International Journal of Nursing Practice 2008; 14: 495502

RESEARCH PAPER

Incontinence: Managed or mismanaged in hospital settings?

Joan Ostaszkiewicz RN MNurs
Research Fellow, DeakinSouthern Health Nursing Research Centre, Victoria, Australia

Beverly OConnell RN MSc PhD FRCNA

Professor, Inaugural Chair, DeakinSouthern Health Nursing Research Centre, Victoria Australia

Lynne Millar BA (Hons)

Research Fellow, Deakin University, Victoria, Australia

Accepted for publication August 2008 Ostaszkiewicz J, OConnell B, Millar L. International Journal of Nursing Practice 2008; 14: 495502 Incontinence: Managed or mismanaged in hospital settings? This paper reports the results of a survey of inpatients to determine the prevalence of their continence status and the overall management of their incontinence. A survey of 447 hospitalized adults was conducted and an audit of their medical records. Twenty-two per cent of patients reported urinary incontinence, 10% faecal incontinence, 78% nocturia, 23% urinary urgency and 11% trouble passing urine. Pre-existing bladder and bowel problems were reported by 34% and 26% of patients respectively. Sixty per cent of patients were using a continence product or device. There was a lack of documentation in the medical records about patients continence status and about their pre-admission bowel and bladder status. The ndings reveal that the management of incontinence in acute and subacute settings is suboptimal. There is a need to raise clinical awareness about incontinence in hospital settings and to implement a structured approach to its assessment and management. Furthermore, as the costs associated with the management or mismanagement of incontinence in hospital settings are not fully understood, there is a need for further research on this issue. Key words: assessment, documentation, hospital, incontinence, prevalence.

INTRODUCTION
There is a large body of evidence on the prevalence and nature of bowel and bladder elimination symptoms among community dwelling non-institutionalized adults.1 By contrast, there is a lack of information about these symptoms for individuals admitted to hospital settings. Gener-

Correspondence: Joan Ostaszkiewicz, DeakinSouthern Health Nursing Research Centre, School of Nursing, Deakin University, 221 Burwood Hwy, Burwood, Vic. 3124, Australia. Email: joan. ostaszkiewicz@deakin.edu.au doi:10.1111/j.1440-172X.2008.00725.x

alizing data from a population of community dwelling non-institutionalized adults to inpatients of hospital settings is problematic and should be done cautiously owing to important differences in these populations, such as health and functional status. The limited data that are available from published research on incontinence in hospital settings reveal that much of this research was conducted some time ago and only two studies provide data on the Australian population.2,3 It also reveals that the prevalence of incontinence in hospital settings is wide ranging; from 10.5 to 43% for urinary incontinence and 7 to 33% for faecal incontinence214 (see Table 1 for
2008 Blackwell Publishing Asia Pty Ltd

496

Table 1 Research on the prevalence of incontinence in hospital settings Country Australia Australia USA Prospective survey Population Method Symptom Finding

Citation

Fonda, Nickless & Roth (1988)2 627 admissions to an acute care teaching hospital 100 consecutive patients > age 70 17 004 medical les of individuals admitted to nursing homes from acute care Prospective assessment Retrospective review of a nursing home and hospital database. Prospective evaluation FI 33% UI FI UI UI or FI

Nair, ODea, Lim & Thakkinstian (2000)3 Berlowitz, Brand & Perkins (1999)4

23.4% at least 1 episode 7% at least 1 episode 40% 43.4%

2008 Blackwell Publishing Asia Pty Ltd

USA Brazil Singapore USA USA USA Italy Prospective survey UI UI UI and FI UI and FI UI UI 35% 22% 19.7% 21% 10.5% 22.3% 152 acutely unwell patients in acute or critical care units in a university afliated veteran affairs medical centre 77 inpatients of surgical, obstetric and clinical units in a large hospital Acute assessment and rehabilitation geriatric ward 608 acute care patients in medial, surgical and intensive care units Elderly female hip fracture patients Observational descriptive design Retrospective review of 6515 medical les Phone interviews 2 weeks post discharge Observational prospective study USA USA 919 hospitalized elderly from medical and surgical wards 81 community and university hospitals 13 729 patients aged 65 or over on medical or geriatric wards. UI data based on 4.268 subjects 247 patients pre-hospital admission status Prospective survey + retrospective review 42% 35% Bladder and rectal problems UI USA 363 patients aged 65 years of age or over admitted to acute medical and services of a university hospital Elderly people newly admitted to an acute care setting UI and FI 32.4%

Bliss, Johnson, Savik, Clabots & Gerding (2000)5

Da Silva & Santos (2005)6

Ding & Jayaratnam (1994)7

Junkin & Selekof (2007)8

Palmer, Baumgarten, Langenberg & Carson (2002)9 Palmer, Bone, Fahey, Mamom & Steinwachs (1992)10 Mecocci et al. (2005)11

Schultz, Dickey & Skoner (1997)12

Sier, Ouslander & Orzeck (1987)13

J Ostaszkiewicz et al.

Zulkowski & Kindsfater (2000)14

FI, faecal incontinence; UI, urinary incontinence.

Incontinence in hospitals

497

summary of studies). The variation in prevalence rates could be explained by differences in denitions, methods, populations and measurement time frames. One of the factors that confounds the interpretation on data on the prevalence of incontinence in hospitalized populations is the difculty of determining whether the condition occurred in hospital or preceded the patients hospital admission.9,13

prevalence and management of incontinence in these settings.

Management of incontinence in hospital settings

Although incontinence is potentially a common problem for hospitalized individuals, there is some evidence to suggest that it is poorly detected and managed in hospital settings. For example, a retrospective comparison of a nursing home and hospital database of patients discharged from Veteran Affairs (VA) acute medical care and admitted to a VA nursing home in the USA identied that 43% of these patients were incontinent but only 3.4% of cases had incontinence documented as a discharge diagnosis.4 Similarly, Cheater17 reported that of 229 urinary incontinent patients in wards for the elderly in the UK, 14.3% had no documentation of this in either the nursing or medical records, and Schultz and colleagues12 found that of 247 individuals who were interviewed prior to admission to an acute care hospital, 133 (43%) reported urinary incontinence and of these, only 10 had urinary incontinence documented on their admission to hospital. There is also some evidence to suggest that the clinical management of incontinence in hospital settings is characterized by an over-reliance on continence products18 and inadequate attention to identifying and addressing possible contributing factors. The assessment and management of incontinence by nurses in acute care are potentially limited by a lack of knowledge about the condition, a lack of time, lack of support, a culture that does not actively promote independent practice and holistic care,19 conicting clinical priorities and patients acceptance of their continence conditions.20 It has been suggested furthermore that nurses in acute care settings perceive incontinence to be a trivial symptom in comparison to medically oriented diagnoses and that they lack knowledge about it.20,21 Another view is that the stigma associated with loss of control over body waste leads both nurses and patients to engage in a process of mutual pretence or that bladder and bowel care are considered basic activities in the context of an environment that values technological expertise.22 This issue is important because of the fact that health professionals can reinforce incorrect and negative lay beliefs about incontinence, such as those related to age or stigma.23,24 Moreover, the attitudes of staff and carers can result in inappropriate care and negative outcomes for people with incontinence.24 Curiously, one study that
2008 Blackwell Publishing Asia Pty Ltd

The signicance of incontinence among hospitalized individuals

An early Australian study that examined the prevalence and impact of incontinence in hospital individuals reported an association between incontinence and a longer length of hospital stay.2 This group of patients were also found to have a greater risk of being discharged to a residential aged care setting.2 More recent ndings from a retrospective review involving 54 subacute care units in Australia and New Zealand conrm the latter claim.15 Specically, Green and colleagues found that individuals with incontinence who had been inpatients of a subacute care setting were less likely to return home than those who were continent (57% compared with 82%) and were more likely to be discharged to a nursing home or for further care (29% compared with 12%).15 Not only does incontinence impact on hospital discharge; its effects are also felt at a nancial level. A recent study revealed that nurses in a subacute care setting in Australia spent a median time of almost 2 h per day per patient with incontinence on continence care tasks (i.e. providing toileting assistance, changing pads, bed and attending to catheter care).16 The researchers estimated this time as equivalent to 13% of staff time over a 24 h day. They equated these costs to $41 AU per patient per day and when the cost of consumables was added to this, the total face-to-face costs added an additional $50 AU per day to the costs of care, or 12% of total costs per single room and 21% per double room. Green and colleagues also reported that the costs associated with incontinent patients in rehabilitation and geriatric evaluation and management units were higher compared with patients who were continent.15 Based on these ndings, the cost of providing continence care to patients with incontinence in subacute care settings is high. Clearly, there is a need to conduct further research on the costs of incontinence in both acute and subacute care settings and to base this research on a sound understanding of the

498

J Ostaszkiewicz et al.

described the attitudes of nurses working across a range of health-care settings reported that nurse working on medical or surgical units held more negative reactions and feelings towards urinary incontinence than nurses working in nursing homes.25 Given the signicance of these ndings, we aimed to obtain a better understanding of the prevalence of incontinence in a hospitalized population and to investigate the extent to which it was identied and managed.

computer statistical package SPSS for Windows. The prevalence of incontinence and other bladder and bowel symptoms were calculated by dividing the number of cases of patients with these symptoms by the total number of respondents then multiplying the resulting gure by 100, thereby obtaining a percentage. Those patients whose responses to individual items were not applicable or missing were excluded from the analysis on that item.

Objectives
The objectives of the project were to: calculate the prevalence of urinary and faecal incontinence and other bladder and bowel symptoms in an inpatient population; determine the use of continence products or devices; and identify the extent to which bladder and bowel symptoms in patient medical records were documented.

RESULTS Description of sample

Four hundred and forty-seven patients participated in the survey, representing 75.3% of patients (n = 593) from the participating wards. There were signicantly more female (n = 247) (56%) than male patients (n = 197) (44%): c2 (1, n = 444) = 5.63, P < 0.05 (three did not indicate gender). Their mean age was 70 years (SD = 18.7; range 16100 years).

Bladder and bowel symptoms

METHOD
The survey was conducted in a sample of consenting inpatients of medical, surgical, rehabilitation and geriatric evaluation and management wards in three acute care hospitals and one subacute care facility. In so far as the survey was conducted on a convenience sample and provided information on the proportion of people in this population who had incontinence or other bladder and bowel symptoms, the survey provided point prevalence data. Patients were included if they were cognitively intact, medically stable, able to respond to questions and able to provide informed consent (as determined by the surveyors clinical judgment and with reference to patients medical records). Patients responded to a brief questionnaire that was conducted by the surveyors, all of whom were trained health-care professionals. The medical records of consenting patients were also reviewed to check whether or not any documentation existed about their admission bowel and bladder status and continence symptoms in the preceding 24 h period. The project was endorsed by the Quality and Risk Management Committee of the Health Network. The survey questionnaire was developed based on a previous tool designed by OConnell, Day, Wellman and Baker.26 Drafts of the questionnaire were circulated to continence and research specialists for comment and a nal draft version was piloted to establish face validity. Data were quantitative and were analysed using the
2008 Blackwell Publishing Asia Pty Ltd

Patients were asked to indicate whether or not they had experienced any of the following symptoms in the preceding 24 h; accidental leakage of urine, nocturia, urinary urgency, trouble passing urine and accidental leakage from bowel (see Table 2). Twenty-two per cent of respondents (n = 86) reported having experienced urinary leakage in the preceding 24 h. Of these, 54 respondents responded to a question about the number of times this had occurred in this period. The mean frequency of accidental urine leakage in the preceding 24 h for this subgroup was 3 (range 110). Ten per cent of respondents (n = 44) reported having experienced accidental leakage from their bowel in the preceding 24 h. Of this group, 23 indicated the frequency of this in this period. The mean frequency of accidental bowel leakage for this subgroup was 2. Patients were also requested to indicate whether or not they had experienced any bladder or bowel problems at home. The ndings revealed that 34% of respondents had a pre-existing bladder problem and 26% reported a pre-existing bowel problem.

Factors associated with incontinence

Data were analysed to identify factors associated with reported episodes of incontinence in the preceding 24 h. Two factors emerged as statistically signicant for the presence of urinary incontinence. These were (i) mobility and (ii) a pre-existing bladder problem. Specically, patients who required person assistance to mobilise or

Incontinence in hospitals

499

Table 2 Bladder and bowel symptoms Symptoms Accidental leakage of urine (n = 398) Accidental leakage from bowel (n = 423) Urinary urgency (n = 324) Nocturia (n = 384) Mean frequency of nocturia (n = 260) Trouble passing urine (n = 374) Pre-hospitalization bladder problems (n = 369) Pre-hospitalization bowel problem (n = 353) n 86 44 75 298 2.1 40 125 92 Prevalence (%) 22 10 23 78 11 34 26 Gender (27 male : 59 female) (22 male : 22 female) (27 male : 48 female)

(23 male : 17 female) (41 male : 84 female) (34 male : 56 female)

supervision or were not currently mobile were signicantly more likely to experience accidental leakage of urine than patients who mobilised with a gait aid or who were able to mobilise independently, c2 (2, n = 386) = 10.36, P < 0.01. Patients who reported a pre-existing bladder problem were also signicantly more likely to report having had accidental urine leakage in the preceding 24 h, c2 (1, n = 367) = 58.95, P < 0.0001. This mobility impaired group of patients were also more likely to experience faecal incontinence than patients who mobilised with a gait aid or who were able to mobilise independently c2 (2, n = 414) = 5.65, P = 0.059. There was no signicant relationship between pre-existing bowel problems and faecal incontinence in the preceding 24 h.

18 (16%) had no form of continence product/device in use at the time of the survey.

Documentation of incontinence
The admission notes of the medical records of all patients were reviewed to identify whether or not there was any documentation about their bowel and bladder status on admission. This revealed that 43% (n = 184) had no documentation concerning patients bladder function in the admission notes and 51% (n = 219) had no documentation concerning patients bowel function. An analysis was conducted on the association between documentation about patients bladder and bowel function in the admission notes and patients reported pre-hospitalization bladder and bowel function. Of 123 patients who reported having had a bladder problem at home, 43 (35%) had no information recorded about their bladder function in their admission notes and of 90 patients who reported a bowel problem at home, 41 (46%) had no information recorded about their bowel function in their admission notes. To assess the extent to which incontinence episodes during hospitalization were identied, the progress notes for the preceding 24 h for all patients were reviewed. This revealed that of 87 patients who reported having experienced accidental urine leakage in this period, 49 (57%) had no documentation about this episode in their progress notes. Similarly, of 44 patients who reported having had accidental leakage from bowel in the preceding 24 h, 26 (61.9%) had no documentation of this in the preceding 24 h progress notes. The review of documentation additionally revealed that of those patients who reported having had an episode of urinary incontinence in the preceding 24 h (n = 87), 25
2008 Blackwell Publishing Asia Pty Ltd

Use of continence products/devices

Two hundred and sixty-six patients (59.6%) from a sample of 446 reported using some type of continence product/device at the time of the survey. The most commonly used continence product/devices were absorbent continence pads (n = 136), followed by washable bed protection (n = 83), draw sheets with mackintosh (n = 64) and urethral catheters (n = 34). Some patients were using more than one type of continence product/ device. An analysis of data from the 121 patients whose only form of continence management was an absorbent continence pad, revealed that 50 (41%) of this group reported having had no episodes of urinary or faecal incontinence in the preceding 24 h. By contrast, of 113 patients who reported having experienced some form of accidental leakage of urine or faeces in the preceding 24 h,

500

J Ostaszkiewicz et al.

(29%) had nothing documented about their bladder function in their admission notes. Similarly, of those patients who reported having had an episode of bowel leakage in the preceding 24 h, 14 (34.1%) had no documentation about their bowel function in their admission notes.

DISCUSSION
The rst objective of this study was to calculate the prevalence of urinary and faecal incontinence and other bladder and bowel symptoms in inpatients of medical, surgical, rehabilitation and geriatric evaluation and management wards in three acute care hospitals and one subacute care facility. The ndings indicated that bladder and bowel symptoms affected a considerable proportion of this inpatient population. Twenty-two per cent of patients in this study reported having had urinary incontinence and 10% reported faecal incontinence during the surveillance period. This estimate is considered conservative however, as some groups of high-risk patients were excluded from the study, including individuals with cognitive impairment. The prevalence of urinary incontinence reported in this study nevertheless falls within the range reported in other similar settings214 (see Table 1). The prevalence of faecal incontinence (10%) is considerably lower than the 33% rate reported in hospitalized individuals in the study by Bliss and colleagues,5 but is higher than the 7% rate reported by Fonda et al.2 Other notable ndings were the high rates of nocturia and urinary urgency. These ndings are clinical important as previous research has highlighted an association between these symptoms and falls.2729 The nding that approximately one in ve patients experience urinary incontinence and one in 10 experience faecal incontinence during their hospital stay is concerning. As the population ages, in the absence of a proactive stance, these rates are likely to increase and to place considerable demands on available health resources. Incontinence is a costly condition to manage and as demonstrated by previous research, is associated with a longer length of hospital stay2 and admission to a residential aged care setting.2,15 The costs of managing incontinence in hospitals are however inadequately represented in the current casemix classication system.30 Even where the incontinence has been correctly identied and coded using the Australian Rened Diagnosis Related Groups (ARDRGs), this coding rarely affects the DRG costing (cost/ reimbursement allocation).30 Hence, the substantial costs associated with providing nursing care for patients with
2008 Blackwell Publishing Asia Pty Ltd

incontinence are currently under-funded. Clearly, this is an issue that warrants further attention. The second objective of this study was to determine the use of continence products or devices in acute and subacute care settings. Almost 60% of the sample was using some form of continence product/device at the time of the survey. To our knowledge there is only one other study that has investigated the use of continence products usage in an acute care setting.18 The ndings of that study also revealed a 60% usage of continence products/ devices. Kalid8 further added that alternative interventions could have been utilized in at least 50% of these patients.18 The data from the current project also revealed that a substantial proportion of patients who had an absorbent continence pad in situ, had experienced no episodes of either urinary or faecal incontinence in the preceding 24 h. By contrast, 16% of patients who had experienced an episode of urinary or faecal incontinence in the preceding 24 h were not using any form of continence product or device. The data suggest an overuse of continence products/devices and a potential lack of understanding about when to use these items. It might be useful therefore to develop guidelines on the use of continence products/devices that can be used to support clinical decision-making. Given the considerable costs associated with these items, this is an important area to target for future cost savings. The third objective of the study was to identify the extent to which bladder and bowel symptoms were documented in patients medical records. The ndings revealed that incontinence was poorly documented in both the admission notes and progress notes of these records. This nding is congruent with other research on this topic which identies that incontinence is poorly documented as a discharge diagnosis for individuals admitted to nursing homes from acute care in the USA,4 for patients in wards for the elderly in the UK17 and for patients with a pre-existing continence problem who are admitted to an acute care hospital in the USA.12 This lack of documentation on admission to hospital reveals a gap in admission processes and insufcient attention to the assessment of an important aspect of care. One explanation for this lack of documentation regarding incontinence in the medical records could be related to a taken-forgranted practice31 that does not warrant attention and documentation. It is important to raise nurses awareness about this issue and to encourage them to document incontinence and associated care so as to communicate

Incontinence in hospitals

501

this problem and to acknowledge nursings contribution to its management.

Limitations
The ndings of this study should be interpreted cognisant of the limitations associated with self-report and with the exclusion of some groups of high-risk patients. The latter fact means that the data are likely to underrepresent the prevalence of incontinence in acute and subacute care settings. Although a concerted effort was made to establish the face-validity of the survey instrument, further work is required to establish its psychometric properties. Notwithstanding these limitations, this study provides valuable insights into the potential magnitude of urinary and faecal incontinence and associated factors and provides recommendations for policy and practice.

Unit Peter James Centre/Deakin University Program of Research in Aged Care & Rehabilitation. The research team would like to acknowledge the contributions of colleagues in Eastern Health who assisted in the design of the project and in collecting the data as well as colleagues who commented on drafts of the manuscript.

REFERENCES
1 Hunskaar S, Burgio K, Clark A et al. Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Abrams P, Cardoza L, Khoury S et al. (eds). Incontinence: 3rd International Consultation on Incontinence: Recommendations of the International Scientic Committee. Paris: Plymbridge Distributors Ltd, 2005; 255312. 2 Fonda D, Nickless R, Roth R. A prospective study of the incidence of urinary incontinence in an acute care teaching hospital and its implications on future service development. Australian Clinical Review 1988; 8 (30): 102107. 3 Nair B, ODea I, Lim L, Thakkinstian A. Prevalence of geriatric syndromes in a tertiary hospital. Australasian Journal on Ageing 2000; 19 (2): 8184. 4 Berlowitz D, Brand H, Perkins C. Geriatric syndromes as outcome measures of hospital care: Can administrative data be used? Journal of the American Geriatrics Society 1999; 47: 692696. 5 Bliss DZ, Johnson S, Savik K, Clabots CR, Gerding DN. Fecal incontinence in hospitalized patients who are acutely ill. Nursing Research 2000; 49 (2): 101108. 6 da Silva AP, Santos VL. Prevalence of urinary incontinence in hospitalized patients. Revista da Escola de Enfermagem da U S P 2005; 39 (1): 3645. 7 Ding YY, Jayaratnam FJ. Urinary incontinence in the hospitalised elderlya largely reversible disorder. Singapore Medical Journal 1994; 35 (2): 167170. 8 Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. Journal of Wound, Ostomy and Continence Nursing 2007; 34 (3): 260 269. 9 Palmer MH, Baumgarten M, Langenberg P, Carson JL. Risk factors for hospital acquired incontinence in elderly female hip fracture patients. Journal of Gerontology 2002; 57A (10): M672M677. 10 Palmer MH, Bone LR, Fahey M, Mamom J, Steinwachs D. Detecting urinary incontinence in older adults during hospitalization. Applied Nursing Research 1992; 5 (4): 174180. 11 Mecocci P, von Strauss E, Cherubini A et al. for the GIFA Study Group. Cognitive impairment is the major risk factor for development of geriatric syndromes during hospitalisation: Results from the GIFA study. Dementia and Geriatric Cognitive Disorders 2005; 20: 262260. 12 Schultz A, Dickey G, Skoner M. Self-report of incontinence in acute care. Urologic Nursing 1997; 17 (1): 2328. 2008 Blackwell Publishing Asia Pty Ltd

Conclusion
The ndings of this study indicate that approximately one in ve patients admitted to an acute or subacute care hospital experience urinary incontinence and one in ten experience faecal incontinence. Other symptoms of concern are nocturia, urinary urgency and, to a lesser extent, voiding difculties. As nocturia and urinary urgency are associated with falls, these symptoms should be considered in the context of hospital admission screening and assessment and in planning inpatient and discharge care. Just over one-third of patients reported having had a problem with their bladder at home and just under onethird reported having had a bowel problem. Incontinence and other related bladder and bowel symptoms are common in the community and clearly, acute illness will make it more difcult for patients to manage their symptoms. There are a number of other issues that need to be addressed. These include the inconsistent documentation of patients bladder and bowel status and continence care and the unnecessary use of continence products and devices. The data from this study reinforce the need for a systems-based approach to the assessment and management of incontinence and other related bladder and bowel symptoms in hospitalized individuals: a process that enables continence symptoms to be identied and addressed.

ACKNOWLEDGEMENTS
This project was funded by Eastern Healths Active Ageing Program and was undertaken as a collaboration of the Eastern Health, Deakin University Nursing Research

502

J Ostaszkiewicz et al.

13 Sier H, Ouslander J, Orzeck S. Urinary incontinence among geriatric-patients in an acute-care hospital. Journal of the American Medical Association 1987; 257 (13): 1767 1771. 14 Zulkowski K, Kindsfater D. Examination of care planning needs for elderly newly admitted to an acute care setting. Ostomy/Wound Management 2000; 46 (1): 3236. 15 Green JP, Smoker I, Ho MT, Moore KH. Urinary incontinence in sub-acute carea retrospective analysis of clinical outcomes and costs. The Medical Journal of Australia 2003; 178 (11): 550553. 16 Morris AR, Ho MT, Lapsley H, Walsh J, Gonski P, Moore KH. Costs of managing urinary and faecal incontinence in a sub-acute care facility: A bottom-up approach. Neurourology and Urodynamics 2004; 24: 5662. 17 Cheater FM. Retrospective document survey: Identication, assessment and management of urinary incontinence in medical and care of the elderly wards. Journal of Advanced Nursing 1993; 18 (11): 17341746. 18 Kadir FS. The Pamper generation: An explorative study into the use of incontinence aids in a local acute peripheral care setting. Singapore Nursing Journal 2004; 31 (4): 34 38. 19 Cooper G, Watt E. An exploration of acute care nurses approach to assessment and management of people with incontinence. Journal of Wound, Ostomy and Continence Nursing 2003; 30 (6): 30313. 20 Dingwell L, Mclaffety E. Do nurses promote urinary continence in hospitalized older people?: An exploratory study. Journal of Clinical Nursing 2006; 15: 12761286. 21 Norheim A, Vinsnes AG. Staffs attitudes towards hospitalised elderly patients with urinary incontinence. Nordic Journal of Nursing Research and Clinical Studies 2005; 25 (1): 2125. 22 Norton C. Stigma and social exclusion in health care. Stigma Conference Papers, 2006. Available from URL:

23

24

25

26

27

28

29

30

31

http://www.defeatingstigma.org/index_les/Page476. htm. Accessed 18 March 2007. Mitteness LS. Knowledge and beliefs about urinary incontinence and adulthood and old age. Journal of the American Geriatrics Society 1990; 38: 374378. Roe B. Effective and ineffective management of incontinence: A qualitative study with implications for health professionals and health services. Clinical Effectiveness in Nursing 1997; 1: 1624. Vinsnes AG, Harkless GE, Haltbakk J, Bohm J, Hunskaar S. Healthcare personnels attitudes towards patients with urinary incontinence. Journal of Clinical Nursing 2001; 10: 455462. OConnell B, Day K, Wellman D, Baker L. Development, implementation, and evaluation of a continence education package in acute and sub-acute care settings. Journal of Wound, Ostomy and Continence Nursing 2005; 32: 101111. Brown JS, Vittinghoff E, Wyman JF et al. Urinary incontinence: Does it increase risk for falls and fractures? Journal of the American Geriatrics Society 2000; 48 (7): 721725. Stewart RB, Moore MT, May FE, Marks RG, Hale WE. Nocturia: A risk factor for falls in the elderly. Journal of the American Geriatrics Society 1992; 40 (12): 12171220. Tinetti ME, Inouye SL, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. Journal of The American Medical Association 1995; 273 (17): 13481353. Moore K, Ho MT, Lapsley H et al. Project Two. Development of a Framework for Economic and Cost Evaluation for Continence Conditions. Sydney, Australia: University of New South Wales, 2006. Available from URL: http://www. bladderbowel.gov.au/doc/Economic%20Cost% 20Evaluation.pdf. Accessed 22 April 2006. Parker J, Gardner G. The silence and silencing of the nurses voice: A reading of patient progress notes. The Australian Journal of Advanced Nursing 1992; 9 (2): 39.

2008 Blackwell Publishing Asia Pty Ltd