Running head: INCONTINENCE 1

Incontinence among Long Term Care Residents

Kim Beatty, Juley Cole, Chelsey Hansen, Lacy Salazar, & Bailey Thatcher
Dixie State University












INCONTINENCE 2

Incontinence among Long Term Care Residents
The purpose of this paper is to summarize the research about how staffing ratios at long
term care facilities affect resident care, specifically in regards to incontinence.
Practice Question
Nursing staff in long term care facilities often have a heavy resident load with a high
turnover rate of employees. This suggests there may be insufficient staff to assist residents in
their toileting needs, ensuring continent residents remain continent. This project will investigate
the possible correlation of residents developing incontinence due to lack of staff.
P- Patient Population or Problem
The patient population will include males and females residing in long term care facilities
over the age of 65 with daily incontinence for no medical reason.
I- Intervention
The intervention of interest is the nursing staff to resident ratio and how it correlates with
residents being incontinent.
C- Comparison
The comparison intervention is an increase in nursing staff versus a decrease in nursing
staff.
O- Outcomes
Identify the correlation between low nursing staff and incontinence among residents.
The Following Question was Developed
In long term care facilities, does a low nursing staff to resident ratio increase the
incontinence rate of the residents?
Evidence
INCONTINENCE 3

The type of question this paper will examine is causation. Based on this type of question,
the following databases and internet sites searches were utilized: Cohort, Case Control,
Descriptive, or Qualitative studies
Search Items and Results of Search
Search terms developed from the PICO question included: residents in long term care
facilities, 65 years of age or older, male or female, incontinent, nursing staff to resident ratio, and
articles written within the last five years. Our group located five articles based on this criteria
and type of question. These included one cohort study, two systematic reviews and two
qualitative studies. Based on these articles, our groups research had to extend beyond the five
year parameter. The years 2003-2013 were used instead of the last five years because of
insufficient amounts of current research on this topic.
Study One
In a systematic based article written by Thompson (2004), the author indicates the portion
of the population in need of long term care is growing, and that the type of care that residents
require is more labor intensive. Thompson looked at long term care facilities in general and
estimated that 3% to 8% of costs or 1 hour of care/day is spent on managing incontinence in the
nursing home (p. 306). Given that 56% of residents require assistance when toileting, there is a
great demand for staff to meet this need. Thompson shares that when a resident is newly
identified as incontinent, there is a protocol referred to as a Resident Assessment Protocol which
helps staff to identify and correct reversible causes of incontinence. Sadly, most long term care
facilities dont have sufficient staff to implement this protocol. Thompson further summarizes
that nursing staff at these facilities also have a high turnover rate, making it difficult to provide
consistency in resident care which affects adherence to continence programs. Given the
INCONTINENCE 4

information in this article, it supports the correlation between low nursing staff to patient ratio
and its effect on the incontinence rate at long term care facilities.
Study Two
In their study Vinsnes, Harkless, and Nyronning (2007) observed a small random sample
size of 33 patients in a long term care facility in Norway. This sample included sixteen women
and two men who were suffering from urinary incontinence. During the study, the residents were
monitored for 24 hours to determine what education was needed by the staff on how to handle
incontinence among the residents. Afterwards, the residents stated that the staff ignored them or
made them wait to use the toilet, increasing their frequency of incontinence. Other residents
would have liked the nursing staff to be more involved in assisting with incontinence problems,
and some residents simply chose not to seek help from the nurses for their toileting needs. The
residents responses clearly show how highly dependent they are on the staff for providing
toileting assistance, thus increasing their risk for incontinence if their toileting needs were not
met in a timely manner.
Study Three
In the article by Polivka, Salmon, Hyer, Johnson and Hedgecock (2003) called The
Nursing Home Problem in Florida, the issue of nursing care deficiency in relation to budget was
explored. One of these deficiencies focused on incontinence rates in regards to nursing staff
ratios in long term care facilities. This qualitative study showed that Medicare residents were
associated with higher quality deficienciesfrom lower reimbursement and therefore a lack of
resources to pay for adequate staffing (p. 4). Furthermore, it was discovered that when staffing
was below the minimal recommendations set by the Health Care Financing Administration, the
care that residents received was negatively impacted in terms of quality. The incontinence rates,
INCONTINENCE 5

including indwelling catheters and bladder/bowel incontinence, were markedly higher in for-
profit facilities with a high number of Medicare residents then in non-profit facilities which have
increased reimbursement and higher nursing staff ratios.
Study Four
In an article by Rantz et al. (2004) Nursing Home Quality, Cost, Staffing, and Staff
Mix, the article focused on a random sample of 92 long term care facilities in Missouri and
rated their quality of care, scoring them as good, average, and poor. Facilities that received a
good rating all focused on the basics of care. An association was made that the facilities with
the best ratings had a higher number of staff, particularly registered nurses. The article states
staff in the facilities with good resident outcomes were observed doing key care delivery
processes for ambulation, nutrition, and hydration, and toileting and bowel regularity (p. 33).
Although a direct correlation between incontinence and nursing staff ratio was not made in this
article, it defined what good care entails and how that care affects incontinence rates.
Study Five
The final study examined was second in a two-part series titled Nursing Home Staffing
and Training Recommendations for Promoting Older Adults Quality of Care and Life. The
authors (Maas , Specht, Buckwalter, Gittler, & Bechen, 2008) note that the number of nursing
staff is directly related to quality of care in long-term facilities. First and foremost, the article
states that according to the National Citizens Coalition for Nursing Home Reform 2007, failure
to take a resident to the bathroom when requested or prescribed is an example of neglect (p.
125). Despite this mandate, residents are only being toileted an average of 1.8 times per day,
even if on a scheduled toileting program. This low percentage is troubling, especially since its
been shown that many individuals with incontinencecan be maintained continent if they are
INCONTINENCE 6

regularly assisted with toileting (p. 128). According to this article, a main cause of this problem
is the deficit of nursing staff to residents in long-term care. This further supports the idea that
low nursing staff ratios negatively impact the residents risk of developing incontinence in long-
term care facilities.

Summary of Evidence and Practice Recommendation
Conclusion
Based on the studies that were reviewed, evidence shows a direct correlation between
nursing staff to resident ratio when analyzing risk for incontinence in long term care. However,
there are limited studies to date which have been conducted on this topic, necessitating a wider
date range for research articles. Clearly, there is a need for more evidence based practice studies
to corroborate the results.











INCONTINENCE 7

References
Maas, M. L., Specht, J. P., Buckwalter, K. C., Gittler, J., & Bechen, K. (2008). Nursing home
staffing and training recommendations for promoting older adults quality of care and
life: Part 1. deficits in the quality of care due to understaffing and undertraining.
Gerontologic Nursing, 1(2), 134-152.
Polivka, L., Salmon, J. R., Hyer, K., Johnson, C., & Hedgecock, D. (2003).The nursing home
problem in Florida. The Gerontologist, 43(2), 7-18. Retrieved from http://search.proquest
.com.libproxy.dixie.edu/docview/210978036?accountid=27045
Rantz, M. J., Hicks, L., Grando, V., Petroski, G. F., Madesn, R. W., Mehr, D. R., . . . Maas, M.
(2004). Nursing home quality, cost, staffing, and staff mix. The Gerontologist, 44(1), 24-
38.
Thompson, D. L. (2004). Geriatric incontinence: The long-term care challenge. Urologic
Nursing, 24(4), 305-313. Retrived from http://search.proquest.com/docview/2201
66228?accountid=27045
Vinsnes, A. G., Harkless, G. E., & Nyronning, S. (2007). Unit-based intervention to improve
urinary incontinence in frail elderly. Vard I Norden, 27(3), 53-56. Retrieved from http://
search.proquest.com/docview/607933654?accountid=27045