Certified Nursing Assistant and Care Assistant Views on Incontinence Care: Insights for the Creation of Quality Improvement Programs

Background: Incontinence is a prevalent condition affecting the health and quality of life of many elderly, particularly those living in institutional settings. Incontinence can lead to skin breakdown and infection and rates of occurrence of both are increasingly being used to assess facility quality. Certified nursing assistants (CNAs) and care assistants (CAs) provide most of the hands-on care in long-term care facilities, yet little is known about their views on managing incontinence.
Aims: This study examined the knowledge and attitudes of CNAs and CAs regarding incontinence care to inform quality improvement (QI) programs related to this condition. Sample: The population consisted of 69 CNAs and 22 CAs, comprising 15 focus groups, from 32 facilities in Georgia in the southeastern United States (US).
Methods: Experts in elder care, including social workers and physicians, consulted on the script and trained facilitators guided sessions. Data were subject to extensive content analysis to identify themes related to incontinence care.
Results: The majority of CNAs and CAs cared for incontinent residents. Both groups were aware of risk factors for the condition, particularly the role of dementia and stroke. They were familiar with the standard clinical consequences, but emphasized the negative effect of incontinence on resident pride and well-being. Bladder and bowel training programs were viewed as highly effective treatments, but all groups stressed that learning resident toileting patterns was most important and could often prevent episodes. Areas for care improvement were: communication between shifts about resident toileting patterns; teamwork when the facility was shortstaffed to maintain toileting schedules; securing clothing that did not impede toileting; and notifications about changes in medications which affect toileting patterns. All staff agreed that some residents could avoid episodes, but did not want to.
Conclusion: The findings here underscore that including CNAs and CAs in designing incontinence QI efforts is critical and one promising path may be to increase staff autonomy in managing the condition. Themes identified here also indicate the need to improve communication between staff, particularly across shifts, and with families. Such adaptations are likely to help reduce episodes and hence minimize negative sequelae from the condition.

Author(s): Victoria Phillips and Deborah Yarmo-Roberts

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