Hypothesis / aims of study
Suppression of the desire to void is a common practice in nurses (1), however factors influencing nurses’ bladder behaviours at work remain poorly understood (2). This is the first known qualitative study to explore nurses’ experiences of urinary symptoms in the workplace, using a socio-ecological framework of health behaviour.
Study design, materials and methods
This study formed part of an exploratory mixed method investigation of the links between pelvic floor dysfunctions and work. Concurrent to the collection of survey data on this topic we used qualitative design for an in-depth exploration of nurses’ and midwives’ experiences through focus group discussions. Participants were female registered nurses and midwives from a broad range of clinical areas at two urban hospitals in Sydney, NSW Australia. A schedule of open ended questions guided discussion. Nurses were asked 1) "Do you have any experience of bladder (urinary) symptoms or urine leakage at work that you feel comfortable sharing?" 2) "Are your work activities affected by the experience of symptoms?" and 3) "Are there any work activities that provoke symptoms or make the experience of symptoms worse?"
Discussions were recorded, transcribed verbatim into Microsoft Word, then transferred, stored and managed in NVivo software version 11. An inductive thee-stage process guided data analysis. Open coding of data, led to the creation of categories and subcategories of nurses’ and midwives experiences through an iterative process of listening to recordings, in sync with reading the transcribed text. Abstraction of categories provided a conceptual description of the focus group data by the development of major themes and subthemes, guided by a socio-ecological framework of health behaviour (3).
In total, 96 female registered nurses and midwives participated in 12 focus groups held July to September 2016. The mean age of participants was 42.3 years (range 21 to 67 years) and mean number of hours worked each week was 35.5 hours (range 8 to 80 hours). Content analysis confirmed nurses’ experience of urinary symptoms at work as primarily related to delaying the urge to void. While a few nurses disclosed difficulty with management of symptoms of urinary dysfunction such as urinary urgency or incontinence, the main discussions focused on nurses’ experiences of bladder discomfort from delayed voiding at work. Four key themes explain the major influences on nurses’ bladder behaviour: ‘nurse culture’, the ‘nursing team’, ‘nursing role’ and the physical work environment.
For many nurses, a work culture of ‘patient-first’ care over-rode healthy self-care practices. Nurses expressed that they knew that they should be looking after themselves, they just didn’t do it. In addition to ignoring the urge to void, some managed urinary urge by purposeful limiting of fluid intakes. Compounding these common workplace practices, social dynamics of inter-personal relationships in the nursing team, between colleagues and with the team leader or nurse manager, influenced nurses’ actual or perceived ability to leave patient care for toilet or rest breaks. Further, there were barriers to voiding opportunities arising from practical demands of the nursing patient-care role, fueled by insufficient staffing. Finally, inadequacies in accessibility of female amenities due to distance from or insufficient number in the work area, reinforced nurses’ poor self-care practices.
Interpretation of results
The influence of the workplace on a nurses’ response to bladder cues for bladder emptying is complex, dependent on several mediating influences. Planning for voiding opportunities in an individuals’ cultural, social and environmental context is a normal behaviour to maintain continence and effectively manage symptoms of urinary dysfunction. In nurses however, there are several occupational barriers that restrict autonomy over their bladder function. Further, the common practices of delaying voiding and limiting fluids are modifiable behaviours that may be detrimental to health. Solutions for the prevention of nurses' urinary symptoms in the workplace will require strategies that address cultural and social factors, as well as issues of workforce management and toilet access. Practical changes in work environments such as increased staffing, regulation of breaks and improved access to amenities will support nurses' healthy self care practices including autonomy over bladder function. However, changes to nurses' work culture and the social dynamics of nursing teams to improve self-care bladder behaviours may not be as easily addressed.