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Alert for Directors of Nursing

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Establishing, Implementing, and Continuing an Effective Continence Program in a Long-term Care Facility

Urinary incontinence (UI) affects more than half of all Americans in home or long-term care settings. However, studies show that appropriate treatment can help most people who suffer from UI to regain some control. Your role as Director of Nursing (DON) places you in a unique position. A program of diagnosis and treatment specifically for incontinence can improve the condition or cure many residents in your facility who have UI.

The key to the success of this program is the active participation of certified nursing assistants (CNAs) in implementing a continence care plan. To assist you in educating the caregivers in your charge, the Agency for Health Care Policy and Research, American Medical Directors Association, and American Health Care Association have developed a short, plain-language booklet entitled Helping People With Incontinence.

You may wish to refer to Managing Acute and Chronic Urinary Incontinence, a quick reference guide (QRG) for clinicians that was developed by a private-sector panel supported by AHCPR, as well as the AHCPR-supported clinical practice guideline (CPG), Urinary Incontinence in Adults. These documents provide more detailed information to help you develop your program.

In situations where continence programs have been implemented, the results prove their effectiveness. For example, a Chattanooga, TN, nursing facility using the 1992 AHCPR UI guideline was successful in reducing the number of incontinent patients by 65 percent and more than doubling the number of normally dry residents over a 14-month period. This included six residents who had been considered untreatable.

The essential elements of a continence program are education, motivation, and followup. It requires your commitment to:

  • Initiate and maintain a comprehensive, science-based approach to diagnosing and treating UI.
  • Provide ongoing education and motivation to CNAs in your charge.
  • Develop and foster a team approach, encouraging CNAs, licensed nurses, and attending physicians to participate actively in the continence program.
  • Continually followup by providing feedback and responding to the changing needs of caregivers who implement the program.


Evaluating UI

In order to get started, your team will need to assess each resident carefully to determine the type of UI he or she might have. This assessment should include:

  • A focused medical, neurologic, and genitourinary history that includes an assessment of risk factors, a review of medications, and a detailed exploration of UI and associated symptoms.
  • The completion of bladder records to determine the frequency, timing, and amount of voids; number of incontinent episodes; activities associated with UI; and fluid intake.
  • A mental status evaluation, including assessment of cognition and of the ability to self-toilet.
  • A functional assessment of manual dexterity and mobility.
  • An environmental assessment (e.g., access and distance to toilets and toilet substitutes; whether the chair/bed allows ease when rising).
  • A physical examination (by a primary care provider), including any necessary supplementary assessments, such as measurement of post-void residual volume.

Identifying UI

Some residents' UI is transient, caused by a reversible condition or cause, such as urinary tract infection, stool impaction, or the use of caffeine or certain medications. In some cases, once the condition or cause is resolved, so is the resident's UI.

But in many other residents with UI—especially older and frail residents—the factors causing UI are multiple and complex. For these residents, a more comprehensive approach to treatment is required. Such an approach must be tailored to the resident's type of UI. UI can be classified as:

Urge incontinence—involuntary loss of urine associated with a strong sensation of urgency, often on the way to the bathroom.

Stress incontinence—loss of urine during coughing, sneezing, laughing, or other activities that increase bladder compression.

Mixed incontinence—combination of urge and stress incontinence.

Overflow incontinence—leakage of urine associated with overdistension of the bladder.

Functional incontinence—physical or cognitive limitation that may impair toileting.

Unconscious or reflex incontinence—loss of urine that occurs without warning or sensory awareness in residents such as paraplegics and in others without overt neurologic dysfunction.

Treating UI

There are three major categories of treatment for UI:

Behavioral—noninvasive interventions that involve the patient and caregiver, including pelvic exercises, toileting schedules, and bladder training.

Pharmacologic—medications to control abnormalities in bladder/sphincter function.

Surgical—to repair or treat specific anatomical problems.

Other measures and supportive devices in the management of UI include use of catheters, external collection systems, pelvic organ support devices, and protective pads and garments. These treatment options are explained more fully in the quick reference guide.

As a general rule, the first treatment choice should be the least invasive with the fewest potential adverse complications that is appropriate for the individual resident. Behavioral techniques meet these criteria for many forms of UI, and these will be the main techniques used by the CNAs. But the resident's or family's wishes always must be respected.

Although many persons can benefit from behavioral, pharmacologic, or surgical interventions for UI, many others cannot. Typically, these persons have cognitive or physical impairments that prevent them from learning or performing behavioral methods. In addition, these individuals often cannot tolerate or would not benefit from pharmacologic or surgical options.

The care plan for persons with chronic UI should include attention to toileting schedules, fluid and dietary intake, strategies to decrease urine loss at night, use of the most absorbent and skin-friendly protective garments, and prevention and early treatment of skin breakdown. Specific recommendations for the management of chronic UI are provided in the quick reference guide. Instructions for CNAs, including specific information on toileting options, are contained in the caregiver guide, Helping People With Incontinence.

Before a resident is classified as suffering from chronic intractable UI, the most appropriate intervention should be attempted. Any care plan for these residents must involve careful education of the CNA as to the problem and intent of the treatment option. You should review the caregiver guide with the CNAs to ensure their understanding of their role in the treatment plan.


The key to an effective continence program is teamwork. Your leadership is integral to its success. The team needs reinforcement of the basic principles of behavioral therapy and motivation to continue with the program. Those involved need to know that they are essential members of an important team that includes themselves, you, the residents, and the attending physicians. They also need your support to help them implement whatever treatment plan is chosen.


Maintaining an effective continence program requires:

  • Continual education of CNAs and support staff to ensure that they understand their job.
  • Ongoing evaluation of residents to assess the benefits of the care plan, utilizing bladder records and feedback from the team.
  • Adapting the care plan to meet the changing needs of the resident.


As the DON, you can devise a plan that will maintain or improve the continence of the residents in your facility. The CNAs are critical to the success of that plan; you need to train them carefully and then reinforce their understanding of the behavioral treatments for UI.

More attention is needed to provide the best care for the chronically incontinent, but there are treatments that are effective in improving their continence. This clinical practice guideline, with its various versions, was created to help you find the best methods, no matter the level of your residents' continence.

Implementation of the basic principles of the guideline has shown that significant improvements can be made in even the most difficult cases. You can realize that same success. Tell us about your successes by sending an E-mail message to:

AHCPR Publication No. 96-0063
Current as of August 1996

The information on this page is archived and provided for reference purposes only.



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