Rona Agnew
PhD Research Student
Critical exploration of nursing practice in post stroke patients with urinary Incontinence
Aim of presentation
• Consider the rationale for the research
• Explore some of the challenges of the
research.
• Demonstrate the process for gleaning
the definition of promoting continence.
Background
• 40-60% of people admitted to hospital
after a stroke will have problems with
urinary incontinence (Thomas et al 2007)
• Impact profound on both individual and
families (Davenport et al, 1996; Tilling et al, 2001)
• Negative impact on activities of daily
living, social relationships and quality of
life (Rodgers et al, 2007)
Nursing Perspective
• It is considered an area of particular nurse
expertise (Waters & Luker 1996; Burton 2000; Burton 2003;
Burton & Gibbon 2005; Booth et al, 2005)
• Nurses play an integral role in continence
rehabilitation (Newman, 1996; Booth, 2007)
INTERESTINGLY however is that it is…….
• Not always visible in nursing behaviours
Literature Review
• Evidence suggests that
– nurses are more inclined to contain
incontinence
– Rather than actively promote continence.
(Dingwall & McLafferty, 2006; Booth et al 2007
Research Question
What are the intentions of nurses to
promote urinary continence in patients
following a stroke?
Aim
Critically investigate current nursing
practice in post stroke urinary
incontinence
Objectives
• Exploring current nursing practice in managing
urinary incontinence within post stroke care
• Investigating the intent of nursing activity in the
management of urinary incontinence in post stroke
patients
• Considering nursing beliefs surrounding the
promotion and management of urinary incontinence
• Developing an explanation of nursing practice in
relation to urinary incontinence following a stroke
Theory of Planned Behaviour
Exploration
of Activities
Exploration of
Salient Belief
Definition
development
Questionnaire construct
Nominal Group
Process
Elicitation
Process
Questionnaire
Developed
Analysis
Analysis
Inform
Case
Study
Analysis
Findings
Questionnaire Development
• Target
• Action
Salient Beliefs
• Context
• Time
Behavioural, Normative and control
Initial Questions
• What do nurses mean when they say
that they „promote continence‟
• What do nurses mean when they say
that they „manage urinary incontinence‟
• Are they the same?
• How do they think and feel about
promoting continence?
Foundation for Building Research
• Needed to know and understand:
1. What was meant by nurses when
they say that they „Promote
Continence‟
2. What were the possible salient
beliefs of nurses towards the
behaviour.
Behavioural Category
List of activities associated with the action
Elicitation of Salient Beliefs
Questionnaire Development
Behavioural Category
Definition for promoting
continence
Elicitation Study
Salient beliefs for
questionnaire construct
Glasgow
Edinburgh
Lanarkshire
3 Major
geographical
sites
Participants
–Registered General Nurses
(n=14)
–Variety of nursing backgrounds
–Variety of experience in
managing urinary incontinence
and promoting continence
Questionnaire Development
Behavioural Category
Definition for promoting
continence
Elicitation Study
Salient beliefs for
questionnaire construct
Nominal Group Process
Aim:
Develop a working definition for promoting
continence that can be used in the
questionnaire
Method:
Nominal Group technique
(Van de Ven & Delbecq, 1972; Van de Ven, & Gustafson 1975;
Bartunek & Murninghan, 1984; Burton, 1987; Allen, Dyas & Jones
2004)
Nominal Group Process (Delbecq et al, 1975)
Step 1
Silent generation of ideas in writing
Step 2
Round Robin recording of ideas on a flip
chart
Step 3
Serial Discussions for clarification
Step 4
Preliminary vote on item importance
Step 5
Discussion of the preliminary vote
Step 6
Final vote
Nominal Group Questions
• 2 questions were used to focus the group
discussions:
– What nursing activities do you associate with
managing urinary incontinence in post stroke
patients?
– What nursing activities do you associate with
supporting recovery from urinary incontinence
in post stroke patients?
Questionnaire Development
Behavioural Category
Definition for promoting
continence
Elicitation Study
Salient beliefs for
questionnaire construct
Questionnaire Construct
Aim:
Explore salient beliefs (Behavioural,
Normative and Control belief) of nurses in
relation to promoting continence and
managing urinary incontinence
Method:
– Used concepts from Theory
– 7 structured questions
Elicitation Questions
• Advantages/Disadvantages of carrying
out the behaviour(2)
• Significant People who would influence
the individual behaviour (2)
• What would support or hinder you to
carrying out the behaviour (2)
• Is there anything else you think is
relevant that has not been mentioned in
previous 6 questions (1)
Definition and Questionnaire
Development
• Thematic Analysis of both salient beliefs and
nominal group process was done
– Individually
– Collectively
• Agreement by PhD student and DOS
• Agreement by supervisory team
• Circulated to the group members for sense
checking, feedback and agreement
Activities nurses associate with promoting
urinary continence
• Comprehensive environmental, financial, social, physical and
cognitive assessment
• Assessment of Pre and post stroke continence status including
investigations and identifying the type of urinary incontinence
• 24 hour team approach to consistently deliver and facilitate
continence plan.
• Implement continence plan e.g. using voiding chart, prompted
toileting, bladder retraining and preventing infection.
• Environmental Management including appropriate use of
equipment and adaptations.
• Ongoing evaluation of outcomes, ensuring patient unmet needs
are central to the process.
• Emotional and psychological support
• Health promotion and education
• Discharge planning including the use of containment equipment
such as pads/pants and catheterisation where necessary.
Definition agreed for use in questionnaire
and research.
“Proactive nursing activities
which support and facilitate the
recovery of bladder function
and urinary continence”
Exploration
of Activities
Exploration of
Salient Belief
Definition
development
Questionnaire construct
Nominal Group
Process
Elicitation
Process
Synergy of Data
Behavioural Category
and Definition agreed
Questionnaire
Developed
Conclusion
• Novel investigation of nursing practice
• New insights into nurse activities
• Add to the literature affirming or
otherwise the merits of the theoretical
framework.
• Add value to the debate around the
nursing contribution to stroke
rehabilitation
Thank you
Any questions?
Thanks to the Supervisory Team:
Dr Joanne Booth - Director of Studies
Dr Cynthia McVey