A competing duty of care to protect residents and promote their autonomy is among the factors influencing continence management in Australian residential aged care, writes Dr Joan Ostaszkiewicz.
Recent findings from research conducted as part of my PhD and postdoctoral fellowship at the Centre for Quality and Patient Safety at Deakin University offer new insights into the management of incontinence and the promotion of continence in aged care.
I plan to use the findings to design a new conceptual framework to promote dignity in continence care for care-dependent older people with chronic health conditions and complex personal, physical, and social care needs.
The framework could inform the design of future education programs for the aged care workforce about incontinence, and to support them in their efforts to provide quality continence care for this population.
The term continence care refers to the range of activities undertaken to assist a person who requires help to manage incontinence and/or maintain optimal continence. As some people can only maintain continence if they receive regular help, continence care encompasses more than the management of incontinence. It may also involve monitoring a person’s bowel function and giving them medication to help them use their bowels, or helping a care-dependent person reach and use the toilet regularly.
Based on observations of practice in two aged care facilities, in-depth interviews with residents’ next-of-kin families, and aged care staff from all over Australia, I believe continence management in aged care homes is influenced by multiple factors.
The main factors are:
- Values and beliefs about cleanliness and dignity
- Beliefs about incontinence in old age and dementia
- A competing duty of care to protect residents and promote their autonomy, and
- Concerns about regulation
These values are reflected in practices that centre on: concealing and containing incontinence; minimising the potential for adverse events such as falls and pressure ulcers; conducting frequent checks of residents’ continence status; and by a disproportionate focus on documentation.
Values and beliefs about cleanliness and dignity
In my interviews with staff and residents’ family members, I found both parties had residents’ dignity at the heart of their concerns. Incontinence represents a state of indignity. Staff set themselves the goal of keeping residents clean and well groomed. Hence, their efforts largely centre on assisting residents with their personal care.
Staff rightly anticipate complaints from other staff, family members, managers, and their colleagues if residents do not appear clean and well-groomed. Whilst staff and family members both place a high values on residents’ cleanliness and appearance, they do not always agree on practices that dignify residents.
These differing beliefs and expectations about residents’ continence care cause considerable angst for both parties, particularly for families.
The new framework will emphasise staffs’ role in validating the relationship between residents and their families, and promote a partnership-approach to care. Family members make an important contribution to residents’ quality of life, and are well placed to share information with aged care staff that will help staff personalise continence care.
Another important element of the proposed framework will be its focus on communication strategies that aim to minimise residents’ shame, humiliation, embarrassment and guilt associated with incontinence and care dependence.
Beliefs about incontinence, old age and dementia
Historically, incontinence was considered to be a pathological and inevitable condition of old age and dementia. This ageist view remains pervasive in all sectors of society, and is often shared by residents, their families, and healthcare professionals, including aged care staff.
It is also possible that aged care staff beliefs about incontinence are influenced by their daily experience of caring for the most dependent group of older people in our society. The problem with accepting the pathological view of incontinence in old age is that approaches to care will emphasise palliation and not active prevention or treatment.
Although there are many medical conditions that make it more difficult for people in aged care to maintain continence, incontinence can improve or resolve when underlying conditions are treated, and/or when toileting programs are implemented.
Drawing on information provided by staff and family members about strategies they employ to optimise residents’ continence, the new framework will support decision-making about the most appropriate form of continence care for each individual resident, including end-of-life continence care.
Competing duty of care to protect residents, promote autonomy
The new framework will also provide guidance for staff about practices that optimise residents’ abilities to maintain optimal continence and/or to exercise their autonomy to self-manage incontinence.
In my PhD study I found that, although aged care staff have a duty of care to respect residents’ right to make decisions about their lives, they also have a duty of care to protect residents from harm.
Staff are constantly juggling care priorities. A situation that causes considerable angst for both resident and staff is when residents who are at risk of falling attempt to walk to the toilet unaided, and there are insufficient staff available to provide the levels of supervision and care required. This situation is problematic for staff because they want to respect residents’ rights to independence and promote their functional abilities, but they also have a duty of care to protect residents from falling.
Staff stated they tended to err on the side of protecting residents, which could in part relate to concerns about regulation. Having the right number of staff available who know the residents and their individual needs is an important factor in meeting residents’ continence care needs.
Concerns about regulation
Regulation is designed to protect residents and to promote high quality care. However, I found aged care staff were highly fearful about possible anomalies in documentation, complaints, and adverse events that could result in sanctions and a corresponding loss of funding.
When regulation is viewed as a barrier to care, it can inversely affect and interfere with staff ability to address a person’s social and emotional needs. This is because fear of regulation can cause staff to adopt an overly-protective approach to resident care, perform frequent and potentially intrusive resident checks, develop overly ambitious care plans that cannot be implemented, and focus on the visible aspects of regulatory compliance.
Therefore, it is important for regulatory bodies to get the right balance between over and under regulation, and to be aware of its impact at the direct care level.
The research resulted in a number of recommendations, including the need for a new conceptual framework to underpin education about continence care for care-dependent older people with chronic health conditions and complex personal, physical and social care needs.
The framework will be informed by research from the combined fields of medicine, psychology and sociology about incontinence in frail older people, and will build on aged care workers’ understandings and aspirations to dignify older citizens in their care.
The Continence Foundation of Australia is keen to work with the aged care sector to identify and address the needs of the workforce in relation to information and education about promoting continence in care-dependent older people. Information on educational opportunities can be found here or email firstname.lastname@example.org for details.
Dr Joan Ostaszkiewicz is a postdoctoral research fellow at the Centre for Quality and Patient Safety Research at Deakin University.