The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Recommendation 1.0
Obtain a history of the client's incontinence.
(Level of Evidence = IV)
Recommendation 2.0
Gather information on:
- The amount, type, and time of daily fluid intake, paying particular attention to the intake amount of caffeine and alcohol
- The frequency, nature, and consistency of bowel movements
- Any relevant medical or surgical history which may be related to the incontinence problem, such as, but not limited to, diabetes, stroke, Parkinson's disease, heart failure, recurrent urinary tract infections, or previous bladder surgery
(Level of Evidence = IV)
Recommendation 3.0
Review the client's medications to identify those which may have an impact on the incontinence.
(Level of Evidence = IV)
Recommendation 4.0
Identify the client's functional and cognitive ability.
(Level of Evidence = III)
Recommendation 5.0
Identify attitudinal and environmental barriers to successful toileting. Barriers include:
- Proximity and availability of the nearest bathroom
- Accessibility of commode
- Satisfactory lighting
- Use of restraints
- Staff expectation that incontinence is an inevitable consequence of aging
- Staff belief that few interventions exist to promote continence
(Level of Evidence = III)
Recommendation 6.0
Check urine to determine if infection is present.
(Level of Evidence = IV)
Recommendation 7.0
Determine how the client perceives their urinary incontinence and if they will benefit from prompted voiding. Before initiating prompted voiding, identify the client's pattern of incontinence using a 3-day voiding record.
(Level of Evidence = III)
Recommendation 8.0
Ensure that constipation and fecal impaction are addressed.
(Level of Evidence = IV)
Recommendation 9.0
Ensure an adequate level of fluid intake (1,500 to 2,000 ml per day), and minimize the use of caffeinated and alcoholic beverages where possible.
(Level of Evidence = III)
Recommendation 10.0
Initiate an individualized prompted voiding schedule based on the client's toileting needs, and as determined by a 3-day voiding record.
(Level of Evidence = Ia)
Recommendation 11.0
Initiate a 3-day voiding record, a minimum of 3 weeks and a maximum of 8 weeks, after the prompted voiding schedule.
(Level of Evidence = IV)
Educational Recommendations
Recommendation 12.0
Implement an educational program on promoting continence using prompted voiding. The program should be structured, organized, and directed at all levels of health care providers, clients, family, and caregivers. The educational program should identify a nurse with an interest in an/or advanced preparation in continence care (e.g., nurse continence advisor, nurse clinician, or clinical nurse specialist) to be responsible for providing the educational program. The program should be updated on a regular basis to incorporate any new information.
The program should include information on:
- Myths related to incontinence and aging
- Definition of continence and incontinence
- Continence assessment
- Prompted voiding
- Individualized toileting
- The impact of cognitive impairment on ability to be continent and strategies to manage aggressive behaviours
- Relation of bowel hygiene care to healthy bladder functioning
- Use of a voiding record with individualized toileting
(Level of Evidence = IV)
Recommendation 13.0
Nurses should be knowledgeable about community resources for personal development, referral, and ongoing assistance.
(Level of Evidence = IV)
Organization & Policy Recommendations
Recommendation 14.0
Successful implementation of prompted voiding requires:
- Management support
- Opportunities for education and training
- Active involvement of key clinical staff
- Gradual implementation of the prompted voiding schedule
- Collection of baseline information about clients, resources, and existing knowledge
- Interpretation of this data and identification of problems
- Development of implementation strategy
- Monitoring of the program
(Level of Evidence = IV)
Recommendation 15.0
Organizations are encouraged to establish an interdisciplinary team approach to continence care.
(Level of Evidence = IV)
Recommendation 16.0
Nursing best practice guidelines can be effectively implemented only where there are adequate planning, resources, organizational and administrative support, as well as the appropriate facilitation of the change process by skilled facilitators. The implementation of the guideline must take into account local circumstances and should be disseminated through an active educational and training program. In this regard, Registered Nurses Association of Ontario (RNAO) (through a panel of nurses, researchers, and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines, based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the Registered Nurses Association of Ontario Nursing Best Practice Guideline Promoting Continence Using Prompted Voiding.
(Level of Evidence = IV)
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
