Study design, materials and methods
A mixed methods co-design study with synthesis and triangulation of data from:
(i) A scoping review of literature to identify and appraise current evidence about interventions for managing urinary and faecal incontinence and other bladder and bowel symptoms in RACH.
(ii) Identification and review of frameworks and policy documents about aged care, including the Aged Care Quality Standards.
(iii) An online survey of 177 residential aged care stakeholders (family carers and aged care staff) who ranked the importance of factors consistent with good continence care in RACH.
(iv) Qualitative interviews with 14 residential aged care stakeholders to explore their expectations and understanding of best practice continence care in RACH.
(v) Two co-design workshops with 18 residential aged care stakeholders to explore their perspectives about factors to include in a model prototype.
(vi) The design of a draft model and knowledge translation resources, including an education program about the model.
(vii) A pilot test of the education program with 22 staff (6 Registered Nurses, 11 Enrolled Nurses, 4 Personal Care Workers and one Nurse Unit Manager) from two RACH (one rural and one metropolitan RACH) to determine its effects on staff knowledge, and to obtain feedback about its feasibility, appropriateness, acceptability and the extent to which the education program helped in applying the model to practice.
(viii) Qualitative interviews with 13 aged care residents to validate the components of the draft model.
The scoping review of literature yielded 1,776 peer-reviewed papers (of which 223 were included in the final review) and over 500 guidelines, frameworks and policy documents (of which 24 guidelines and five frameworks/policy documents were considered relevant). Synthesis of data from these sources resulted in the development of recommendations that reflected the best available evidence by topic. They included:
• 14 recommendations about caring for a resident with incontinence and other bladder and bowel symptoms
• 7 recommendations about caring for a resident with an indwelling urinary catheter
• 5 recommendations about caring for a resident with incontinence-associated dermatitis
• 5 recommendations about education for the residential aged care workforce
• 13 recommendations about organisational and policy factors that influence the quality of continence care
• 5 recommendations about end-of-life continence care
Analysis of quantitative survey data revealed the following factors were rated as ‘very important’ for good continence care in residential aged care:
• Access to timely staff help (95%)
• Help to reach and use the toilet (91%)
• Help to maintain continence (88%)
• Dignity (92%)
• A skilled and trained workforce (92%)(Figure 1)
Qualitative data from interviews and co-design workshops revealed four themes with respect to the characteristics of best practice continence care in RACH: (1) Person-centred continence care; (2) Practical assistance to optimise a resident’s continence; (3) Staff knowledge, skills, and education; and (4) Adequate resources.
The synthesised and triangulated data were used to design a draft model of continence care underpinned by the following ten principles:
1. Continence care is person-centred through supported shared decision-making
2. Continence care is clinically informed through an assessment process
3. Continence care is informed by the best available evidence
4. Continence care protects a resident’s dignity
5. Continence care optimises a resident’s functional abilities
6. Continence care is timely and responsive
7. Continence care is inclusive and respectful of a resident’s culture, diversity and identity
8. Continence care is safe
9. Continence care is provided by appropriately trained and skilled staff
10. Continence care is appropriately resourced (Figure 2).
The pilot test data revealed post-education improvements in eight of the ten knowledge questions, and 100% agreement on the feasibility, appropriateness and acceptability of the model and education program. 63% rated the education as ‘very helpful’ in applying the model to practice and 37% rated it as ‘somewhat helpful’. A content analysis of resident interviews validated the importance of the components of the draft model.
Interpretation of results
The Best Practice Model of Continence Care in Residential Aged Care promotes an evidence-based, safe, clinically informed, person-centred approach to continence care that aims to optimise a resident’s functional abilities and respond to their individual needs, choices and dignity. Further research is required to assess its contextual relevance for use in long-term care homes in other countries and its impact on practice and resident outcomes broadly.