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Correspondence: Address correspondence to Catherine E. DuBeau, MD, Section of Geriatrics, University of Chicago, 5841 South Maryland Avenue, MC6098, Chicago, IL 60637. E-mail: cdubeau{at}medicine.bsd.uchicago.edu
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Abstract |
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Key Words: Urinary incontinence • Nursing homes • Tag F315 • Long-term-care quality
Whether and how surveyors and nursing home staff will perceive and implement this change in focus is not yet known, yet it is of critical importance for the success of the revision in improving urinary incontinence management and outcomes. Based on previous work, several barriers to successful implementation are likely (DuBeau, 2005; Mueller, 2002; Parmelee, 2004): lack of basic knowledge among nursing home staff about urinary incontinence and its management (Bowers, Esmond, & Jacobson, 2000; Campbell, Knight, Benson, & Colling, 1991; Lekan-Rutledge, 2000; Palmer, 1995); general staff attitudes about residents with urinary incontinence (Campbell et al., 1991; Yu et al., 1991); nursing staff perception that the goals of urinary incontinence care are skin integrity with dryness, and having toileting plans in place, but not decreasing incontinence frequency (Mangnall, Taylor, Thomas, & Watterson, 2006; Mather & Bakas, 2002); and the discrepancy between nursing staff report and/or documentation of toileting and its success versus actual observations of care (Remsburg, Palmer, Langford, & Mendelson, 1999; Schnelle, Bates-Jensen, Chu, & Simmons, 2004; Schnelle et al., 2003). Knowledge and attitudes about urinary incontinence may differ among nursing home staff, particularly between nursing assistants, who provide the overwhelming majority of direct incontinence care (toileting, personal cleaning, and applying protective garments); licensed nurses, who supervise nursing assistants; and administrative nursing staff (e.g., Minimum Data Set [MDS] coordinators, directors of nursing [DONs]). Very little is known about urinary incontinence knowledge and attitudes among state nursing surveyors or the congruence of their knowledge and attitudes with those of staff.
The purpose of this study was to survey nursing home staff and state surveyors regarding knowledge about urinary incontinence assessment and management and the F315 revision; attitudes about perceived and/or experienced barriers and challenges to implementing F315 compliance; ongoing and future plans for implementing F315 compliance; and concerns about the F315 revision.
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Methods |
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Identical all-day training sessions were held in Topeka and Wichita in January 2006. Presentations covered current standards and best practices for urinary incontinence and catheter assessment and management (by a geriatrician); the intent of the revision and surveyor criteria for compliance (by the KDOA Director for Long-Term Care, Licensure Certification, and Evaluation); and methods for implementing best practices (by an advanced practice nurse).
Survey Sample
All workshop attendees were eligible and invited to participate. As noted above, they included nursing home staff (administrators, nursing directors [DONs and assistant DONs], MDS coordinators, staff nurses, nursing assistants, and medical staff) and all state nursing home surveyors. At the time of the survey, there were 358 nursing home facilities in Kansas (P. Kelley, KACE, personal communication, October 2006) and 70 state surveyors (D. Deason, KDOA, personal communication, October 2006).
We placed surveys in the packets attendees received at onsite registration. Attendees were instructed to fill out and return the questionnaires (which took about 10–15 min to complete) before the program began. We did not collect personal or facility names from survey respondents and do not have information on the positions and/or facilities of attendees who did not complete the survey because neither KACE nor KDOA collected this information. We obtained institutional review board approval from the University of Chicago, and the study did not require written informed consent.
Survey Design
We designed the survey to capture a range of knowledge areas and attitudes across different types of respondents with variable expertise and training; we did not intend it to function as a summative scale measure. We based the knowledge questions on the F315 revision and relevant research on urinary incontinence in nursing homes (Fonda, DuBeau, Harari, Ouslander, Palmer, Roe, 2005), especially studies of knowledge about urinary incontinence among nursing home registered nurses and nursing assistants (Campbell et al., 1991; Lekan-Rutledge, 2000): for example, whether incontinence is normal with age and/or dementia (Mangnall et al., 2006; Palmer, 1995); knowledge of toileting regimens; and urinalysis collection and interpretation (Juthani-Mehta et al., 2005). We included items regarding two therapies often underutilized in nursing homes, urinary incontinence medications (Briesacher, Stuart, & Doshi, 2002) and catheters for hospice patients (Fainsinger & Bruera, 1991; Nursing Home Comparisons, 2006). To our knowledge, there are no data regarding urinary incontinence knowledge among nursing home administrators and state surveyors. We based the attitude questions on available literature and our own experience. These items covered perceived barriers to F315 compliance, especially staffing levels (Lekan-Rutledge, Palmer, & Belyea, 1998; Mather & Bakas, 2002; Palmer, 1995) and the probability of increased deficiency citations (as had occurred in Kansas); perceptions about whether residents and their families consider urinary incontinence a significant problem (Johnson, Ouslander, Uman, & Schnelle, 2001); the effectiveness of toileting for residents with dementia (Palmer, 1995; Remsburg et al., 1999); concerns about catheterizing residents for postvoiding residual volume; and the responsibility for urinary incontinence assessment (Taunton, Swagerty, Lasseter, & Lee, 2005). We structured these items using a 5-point Likert scale (from "strongly agree" to "strongly disagree," with a don't know option). We intentionally did not use true/false responses for the knowledge items because we wanted to capture respondents' possible uncertainty. We also collected data on respondents' position and titles; where appropriate, the characteristics of their affiliated nursing home (location, size, ownership [for profit vs nonprofit], percentage of residents with urinary incontinence and catheters); and the intended roles of the facility medical director in meeting F315 compliance. At the end of the survey, respondents could write comments in answer to the question "What is your major concern or any other comments about the new F315 tag and surveyor guidance?"
Analysis
We preformed descriptive analyses (frequencies and percentages) for respondent and facility characteristics. We analyzed knowledge, attitudes, and barriers by type of respondent and facility characteristics using chi-square.
We used factor analysis to perform an exploratory evaluation of the component domains of the knowledge and attitude questions, using principal components analysis for the extraction of communalities and varimax rotation. We evaluated factor number through a combination of criteria (Kim & Mueller, 1978): items with factor loadings greater than.40; scree test of eigenvalues; and the criterion of substantive import, using 8% of the total variance as the minimum factor contribution.
We based qualitative analysis (Tesch, 1990) of the write-in comments on grounded theory (Strauss & Corbin, 1998) and used a combination of inductive manifest and latent content analysis (Berg, 1995). The units of analysis included words, short phrases, sentences or sentence fragments, and groups of sentences comprising the entirety of a respondent's comment. We based manifest coding on identifying verbatim words or phrases and counting their occurrence. We based latent coding on inferences of the meaning behind phrases and/or sentences, and we included as units of analysis written emphases and adjacent punctuation, especially capitalization, exclamation marks, and underlining. Two analysts working separately did the initial open coding, identifying recurrent manifest content and generating general themes about the latent content. The analysts together then reviewed their observations and generated a consensus list of manifest content. For each proposed instance of latent content, they compared multiple examples of the supporting verbatim phrases or sentences to reach consensus. The analysts' content lists were then codified, combined, and refined to eliminate redundancy, and each analyst then separately reanalyzed the comments using the revised content list. The analysts then reviewed together the second round of codings, discussed discrepancies, and agreed upon a final consensus coding. We collected the verbatim speech associated with each occurrence of manifest and latent content and grouped them using the coding frame of the profession/position of the respondent who had made the comment.
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Results |
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Table 1 presents results of the principal components analysis. Based on the a priori criteria, the knowledge question model comprised six factors explaining 54% of the total variance. Three items, each of which loaded on separate factors, did not meet criteria for significant factor loading. Two of these items concerned drug treatment for urinary incontinence, suggesting that this topic lies outside of nursing home staff's and surveyors' usual urinary incontinence knowledge. The attitude question model comprised four factors, explaining 57% of the total variance. Two items had borderline significant loadings ("F315 diverts attention from other concerns" =.37, and "F315 results in increased citations" =.39); although both items concerned potential effects of the F315 revision, each loaded on different factors.
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Attitudes About Urinary Incontinence Care and the F315 Guidance Requirements
When asked about specific potential problems in meeting F315 compliance (more than one factor could be chosen), 77% of respondents agreed it was the required documentation, 72% nursing assistant staffing levels, 66% nursing education, 64% staff turnover, 62% physician cooperation, 51% nursing staffing levels, and 39% cost. Neutral responses were highest for nursing staffing levels (23%) and cost (29%). Nursing home surveyors were less likely to cite documentation as a problem (68% vs 85% all others, p =.05), and administrators were more likely to cite cost (64% vs 36% all others, p <.001). Table 3 lists responses to the other attitude items. Administrators were more likely to be concerned that F315 would divert attention from other resident needs (39% vs 33% nurses, 8% surveyors; p <.001) and result in more deficiency citations (87% vs 78% nurses, 62% surveyors; p <.001). Nurses were less likely to respond that they should have primary responsibility for urinary incontinence management (56% vs 77% administrators, 75% surveyors; p =.025). A majority of all respondents (71%) felt that urinary incontinence is one of the most bothersome problems for residents, although surveyors tended to agree more than nursing staff (80% vs 61%, p >.05). Surveyors were more likely to feel that families consider urinary incontinence one of a resident's most bothersome problems (83% vs 76% administrators, 72% DONs/assistant DONs, 61% staff nurses; p =.029). Responses to attitude questions did not differ by facility location, size, or percentage of residents with urinary incontinence or catheters (data not shown). Respondents from nonprofit nursing homes were more likely to feel that physician cooperation would be a problem in meeting F315 compliance (78% vs 61% for-profits, p =.001).
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Additional Comments
Overall, 35% of respondents (n = 173) wrote in additional comments at the end of the survey, some of which were extensive. There were no differences between those who did and did not write comments by position or facility characteristics (data not shown). Content analysis revealed several major themes (Table 4). Although the themes differed somewhat by type of respondent, one should not infer a causal relationship between profession and specific themes from this analysis (Berg, 1995). What was especially striking was the emotional tone in the comments by nurses, evident in both content and punctuation: "It's very challenging to know HOW to make it happen affectively [sic]"; "I also hope the surveyors TRUST us as nurses!"; "You people are all OUT OF YOUR MINDS!"
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Discussion |
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Our results raise important concerns that the F315 revision will be unlikely to improve the quality of incontinence care in nursing homes. Significant knowledge gaps persist despite CMS efforts to disseminate the revision (sending all nursing homes and state survey agencies the new guidance and providing a national Web cast about the revision) and the availability of evidence-based nursing home urinary incontinence guidelines (e.g., from the American Medical Directors Association). We found that misunderstanding of the revision fostered attitudes that will mitigate against successful implementation (Berta et al., 2005), particularly nurses' strong feelings that F315 violates residents' rights. Respondents widely perceived pelvic examinations and catheterization for postvoiding residual volume as invasive and required (postvoiding residual volume is not required for all residents, although it takes close reading of the guidance to determine this); they even perceived toileting as intrusive: "Residents ... do not want anything to do with a incontinence plan!—90 to 100 yr old woman that in their [sic] words ‘dribble’ [and] have done so for 20 years with no plans to try to change." Resident dignity was a particular concern in facilities in small towns where the staff had known many residents prior to their nursing home admission: "My mother, mother-in-law, and great aunt are residents of my facility—I would [not] and will not allow cathing—It would be humiliating and worrisome to older adults."
The ability of staff education programs to ameliorate these knowledge gaps is uncertain. Although some educational interventions have demonstrated short-term gains in staff knowledge about urinary incontinence (Lekan-Rutledge, 2000), others have not (Campbell et al., 1991), and there are few long-term outcome studies. One study improved urinary incontinence outcomes using the systems-level approach of a computerized management program, yet the program required extensive support and feedback to be effective (Schnelle, McNees, Crooks, & Ouslander, 1995). Clinical computer programs are still an anomaly in nursing homes, where they tend to be used only for managerial purposes and MDS reporting, and capital and maintenance costs can be prohibitive. Lack of computer and/or clinical software experience among staff, especially licensed practical nurses and nursing assistants, may decrease the validity, reliability, and utility of such decision-making systems (Alexander, 2006). Replacement of traditional staff education with urinary incontinence quality-improvement programs (e.g., based on principles of continuous quality improvement; Schnelle, Ouslander, Osterweil, & Blumenthald, 1993) has proven only partially effective. In one demonstration project, only one third of nursing homes adopted and maintained the program, another third did so partially, and the remainder not at all (King, 2001). To move staff away from the existing culture of paper compliance—with its focus on MDS-based care plans—to one of quality improvement will require a framing shift and an understanding of process measures (Mor, 2005; Schnelle, Ouslander, & Cruise, 1997). However, researchers have done little work to validate nursing home care process measures or define the performance levels constituting "quality care" (Mor, 2005). Previous work has suggested that the validity of existing urinary incontinence process measures is poor (Schnelle et al., 2004), and "acceptable" rates of urinary incontinence in nursing home residents are unknown (DuBeau, 2005).
The discrepancies between nursing home staff and surveyors in knowledge and attitudes that we found can foster antagonism that will undermine the regulatory-based approach to improving urinary incontinence care inherent in the F315 revision. Organizational learning theory suggests that a lack of congruence between stakeholders' beliefs and values will decrease nursing home staff's ability to gain knowledge and improve urinary incontinence care through interactions with surveyors (Berta et al., 2005). Particularly troubling was our finding that 54% of surveyors believed that a check and change program is never appropriate as the only intervention for urinary incontinence. In fact, F315 specifies that check and change is indicated for residents who have failed prompted voiding trials and/or prefer supportive management. The F315 revision added this specification in response to research on preferences for supportive urinary incontinence care, especially among residents' families (Johnson et al., 2001; Schnelle, Keeler et al., 1995) and to reflect the patient-centered approach to improving quality of life in nursing homes in the CMS 8th Scope of Work initiative for Quality Improvement Organizations (CMS, 2004a).
The F315 revision appears to be another instance of instituting nursing home care standards without a realistic assessment of whether resources and organizational structures exist to meet them, thus creating a barrier to quality improvement (Schnelle et al., 1997). Most facility respondents in our survey indicated that they planned to use supervisory and staff nurses to implement F315 compliance, despite the fact that urinary incontinence management (toileting and check and change) is carried out primarily by nursing assistants, and despite nurses' perception that insufficient nursing assistant staffing is a greater barrier to implementation than nursing staffing. These implementation plans promote a hierarchical structure that is antithetical to cultivating quality of care and nursing retention (Mueller, 2002) and are heavily resource-dependent in a difficult reimbursement climate (DuBeau, 2005; Mueller, 2002). Although some investigators have suggested that greater direct patient care by registered nurses is more likely to improve care outcomes than higher nursing assistant staffing (Horn, Buerhaus, Bergstrom, & Smout, 2005), others have disagreed (Mor, 2005). Higher registered nurse staffing without increased direct care time may not improve urinary incontinence care by nursing assistants because nurses and other clinical professionals often fail to significantly influence nursing assistants, particularly when their interactions are limited or do not validate common nursing assistant care models (Anderson et al., 2005). The ability of quality improvement initiatives to fundamentally change nursing home culture requires strong, flexible, and creative facility leadership (Mueller, 2002), a close working relationship and mutual support between supervisory nursing and nursing assistants, and the inclusion of nursing assistants in educational sessions and implementation plans. Unfortunately, very few nursing assistants attended the Kansas workshops. Because nursing assistants report that toileting is the first task they forgo when staffing levels are low (Bowers et al., 2000), their input is vital to ensure that quality care can be incorporated into their daily routines (Anderson, Corazzini, & McDaniel, 2004). Also, the individualized toileting programs emphasized in F315 require a major change in the perceived efficiency of nursing assistants' usual structured routines of care (Campbell et al., 1991).
Our results indicate that nursing home staff perceive inadequate input from physicians, advanced practice nurses, and medical directors as a barrier to effective F315 compliance. Medical input is especially important given the emphasis in the revision on urinary incontinence assessment, including detailed physical exams, evaluation of medications and comorbidity as causes of urinary incontinence, and differential diagnosis. Nursing staff reported a lack of physician "buy-in" regarding F315: "[The doctors] do not see incontinence as a major problem"; "Physician participation is already a major problem with compliance i.e. [sic] physicians feel guidelines are stupid and don't apply to them." These statements are consistent with a smaller Kansas study that found that medical directors viewed urinary incontinence as a nursing and not a medical problem (Taunton et al., 2005). Indeed, no physicians participated in the Kansas workshops despite the explicit linkage between the F315 revision and the revised Medical Director F501 tag. Educational efforts by groups such as the American Medical Directors Association will reach only a minority of nursing home physicians and will not fix this problem.
Our study has several limitations. We conducted it in a single Midwestern state, and the represented nursing homes were predominantly rural and small. Kansas has fewer residents per nursing home than the national median (48 vs 82; OSCAR Data Current Surveys, 2006) and fewer for-profit facilities (50% vs 66% nationally; OSCAR Data Reports, 2006). However, knowledge and attitude responses did not differ by facility size; the small observed differences by facility ownership and location may have reflected the association between ownership and location (51% of rural facilities were nonprofit vs 44% of nonrural nursing homes, p =.019). We were unable to assess whether survey respondents systematically differed from nonrespondents, and there may have been self-selection of the workshop attendees with a bias toward having less knowledge about urinary incontinence and F315 and more positive attitudes about regulatory changes. However, the attitudes we encountered were considerably negative, suggesting that bias was less likely, and the knowledge deficits we found were similar to those found in other studies (Campbell et al., 1991). In addition, our survey response rate was excellent (85%), and our sample included significant numbers of representative stakeholders (especially remarkable considering the distances attendees had to travel). Because of their very low attendance, we were unable to assess the knowledge and attitudes of nursing assistants, physicians, and advanced practice nurses.
In summary, despite its genesis from nursing home quality-improvement efforts and paradigms, the revised Tag F315 guidance will be unlikely to drive the improvements in the quality of urinary incontinence care it was intended to address. Our results have some encouraging findings: Most respondents agreed that urinary incontinence is not normal with aging and that residents with dementia can respond to prompted voiding. The knowledge deficits and attitudinal barriers we observed potentially could be addressed in several ways: more intensive and quality-improvement-focused educational efforts involving nursing assistants and physicians as well as supervisory staff; simplified tools to help clarify and meet the intent of the F315 revision; and efforts to align the survey process with clear and feasible practice standards. Such efforts alone, however, are unlikely to fundamentally change the present poor level of urinary incontinence care. What nursing homes require to improve incontinence care and outcomes extends beyond specific content knowledge, process measures, and regulatory enforcement. Federal, state, and other urinary incontinence guideline efforts should focus on managerial structures and methods that facilitate quality improvement as a routine part of nursing home care. Further research is needed to determine nursing home residents' and families' definitions and values regarding "quality" urinary incontinence care and how to incorporate them into quality improvement measures and strategies. To fail to do so will only perpetuate "policy without technology" (Schnelle et al., 1997, p. 527), and it indeed will be a fair accusation that "you people are all OUT OF YOUR MINDS!"
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1 Section of Geriatrics, University of Chicago, IL.
2 Wesley Woods Center of Emory University, Atlanta, GA.
3 University of North Carolina at Chapel Hill.
Decision Editor: Linda S. Noelker, PhD
Received for publication October 31, 2006. Accepted for publication March 30, 2007.
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