This proposal is looking for an improvement in the use of continence pads on elderly patients who are suffering from Urinary Incontinence (UI). Incontinence predicament was viewed by Ostaszkiewicz, Tomlinson and Hutchinson, (2018); British Association of Urological Surgeons (2018) and Abrahams et al (2010) as occurring when the bladder and bowels are incapable of controlling excretions. Incontinence was identified by the International Continence Society (2015a) as predominate to adults aged 65 years and above and also to those suffering from chronic disease, neurological disorders such as multiple sclerosis, Parkinson’s disease, strokes, and brain or spinal injuries.

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Numerous researches were carried out in recent years to determine continence care and issues related to UI. In respond towards UI, the Department of Health (2018) advocated for collaborated support from healthcare practitioners in the form of advice, incontinence absorbent products, and proper management use of continence pads. Thus, the need to improve the use of continence pads to elderly patients suffering from UI motivated the researcher to carry this proposal.

Ethical Considerations

Ethics means moral criterions that help to protect patients from physical, mental harm and abuse, (Creswell, 2010). Best and Khan (2011) further defines them as guidelines that distinguish between acceptable and unacceptable behaviour in a research study. Ethics promote mutual understanding between the researcher and participants, and there enabled the researcher to report fairly and accurately participant’s opinions without personalised bias. Israel and Hay (2006) and Carvalho, Reeves and Orford (2017) argued that adherence to ethical considerations helps to maintain informed consent, anonymity, confidentiality, objectivity, integrity, respect for intellectual property and human subjects protection, (see Appendix 1).The Nursing and Midwifery Council (NMC) (2015) viewed respect for people’s dignity as a fundamental expectation that should be adhered by healthcare practitioners as stipulated under the core values of the National Health Service (NHS) standards in UK.

Context of the Problem

The milieu problem identified is based on the improvement of continence pads to the elderly patients who are suffering from UI placed in acute hospital using DMAIC. During his placement at an acute hospital, the researcher observed adult patients wearing continence pads which they do not have need of and some wearing mistaken sizes. Chu-Yun, Shang-Qun and Chang-De (2017) observed UI condition as normal to the old aged and was viewed to be characterised with stigmatisation as well as unreported, under-diagnosed and under-treated scenarios. Goksin and Asiret, (2018) further argued that UI occur to women due to related changes that occur to them during pregnancy and childbirth. According to the International Continence Society (2015b), people aged 65 years were viewed to constitute a large number of acute hospital patients suffering from UI with a percentage of around 20-42%.

In support of the above, Newman, Rovner and Wein (2017) observed the complications of UI as leading to skin problems that can be noticeable as rashes, skin infections and moisture ulceration. On the other hand, Ebrahimi and Chapman (2018) viewed strain in relationships, low mood, job difficulties, and difficulty participating in daily activities, social isolation, anxiety, social exclusion and depression as results of socio-psychological consequences of incontinence. The aforementioned challenges associated with UI, led to the promotion and use of other incontinence products such as pads. The researcher was motivated by the need to improve the quality of different forms, shapes and sizes of continence pads so as to control effectively UI amongst the elderly patients placed in acute hospitals.

Project aims and objectives

The main aim seeks to improve the use of continence pads on elderly patients in an acute hospital setting using DMAIC. Continence pads were observed by the researcher to be in different forms, sizes and shapes at which the elderly patients sometimes found it difficult to wear them. Hence, the need to rectify this problem by improving their sizes, shapes and forms so as to best suit each individual patient. The following objectives were looked at;

Ascertain the ways to improve the use of continence pads on elderly patients in an acute hospital setting using DMAIC.
Scrutinize the occurrence of continence pad mismanagement amongst elderly patients in an acute hospital settings using DMAIC.
Suggest possible improvements that can be made on the size, form and shape of continence pads on elderly patients suffering from UI in an acute hospital settings using DMAIC.

Background Literature

Numerous studies were conducted in order to understand the various challenges faced by people with incontinence problems. Ostaszkiewicz, Tomlinson and Hutchinson (2018) looked at the problems of incontinence and how to enhance quality continence care. Their study surveyed 447 hospitalised adults and found out ‘dignity’ and ‘quality continence care’ as the effective ways to address incontinence problems. Dignity was viewed by Ostaszkiewicz, Tomlinson and Hutchinson (2018) to be widely used in the nursing field as it helps health care practitioners to adhere to privacy laws and legislative guidance found in health and social care settings, whilst ‘quality continence care’ was viewed to be of paramount importance in trying to maintain desired standards amongst health practitioners in acute care settings (NMC, 2015). More so, their study was considered to be a ‘central construct’, primarily based on subjective ideology. Ostaszkiewicz, Tomlinson and Hutchinson (2018) study was conducted in Australian home care based settings. To bridge this gap, this proposal looked at how to improve the use of continence pads on elderly patients in acute UK hospitals using DMAIC.

Another study carried out in England by Orrell et al. (2013) examined views on strategies to manage and enhance the quality care for older people with UI. Their study revealed the failure by health care professionals as the major blockade in recognising the problems associated with UI and to acknowledge different attitudes and perspectives on incontinence. The study provided crucial information in understanding incontinence management and the related barriers faced in achieving continence pads use amongst the elderly suffering from UI. Orrell et al. (2013) sampled 16 continence care services (3 acute care trusts and 13 National healthcare trusts) using a qualitative paradigm, semi-structured interview and a purposive sampling method. To show methodology gap, this proposal adopted a mixed research approach using a case study design and a purposive sampling method.

More so, Myint et al. (2008) carried out a study in UK to examine the relationship between cognition, continence and transfer status of patients suffering from stroke from the time of discharge and discharge destinations. The study found out that stroke is a major chronic illness predominated by older people and is largely associated with morbidity and disabilities. Myint et al (2008) longitudinal study deals with stroke admission cases from 1997 to 2003 and it targeted a population catchment area of about 568,000. Their study indicated that a total of 2,521 people discharged from acute care hospitals, who had suffered stroke related conditions showed signs of confusion, UI and further intensity signs of incontinence.

A review of studies by Payne (2015) on the causes, challenges and effects of UI which put forward continence assessment strategies for selecting incontinence pads for a person and the problems coupled with the use of incontinence pads; found out community nurses as playing a critical role in selecting appropriate absorbent incontinence pads for patients who suffer from UI. Payne (2015) observed various types of pads which can be used by patients with different UI conditions. These pads were found to be chosen based on the pad’s absorbency and the patient’s lifestyle. Payne’s (2015) research concluded good incontinence management as a solution to restoring UI in patients, dignity and wellbeing.

Nichols and Layton (2012) also carried out a study in order to discover closely the lifestyle management for those with UI. Patients with UI were assessed in terms of their daily impact of urinary incontinence, management techniques and life issues. The study used a systematic approach in selecting participants who were seeking clinical help for UI and it was open to individuals above 18 years. It was revealed by Nichols and Layton (2012) that of the 374 adult respondents, 63 percent were male with a median age of 52.5 years and 37 percent were female with a median age of 56 years. The findings revealed that 8-43% prevalence of incontinence were predominated by sampled male population which was increasing by age.

Furthermore, Nazarko (2015) in her study entitled, ‘Use of Continence Pads to Manage Urinary Incontinence in Older People’, examined how nurses and healthcare professionals promote the use of incontinence pads to patients with UI. The use of incontinence pads was revealed to minimise the risks of skin damage, odour, embarrassment and leakage. Nazarko (2015) further observed that it is imperative to promote equally continence management with incontinence sensitively so as to maintain a strong person’s dignity. This was revealed to avoid complications of UI. Nazarko (2015) study collaborates with a study carried out by Dingwall (2008), who assured the design of continence pads as being adept to contain urine, maintain dignity and prevent clothing, furniture, and bedding from becoming wet. The study by Dingwall (2008) further reported that continence assessment helps the nurse to determine if the patient has mild, moderate, or severe incontinence as provided by the Bowel and Bladder Service.

Moreover, a qualitative study by Brady et al. (2016) which investigated the patients’ and nursing staff’s perspectives on implementing continence care for patients after a stroke; the following themes were observed, communication about continence, mixed perceptions about continence, ambiguities, continence issues and inconsistence involved in continence care decisions. Patients were revealed to give meaningful severity of their urinary incontinence. On the other hand, staff members who were interviewed described the lack of knowledge on UI as a result of staff failure to be trained. They also enclosed continence interventions and emphasised the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to the wards. Semi-structured interviews were used to collect data which include 15 patients, 14 nurses and 9 nursing assistance using grounded theory. The study was conducted in a mixed acute and rehabilitation stroke ward setting. The study concluded that there are limitations in access to continence care equipment and products to contain incontinence. This motivated this researcher to propose a study which shall look at how to improve the use of continence pads on elderly patients in an acute hospital setting using DMAIC.

Reasons for Improvement / Patient Safety and Quality

In healthcare practices, quality care is defined by DH (2018) as a suitable dimension of health care provisions so as to fulfil patient’s needs. Puri and Spevetz (2018) further supports that improvement of patient’s quality had a positive impact on their safety. Patient safety was defined by WHO (2011) as a way of error avoidance that might harm patients. NHS England (2013) further viewed patient’s safety as aimed at avoiding unintentional injury to the patients for the duration of the deliverance of care. Wachter (2012) and WHO (2011) viewed harm as having negative impact on patient’s health and can even cause death. Injuries that led to patient’s harm were observed by Watcher (2012) and WHO (2011) to be caused by healthcare staff’s incompetence’s. Thus, healthcare workers have a pivotal mandate to exercise cautiously their duty so as to minimise patient’s harm. Sammer (2010) states that healthcare workers need to come up with reliable ways to improve patients’ safety and quality.

DMAIC/ Service improvement Methodology

Define Measure Analyse Improve Control (DMAIC) methodology was viewed by Morgan and Brenig Jones (2016) to be widely used in service improvements practices which are based on quality care and well-being of patients. DMAIC is known for being an investigative methodology following Lean Six Sigma (Hylton, 2017). Morgan and Brenig-Jones (2016) defined DMAIC as a configuration of better current healthcare practices. In support, Gupta and Saini (2018) noted that DMAIC methodology is adopted to classify improvement’s prospects. The need to improve the use of continence pads on elderly patients in acute hospitals is reviewed in this proposal project. Although DMAIC was discovered by Morgan and Brenig-Jones (2016) to be difficult and takes a long time to complete the project; he suggested the need to take seriously healthcare schemes so as to sustain improvement.

DMAIC use in improving patient’s quality care and well-being was observed by World Health Organisation (WHO) (2017) to be at the centre of NHS and is critical in the healthcare system. Patient’s safety was further supported by Lord Darzi (2008) as being achievable through uninterrupted development of proper provision of quality care. Quality was viewed by the Department of Health (DH) (2018) as attainable once there is clinical effectiveness, public backing and patient attachment. Sale (2005) further pinpointed out the embracement of clinical governance in order to perfect quality, preservation, specialised responsibility as well as maintaining a safe and sound setting for shareholders over an unconcealed and direct way of life.

Phases of DMAIC

Control

Morgan and Brenig-Jones (2016)

Define

The first phase of DMAIC is the definition, identification of the problem and the setting of goals to eradicate the problem setting. The define stage layout the breach in quality and articulate the purpose of this service proposal (Minami et al. 2016). The setting of improper use of continence pads was identified as a problem and therefore need to improve the use these continence pads which are found in different shapes, sizes and forms on elderly patients in acute hospitals. The aims and objectives of the DMAIC methodology were viewed by Minami et al. (2016) to be identified in this first stage. Doctors, healthcare assistants, nurses, manager and deputy manager shall be involved in this service improvement proposal. Their inclusion as revealed by NHS IQ (2010) help to reduce delays in the improvement proposal. Thus, the aforementioned healthcare practitioners shall make concrete decision making on how to improve the use of continence pads to elderly patients in acute hospitals.

Measure

The second phase deals with measurements of the outcomes of the problem identified, (Morgan and Brenig-Jones, 2016). In addition, Langley et al. (2009) indicated that measurements are required to have an insight on the impact of change. The frequency taken by nurses to change the elderly patients with continence pads shall be recorded. Also the unwillingness and difficulties faced by the elderly patients in using continence pads shall be recorded so as to find out the severity of the problem so as to improve its proper use.

Analyse

The third phase includes the analysis of the problem identified. According to Morgan and Brening-Jones (2016) the analysis stage entails detection of the cause of the problem by means of confirmation of measurements. Moreover, Minami et al. (2016) further states that this stage authenticates and seek out to comprehend the origin of the problem from the data that was collected. The continuous data is going to be analysed using quantitative analysis methods such as the mean and standard deviation. Frequencies are going to be used for nominal data. The researcher shall use a Chi-Square for associations between the presence of nursing record entries on UI and elderly patients’ who wishes to improve their condition. Their association shall be based on whether their unwillingness and difficulties in using continence pads differed regarding their willingness to be questioned about UI, and their preference to be questioned about their condition. Logistic regression shall be used in this proposed study so as to control gender and unit. This shall be supported by the Fisher’s exact tests and SPSS version 11.0 (SPSS Inc., Chicago, IL, USA) for the purpose of analysing the collected data.

Improve

Another phase is that of improve. According to Langley et al. (2009) having identified the problem, methodology and analysed the problem at hand; practical knowledge become imperative in service improvement as follows:

● Need to improve size, shape and form of continence pads

This entails the need to correctly supply the correct size, form and shape of continence pads to the elderly patients who suffer from UI. This will go a long way in helping to avoid improper use and unwillingness as well as difficulties that can be faced by the elderly patients in wearing continence pads in acute hospital settings. According to the NHS England (2015-2018) nurses have a responsibility to continuously maintain proper use of continence pads to the elderly patients as recommended in the good practises for healthcare professionals.

● Designing a poster that prompt and remind nurses and patience to take proper use of continence pads in acute hospital settings.

A poster was viewed by El-Sharkawy et al. (2014) as helping to remind nurses to keep proper care use of continence pads to patients with UI.

● Taking regular check-ups to change continence pads to the elderly patients with UI.

Control

The last phase stage focuses mainly on ways to maintain sustainable improvements made (Morgan and Brenig-Jones, 2016).The way to sustain and control improvements was considered by Morgan and Brenig-Jones (2016) to be useful in the healthcare fraternity so as to regularly check the use of continence pads to the elderly patients in acute hospital’s assessment amongst staff and patients.

Lean Methodology

Lean Six Sigma was viewed by Stamatis (2011) to be used mainly to eradicate any flaws in healthcare settings. The aim being to trim down medical mistakes, reducing death toll and recuperating quality and patient care (Stamatis, 2011).

Search Strategies

Various resources and viable literature were viewed to be available within healthcare and clinical databases which include Pub Med Health, CINAHL, and Cochrane. The following keywords were chosen for the purpose of this proposal, continence pads, Urinary Incontinence (UI), pads mismanagement, continence products, managing incontinence and acute hospital care. A case in point, a keyword look for ‘incontinence’ problem on CINAHL yielded 795 papers. The periphery of inclusion years in the search criterion were documents published between 2014 and 2018. A Boolean search on ‘managing incontinence’ brings up 513 documents on Pub Med Health. Also, the key phrase ‘urinary incontinence’ was sprint on Cochrane where it gives in 195 documents and on CINAHL, giving in 85 documents that corresponding to the peer-reviewed criterion.

Conclusion

Evidence gathered from various studies carried out on UI has shown out that there are a multitude of issues associated with continence pad management in acute care settings. The old aged patients were revealed to be at high risk of incontinence problems especially women and those who have suffered from chronic ailments (Office for National Statistics, 2017).Related literature findings have revealed the importance of giving a choice to patients when it comes to choosing their desired continence products, such as pads. That is the choice of absorbent incontinence products used. Management and proper use of continence pads enables patients to maintain dignity and avoid the complications of poorly managed UI. Thus, continence pads assessment is imperative to enable patients chose the most appropriate type of continence pads to minimise risks of skin damage, odour, embarrassment, leakage and avoid difficulties and unwillingness to wear them.

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