Hypothesis / aims of study
The prevalence of urinary and fecal incontinence, constipation, and toilet difficulties are high among nursing home (NH) residents (1, 2). One way to monitor and evaluate the quality of incontinence and constipation care, is to use nursing sensitive quality indicators (QIs), in other words, measure of changes in health status upon which nursing care may have direct influence. The aim of this study was to develop a consensus list of nursing sensitive QIs for NHs using a modified Delphi method. Our hypothesis was that urinary and fecal incontinence, constipation, established toilet routines, use of urinary catheters, and Urinary Tract Infections (UTI) would be included in this consensus list.
Study design, materials and methods
A non-in-person, two round modified Delphi study was conducted. A project group worked out a list of 20 nursing sensitive QIs. Nineteen were selected from Minimum Dataset (MDS) and one from a national quality assessment system. Among the selected QIs were urinary and fecal incontinence, constipation, established toilet routines, urinary catheters, and UTI. Scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next of kin to NH residents), rated the QIs in two rounds on a Likert scale from 1 (not important at all to evaluate the quality of care) to 7 (very important to evaluate the quality of care). A QI reached consensus after the second Delphi round if median score among all experts was 6 or 7, quartile deviation was ≤ 5, and ≥ 75% of the rating of a QI was within two adjoining values (6 or 7) (3). An optional ‘comment’ section was available for each QI.
Results
In total, 44 experts (13 researchers, 17 healthcare professionals, 14 next of kin) in the first round, and 28 of the same experts (8 researchers, 10 healthcare professionals, 10 next of kin) in the second round, rated the QIs. After the second Delphi round, urinary and fecal incontinence, established toilet routines, and urinary catheters did not reach consensus as important QIs. On the contrary, for the QIs constipation and UTI, there were consensus among all experts, and these QIs were therefore included in the list of important measures of quality of care in NHs (see Table 1).
In total, 13 experts (four researchers, four healthcare professionals, and five next of kin) had added comments to the QIs. The experts underlined that establishing good toilet routines were important for the NH residents, and poor follow up from the healthcare professionals could lead to incontinence, constipation, and UTI, indicating low quality of care. Further, it was emphasized that when evaluating quality of care, it was important to ascertain a distinction between the development of incontinence due to lack of follow-up from healthcare professionals and the development of incontinence due to disease.
Interpretation of results
Our finding that urinary and fecal incontinence did not reach consensus as an important nursing sensitive QI, was somewhat unexpected as nursing interventions may prevent or ameliorate incontinence. One reason that incontinence did not reach consensus may be due to that the participants in our study considered incontinence to be a part of normal ageing and disease in old age, and that nursing interventions would have no preventive effect on the prevalence. Similarly, urinary catheters might be judged as necessary due to symptoms of urinary retention. In other cases, indwelling catheters are not used regularly in NHs.