Research

Nursing Home Staff Members

Attitudes and Knowledge about
Urinary Incontinence: The Impact
Of Technology and Training
Katie Ehlman, Amy Wilson, Renee Dugger, Brandon Eggleston,
Nadine Coudret, and Sherri Mathis

he prevalence of urinary
incontinence (UI) in the
general population of
adult women ranges
from 25% to 45% (Abrams,
Cardozo, Khoury, & Wein, 2009).
The prevalence rate of UI has
been estimated to be between
45% and 70% for residents in
long-term care settings (DuBeau,
Simon, & Morris, 2006; LekanRutledge, 2004; McCliment, 2002;
Newman, Gaines, & Snare, 2005;
Palmer, 2008; Sparks, Boyer,
Gambrel, & Lovett, 2004; Yu,
Kaltreider, Hu, Igou, & Craighead,
1989). UI has been identified as a
pivotal reason for admission to a
skilled nursing facility (Abrams et
al., 2009; Newman et al., 2005).
Additionally, in terms of mortality, disability, and skilled nursing
facility admission, UI has a more
severe impact on frail older

Katie Ehlman, PhD, LNHA, HFA, is an

Assistant Professor of Gerontology and
Director, Center for Healthy Aging and
Wellness, University of Southern Indiana,
Evansville, IN.
Amy Wilson, MS, RT(R), RDMS, RVT, is an
Assistant Professor and Clinical Coordinator, of Diagnostic Medical Sonography,
College of Nursing and Health Professions,
University of Southern Indiana, Evansville,
IN.
Renee Dugger, DNP, RN, GCNS-BC, is an
Assistant Professor and Course Coordinator
of Gerontology Nursing, College of Nursing
and Health Professions, University of
Southern Indiana, Evansville, IN.

2012 Society of Urologic Nurses and Associates

Ehlman, K., Wilson, A., Dugger, R., Eggleston, B., Coudret, N., & Mathis, S. (2012).
Nursing home staff members attitudes and knowledge about urinary incontinence: The impact of technology and training. Urologic Nursing, 32(3).

Urinary incontinence (UI) poses challenges for nursing home personnel. The
authors of this study explored differences in attitude and knowledge about UI
among registered nurses, licensed practical nurses, and certified nursing assistants working in skilled nursing homes before and after study interventions.
Key Words:

Urinary incontinence, nursing home residents, licensed practical nurses (LPNs), certified nursing assistants (CNAs), registered nurses (RNs).

adults when compared to healthy

elders (Abrams et al., 2009).
The findings reported in this
article are from a larger study that
examined the benefits of using
bladder ultrasound scanners in
skilled nursing facilities. Skilled
nursing facilities are defined as
nursing facilities certified to
admit Medicare residents (OBRA87) and provide room, board,
nursing care, and therapies. With
the exception of sub-acute settings, skilled nursing facilities
provide the highest level of med-

ical care for individuals outside

of a hospital. A physician functions as a medical director providing coordination of medical
care for residents. Clinical care is
supervised 24 hours a day by registered nurses (RNs) or licensed
practical nurses (LPNs). Skilled
nursing facility payor sources
include Medicare, Medicaid,
long-term care insurance, and private pay with specific limitations
for each source. Education levels
of skilled nursing facility nursing
staff members vary and can

Brandon Eggleston, PhD, MPH, CHES, is an Assistant Professor of Health Services,

College of Nursing and Health Professions, University of Southern Indiana, Evansville, IN.
Nadine Coudret, EdD, RN, is Dean, the College of Nursing and Health Professions, and
Professor of Nursing, the University of Southern Indiana, Evansville, IN.
Sherri Mathis, DOT, OTR/L, is an Assistant Professor of Occupational Therapy, College of
Nursing and Health Professions, University of Southern Indiana, Evansville, IN.
Acknowledgement: Funding for this project was provided by the Indiana State Department
of Health.

UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 / Epub Ahead of Print

Research Summary
Introduction
Prevention and treatment of urinary incontinence
among nursing home residents is a challenge. Urinary
incontinence is not a normal part of aging, and a basic
knowledge level is important for all health care providers
working in skilled nursing facilities.
Purpose
This feasibility study explored differences in attitude and
knowledge related to urinary incontinence among nursing
personnel who provide care for nursing home residents, and
examined staff attitude and knowledge about urinary incontinence. Data were collected before and after a bladder ultrasound scanner was made available, and an educational
intervention was provided.
Methods
One-hundred and seven nursing staff members from
four skilled nursing facilities provided study data, which
assessed attitude and knowledge about urinary incontinence. Forty-eight nursing staff members provided pre- and

potentially impact the staff attitude and knowledge level related

to UI.
A review of the evidencebased practice (EBP) literature
has determined that any assessment of UI should include the
availability of a bladder ultrasound scanner to determine postvoid residual (PVR) urine
amounts (Centers for Medicare
and Medicaid Services [CMS],
2006; Lekan-Rutledge, 2004,
2006; McCliment, 2002; Newman
et al., 2005; Sparks et al., 2004).
In the three years prior to the
study in the state where the
study took place, seven out of a
potential of 506 skilled nursing
facilities (1.3%) purchased a
bladder ultrasound scanner from
a leading patent-holding U.S.
manufacturer of bladder ultrasound scanners (Coombes &
Millard, 1994; Tubaro, Mariani,
De Nunzio, & Miano, 2010).
These data are consistent with
the findings that bladder ultrasound scanners are rarely found
within skilled nursing facilities
(Tracey, 2001; Wooldridge, 2000),
possibly the result of slow integration of technology in longterm care when compared to
acute and primary health care
settings (Singh, 2010). Potential
barriers preventing widespread
adoption of bladder ultrasound

post-test data, which assessed attitude and knowledge

about urinary incontinence. Post-test data were obtained
after an educational in-service, and a bladder ultrasound
scanner was made available at each study site.
Results
The association between position and belief that bladder disorders are a normal part of aging was significant. The
study intervention resulted in a significant positive change in
attitude toward urinary incontinence.
Conclusion
Certified nursing assistants in this study appear to
believe that bladder disorders are a normal part of aging,
and a knowledge gap related to urinary incontinence exists.
Staff education and the placement of a bladder ultrasound
scanner positively impacted both variables.
Level of Evidence VI
(Melnyk & Fineout-Overholt, 2011)

scanners in skilled nursing facilities include cost (Altschuler &

Diaz, 2006) and lack of clear policies and procedures regarding
indications for the use of bladder
ultrasound scanners as well as
staff knowledge levels pertaining
to UI (Ribby, 2006). Despite these
obstacles, the adoption of bladder ultrasound scanners in
skilled nursing facilities has the
potential to improve UI assessment as well as change knowledge and attitude related to UI
among skilled nursing facility
staff.
The two research questions
that guided this study were: a)
What are the differences in UI
attitude and knowledge between
RNs, LPNs, and certified nursing
assistants (CNAs); and b) are
there changes in attitude and
knowledge about UI among nursing care staff after educational inservices and the placement and
utilization of a bladder ultrasound scanner in a skilled nursing facility?
Literature Review
Preparing the health care
workforce to acquire new skills
and adopt new models to
improve quality of care is a major
challenge for 21st century health
care, as noted in the 2001 and

2008 Institute of Medicine (IOM)

Reports entitled Crossing the
Quality Chasm (2001) and
Retooling for an Aging America
(2008) (Institute of Medicine
[IOM], 2001, 2008). The transfer
of knowledge into practice is a
challenge
in
health
care
(Aylward, Stolee, Keat, &
Johncox, 2003; Berwick, 2003),
and the skilled nursing facility
environment is no exception.
The field of gerontology is not
static (Quinn et al., 2004), and
continuing education programs
with skilled nursing facility staff
should focus on integrating EBP
models to improve skilled nursing facility quality.
In 2005, CMS revised the standards for the evaluation of management of UI and urinary
catheters in skilled nursing facilities. The standard F315 tag places
an emphasis on the assessment of
UI and the evaluation of types of
UI programs appropriate for individual residents (CMS, 2005).
With this regulatory change and
the prevalence of UI in skilled
nursing facilities, there is a need
for skilled nursing facilities to
develop an organizational philosophy related to UI stating that UI is
not a normal part of aging
(Mueller, 2004). Additionally, as
organizations, skilled nursing
facilities should strive for a base-

UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 / Epub Ahead of Print

line UI knowledge level among

nursing staff (Mueller, 2004),
ensuring that staff are aware of the
types of UI. Establishing an organizational philosophy where skilled
nursing facility staff members
have a common belief about UI
has been found to improve the
sustainability of UI programs
(Mueller, 2004; Ostaszkiewicz,
Roe, & Johnston, 2005; Schnelle et
al., 1983). In addition, establishing
UI organizational protocols that
included primary prevention
strategies (such as assisting residents to maintain mobility and
transfer abilities) was found to
reduce the incidence of UI among
low-risk residents (Palmer, 2008).
Educational levels of skilled
nursing facility staff members
vary greatly and can potentially
impact staff members attitudes
and knowledge level related to
UI. Personnel in nursing departments comprise 70% of the
workforce within a skilled nursing facility (Singh, 2010). RNs are
state-licensed and have completed an associate degree in nursing
(ADN), diploma in nursing
(Dipl), or a bachelor of science in
nursing (BSN). Few RNs provide
direct care in skilled nursing
facilities because most are in
administrative positions (Singh,
2010). Additionally, RN hours
per resident day and skill mix
decreased between the years
1997 and 2007 (Seblega et al.,
2010).
The majority of care within a
skilled nursing facility is directed by LPNs, who have graduated
from state-accredited programs.
LPNs working in skilled nursing
facilities are responsible for providing prescribed treatments,
administering medications, collecting data related to resident
needs, communicating with family members, and supervising
CNAs. While LPNs provide
supervision, they often lack formal geriatric and management
education (Cherry et al., 2007;
Quinn et al., 2004). Supervisory
training has been recommended
for both RNs and LPNs working
in skilled nursing facilities (IOM,
2001; Siegel & Young, 2010;
Siegel, Young, Mitchell, &

Shannon, 2008).
CNAs constitute the largest
group of health care workers in
skilled nursing facilities and provide up to 90% of the direct care
to residents (Aylward et al., 2003;
Bowers, Esmond, & Jacobson,
2000). CNAs receive 75 hours of
formal training, as required by the
1987 Nursing Home Reform Act,
and are responsible for the activities of daily living and personal
care of skilled nursing facility residents. CNAs are primarily responsible for managing day-today toileting programs for residents and have been described as
the first-line managers of incontinence (Bowers et al., 2000;
Lawhorne, Ouslander, Parmelee,
Resnick, & Calabrese, 2008). CNA
activities are essential for successful
incontinence
programs
(Lekan-Rutledge,
Palmer,
&
Belyea, 1998). Previous research
notes the lack of CNA involvement in developing UI treatment
programs is a barrier to successful
incontinence programs (Schnelle,
Newman, & Fogarty, 1990).
Research is needed to determine
the effect CNA involvement has
in developing and implementing
UI treatment programs.
Skilled nursing facility nursing staff have varying levels of
academic knowledge about caring
for residents with UI. Thus,
improving staff knowledge related
to UI and improving the attitude
about treating UI among staff rests
with those who provide continuing education in skilled nursing
facilities. CNAs have identified
continuing education as a pivotal
factor in job satisfaction and
reduction in turnover (Ejaz,
Noelker, Menne, & Bagakas,
2008). Lack of basic knowledge
about incontinence among RNs
and LPNs has also been noted
(DuBeau, Ouslander, & Palmer,
2007; Palmer, 1995). RN and LPN
responses differed significantly
when asked to identify reasons for
UI (Palmer, 1995). Significant UI
knowledge and attitude discrepancies exist between state surveyors and skilled nursing facility
staff (DuBeau et al., 2007).
Achievement of commonalities in
UI attitudes where staff believe UI

is not a normal part of aging and

achieving a basic knowledge
threshold pertaining to UI are critical among skilled nursing facility
staff and the skilled nursing facility industry.
This feasibility study explored
differences in attitude and knowledge related to UI among RNs,
LPNs, and CNAs. To the authors
best knowledge, this is an initial
attempt to compare self-reported
responses between these three levels of nursing staff groups in relation to knowledge and attitude
about UI. Additionally, this study
examined skilled nursing facility
staff knowledge and attitude about
UI before and after an intervention
program.
Methods

Project Overview
A mid-western public university collaborated with the
nursing staff of four skilled nursing facilities to assess the benefits
of bladder ultrasound scanners
in skilled nursing facilities. The
study funded and provided for
the purchase and placement of
bladder ultrasound scanners in
each skilled nursing facility.
Additionally, the researchers
developed and provided an EBP
educational program for staff
aimed at improving the management and treatment of UI. A
multi-disciplinary team, the
Bladder Research Team, composed of faculty and staff from
the fields of gerontology, nursing,
health services, occupational
therapy, and diagnostic medical
sonography, conducted the 14month project. The four skilled
nursing facilities participating
were located in a mid-size city
and its surrounding community.
Skilled nursing facilities varied
by size one considered small,
two considered medium, and one
considered large. Facility bed
sizes ranged from 63 to 212, with
a mean bed size of 116. Each
skilled nursing facility accepted
Medicare, Medicaid, and private
pay residents. The study was
reviewed and approved by the
universitys Institutional Review

UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 / Epub Ahead of Print

Board.
Data were collected on multiple levels to determine changes
before and after participating in
the project. Initial meetings
occurred at each skilled nursing
facility. Members of the Bladder
Research Team met with the
skilled nursing facility administrator and members of nursing
administration to review the project. The skilled nursing facility
administrator acknowledged participation by signing a memorandum of understanding.
The two research questions
explored in this study were a) what
are the differences in UI attitude
and knowledge between RNs,
LPNs, and CNAs; and b) are there
changes in attitude and knowledge
about UI among nursing care staff
after educational in-services and
the placement and utilization of a
bladder ultrasound scanner in a
skilled nursing facility? These
researchers gained valuable information on two fronts: a) baseline
information on attitudes about UI
and knowledge levels of UI among
nursing staff members working in
skilled nursing facilities, and b) the
impact of educational interventions and of bladder ultrasound
scanner placement on UI attitude
and UI knowledge. This article
offers a unique contribution to the
field since it compares differences
in attitude and knowledge related
to UI among three levels of nursing
staff in skilled nursing facilities:
RNs, LPNs, and CNAs.

Study Design
A quasi-experimental, withinsubject, longitudinal design (two
time points) was used to assess
within group differences. The Staff
Satisfaction and Incontinence
Knowledge survey was administered to skilled nursing facility
staff prior to attending the first staff
in-service
entitled
Bladder
Ultrasound Basics. Identical surveys were distributed 12 weeks
after the first staff in-service and
placement of the bladder ultrasound scanner in the skilled nursing facility. In addition to the longitudinal data collected, cross-sectional data were gathered at the
first data collection time period

and offered valuable insights on

differences between staff attitude
and knowledge related to UI.

Survey Design
The Staff Satisfaction and
Incontinence Knowledge Survey
was designed to capture staff attitude toward and knowledge
about UI. The tool was designed
by the research team to capture a
range of UI knowledge and attitude across a variety of responders. Knowledge questions were
based on current literature pertaining to UI, as well as consults
from a clinical nurse specialist in
gerontology. Basic demographic
data were self-disclosed to allow
researchers to describe the study
population and compare knowledge and attitude across positions.
Staff members provided written consent to participate in the
study and received a study code,
which provided anonymity to
their responses. Codes were used
for survey identification and data
review. The master employee
name and code list was maintained by a researcher and kept at
the university in a locked private
office. Data were reported in
aggregate form only. No individual employee data were shared.

Study Interventions
The Staff Satisfaction and
Incontinence Knowledge Survey
was completed before the study
intervention as a pre-test and at
the conclusion of the study period
as a post-test. The study intervention consisted of the placement of
the bladder ultrasound scanner
and multiple educational interventions. The first educational
intervention was the Bladder
Scanner Basics staff in-service.
The Bladder Ultrasound Scanner
Basics in-service covered EBP
education related to UI, the
mechanics of using the bladder
ultrasound scanner, demonstration of the scanner, and hands-on
practice time for staff. The
Bladder Research Team members
worked with skilled nursing facility staff to assure that competencies were met for the initial
assessment. A total of nine

Bladder Ultrasound Scanner

Basics in-services were held
among each of the four skilled
nursing facilities over a two-week
period. For staff unable to attend
the Bladder Ultrasound Scanner
Basics in-service, a 17-minute
university-designed and produced DVD reviewing the primary topics of the initial in-service was provided. The DVD was
also designed for newly hired staff
members and as a refresher inservice tool for current staff. The
bladder ultrasound scanner was
placed in each skilled nursing
facility two weeks after the initial
Bladder Ultrasound Scanner
Basics in-service. Twelve weeks
after the placement of the bladder
scanner in the skilled nursing
facility, the Bladder Research
Team provided the skilled nursing facility staff at the four care
settings a voluntary interactive
educational refresher in-service.
In this refresher in-service, skilled
nursing facility staff members
played Bladder Jeopardy, including the topics UI regulations; UI
knowledge; signs, symptoms, and
types of bladder dysfunction; the
use of bladder ultrasound scanner
technology; and treatments for UI.
Two refresher in-services were
held at each study site.
In addition to the formal inservice educational interventions
described, additional educational interventions were developed
and implemented during the
study period in response to feedback received from the skilled
nursing facilities. These included
a) cue cards created for and posted in each skilled nursing facility
to prompt the nursing staff to use
the bladder ultrasound scanner,
b) an incentive program to
increase bladder scanner utilization among staff, c) handouts and
posters to increase basic UI
knowledge in skilled nursing
facility staff, d) personal consults
by members of the Bladder
Research Team, and e) update
reports on bladder ultrasound
scanner utilization to each
skilled nursing facility.

Participants
A convenience sample of

UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 / Epub Ahead of Print

Table 1.
Completion of Pre- and PostStaff Knowledge and Attitude
Survey by Position

Table 2.
A Comparison of Attitudes and Knowledge Regarding UI at
Pre-Test by Position
True n (%)

Pre-Test
Only
n (%)

Pre- and
Post-Test
n (%)

CNA

33 (30.8)

LPN
RN
Total

False n (%)

SIG (Fishers Exact Test)

Bladder disorders are a normal part of aging. (N = 105)

CNAs (n = 33)

27

(81.8)

(18.2)

p = 0.002

14 (29.2)

LPNs (n = 56)

28

(50.0)

28

(50.0)

p = 0.003

58 (54.2)

26 (54.2)

RNs (n = 16)

(37.5)

10

(62.5)

16 (15.0)

8 (16.7)

107

48

Notes: RN = registered nurse, LPN =

licensed practical nurse, CNA = certified nursing assistants.

Urinary incontinence is seen in at least 50% of nursing home residents.

(N = 105)
CNAs (n = 33)

33 (100.0)

(00.0)

LPNs (n = 56)

51

(91.1)

(8.9)

RNs (n = 16)

15

(93.8)

(6.2)

NS

Performing a bladder scan is an invasive procedure. (N = 102)

nursing personnel at the four

skilled nursing facilities provided study data. The administration of each skilled nursing facility identified nursing staff to be
educated to use the bladder ultrasound scanners. Participants provided written informed consent
by signing a consent form prior to
the start of the study. Participant
data were coded to maintain
response anonymity. This population consisted of 180 staff
members and constituted the
potential study population. Of
these, 107 (59%) completed the
pre-test. Individual samples for
each question varied based on
question completion rates. CNAs
encompassed 30.8% (n = 33) of
respondents, 54.2% (n = 58) of
respondents were LPNs, and
15.0% (n = 16) were RNs. Results
are reported by the positions of
CNAs, LPNs, and RNs. Positions
are indicative of education, training, and licensure necessary for
each job category. Four percent
(n = 4) of the respondent group
described themselves as male;
the remaining 89% (n = 95) were
female, with 7% (n = 8) not
responding to the item. At posttest, responses were received
from 48 participants; missing
responses resulted in a data set
with a sample size of 43. Of the
48 post-test respondents, 29.2%
(n = 14) were CNAs, 54.2% (n =
26) were LPNs, and 16.6% (n = 8)
were RNs. Table 1 displays the
study population.

CNAs (n = 31)

10

(32.3)

21

(67.7)

p = 0.009

LPNs (n = 55)

(9.1)

50

(90.9)

p = 0.046

RNs (n = 16)

(6.2)

15

(93.8)

The BladderScan is only used when initially assessing a newly admitted resident.
(N = 105)
CNAs (n = 33)

(8.2)

27

(81.8)

LPNs (n = 56)

(7.3)

51

(92.7)

RNs (n = 16)

(0.0)

16 (100.0)

NS

Decreasing daily fluid intake can prevent episodes of urinary incontinence.

(N = 104)
CNAs (n = 33)

11

(33.3)

22

(66.7)

p = 0.001

LPNs (n = 55)

(5.5)

52

(94.5)

p = 0.007

RNs (n = 16)

(0.0)

16 (100.0)

Notes: Numbers are percentages of respondents by position and listed by number

of respondents. RN = registered nurse, LPN = licensed practical nurse, CNA =
certified nursing assistants, NS = not significant. Bolded responses are correct.
= CNAs and LPNs.
= CNAs and RNs.

Results

Attitudes and Knowledge

Regarding UI at Pre-Test
By Position
Data were obtained from 107
participants. Responses were initially analyzed together and then
separated by position, which
provided a means to compare differences in frequency of responses. A Fishers Exact Test was performed to examine the significance of the association of correct responses among CNAs,
LPNs, and RNs. When providing
a true/false answer to the statement, Bladder disorders are a

normal part of aging, the percentage of correct responses differed significantly by position.
Eighteen percent (n = 6) of CNAs
responded correctly, while 50%
(n = 28) of LPNs responded correctly (p < 0.003). The rate of correct responses also differed significantly by position when comparing CNAs (18%, n = 6) and
RNs (62.5%, n = 10) (p = 0.003).
The rate of correct responses did
not differ significantly (p = 0.410)
by position when comparing
LPNs (50%, n = 28) and RNs
(62.5%, n = 10).
Likewise, when asked to
respond to the true/false statement (Performing a bladder

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scan is an invasive procedure),

the percentage of correct responses differed by position. The
rate of correct responses differed
significantly (p = 0.015) by position when comparing correct
responses among CNAs (67.7%,
n = 21) and LPNs (90.9%; n = 50).
The rate of correct responses differed significantly (p = 0.046)
when comparing CNAs and RNs
(CNAs = 67.7%, n = 21; RNs =
93.8%, n = 15). The rate of correct responses did not differ significantly (p = 0.591) by position
(LPNs = 90.9%, n = 50; RNs =
93.8%, n = 15).
When asked to respond with
true or false to the statement,
Decreasing daily fluid intake
can prevent episodes of urinary
incontinence, the percentage of
correct answers differed by position. The rate of correct responses differed significantly by position, from 67.7% (n = 22) among
CNAs and 94.5% (n = 52) among
LPNs (p = 0.002). The rate of correct responses differed significantly by position, from 67.7% (n
= 22) among CNAs compared
with 100% (n = 16) among RNs
(p = 0.009). The rate of correct
responses did not differ significantly by position, with LPNs
reporting a 94.5% (n = 52) and
RNs achieving a 100% (n = 16) (p
= 0.459). The percentage of correct responses did not differ by
position when responding to the
following true/false statements:
Urinary incontinence is seen in
at least 50% of nursing home residents, and The BladderScan
is only used when initially
assessing a newly admitted resident. These results are represented in Table 2.

Attitudes and Knowledge

Regarding UI at Pre-Test
And Post-Test
Forty-eight staff members
from the four skilled nursing facilities of the 107 participants
(44.9%) provided post-test data,
which were obtained at the conclusion of the study. Pre- and postrespondent groups were compared for differences in frequency
of responses. Only paired surveys
were compared to assure respon-

Table 3.
Attitudes and Knowledge Regarding UI at Pre-Test and Post-Test
Correct Answer
Pre-Test n (%)

Correct Answer
Post-Test n (%)

McNemar Test

Bladder disorders are a normal part of aging. (False) N = 46

Total Staff

23 (50.0)

42 (91.3)

p < 0.001*

Urinary incontinence is seen in at least 50% of nursing home residents.

(True) N = 45
Total Staff

40 (88.9)

42 (93.3)

NS

Performing a bladder scan is an invasive procedure. (False) N = 43

Total Staff

34 (79.0)

38 (88.4)

NS

The BladderScan is only used when initially assessing a newly admitted

resident. (False) N = 45
Total Staff

41 (91.1)

41 (91.1)

NS

Decreasing daily fluid intake can prevent episodes of urinary incontinence.

(False) N = 46
Total Staff

41 (89.1)

44 (95.7)

NS

Notes: Numbers are percentages of respondents. NS = not significant. Bolded

responses are correct.

dents were exposed to the study

interventions. When analyzing
true/false statement responses
among groups, researchers found
that when answering Bladder
disorders are a normal part of
aging, McNemars statistic suggests that there is a statistically significant difference in the proportions of correct/incorrect answers
before and after the interventions
(p < 0.001). The percentage of
correct responses increased from
50% (n = 23) in the pre-test to
91.2% (n = 42) in the post-test.
The proportions of correct
answers did not differ between
pre- and post-test surveys when
responding to the following
true/false statements: Performing a bladder scan is an invasive
procedure, Urinary incontinence is seen in at least 50% of
nursing home residents, The
BladderScan is only used when
initially assessing a newly admitted resident, and Decreasing
daily fluid intake can prevent
episodes of urinary incontinence. These results are presented in Table 3.
Discussion
Despite the variances that
exist in formal educational
preparation for nursing positions

in skilled nursing facilities, a

unified organizational philosophy, defined as a common belief
among all staff members that UI
is not a normal part of aging,
must be pervasive for the success
of a UI program. Once staff members believe that UI is not a normal part of aging, they are more
likely to be diligent in carrying
out a plan of care related to UI.
Additionally, basic knowledge
about types of UI and treatment
for UI is necessary for all skilled
nursing facility staff who provide
direct care and emotional support for residents. Education surrounding UI should extend
beyond nursing to include other
departments, such as physical
therapy, occupational therapy,
social work, activities, and environmental services.
With respect to attitude about
UI, there appears to be an association between position and belief
that bladder disorders are a normal part of aging; CNAs overwhelmingly believe this is true
(82%). Fewer LPNs (50%) and
RNs (38%) responded that UI is a
normal part of aging. There was
no association between RNs and
LPNs and the belief that bladder
disorders are a normal part of
aging. Yet, 50% of LPNs and
37.5% of RNs answered true to

UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 / Epub Ahead of Print

the statement Bladder disorders

are a normal part of aging.
Additional research is necessary
to determine if these data are consistent in a larger sample.
Congruency in the belief that UI is
not a normal part of aging is crucial in the development of an
organizational approach to UI in
skilled nursing facilities. Additionally, an organizational approach to UI has the potential to
change attitude across all staff,
beyond nursing to departments
who see the impact of UI, such as
therapy, social work, activities,
and environmental services. The
knowledge level of CNAs was also
much lower than that of LPNs and
RNs at pre-test when asked to
answer true or false to the following statements: Performing a
bladder scan is an invasive procedure, and Decreasing daily fluid
intake can prevent episodes of
urinary incontinence. This information indicates the need for continuing education tailored to
CNAs in select areas related to UI
in the skilled nursing facility
environment.
These data, which demonstrate that staff believe bladder
disorders are a normal part of
aging in skilled nursing facility
residents, could explain, to some
degree, the lack of UI management care planning and treatment. If skilled nursing facility
staff members believe that bladder
disorders are a normal part of
aging, they may be less likely to
vigorously pursue a non-pharmacological UI treatment program,
such as scheduled voiding or
bladder retraining. Recognition
that bladder disorders are not a
normal part of aging, along with
an appreciation for the negative
impact on the residents quality of
life, should aid in increased value
of and use of these management
and treatment programs in the resident care plan.
The study intervention (placement of scanner and education
sessions) resulted in a significantly positive change in attitude
toward UI. These findings can
potentially affect a staff members
belief in playing a role in improving UI among skilled nursing

facility residents. Raising self-efficacy levels among staff is an

important component in UI treatment in skilled nursing facilities,
just as improving self-efficacy of
those with UI is important
(Abrams et al., 2009). Skilled
nursing facility staff who believe
that UI can be treated and
improved are more likely to
embrace a UI treatment program.
Further research is necessary
and should include extending
this study to a larger sample size,
skilled nursing facilities located
in different areas of the U.S., and
different demographic populations among skilled nursing facility residents. Additional research
is needed to determine if knowledge gained will impact resident
care outcomes related to UI.
Limitations
Participants in the study
sample had varying levels of
years of experience in their jobs,
which was not accounted for in
this study. Study participation
did not provide a control group;
thus, randomization of study participants could not occur. All
appropriate nursing staff personnel were able to participate in the
pre-test, intervention, and posttest. However, data analysis was
performed only on paired surveys, and these data were used to
determine the impact of the
intervention. Nursing personnel
attrition occurred in each skilled
nursing facility, which caused
alterations in study participation.
The study site was limited to one
geographical area. The small
sample size, particularly in select
group measures, could potentially lead to Type II error. Because
of the small sample size and the
use of a convenience sample, the
generalizability of certain items
remains in question.
The Hawthorne effect may
have produced a threat to the
data in that the mere act of
administering the pre-test results
is a sensitization that may cause
an attitude change on the posttest. It is also important to note
that novelty effects resulting
from the use of new technology

by the staff members may have

influenced post-test results.
These results may be reflective of
the staffs eagerness or indifference with regard to incorporating
the bladder ultrasound scanner
into the daily routine.
In addition to the limitations
mentioned above, specific limitations surround the bladder ultrasound scanner. Although bladder
ultrasound scanner results have
shown to be just as accurate as
invasive catheterization methods
for measurement of PVR volumes
(Coombes & Millard, 1994), the
accuracy of the results is operator
dependent. If staff perceived the
PVR volumes as inaccurate, they
may have experienced decreased
confidence in helping a resident
with his or her UI problems.
Decreased staff confidence may
have occurred due to lack of a
staff member who acted as a
bladder ultrasound champion to
encourage repeated use of the
scanner and to monitor potentially inaccurate results.
Implications for Management
And Practice
Findings from this feasibility
study identify distinct implications for management and practice. These include improving
knowledge of UI among all
skilled nursing facility nursing
staff and integrating a bladder
ultrasound scanner into practice.
A knowledge gap about UI
was noted at pre-test among each
classification of nursing staff personnel. It is the contention of the
researchers that treatment of UI
in skilled nursing facilities
would improve if all skilled
nursing facility nursing staff who
provide direct care and emotional support to residents had an
increased knowledge of incontinence that includes types of UI
and EBP UI treatment programs.
This increased knowledge can
potentially improve communication between direct care staff and
charge nurses involved in resident assessment of UI. The
model (see Figure 1) depicts how
an increase in knowledge of UI
among frontline skilled nursing

UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 / Epub Ahead of Print

Figure 1.
Increased Nursing Home Quality Through Knowledge of Urinary Incontinence

An increase in the knowledge of direct care staff related to types of urinary

incontinence and treatment options for urinary incontinence.

An increase in charge nurse knowledge related to types of urinary incontinence

and evidence-based management of urinary incontinence plans for residents.

An increase in the number of evidence-based urinary incontinence treatment

plans for nursing home residents and implementation.

A decrease in resident urinary incontinence episodes.

A decrease in resident stress.

An increase in resident health-related quality of life.

An increase in nursing home quality.

Note: This figure represents a path to increasing nursing home quality through increased knowledge of urinary incontinence
among direct care staff.

facility staff will ultimately lead

to improved skilled nursing facility quality.
EBP research identifies the
need to utilize bladder retraining
programs and scheduled voiding
program for management and treatment of incontinence (DowlingCastronovo & Bradway, 2007;
DuBeau, 2005; DuBeau et al., 2006;
Newman, 2007; Shamliyan, Kane,
Wyman, & Wilt, 2008; Watson,
Brink, Zimmer & Mayer, 2003;
Wyman et al., 2004). A bladder
ultrasound scanner may be utilized in a bladder retraining program to notify the resident when
the bladder is distended and
voiding is required. The scanner
may also be useful when initiating a scheduled voiding program.
If a resident is unable to void,
urinary volume may be scanned
and measured to determine the
need for urinary catheterization.
However, adding another regimen to an already hectic schedule of existing duties can be discouraging for skilled nursing
facility staff.

Finally, the basic understanding that UI is not a normal

part of aging must be integrated
throughout the skilled nursing
facility if any UI program is to be
successful. Basic knowledge
about UI is necessary for all
skilled nursing facility staff providing direct care and emotional
support for residents, including
nursing, therapy, social work,
activities, environmental services, and administration departments.
Conclusion
Increased knowledge related
to UI, the use of the bladder ultrasound scanner for treatment
intervention, and the development of an organizational philosophy about UI are three crucial
determinants for improving UI in
skilled nursing facilities. Data
from this study suggest there is a
knowledge gap and attitudinal
misconception related to UI in
skilled nursing facilities. Educating skilled nursing facility

staff who provide emotional support and care to residents is the

first step in the development of
an organizational philosophy on
UI in skilled nursing facilities.
Further research will determine
if educational interventions and
the placement of a bladder ultrasound scanner will reduce the
episodes of UI and improve quality of life for skilled nursing facility residents.
References
Abrams, P., Cardozo, L., Khoury, S., &
Wein, A.J. (Eds.). (2009). Incontinence (4th ed.). Paris: Health Publication.
Altschuler, V., & Diaz, L. (2006). Bladder
ultrasound. MEDSURG Nursing,
15(5), 317-318.
Aylward, S., Stolee, P., Keat, N., &
Johncox, V. (2003). Effectiveness of
continuing education in long-term
care: A literature review. The Gerontologist, 43(2), 259-271.
Berwick, D. (2003). Disseminating innovations in health care. Journal of the
American Medical Association,
289(15) 1969-1975. doi.org/10.1001/
jama.289.15.1969
Bowers, B., Esmond, S., & Jacobson, N.
(2000). The relationship between
staffing and quality in long-term care

UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3 / Epub Ahead of Print

facilities: Exploring the views of

nurse aides. Journal of Nursing Care
Quality, 14(4), 55-64.
Centers for Medicare & Medicaid Services
(CMS). (2005). Urinary incontinence
F315 483.25(d).
Centers for Medicare & Medicaid Services
(CMS). (2006). CMS manual system
Pub. 100-07 state operations
provider certification. Retrieved
from http://www.cms.gov/transmittals/downloads/r22soma.pdf
Cherry, B., Marshall-Gray, P., Laurence, A.,
Green, A., Valadez, A., Scott-Tilley,
D., & Merritt, P. (2007). The geriatric
training academy: Innovative education for certified nurse aides and
charge
nurses.
Journal
of
Gerontological Nursing, 33(3), 37-44.
Coombes, G.M., & Millard, R.J. (1994).
The accuracy of portable ultrasound
scanning in the measurement of
residual urine volume. The Journal
of Urology, 152, 2083-2085.
Dowling-Castronova, A., & Bradway, C.
(2007) Assessment and management
of older adults with urinary incontinence. Presented at The National
Gerontological Nursing Association
and American Association of
Colleges of Nursing Conference, St.
Louis, MO, October 2008.
DuBeau, C.E. (2005). Improving urinary
incontinence in nursing home residents: Are we FIT to be tied? Journal
of the American Geriatrics Society,
53(7), 1254-1256. doi.org/10.1111/
j.1532-5415.2005.53366.x
Dubeau, C., Ouslander, J., & Palmer, M.
(2007). Knowledge and attitudes of
nursing home staff and surveyors
about the revised federal guidance
for
incontinence
care.
The
Gerontologist, 47(4), 468-479.
DuBeau, C.E., Simon, S.E., & Morris, J.N.
(2006). The effect of urinary incontinence on quality of life in older
nursing home residents. Journal of
the American Geriatrics Society,
54(9), 1325-1333. doi.org/10.1111/
j.1532-5415.2006.00861.x
Ejaz, F., Noelker, L., Menne, H., &
Bagakas, J. (2008). The impact of
stress and support on direct care
workers job satisfaction. The
Gerontologist, 48(1), 60-70.
Institute of Medicine (IOM). (2001).
Crossing the quality chasm: A new
health system for the 21st century.
Washington, D.C.: National Academy
Press.
Institute of Medicine (IOM). (2008).
Retooling for an aging America:
Building the health care workforce.
Washington, D.C: National Academies
Press.
Lawhorne, L., Ouslander, J., Parmelee, P.,
Resnick, B., & Calabrese, B. (2008).
Urinary incontinence: A neglected
geriatric syndrome in nursing facilities. Journal of the American Medical Directors Association, 9(1), 2935. doi.org/10.1016/j.jamda.2007.08.
003
Lekan-Rutledge, D. (2004). Urinary incontinence strategies for frail elderly

women. Urologic Nursing, 24(4),

281-301.
Lekan-Rutledge, D. (2006). The new F-tag
315. Journal of the American
Medical Directors Association, 7(9),
607-610. doi.org/10.1016/j.jamda.
2006.09.001
Lekan-Rutledge, D., Palmer, M., & Belyea,
M. (1998). In their own words:
Nursing assistants perceptions of
barriers to implementation of
prompted voiding in long-term care.
The Gerontologist, 38(3), 370-378.
McCliment, J. (2002). Non-invasive
method overcomes incontinence:
Program retrains residents to recognize the urge to void. Contemporary
Longterm Care, 25(5), 15.
Melnyk, B.M., & Fineout-Overholt, E.
(2011). Evidence-based practice in
nursing and healthcare: A guide to
best practice (2nd ed). Philadelphia:
Lippincott, Williams & Wilkins.
Mueller, C. (2004). Quality improvement
and incontinence in long-term care.
Clinics in Geriatric Medicine, 20(3),
539-551. doi.org/10.1016/j.cger.2004.
04.008
Newman, D.K. (2007). Program of excellence in extended care: Understanding bladder conditions. Bothell,
WA: Verathon
Newman, D., Gaines, T., & Snare, E.
(2005). Innovation in bladder assessment: Use of technology in extended
care. Journal of Gerontological
Nursing, 51(12), 33-41.
Ostaszkiewicz, J., Roe, B., & Johnston, L.
(2005). Effects of timed voiding for
the management of urinary incontinence in adults: Systematic review.
Journal of Advanced Nursing, 52(4),
420-431.
Palmer, M. (1995). Nurses knowledge
and beliefs about continence interventions in long-term care. Journal
of Advanced Nursing, 21(6), 10651072.
Palmer, M.H. (2008). Urinary incontinence quality improvement in nursing homes: Where have we been?
Where are we going? Urologic
Nursing, 28(6), 439-444.
Quinn, M.E., Berding, C., Daniels,
E., Gerlach, M.J., Harris, K., Nugent,
K., Clarke, G. (2004). Shifting paradigms: Teaching gerontological nursing from a new perspective. Journal of
Gerontological Nursing, 30(1), 21-27.
doi: 527733041
Ribby, K. (2006). Decreasing urinary tract
infections through staff development, outcomes, and nursing
process. Journal of Nursing Care
Quality, 21(3), 272-276.
Schnelle J.F., Traughber, B., Morgan. D.B.,
Embry, J.E., Binion, A.F., & Coleman,
A. (1983). Management of geriatric
incontinence in nursing homes.
Journal
of
Applied
BehaviorAnalysis. 16(2), 235-241.
doi:10.1901/jaba.1983.16-235.
Schnelle, J., Newman, D., & Fogarty, T.
(1990). Management of patient continence in long-term care nursing
facilities. The Gerontologist, 30(3),

373-376.
Seblega, B., Zhang, N., Unruh, L., Breen,
G., Paek, S., & Wan, T. (2010).
Changes in nursing home staffing
levels, 1997 to 2007. Medical Care
Research & Review, 67(2), 232-246.
doi:10.1177/1077558709342253
Shamliyan, T.A., Kane, R.l., Wyman, J., &
Wilt, T.J. (2008). Systematic review:
Randomized, controlled trials of
nonsurgical treatments for urinary
incontinence in women. Annals of
Internal Medicine, 148(6), 459W100.
Siegel, E.O., & Young, H.M. (2010).
Communication between nurses and
unlicensed assistive personnel in
nursing homes: Explicit expectations. Gerontological Nursing.
36(12),
32-37.
doi:10.3928/
00989134-20100702-02
Siegel, E.O., Young, H.M., Mitchell, P.H.,
& Shannon, S.E. (2008). Nurse
preparation and organizational support for supervision of unlicensed
assistive personnel in nursing
homes: A qualitative exploration.
The Gerontologist, 48(4), 453-463.
Singh, D.A. (2010). Effective management
of long-term care facilities. Sudbury,
MA: Jones and Bartlett.
Sparks, A., Boyer, D., Gambrel, A., &
Lovett, M. (2004). The clinical benefits of the bladder scanner: A
research synthesis. Journal of
Nursing Care Quality, 19(3), 188192.
Tracey, R. (2001). Bladder ultrasound
reduces catheterizations. Retrieved
from http://imaging-radiation-oncology.advanceweb.com/Article/Bladd
er-UltrasounD
Reduces-Catheterizations.aspx
Tubaro, A., Mariani, S., De Nunzio, C., &
Miano, R. (2010). Bladder weight
and detrusor thickness as parameters of progression of benign prostatic hyperplasia. Current Opinion in
Urology, 20(1), 37-42.
Watson, N.M., Brink, C.A., Zimmer, J.G.,
& Mayer, R.D. (2003). Use of the
Agency for Health Care Policy and
Research Urinary Incontinence
Guideline in nursing homes. Journal
of the American Geriatrics Society,
51(12), 1779-1786.
Wooldridge, L. (2000). Ultrasound technology and bladder dysfunction.
American Journal of Nursing,
100(6), 3-14.
Wyman, J., Bliss, D., Dougherty, M., Gray,
M., Kaas, M., Newman, D., ... Wells,
T. (2004). Shaping future directions
for incontinence research in aging
adults: Executive summary. Nursing
Research, 53(65), 51-10.
Yu, L., Kaltreider, D., Hu, T., Igou, J., &
Craighead, W. (1989). The ISQ-P
tool: Measuring stress associated
with incontinence. Journal of
Gerontological Nursing, 15(2), 9-15.

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