restorative nursing bladder training program: recommending a strategy

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Restorative Nursing Bladder Training Program: Recommending 6 %,,S.O

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Josephine Glenn, MSN RN CS CRRN Key words

bladder training, restorative program

This article describes a Restorative Nursing Bladder Train- a 50% reduction; and 1 patient showed a 30% reduction. ing program, a performance improvement initiative aimed at helping patients regain bladder control by postponing voiding, and then urinating according to a specific, individualized timetable. Data were collected on 14 patients who participated in the program from April 1999 through Janu- ary 2001. Eight patients achieved a 100% reduction in incontinent episodes; 1 patient documented a 90% reduction; another patient attained an 85% reduction; 3 patients showed

Urinary incontinence affects 15% to 30% of community- dwelling elderly persons, one-third of older adults in acute care settings, and approximately 50% of institutionalized elderly patients (Resnik & Yalla, 1985). It affects an estimated 13 million Americans, including 15% to 35% of the community-dwelling population of people over the age of 60 (Agency for Health Care Policy and Research, 1996). Its burden is substantial and must be measured in medical, psychosocial, and economic terms. Medically, people are predisposed to perineal rashes, pressure sores, urinary infections, urosepsis, falls, and fractures. Psy- chosocially, people are frequently embarrassed, isolated, stig- matized, depressed, and regressed. Economically, in America, more than $8 billion was spent because of incontinence prob- lems in 1984 (Urinary Incontinence Guideline Panel, 1992). This figure exceeds the amount spent annually on dialysis and coronary artery bypass surgery combined.

Urinary incontinence is costly to nursing facilities. Urinary incontinence cost Part A of the Medicare program $8.6 billion in 1995 (Wagner & Hu, 1998), with the cost being directly related to the need for nursing facilitated from secondary prob- lems such as urinary tract infections, skin breakdown and in- fection, falls and subsequent injury, psychological distress, and withdrawal (Engel et al., 1990).

Rising to the challenge The performance improvement initiative that was under-

taken by this facility was the Restorative Nursing Bladder Training program (Collard, 1995). The program was implemented for the purpose of restoring independent bladder control and elimination by helping a patient to postpone voiding and to urinate according to a specific, individualized timetable. To comply with Omnibus Budget Reconciliation Act (OBRA) and federal regulations for our new postacute rehabilitation unit,

Josephine Glenn, MSN RN CS CRRN, is a nurse manager at the Post Acute Rehabilitation Unit Kennedy Health System, Health Care Center at Washington in Sewell, NJ. Address correspondence to Josephine Glenn, Post Acute Rehabilita- tion Unit Kennedy Health System, Health Care Center at Washington, 535 Egg Harbor Road, Sewell, NJ 08080, or e- mail j.glenn @ kennedylzealth.org.

formal restorative nursing programs needed to be developed to maintain patients at their highest possible levels of physical, emotional, and social well-being. The basic goals of nursing restorative programs are to promote mobility, foster ability to do activities of daily living (ADLs), restore continence, prevent contractures, and facilitate communication. The restorative bladder training program was implemented to promote continence.

Restorative nursing is a continuous process that maximizes and prolongs patients' abilities with specific, measurable objectives. Bladder training is a method of behavioral therapy that has been successfully used to reduce the frequency of incontinent episodes in a cognitively intact population (Colling, Newman, McCormick, & Pearson, 1993). The concept of bladder training, originally r e f e d to as bladder drill or bladder discipline, was first described by Jeffcoate and Francis (1966). Bladder training is widely used to treat urinary incontinence in both primary and secondary care, and in institutional settings in the community (Roe, Williams, & Palmer, 2002). Behavioral intervention pro- vides an efficient, low-risk approach to incontinence (Burgio & Goode, 1997). Because of its effectiveness, and the absence of documented side effects, it is an attractive treatment option for many older adults. Reports about bladder retraining have shown it to be effective in treating urinary frequency, urgency, and urge incontinence (Anders, 1999). Reports in the 1iterature.show that prompted voiding is an effective intervention to increase dryness (Palmer, Bennett, Marks, McCormick, & Engel, 1994).

In our restorative bladder training program, the nursing department director was responsible for the implementation, maintenance, and communication of the ongoing program performance outcomes. All staff members participated in moni- toring, evaluating, and-if applicable-changing processes and systems to improve both interdisciplinary and individual performances.

Rehabilitation Nursing Volume 28, Number 1 JanuaryEebruary 2003 15

Bladder Training Program

The organizational resources allocated for the program included pay for attendance at the mandatory staff inservice sessions, and education concerning implementing this program, as well as paying the cost of educational materials. There was an interdisciplinary approach to implementing the program. First, our facility’s medical director, administrator, and director of nursing approved its use. The nurse manager coordinated the bladder restorative process. A nurse completed an assessment to determine if the patient was a candidate for the program.

The staff nurse consults the patients’ physician or a urologist for medical treatment of incontinence. Factors that contribute to incontinence include the use of diuretics, sedatives and hyp- notics, beta blockers, antihistamines, antidepressants, and anti- cholinergic medication. Delirium, infections, urethritis, depression, excessive urine production, restricted mobility, and stool impaction also contribute to urinary incontinence (Urinary In- continence Guideline Panel, 1992).

In our bladder training program, the patient and his or her family members were taught the purpose and expected outcomes and were involved in the program to the extent possible. Physi- cal and occupational therapists evaluated and treated the patients for surface to surface transfer training. A registered dietitian was involved in developing the patients’ individualized hydration plans, and identified the foods and liquids the patients should avoid (caffeine or artificial sweeteners for example), because they cause bladder irritation. Certified nursing assistants (CNAs), supervised by a nurse, helped the patients follow their plans. The activities staff worked with patients to help them-through con- versation, physical, or mental activities-to postpone toileting until the scheduled time. The social worker was available to help resolve issues that were related to incontinence (embarrassment, depression), and the care manager developed the written individualized patient care plan.

The bladder retraining process An assessment to determine if a patient was a candidate for

bladder retraining was done by the charge nurse on admission (see Figure l*). The Bladder Retraining Assessment Form was used. The assessment includes cognition, patient awareness of need to void, stability of health status or medical condition, ability of patient to transfer, and a patient’s desire to be continent. For every “yes” answer, 1 point is given and for every “no” answer, zero points are given. If the total points are 3 or less, the patient is considered not likely to be a candidate for bladder retraining. If the points total from 4 to 7, the patient is likely to benefit from the retraining program. Additional comments about factors that may affect the patient’s ability to participate in the process may be added to the form in the space provided.

*Figures I-5 appear at the end of this article pp. 18-22

Step 1-hydration phase: The primary care staff develops a hydration plan that is based on individual patient preferences and habits. The plan sets fluid intakes of approximately 2000cc to 2500cc daily, as long as intake is not contraindicated by fluid-restricted, patient care management of congestive heart fail- ure, renal disease, or other conditions. A total of 2000cc to 2500cc daily is necessary because increased fluids permit the bladder muscle to stretch and redevelop muscle tone. A fluid intake worksheet is started by the charge nurse.

Step kstablishing a voiding pattern: A voiding pattern sheet is initiated by the charge nurse; the CNAs are responsible for observing the patient every hour in a 24-hour period and marking whether the patient was “wet” or “dry.” This was done for 1 to 2 weeks to establish a voiding pattern, as recommend- ed by Collard (1995). In our unit, because of the short length of stay, voiding patterns are observed for 24 hours (see Figure 2”).

Step hstablishing a timetable for voiding: After the initial pattern is identified through step 2, a plan for voiding times is established that is based on the times the patient is found wet in step 2. Staff members work with the patient to postpone voiding until 5 to 10 minutes before the established wet time, an in- terval sufficient for the patient to get to the toilet before he or she voids. The nursing assistants work with the patients one on one to encourage them to participate in activities to help them postpone voiding until the scheduled time. The goal is to get the patient to void according to the prearranged timetable and not in response to an urge to urinate. Staff members work with this pattern even during the night if that is indicated in Step 2 (Fig- ure 3), and if the patient agrees, until the patient’s continence is restored (see Figure 4*).

If a patient is unable to delay voiding, the time of the un- scheduled void is marked on the worksheet as “UTD” (unable to delay). Steps I and I1 can be done in combination or separately, as discussed above. The hydration plan must be consistently followed, even if the patient is occasionally UTD.

Initial, weekly, and final documentation is done by the charge nurse to show progress, regression, necessary adjustments (e.g. having the patient use a commode instead of ambulating to a bathroom), and final outcome of the plan. The program is care planned by the care manager, showing all steps of the program. Charge nurses must see that the retraining plan is followed and the CNAs must document that the work is completed before they complete their work shifts. For examples of how Steps I1 and 111 were used in our facility, see Figure 3” and 5*, respectively.

Analysis and results Data were collected on 14 patients (9 women, 5 men) from

April 1999 through January 2001. The average age of the participants was 83 years. The primary diagnoses included 4 cere- bral vascular accidents, 2 fractures, 2 congestive heart failures, and 1 each of acute urosepsis, azotemia, dehydration, hyper- glycemia, cellulites, and edema. The anticipated discharge living arrangements were as follows: 10 patients were discharged to home with family support, 2 were discharged to assisted living facilities, and 2 were discharged to long-term care facilities. The average recovery time for the patients (Step I through Step 111) was 18 days. Bladder restoration results for the participants

16 Rehabilitation Nursing Volume 28, Number I January/February 2003

showed that 8 patients had a 100% reduction in incontinent episodes, 1 had a 90% reduction, 1 had a 85% reduction, 3 had a 50% reduction, and 1 had a 30% reduction. The percentage reduction was calculated by dividing the number of incontinent episodes in a 24-hour period after the intervention by the number of episodes in a 24-hour period before the intervention. This quotient was subtracted from 1 .OO, then converted to a percentage and rounded to the nearest whole number.

Table 1 summarizes the recovery time and the number of incontinent episodes for each patient before and after the bladder training program.

Six of the patients were on some form of diuretic therapy; eight were not. A contributing factor to the urinary incontinence may have been the presence of a foley catheter during hospital- ization and before patient admission to our rehabilitation unit. The average length of stay for the rehabilitation of, and treatment for, their primary diagnosis was 47 days.

There were few challenges in implementing this program. The facility’s administrative staff supported it through planning, by educating associates about it, by setting priorities, and by pro- viding paid educational time, resources, and materials, as well as supporting all associates and medical staff members with questions and concerns about the program as appropriate.

To determine long-term effects of the program, post discharge telephone interviews were done in February 2001 with the 14 participants. Three months postdischarge was the time frame in which results were measured. Eight questions were asked to collect data with which to determine continued conti- nency and patiendfamily satisfaction with the program. Five patients had maintained the same level of continence, were sat- isfied with the program, and were likely to recommend it to others. Two patients had died, the telephone of two others had been disconnected, and 5 messages were left that did not bring a re- turn call. We recommend that in the future, telephone calls be

Recovery Preintervention Postintervention Time episodest episodest

Patient (days) 24hrs ( 1 2 ) 24hrs ( 1 2 )

1 14 2 45 3 3 4 14 5 6 6 29 7 34 8 14 9 7

10 13 11 26 12 14 13 7 14 30

2 7 10 5 1 4 15 12 15 6

12 5 8 7

0 0 7 0 0 0 0 6 7 0 0 1 4 1

made within 2 weeks after discharge to obtain more information on long-term effects of the program.

Conclusion As measured by the Restorative Nursing Bladder Training

Program outcomes and postdischarge telephone interviews, the program decreased episodes of incontinence, improved facility quality indicator scores, increased patient satisfaction, and decreased the use of incontinence products.

The psychosocial impact of the program is also important to consider. Often, urinary incontinence imposes a burden on patients and their families. Women with urinary incontinence are often reported to be depressed and embarrassed about their appear- ance and odor (Resnick, 1988). Consequently, excursions outside the home, social interaction with friends and family, and sexual activity may be restricted or avoided entirely (Collard, 1995).

As a result of the bladder training program at our facility, all program participants now receive referrals and recommenda- tions for follow-up at a continence center upon discharge. The center is an outpatient, community-based program that offers a personalized, comprehensive approach to treatment of incontinence, including urological testing to determine its cause and extent. Staff members include a urogynecologist, a board- certified urologist, and a certified nurse practitioner.

The results of this program support the effectiveness of bladder training as an intervention for urinary incontinence. An es- sential element in the success of the program was the support and teamwork of the facility’s nursing staff. A successful program requires commitment and time by staff members and patients. This program has much potential for replication by other facilities. It requires that all incontinent patients be assessed to determine whether they could benefit from a bladder retraining program, and then instituting the program.

Acknowledgments The author acknowledges Jane Sistek, director of nursing,

for her support of the program and assistance with manuscript preparation. This program is successful because of the diligent and caring nature of the entire team at Health Care Center at Washington.

References Agency for Health Care Policy and Research. (1996). Urinary incontinence

in adults: acute and chronic management. Rockville, MD: U.S. Depart- ment of Health and Human Services.

Anders, K. (1999). Bladder retraining. Professiorial Nirrse. 14,334-336. Burgio, K.L., & Goode, P. (1997). Behavioral interventions for inconti-

nence in ambulatory geriatric patients. The Ariiericari Journal of the Medicul Scietices, 314:4, 257-261.

Collard, B.J. (1995). Restorative nursing: A practical guide for building a program. Larson Publishing Company, Westminster, CO.

Colling, J., Newman. D., McCormick, K., & Pearson, B. (1993). Behav- ioral management strategies for urinary incontinence. JWOCN, 2@9-13.

Engel, B.T., Burgio. L.D., McCormick, K.A., Hawkins, A.M., Scheve, A.S., & Leahy, E. (1990). Behavioral treatment of incontinence in the long-term care setting. Joirrrtnl of Attiericarz Geriatric S o c i e t y ,

Jeffcoate, T., & Francis, W. (1966). Urgency incontinence in the female. 3 8 3 6 1-363.

Antericnri Jourtid of Obstetrics arid Gyriecology, 94:604-6 18.

Rehabilitation Nursing Volume 28, Number 1 JanuarylFebruary 2003 17


Palmer, M., Bennett, R.G., Marks, J., McCormick, K.A., & Engel, B.T. (1994). Urinary incontinence: A program that works. The Journal of Long-Term Care Administration, Summer 19-25.

Resnick, N.M. (1988). Voiding dysfunction in the elderly. In S.V. Y a k , E.J., McGuire, & Ebadaw, et al., (Eds.), Neurology and urodynamics: Principles and practice, p. 303-330. New amics: Principles and Prac- tice. New York: MacMillan Publishing Co. Inc.

Resnick, N.M., & Yalla, S.V. (1985). Management of urinary incontinence in the elderly. New England Journal ofhfedicine, 313,800-805.

Roe, B., Williams, K., & Palmer, M. Bladder training for urinary incontinence in adults (Cochrane Review). In: The Chrane Library, Issue 1, 2002. Oxford: Update Software.

Urinary Incontinence Guideline Panel. (1992). Urinary incontinence in adults. Clinical Practice Guideline. AHCPR Pub No. 92-0038. Rockville, MD: Agency for Health Care Policy & Research, Public Health Service. U.S. Department of Health and Human Services.

Wagner, T.H., & Hu, T.W. (1998). Economic costs of urinary incontinence in 1995. Urology, 51:355-361.

Continuing education articles discuss current trends and issues affecting rehabilitation nursing. This continuing education offering (code number RNC-206)

o*ti"*P "@)it A will provide 1 contact hour to those who I* c read this article and complete the appli- v4c&~0 cation form on page 40. This independent study offering is appropriate for all rehabilitation nurses. By reading this article, the learner will achieve the following objectives: 1. Describe the three phases of the bladder retraining

process. 2. Explain how an interdisciplinary approach can be used

to implement this bladder training program. 3. Identify at least three positive patient care outcomes

resulting from a successful bladder training program. I

Step I

I. Cognition

Is able to understand

Is able to communicate

Assessment Dates

Has memory recall I I I I 11. Is aware when needs to void

111. Health status and medical condition are stable and do not affect the urinary incontinence status

IV. Resident is able to transfer without requiring extensive assistance

V. Resident desires to be continent of urine

Further commentshnformation that affect ability in bladder retraining:

SCORING GUIDE (Give one point for each "yes" answer and zero for each "no" answer.) 0 to 3 points = Not a likely candidate for bladder retraining 4 to 7 points = Likely to benefit with a bladder retraining program (Front the manual, Restorative Nursing: A Practical Guide to Building a Program, p.14-34. Reprinted rvitli permission from BJ Collard, author and president of CTS, Inc. Westniinster, CO 80234, 303/426-9712.

18 Rehabilitation Nursing Volume 28, Number 1 JanuaryEebruary 2003

Establishing Voiding PatternNoiding Record Step I1

I I I I I I I

1. Check every hour and mark “D’ for dry and “ W for wet for one to two weeks

2. From this data of graphing wet or dry, should be able to identify a pattern of when resident voids

Voiding pattern identified:

Continue to follow hydration plan of:

Resident Name I.D. Number

(Front the inanual, Restorative Nursing: A Practical Guide to Building a Program, p. 14-36. Reprinted with permission from BJ Collard, author and president of CTS, Inc. Westniinster, CO 80234, 303/426-9712.

Rehabilitation Nursing Volume 28, Number 1 JanuarylFebruary 2003 19

W

a call for syznposia, papers, and posters

for the ARN 29th

Am~ual Educational Conference

8 am 9 am

October 15-18,2003 New Orleans

WET WET

ARN is now accepting abstract submissions for the 2002 conference.

Many exciting and creative ideas are realized everyday in your practice settings, so why not share this information with your colleagues? Paper and poster sessions provide an up-to- date look at the innovative techniques you and your colleagues are developing and implementing in response to nursing care issues. By being a paper or poster presenter, you contribute to the high quality of our conference and provide your colleagues with an opportunity to share in your knowledge.

Sharing your expertise is not the only benefit of presenting at the ARN conference. When your abstract is accepted as a poster, you have the opportunity to win an award for your work. When your abstract is presented as a paper, ARN thanks you for your efforts with a $25 gift certificate toward ARN merchandise. So, let us hear from you!

10 am 11 am

9 Assessment Tools *t. BurnRehab 9 Cancer *:* Case ManagemendManaged Care + Complementary /Alternative Therapies *3 Disease Management 0 Education (patient and staf0 0 Health Promotion 9 Innovative Approaches to Patient Care *3 Nutrition 0 Pediatrics 9 Pulmonary Rehab *:* Rehab in the Community *:* Subacute/Skilled NursingILong Term Care *> Team Building 0 Technology/Computers/Internet *:* Wound Care

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The receipt deadline for symposium, paper and poster ab- stracts is April 1,2003. For more information or for an applica- tion, go to www.rehabnurse.o&eabstmct.htm or call 800/229-7530.

1 Pm 2 um


DRY WET

Step I1 Implemented

3 Pm 4 ~m

DATE/TIME I 3/8/00 7 am I WET

WET DRY

5 Pm DRY

I 12pm I WET I

6 Pm 7 um

DRY

WET

8 Pm 9 ~m

DRY DRY

10 pm 11 Dm

WET DRY

12 am 1 am

DRY DRY

I 2 a m I DRY I

5 am 6 am

I 3 a m I DRY I

DRY DRY

I ~~ 4 a m I DRY I

(Takeitfroin l e niariual, Restorative Nursing: A Practical Guide to Building a Program, p. 14-15. Reprinfed wifk permission from BJ Col- lard, aicthor and president of CTS, bic.. Westniinstcr, CO 80234, 303/426-9712.

20 Rehabilitation Nursing Volume 28, Number 1 January/February 2003

Step I11

1. Mark in times for delayed voiding planlscheduled highlight. 2. Distract patient and work with himiher to delay voiding conscientiously. 3. Take himiher to bathroom at their delayed voiding schedule. 4. Provide positive reinforcement when have successfully delayed voiding. 5. Continue with prearranged schedule even if resident unable to delay void. 6. Mark times “UTD”-unable to delay.

Voiding pattern identified:

Delayed voidinghesisting urge plan:

Continue to follow hydration plan:

Resident Name I.D. Number

(Taken front the martiral, Restorative Nursing: A Practical Guide to Building a Program, p. 14-37. Reprinted with permission from BJ Collard, author and president of CTS, Inc. Westminster, CO 80234, 303/426-9712.

Rehabilitation Nursing Volume 28, Number 1 JanuaryFebruary 2003 21


6am WET WET DRY DRY DRY DRY

(From the manual, Restorative Nursing: A Practical Guide to Building a Program, p. 14-15. Reprinted with permissiorifrom BJ Collard, author and president of CTS, Inc., Westminster, CO 80234, 303/426-9712.

22 Rehabilitation Nursing Volume 28, Number 1 JanuaryEebruary 2003

restorative nursing bladder training program: recommending a strategy

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