Age and Ageing Advance Access originally published online on August 14, 2008
Age and Ageing 2008 37(6):706-710; doi:10.1093/ageing/afn140
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Exploring reasons for variation in urinary catheterisation prevalence in care homes: a qualitative study
SIR—About half of long-term care home residents have urinary incontinence[1, 2]. Among elderly care home residents, urinary catheters are independently associated with increased mortality and morbidity[3, 4]. Urinary catheter care bundles are now used by acute and community trusts to focus on catheter care[5, 6]. English care homes with a high prevalence of urinary catheters among their residents did not vary significantly from lower-prevalence homes in home size, residents' medical needs, staffing, staff knowledge or reported catheter care practices[2, 7]. Care homes that have a complete care culture that is focused on residents individual needs rather than those that are task-centred or cosmetic (primary emphasis on business needs) may have fewer catheterised residents[8]. In this study, we used qualitative research methods[9] to explore whether different approaches to toileting and catheter care, and a home's culture of care (care delivery, attitudes and communication) are responsible for the variation in the prevalence of catheterisation.
Participants
We purposively selected 14 registered large care homes with either higher (>9%) or lower (<6%) catheterisation prevalence derived from catheterisation data relating to 2003[2, 9]. We approached homes, by letter then telephone, through 2005 and 2006. (See Appendix 1 and 2 in the supplementary data at Age and Ageing online.)
The 14 private and voluntary owned homes provided nursing and residential care services; four also offered specific dementia care (See Appendix 2 in the supplementary data at Age and Ageing online). The number of resident places ranged from 40 to 70 and the catheterisation prevalence ranged from 0 to 18%. Twelve nurse managers, 10 nursing grades and 21 care assistant grades were interviewed (see Appendix 2 in the supplementary data at Age and Ageing online).
Ethics
The study received approval from the South West Multi-centre Research Ethics Committee (MREC/02/6/77, July 2004). Managers and three nurses and/or carers in each home, gave written informed consent to participate and were offered a £10 voucher.
Interviews
Semi-structured interviews were developed by the study team, with the community and hospital continence team and a microbiologist. (See Appendix 3 in the supplementary data at Age and Ageing online.) The open questions aimed to explore in-depth, asking for examples, how a decision to insert a catheter was reached and how catheterisation was reviewed. They explored the home's care culture, attitudes to catheterisation, communication and staffing.
Data analysis
Interviews were audio-recorded, and transcribed verbatim (JB and RHJ). The transcribed data were analysed independently by three researchers (CM, JB, MW). We used a ‘Framework’ analytical approach[10], to develop a coding index around ideas and theories behind high and low prevalence of catheterisation (see Appendix 4 in the supplementary data at Age and Ageing online)[10]. Concepts and overarching themes were derived and developed from the interpretive analysis.
Urinary catheters were inherited from hospitals
Staff from all care homes stated that the decision to catheterise a resident was usually made when residents were hospitalised and they rarely catheterised a resident themselves. They reported that the hospitals' greater readiness to catheterise patients may be due to insufficient hospital staff to facilitate adequate toileting (see Box 1, Appendix 5 in the supplementary data at Age and Ageing online).
Proactive approach
Staff in all homes recognised that catheterisation of a resident was a method of last resort, but homes with lower prevalence of catheterisation took a more proactive approach to removing inherited catheters, toileting, managing continence, mobility and to maintaining residents' dignity and independence. Staff in low catheterisation homes would often encourage the resident to return to regular toileting and/or the use of continence aids. In contrast, staff in homes with higher prevalence of catheterisation reported that they usually left an inherited catheter in situ, unless it became blocked or the resident pulled it out and they always complied with the wishes of residents who wanted to keep a catheter.
Staff in homes with lower prevalence of catheterisation considered toileting to be a priority among their care duties and managed incontinence with two- to three-hourly toileting and the diligent use of continence pads. They demonstrated a person-centred approach and said structured toileting and washing routines, although more work-intensive for staff, were better for the residents’ comfort and long-term mobility; and they always encouraged reluctant residents to use the toilet.
In contrast, homes with higher prevalence of catheterisation described a less proactive approach to toileting. Staff wanted to deliver the best care for their residents, but most reported they felt impeded by limited staff. Many reported that catheters reduced their workload and were preferable for incontinent immobile residents. They described how staff shortages, less committed agency staff and time pressures prevented them from toileting residents or changing their continence pads often enough. These staff frequently mentioned residents sitting for long periods on wet continence pads (Table 1 and Box 1).
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Staff's attitude to catheters
A home manager's attitude to catheters was usually reiterated by other staff. Staff in the higher catheter-prevalent homes viewed catheters as preserving dignity, and prevented frequently wet pads, clothing, bedding and urine smells. In contrast, staff in the lower catheter-prevalent homes considered having a long-term, indwelling urinary catheter undermined a person's dignity. They described catheters as invasive, uncomfortable or restrictive of movement and reduced a resident's independence. One manager described training she had received covering the person-centred care approach (Box 1).
Staffing and communication
Many staff reported that residents in care homes had become more dependent in recent years, and several care homes complained that, for funding reasons, residents were inappropriately classified to receive residential care, rather than nursing care. Whereas several staff from homes with higher prevalence of catheterisation reported that the number of catheters could be reduced if there were more staff to undertake toileting, homes with low prevalence of catheterisation reported they had adequate staffing.
Across all homes, staff reported that the continence nurses, residents and their family, and district nurses in residential care units, were all involved in continence care decisions. Some homes complained that they, or residents, had to purchase incontinence pads as continence nurses did not have sufficient resources.
Communication and morale in nearly all homes were good. During handovers in all homes, key issues were highlighted verbally and all issues were also recorded in the residents’ individual care plans. However, staff in homes with lower prevalence of catheterisation more often routinely discussed a resident's continence and toileting needs at handovers. In two high-catheterisation homes problems with transfer of knowledge at handovers were highlighted, because of high numbers of agency staff, and in another, care staff were not involved in handovers, as their shift commenced after hand-over, to save on salaries (Box 1).
Study strengths and weaknesses
No homes refused participation, data saturation was attained and common themes were found, by the three independent researchers, across a range of homes. For these reasons the findings are likely to reflect the characteristics of other homes with similar prevalence of catheterisation. Although we excluded smaller homes, our previous study in the same locality[2] demonstrated that smaller homes did not differ from larger homes in terms of resident case-mix and prevalence of catheterisation.
Other work in this area
Our previous care home questionnaire study was not able to identify the differences in proactive care that we have now found using qualitative methods[2, 7]. A European questionnaire survey[11] found that central or southern European countries had a different approach to caring for elderly people in their own homes and accepted the use of urinary catheters more readily than northern countries. As in our study, differences in prevalence of catheterisation could not just be explained by medical conditions[11].
Our findings show similarities to the findings of other recent qualitative work in the field[12, 13]. Dingwell and McLafferty[13] found, in elderly care wards, that many urinary catheters were inserted during an acute illness, but patients were transferred to rehabilitation wards without any documentation for continued use. They also reported that staff preference determined the use of catheters[12]. Catheterisation often outlives the medical indication for its use and many hospital physicians are unaware of their patient's catheterisation status[14]. The proactive approach of the care homes with lower prevalence of catheterisation in our study is consistent with the ‘complete communities’ described by Davies[8], in which care is person-centred and orientated towards enabling residents to attain their optimal quality of life through maintaining resident mobility and independence.
We agree with Georgiou et al. that the rate of indwelling catheterisation may be a good marker for quality of care, and could be used for performance management[1]. In any audit, variations in case-mix should be taken into account. The inappropriate grading of residents has also been reported by almost half the care staff Ball et al. interviewed[15]. Our previous work did not show any differences in staffing numbers between high and low homes[2, 7]. The shortages reported in staff in high homes in this study may be due to increasing inappropriate grading of residents due to financial constraints.
Residents should be transferred from hospitals to care homes with a clear documented urinary catheter review plan. Audits will help to determine how many catheterised patients are discharged from hospitals to care homes. Care homes should be encouraged by continence advisors to implement urinary catheter care bundles[5]. A proactive approach to continence care and catheter removal will be needed to encourage homes to preserve residents’ mobility and independence. Residents’ continence needs should be discussed routinely at handovers. Education, including the use of a person-centred approach, will need to be cascaded down from continence advisors to nursing managers and care staff. Inappropriate categorisation of residents to residential care, rather than nursing, needs to be audited, as it may adversely affect residents’ care.
- The key determinant of urinary catheterisation prevalence in care homes was how proactively did staff remove urinary catheters from residents discharged from hospital to their home.
- A clear documented catheter and continence care plan is needed when patients are discharged from hospitals to care homes.
- Care homes with a lower urinary catheterisation prevalence had a more proactive approach to management of continence, using structured toileting regimes and encouraging residents’ mobility.
- Inappropriate categorisation of residents to residential rather than nursing care in care homes needs to be addressed as it increases the burden on staff, which may be to the detriment of residents’ care in some homes.
Supplementary data for this article are available at Age and Ageing online.
Acknowledgements
We wish to thank the care home staff for their enthusiasm in this study; Dr Ian Donald, Dr Sue Davies and the continence nurses in West Gloucestershire PCT for advice on interview schedule development.
This study was partly funded with a small grant from The Bristol, Gloucestershire, Bath and Swindon Primary Care Network Bursary Scheme.
1 Department of Microbiology, Health Protection Agency Primary Care Unit, Gloucestershire Royal Hospital, Gloucester GL1 3 NN, UK
2 Previously Health Protection Agency Primary Care Unit, Now Scientist Unit, Health and Safety Laboratory, Harpur Hill, Buxton SK17 9JN, UK
3 Previously Health Protection Agency Primary Care Unit, Now HPA HIV and STI Department, Centre for Infections, London, London NW9 5EQ, UK
4 Research and Development Support Unit, Gloucestershire Hospitals, NHS Foundation Trust, Leadon House, Gloucestershire Royal, Hospital, Gloucestershire, Gloucester GL1 3 NN, UK
* To whom correspondence should be addressed Email:cliodna.mcnulty{at}hpa.org.uk
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