White toilet bowl in a bathroom with black background

Dr Joan Ostaszkiewicz questions whether padding incontinence at night is really the best we can do for people living in residential aged care.

Recently I came across two publications that advocated the widespread use of continence pads to address residents’ continence care needs at night. One of these publications claimed that using disposable continence pads and bed protection pads at night made residents feel more dignified than if they were toileted. The other publication claimed using fewer, but more absorbent pads at night would “protect resident dignity and comfort” and “support a person-centred approach to adult incontinence care.”

Joan Ostaszkiewicz
Joan Ostaszkiewicz

Notwithstanding concerns about the rigour of the research, and potential conflicts of interest, the claims are noteworthy. Does the practice of promoting the use of continence pads to manage residents’ continence care needs at night reflect good or bad care? Is padding incontinence at night, the best we can offer? These are important questions that should invite debate from the nursing profession, the aged care service sector, and more importantly, from residents and their families.

As an academic and a nurse with a clinical background as a continence nurse advisor, I am interested in promoting access to high quality continence care for all people, particularly those who live in a residential aged care facility. However what constitutes quality continence care and what is feasible and appropriate in the context of residential aged care is highly contested.

According to a report by Deloitte Access Economics and the Continence Foundation of Australia, 71 per cent of people living in Australian residential aged care facilities are incontinent of urine, faeces, or both. Likewise, 68 per cent depend on staff for assistance to use the toilet, and would be incontinent if this assistance was not available. Constipation, faecal impaction, urinary urgency and frequency, urinary tract infections (UTIs), and nocturia are also common bladder/bowel symptoms.

Researchers have expressed longstanding concerns an overreliance on continence products to manage incontinence in nursing homes, rather than actively assessing, preventing and treating their incontinence. One study from the US revealed that nursing home residents were infrequently toileted (i.e. an average of 0.5 times per 12 hours) and infrequently changed (i.e. an average of 1.3 times per 12 hours). Another disturbing finding was that night-time continence care was characterised by regular continence care ‘rounds’ that did not take account of residents’ sleep/awake status, and were a major cause of sleep disruption accounting for almost half of all night-time awakenings.

There is no equivalent research about the number of times residents in Australian residential aged care facilities receive toileting assistance, or the average number of times their continence pads are changed, either during the day or the night. However, in my recent PhD study, I interviewed nurses and personal care workers, and conducted observations of day and night practice, and found a ritualistic practice of checking and changing most residents’ pads at least once if not twice per night. The ritual is mainly related to the belief that all residents are intractably incontinent because of their old age and dependent status, and to staffs’ concern that residents are at risk of developing pressure injuries. Staff often claimed using absorbent disposable pads ‘dignified’ and ‘protected’ residents. Another key factor that influenced staff decisions about care was the ratio of staff to residents.

Currently there is little transparency to the decision-making processes that underpin continence care. International evidence-based guidelines about managing incontinence among frail older adults promote an individualised approach that is informed by a comprehensive continence assessment. Decisions about night-time continence care should be informed by objective information about the resident’s:

  • personal preferences,
  • frequency, severity, and type of incontinence
  • skin health,
  • sleep/wake status, and
  • ability to spontaneously move in bed.

A thorough continence assessment will assist in determining the appropriateness of a ‘pad check and change program’, a toileting assistance program, or a combination of both, and the frequency with which to deliver such care. Staff should consider auditing night-time continence care practices to ensure decisions about care are consistent with evidence-based guidelines.

There is a large body of research from other countries demonstrating that daytime toileting assistance programs are effective in reducing residents’ rates of incontinence. However, the uptake and sustained use of these programs by staff under usual care conditions is low. Incontinence rates typically return to baseline levels once the research team leave. This implies that the high rates of incontinence in residential aged care facilities may partially relate to a lack of opportunity to use the toilet, rather than underlying pathophysiological bladder dysfunction alone.

In my PhD study staff cited multiple factors that hindered them from consistently providing residents with assistance to use the toilet, during the day and the night. At night, one such barrier was that staff-to-resident ratios did not support staff using lifting machines to transport highly dependent residents to the toilet as often as residents required. If staffing levels are indeed insufficient to assist residents maintain continence, there is a need to question the ethics and the human rights issues of such under-resourcing.

Another factor that influenced staff decisions about providing continence care was their expectation of how residents would respond. Some residents express their preference for care in a behavioural manner, in other words, by physically resisting staff attempts to check and change their continence pads, or by resisting staff attempts to assist them to the toilet. Arguably, such resistance should be interpreted as a resident’s preference for independent control over their own body. Whilst the Residential Aged Care Accreditation Standards advocate residents’ rights to independence, choice, decision-making, participation and control over their lifestyle, I found staff felt limited in how much they could actually operationalise such rights when it came to managing residents’ incontinence. Staff described having a duty of care to respect residents’ right to decline such assistance; however they also had an equally compelling duty of care to keep residents clean and protect them from pressure injuries.

Ultimately, decisions about providing continence care at night in residential aged care facilities should be based first and foremost on residents’ individual preferences for care. They should also be based on objective data about the frequency, severity, and type of incontinence, the resident’s skin health, sleep/wake status, and ability to spontaneously move in bed. And, where appropriate, family members should also be involved in decision-making about residents’ continence care. While continence pads play an important role in managing intractable incontinence, dignified continence care should never be reduced to a function of having ‘the right pad’ and being changed at regular intervals.

Dr Joan Ostaszkiewicz is a Postdoctoral Research Fellow at the Centre for Quality and Patient Safety Research at Deakin University. Along with her colleagues at Deakin she is conducting research to better understand what ‘quality continence care’ means for people living in residential aged care facilities. To participate, please email rachel.isaacs@deakin.edu.au or phone 03 9246 8318.

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Top tips

  1. Continence products play an important role in the management of incontinence, but should not be the default model of care
  2. Continence care practices should be audited to ensure they align with evidence-based guidelines
  3. Decisions about continence care should be informed first and foremost by residents’ preferences for care
  4. Further information about strategies to prevent or manage incontinence is available from The National Continence Helpline 1800 330 066. Visit the Continence Foundation of Australia website for more resources.

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  1. As soon as my mother moved into a low care hostel I discovered by accident she was given these incontinence pads because there was just not enough people to help her to the toilet. They could have made it easier for her to get to the toilet with more grab rails, etc but no they just gave her pads. And this was one of the better quality places.

  2. As always, if organisations supplied enough staff then residents could have what they prefer and need, but this does not happen. Aged Care Workers are overworked and underpaid – especially personal care workers.

  3. “Incontinence” is preferred by facilities for funding purposes. Staffing is always an issue and private facilities are driven by the all mighty dollar.

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