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Title: Case studies in the nursing management of urinary incontinence in confused, elderly patients
Author: Anderson, Margaret Joan
Awarding Body: University of Edinburgh
Current Institution: University of Edinburgh
Date of Award: 1991
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The nursing care of the confused, elderly patient suffering from urinary incontinence (UI) is poorly understood. The objectives of a study to examine the complex relationships between patient characteristics, the social and physical environment and the organisation of nursing care were to: (i) explore the ways in which nursing staff approached the problem of UI in the confused, elderly patient; (ii) examine the effect of the organisation of care on the management of UI; and (iii) examine the application of principles derived from behavioural psychology to nursing practice. As the issues are complex, an extensive review of literature in four fields was undertaken. Biomedical explanations of UI and the nature of the dementing illnesses were examined and it was concluded that evidence of an environmental component in UI was probable. Models derived from behavioural psychology were found to be inadequate to understand behavioural problems associated with a dementing illness. A contextual-dialectic framework was proposed which provided also the rationale for the study design and research methods. A combination of action-science research using case studies and single case experimental studies provided the best means of exploring the issues and was consistent with evolving thinking in nursing in which the role of the nurse is to facilitate the interaction between person and environment. Two main propositions stated that (i) under the conditions of a routine geriatric model of nursing care, the level of UI in a ward would be high and (ii) under the conditions of an intervention model in which the nurse sought to manage the interaction between person and environment, levels of UI would be reduced. Comparisons from preliminary studies in two psychogeriatric wards and one residential home provided insights that were applied in two main studies. By using the concept of accident to categorise UI as fundamental, predisposing and precipitating factors, two frames of reference, the biological and the social, were linked. Staff were encouraged to reframe the problem of UI through this perspective and to assist in the development and testing of nursing interventions. In a residential home, the legibility of the environment was improved by the use of signposts as recommended by the Department of Health, on the assumption that this would reduce episodes of UI by making toilets easier to locate. Rapid and marked improvement was shown in one of four cases over a period of four weeks following a programme of guided orientation. In a psychogeriatric ward, systematic and sustained interactions between nurse and patient was improved when the organisation of nursing was altered to limit the number of nurses caring for a small group of elderly, incontinent men. Systematic and sustained interaction was improved by alterations in the arrangement of furniture and facilitated prompted voiding. The findings showed a reduction in UI of one third of the baseline figure and an increased appropriate use of the toilet. It was concluded that, to be effective, an intervention like prompted voiding requires a shift from a routine, geriatric model of care to an interventionist model inherent in a process of systematic nursing organised in an integrated code of primary nursing practice. Although nurses are exhorted to adopt a patient-centred and individualised approach to patient care, in practice a powerful conflict exists in caring for an individual in a collective and congregate setting that can be countered only by overt strategies. It was concluded that, while alterations in the environment were necessary, these were insufficient alone to affect UI in the confused, elderly patient and that the active presence of a nurse was required. Recommendations for nursing management, education, practice and research are made.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available