Gap Analysis - Promoting Continence Using Prompted Voiding
Gap Analysis:
Promoting Continence Using Prompted Voiding, Revised 2011
Work Sheet
This guideline can be downloaded for free at:
The RNAO Toolkit: Implementation of Best Practice Guidelines, Second Edition is also available at:
Gap Analysis – June 2016Page 1 of 6
Gap Analysis - Promoting Continence Using Prompted Voiding
Date Completed:Team Members participating in the Gap Analysis:
Completion of this gap analysis allows for the annual comparison of your current practice to evidence based practices as regulated by the MOHLTC. See Appendix A for this and other regulations that apply to a continence care and bowel management program in your home.
RNAO Best Practice Guideline Recommendations / Met / PartiallyMet / Unmet / Notes(Examples of what to include: is this a priority to our home, information on current practice, possible overlap with other programs or partners)
Practice Recommendations
1.0 Obtain a history of the client's incontinence.
(Level of Evidence IV)
2.0Gather 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.
3.0 Review the client's medications to identify those which may have an impact on the incontinence.
(Level of Evidence = III)
4.0 Identify the client's functional and cognitive ability.
(Level of Evidence = III)
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; and
- Staff belief that few interventions exist to promote continence.
6.0 Check urine to determine if infection is present.
(Level of Evidence = III)
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)
8.0 Ensure that constipation and fecal impaction are addressed.
(Level of Evidence = IV)
9.0 Ensure an adequate level of fluid intake (1500 - 2000 ml per day), and minimize the use of caffeinated and alcoholic beverages where possible.
(Level of Evidence = III)
10. 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)
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)
Education Recommendations
12.0 Implement an educational program on promoting continence using prompted voiding. The program should be structured, organized, and directed at all levels of healthcare providers, clients, family and caregivers. The educational program should identify a nurse with an interest in and/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 current evidence. 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.
- Education about conservative management strategies; and
- Rationale for conservative management strategies
13.0 Nurses should be knowledgeable about community resources for professional development, referral and ongoing assistance.
(Level of Evidence = IV)
Organization and Policy Recommendations
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; and
- Monitoring of the program
15.0 Organizations are encouraged to establish an interprofessional team approach to continence care.
(Level of Evidence = IV)
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, RNAO (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of ClinicalPractice Guidelines, based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the RNAO Nursing Best Practice Guideline Promoting Continence Using Prompted Voiding.
(Level of Evidence = IV)
Appendix A
Applicable Ministry of Health and Long-Term Care Regulations for
a Continence Care and Bowel Management Program
Required programs48. (1) Every licensee of a long-term care home shall ensure that the following interdisciplinary programs are developed and implemented in the home:
3. A continence care and bowel management program to promote continence and to ensure that residents are clean, dry and comfortable.
(2) Each program must, in addition to meeting the requirements set out in section 30,
(a) provide for screening protocols; and
(b) provide for assessment and reassessment instruments. O. Reg. 79/10, s. 48 (2).
Section 30
30. (1) Every licensee of a long-term care home shall ensure that the following is complied with in respect of each of the organized programs required under sections 8 to 16 of the Act and each of the interdisciplinary programs required under section 48 of this Regulation:
- There must be a written description of the program that includes its goals and objectives and relevant policies, procedures and protocols and provides for methods to reduce risk and monitor outcomes, including protocols for the referral of residents to specialized resources where required.
- Where, under the program, staff use any equipment, supplies, devices, assistive aids or positioning aids with respect to a resident, the equipment, supplies, devices or aids are appropriate for the resident based on the resident’s condition.
- The program must be evaluated and updated at least annually in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices.
- The licensee shall keep a written record relating to each evaluation under paragraph 3 that includes the date of the evaluation, the names of the persons who participated in the evaluation, a summary of the changes made and the date that those changes were implemented. O. Reg. 79/10, s. 30 (1).
Continence care and bowel management
51.(1)The continence care and bowel management program must, at a minimum, provide for the following:
- Treatments and interventions to promote continence.
- Treatments and interventions to prevent constipation, including nutrition and hydration protocols.
- Toileting programs, including protocols for bowel management.
- Strategies to maximize residents’ independence, comfort and dignity, including equipment, supplies, devices and assistive aids.
- Annual evaluation of residents’ satisfaction with the range of continence care products in consultation with residents, substitute decision-makers and direct care staff, with the evaluation being taken into account by the licensee when making purchasing decisions, including when vendor contracts are negotiated or renegotiated. O.Reg. 79/10, s.51(1).
(a) each resident who is incontinent receives an assessment that includes identification of causal factors, patterns, type of incontinence and potential to restore function with specific interventions, and that where the condition or circumstances of the resident require, an assessment is conducted using a clinically appropriate assessment instrument that is specifically designed for assessment of incontinence;
(b) each resident who is incontinent has an individualized plan, as part of his or her plan of care, to promote and manage bowel and bladder continence based on the assessment and that the plan is implemented;
(c) each resident who is unable to toilet independently some or all of the time receives assistance from staff to manage and maintain continence;
(d) each resident who is incontinent and has been assessed as being potentially continent or continent some of the time receives the assistance and support from staff to become continent or continent some of the time;
(e) continence care products are not used as an alternative to providing assistance to a person to toilet;
(f) there are a range of continence care products available and accessible to residents and staff at all times, and in sufficient quantities for all required changes;
(g) residents who require continence care products have sufficient changes to remain clean, dry and comfortable; and
(h) residents are provided with a range of continence care products that,
(i) are based on their individual assessed needs,
(ii) properly fit the residents,
(iii) promote resident comfort, ease of use, dignity and good skin integrity,
(iv) promote continued independence wherever possible, and
(v) are appropriate for the time of day, and for the individual resident’s type of incontinence. O.Reg. 79/10, s.51(2).
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