Hu TW, Traughber B. Reduction of urinary incontinence in nursing homes. Does it reduce or increase costs? I Am Geriatr Soc 1988;36.34-9,

47, Yu LC, Kaltreider OL,Hu T,lgou IF, Craighead WE. The ISQ-P tool measuring stress associated with incontinence. I Gerontal Nurs 1989;15(2).9-15.

MARY H. PALMER is a stafffellow at the National Institute of Nursing Research in Bethesda, Maryland.

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