Nursing Staff's Experiences of Providing Toilet Assistance to Elderly Nursing Home Residents with Urinary Incontinence

Introduction: Urinary incontinence is a common condition among elderly. It affects their daily life and quality of life. Toilet assistance may decrease urinary incontinence episodes among elderly. Many nursing home residents do not receive the available evidence-based toilet assistance they need. Aim: The aim of the present study was to describe nursing staff members' experiences of providing toilet assistance to elderly nursing home residents with urinary incontinence. Design: A descriptive design with a qualitative content analysis method was used. Method: Four nurses and seven auxiliary nurses were interviewed in three homogenous focus groups. Data were collected during spring 2015. Results: The most essential opportunity factor for good toilet assistance was the nursing staff's attitude and behavior regarding the elderly's need to visit the lavatory. This resulted in individual toilet assistance in which the elderly's integrity and needs were cared for. Functioning routines and sufficient staff availability were crucial in determining whether the elderly could visit the lavatory. Other enabling factors for good toilet assistance were information and education of staff. The main obstructing factors for good toilet assistance were the elderly's decreased cognitive ability, negative attitudes toward receiving toilet assistance and lack of communication and cooperation between professionals with regard to prescribing and fastening individual incontinence aids. Conclusion: Providing toilet assistance is a considerable nursing intervention for elderly to help them regain continence or contain incontinence, whenever possible. Person-centered incontinence care is important for developing and adjusting toilet assistance based on each older person's individual needs.


Introduction
Toilet assistance is a behavioral intervention in helping older people to manage urinary incontinence (UI) as well as promote continence.Many nursing home residents do not receive the available evidence-based toilet assistance they need [1] [2] [3].There is a need for scientific studies that can describe nursing staff members' experiences of providing toilet assistance in nursing homes.
Urinary incontinence (UI) is a common condition among elderly and affects their daily life and quality of life [3] [4] [5].The International Continence Society defines UI "as any involuntary leakage of urine" [6].In Sweden, there are about 1.8 million persons 65 years of age or older, and 35% -40% of them experience UI.In nursing homes, more than half of residents may be incontinent [3] [5].The prevalence of UI in nursing homes is associated with environmental factors [7] [8] [9], immobility and medical diseases, such as diabetes mellitus, stroke and dementia [5].
Toilet assistance is intended to maintain continence by assessing each person's individual urination habits.Toilet assistance includes prompted voiding, habit training and timed voiding.Prompted voiding means that verbal prompts are used to ask the elderly whether they are wet or dry, and whether they need toilet assistance.If such needs arise, then the staff helps them to the lavatory.Habit training means identifying the elderly person's natural voiding pattern and creating an individualized toileting schedule.Timed voiding is based on predetermined intervals between toiletings [3] [10] [11].There is proven experience suggesting that less urine leakage occurs in residents with dementia who have undergone habit training [12].There is limited scientific evidence suggesting that toilet assistance in the form of prompted voiding in combination with physical training has positive effects on incontinence episodes in frail elderly [1] [2] [3].A review paper showed that prompted voiding combined with use of incontinence aids is the primary conservative behavioral approach to management of UI in older people living in care facilities [11].
The person-centered practice framework proposed by McCormack et al. [13] highlights the importance of the development of effective teamwork, workload management, time management and staff relationships to include patient satisfaction and involvement in care as well as feelings of well-being [13].It is important that nurses working with older people provide person-centered incontinence care [14].Older persons who have developed symptoms of UI should undergo an assessment, the results of which enable nursing staff to work with the individual person to determine whether promoting continence is possible.If the old person is frail, dependent and has significant comorbidities and cognitive impairment, it may be more appropriate to contain UI [15].According to Na-D.Hägglund et al. zarko [15], when continence promotion is inappropriate, the intentions of person-centered care should be to contain UI and provide dignified, respectful care.
Nursing home residents have an increased risk of developing UI compared to other same-age older persons [10].Toilet assistance is a person-centered intervention for nursing home residents with UI.Evidence from staff experiences of providing toilet assistance to nursing home residents are limited [11].No previous study could be found that has focused on the topic.This knowledge can be used to facilitate implementation of toilet assistance among nursing home residents, the intention being to regain continence or contain UI as well as enable the best possible quality of life for each individual.
The aim of the present study was to describe nursing staff members' experiences of providing toilet assistance to elderly nursing home residents with urinary incontinence.

Methods
A descriptive design was used and is appropriate when little is known about a topic [16].

Setting and Participants
The present study was conducted in a nursing home in Sweden during spring 2015.The facility included a dementia ward and a short-term ward, with 46 accommodations in total.A purposive sampling was used, where all informants had at least one year of experience of providing toilet assistance, which allow more detailed questions on the subject matter [16].
Approximately 31 day-/night-shift auxiliary nurses and nine day-/night-shift nurses who had experience of providing toilet assistance in a nursing home were invited to participate.In total, eleven informants, all female day-shift workers, agreed to participate in the present study: seven auxiliary nurses and four nurses.

Data Collection
Three homogenous focus group discussions were conducted in a conference room at the workplace: one with three auxiliary nurses; one with four auxiliary nurses and one with four nurses.The focus group participants had similar educational backgrounds and experiences, which was intended to make them more willing to compare notes, valuations, thoughts and ideas with each other [16].
The first author moderated the interviews and an assistant, with research knowledge in elderly care nursing, was present in all three focus group interviews and took notes on the group discussions.The moderator used a semistructured interview guide containing six open-ended questions to guide the group discussions, Table 1.The interviews began with one open-ended question: "What do you think when you hear the word toilet assistance?"Each interview lasted between 35 to 50 minutes.The interviews were audio-recorded and transcribed verbatim by the two remaining authors.

Data Analysis
A qualitative content analysis method was used to analyzing interview transcripts and discovering patterns and categories.The authors performed the data analysis, using a qualitative content analysis method by Graneheim and Lundman [17] that included manifest (close to the text) analysis.The analytical phase began by reading all transcriptions carefully several times to grasp the meaning of the whole and then dividing it into meaning units.Such a unit could be a sentence, paragraph or page incorporating one meaning corresponding to the study aim.The meaning units were condensed, that is, shortened, but they remained close to the text.The condensed meaning units were further condensed and formed into codes.The various codes were then grouped based on similarities and differences, which generated subcategories and categories.A category can be seen as a thread throughout the codes and often includes a number of sub-categories at varying levels of abstraction, Table 2.

Ethical Considerations
The participants were informed about the study both in writing and orally, and informed consent was obtained from all participants.They were also informed that participation was voluntary and that they had the right to discontinue without any explanation or consequences for themselves.All information was treated confidentially.The Regional Research Ethics committee at Uppsala, Sweden, approved the study (reg.no.Dnr 2014/480).

Findings
The socio-demographic characteristics of the participants are described in Table  The findings are presented in two categories divided into opportunities for and obstacles to good toilet assistance, Table 4.The encounter between the older person and the staff was considered important to identifying and understanding the elderly's needs.The nursing staff identified when the elderly needed to visit the lavatory and then helped them to the lavatory.The staff asked the residents whether they needed toilet assistance.Both nurses and auxiliary nurses thought it was a matter of course to provide toilet assistance, and identifying each resident's natural voiding pattern was an opportunity to provide individual toilet assistance.The staff considered that visiting the lavatory was a basic need for the elderly, and that staff not helping them to the lavatory was an indignity.
I also think that it's a basic need we have.Being able to go to the lavatory is a fundamental need, relieving oneself, being able to pee.You know, simply a fundamental need a person has.(Nurse) The encounter between the older person and the staff was considered important to identifying and understanding the elderly's needs.To provide individual toilet assistance, it was important to ask each elderly person about urination habit needs at admission.Opportunities for good toilet assistance emerged when the staff got to know the older person.On the long-term ward, the staff could more easily identify and follow-up the elderly's urination needs than they could on the short-term ward, where the elderly stay for shorter periods.
According to the staff, being creative was useful when providing toilet assistance.Changing the language from "take a leak/piss" to "pee" and changing the color of the toilet seat were proposals for creative actions.Trying to understand when the elderly needed toilet assistance was like doing detective work.

Safeguarding the Elderly's Individual Differences and Integrity
The staff reported having been able to note early signs of a person needing to visit the lavatory.
… just looking at the older person.What is different now?Now "Agda" is becoming a bit anxious or you take the time to consider what may be wrong… That's what's important.(Auxiliary nurse) The staff felt that providing toilet assistance to men was different from helping women.Sometimes, male residents made "inappropriate proposals" to the female staff during toilet assistance.Among the female residents, there were some who refused toilet assistance from male staff.
Providing toilet assistance should build on respect for the elderly's integrity.The staff said that it was important to ask the older person for permission before taking his/her pants down.Not all older persons appreciated the staff talking out loud about their need for toilet assistance.

Common Values
Today, providing toilet assistance had become a matter of course.According to the nursing staff, older persons are provided toilet assistance more often today than they were before.So I think it was done too little before… You put a diaper on them and sat them in a wheelchair, then the diaper wasn't changed until it was time for bed in the evening.(Auxiliary nurse) The staff felt the outcome of providing toilet assistance was successful each time the elderly reached the lavatory in time, before their incontinence aid or pants got wet.The staff considered that helping the elderly with toilet assistance was an important intervention for containing their incontinence.
Incontinence should be minimized by having toilet assistance even if the elderly residents are not completely dry.They may always need a protective pad, but it should be as minimal as possible, so they don't need the thickest, largest pad available.(Nurse)

Developing Routines
One important factor in promoting good toilet assistance was having established routines.The staffs need to ask each elderly person about urination habits at admission.Every new nursing home resident had to undergo a basic UI investigation to assess individualized needs for toilet assistance, and this should occur before prescribing the appropriate incontinence aid, if one was needed.
If there was a change in the elderly person's condition, it was important to start a new investigation to ensure that he/she received appropriate individual toilet assistance and was prescribed appropriate individual incontinence aids.
Before the staff were a bit lazier.They grabbed a diaper that fit, but now as soon as something changes there is a new assessment.For example, measuring urine leakage, that's something new.(Auxiliary nurse) The staff practice of providing toilet assistance to the elderly began with timed voiding, and then gradually they were able to attend to habit training.

Resources
The staff had received information and training in basic UI assessment, toilet assistance and prescribing and monitoring toilet assistance.Every ward had two continence agents (auxiliary nurses) who were responsible for updating information on new routines and incontinence aids and who also arranged staff meetings.
We have two continence agents on the ward.They provide the information and then we usually get a report at staff meetings.(Auxiliary nurse) On the dementia ward, the staff had in-service training in dementia care, which provided useful information on how to note early signs of a person in need of a lavatory visit.The nurses felt that the axillary nurses on the dementia ward learned each older person's signs better than the auxiliary nurses on the short-term ward did.
The staffing level was another important resource in providing toilet assistance around the clock.The day-shift staffs were, however, unsure about wheth-er the elderly received toilet assistance at night.The night staff said it could be risky to help the elderly to the lavatory, because they often worked alone at night.

The Elderly's Cognitive Ability
Sometimes the staff found it difficult to provide toilet assistance to older persons with dementia, who sometimes did not understand what they were to do in the lavatory.This situation could lead to frustration among elderly residents.At the admission dialogue with the elderly person and his/her relatives, it was sometimes difficult for them to describe the elderly person's urination habits and needs.In such cases, opportunities for individualized toilet assistance were not as good.

The Elderly's Attitude toward Receiving Toilet Assistance
The staff stated that providing toilet assistance had stirred different emotions among the elderly.Several older persons did not want to bother the nursing staff.Others were thankful, but felt they were a burden to the staff.Some elderly were ashamed of asking for help with visiting the lavatory at night.The staff found it more difficult to talk with male than female elderly persons about receiving toilet assistance, owing to the men's embarrassment.
The staff stated that some elderly wanted incontinence aids just to be on the safe side, and others wanted incontinence aids instead of toilet assistance.
And there are older residents who think going to the lavatory is difficult.It's easier to use the pads instead… where I can relieve myself whenever I like.(Auxiliary nurse) According to the staff, the elderly and his/her relatives were more involved in the care and placed higher demands on nursing, though they did not place high demands on receiving toilet assistance.
In my experience, they don't have the same expectations for toileting that they have for choosing what they will have for breakfast, for example.They don't focus the same energy or expectations or importance on being able to use the lavatory.I've never heard anyone say: I want to visit the lavatory at 9 o'clock.(Nurse)

Lack of Co-Operation and Communication between Professionals
The nurses felt there was a lack of co-operation and communication between auxiliary nurses and nurses concerning prescribing and fastening individual incontinence aids.The nurses believed urine leakage had increased among the residents and that this was because the auxiliary nurses did not listen to the nurses' directives.The nurses experienced "us vs. them thinking" among the staff and auxiliary nurses.They said that providing toilet assistance with use of incontinence aids, if needed, is the main conservative treatment for regaining continence or containing incontinence; however, it requires proper fastening of the incontinence aid.
… why don't they do like we say?They are trained in fastening incontinence pads and they do it wrong anyway.…Why is it we can't reach each other?Or are they thinking this is how we've always done it and always will? (Nurse) The nurses meant that it was difficult to get the staff team to carry out padweight tests and fasten incontinence aids, because the auxiliary nurses often believed that changed working routines would lead to increased workload.The auxiliary nurses, however, thought there were too many restrictions on providing individual incontinence aids, for example, when the elderly sometimes needed larger incontinence aids during the night or when they had diarrhea.

Discussion
The most essential opportunity factor for good toilet assistance was the nursing staff's attitude and behavior regarding the elderly's need to visit the lavatory.This resulted in individual toilet assistance that involved seeing to the elderly residents' integrity and needs.Functioning routines and appropriate staffing levels were crucial in determining whether or not the elderly were able to visit the lavatory.Other enabling factors for good toilet assistance were information and education of staff, e.g.provided through in-service training and training offered by continence agents.The main obstructing factors for good toilet assistance were the elderly persons' cognitive ability and attitudes toward receiving toilet assistance as well as lack of communication and co-operation between professionals with regard to prescribing and fastening individual incontinence aids.
A study on staff members' attitudes and ability to imagine elderly residents' situation showed that empathy is vital to ensuring that the elderly's needs regarding visiting the lavatory are met.Person-centered care is based on the attitude that nursing staff should offer the elderly dignified and respectful care, ensure the elderly's needs are met, and that the elderly's autonomy should be protected and their own resources be made use of [13] [15].In cases where the elderly cannot self-initiate requests for toileting, for example in cases of dementia, the nursing staff must recognize these signs and provide good toilet assistance, which the staffs in the present study were able to do.The staffs, however, need continuing in-service training in dementia care, for example, in how to manage harassment when providing toilet assistance.
In the present study, the staff found it more difficult to talk with male than female elderly persons about receiving toilet assistance, owing to the men's embarrassment.It is important to have a gender perspective when providing person-centered incontinence care.DeMoraes et al. [18] stated that men with UI often experienced impotence, poor mental health, decreased self-esteem and that these symptoms have implications for their manhood.For this reason, in their care decisions, staff should deal with the issue and point out that UI is a com-mon condition in men and that help is available.In the present study, female residents preferred not to talk about their UI with male staff.The reason could be that the women felt uncomfortable with male staff in these situations.Hägglund [19] stated that providing toilet assistance could involve the risk of violating someone's privacy.The nursing staff should therefore be aware of emotions and experiences in connection with UI problems commonly found among the elderly [3] [20].
It is vital that nursing staff work with individual toilet assistance.Ageing and the long-term conditions associated with ageing increase the risk of UI for the individual [21].There is proven experience suggesting fewer UI episodes in nursing home residents with dementia who have undergone habit training [12].The nursing staff in the present study received training in providing toilet assistance in the form of prompted voiding, habit training and timed training.The staff practice of providing toilet assistance to the elderly residents began with timed voiding; gradually, however, they could begin habit training.Having adequate staffing levels [13] was another important resource for providing toilet assistance around the clock.However, the night staff meant that it could be risky to help the elderly to the lavatory, because they often worked alone at night.Narzako [15] stated that the goal could be to promote continence during the day and manage incontinence at night.
Our findings showed that development of routines provides opportunities to include timed voiding and habit training in basic incontinence care.Staff members need to ask each elderly person about his/her urination habits at admission.The foundation of toilet assistance is to make it more personalized, so that every old person receives individualized toilet assistance and correct prescription of individual incontinence aids, when needed [10].The nursing staff may understand the routines, but need time and appropriate staffing levels [13] to provide good toilet assistance around the clock.The staff who participated in the present study stated that the elderly preferred large incontinence aids at night and did not wish to disturb the night staff, given the lack of staff and the exhaustive routines they must perform at night.
The continence agents were important resources on the wards and provided crucial information and training to colleagues concerning new routines and incontinence aids.Having two agents on each ward was an enabling factor and in accordance with the provincial guidelines in UI among elderly [22].
The present study revealed a lack of communication and co-operation between professionals.The nurses felt the auxiliary nurses did not follow their directives, especially with regard to using individual incontinence aids.The auxiliary nurses meant that they sometimes had to use larger incontinence aids, for example, at night.Lack of communication may be due to professionals not having the same information.Did the nurses understand the auxiliary nurses who stated that the prescribed incontinence aids were not proving sufficient?Was there any action plan for these problems?Did the auxiliary nurses understand how to assess UI, carry out pad-weight tests before prescribing individual incon-tinence aids and fasten in continence aids?The nurses meant that fastening incontinence aids properly and providing toilet assistance could lead to decreased workload.The nurse is responsible for the entire prescription process and plays an essential role in teaching pad-weight testing [22].Nurses play a key role in preventing and treating UI within elderly care [23] [24].Moreover, the nurse is also responsible for supporting dissemination and use of national and local guidelines [25] [26].

Strengths Limitations of the Study
Three criteria are used to assess the trustworthiness of the findings: credibility, dependability and transferability [27].Credibility was ensured by using purposive sampling; all informants had at least one year experience of providing toilet assistance for elderly in a nursing home.However, none of the night-shift nursing staff participated, which may have affected the findings.Examples from the data analysis were described in the methods section, and citations from meaning units belonging to the subcategories were presented, representing both auxiliary nurses and nurses.
Dependability was ensured through use of a semi-structured interview guide.However, no pilot interviews were conducted before initiating the study, which may have affected the findings [16].All authors analyzed the interview texts and critically discussed the data to ensure that they are original [16].Repeated analyses were conducted until the subcategories were mutually exclusive and good consistency was achieved [27].
The present findings can be transferred to nursing homes.The reader can follow the structure of the study, from the sampling and analysis process to the findings, which increases the study's transferability [27].

Conclusions and Clinical Implications
Providing toilet assistance is a considerable nursing intervention for elderly to help them regain continence or contain incontinence, whenever possible.Person-centered incontinence care is important in developing and adjusting toilet assistance based on each older person's individual needs.
For elderly persons, toilet assistance can increase quality of life.Visiting the lavatory is a human right.For the staff, when providing toilet assistance it is important to develop methods for treating elderly persons from different cultures and with different values.At the societal level, providing good toilet assistance may counteract the development of UI among the elderly and decrease the costs of waste management and laundry services.Ethical aspects in conjunction with providing toilet assistance for the elderly persons should be considered in person-centered incontinence care.

3
. The auxiliary nurses were between 25 -63 years of age and had worked in the nursing home between 2 -29 years.Corresponding figures for nurses were 30 -52 years of age and 2 -15 years of work experience in the current position.The nurses had all received training in incontinence care.

Table 1 .
Interview guide.How does the elderly signal his/her need of toilet assistance?How do you pick up the elderly's need of receiving toilet assistance in time?How do you experience the help the elderly receive to arrive at the lavatory in time?

Table 2 .
Examples of the data analysis process from meaning unit to category.

Table 3 .
Socio-demographic characteristics of the participants.

Table 4 .
A summary of categories and subcategories who describe nursing staff experiences of providing toilet assistance to elderly nursing home residents with urinary incontinence.