y J Wound Ostomy Continence Nurs. 2015;42(2):183-189. Published by Lippincott Williams & Wilkins
CONTINENCE CARE
Knowledge, Attitudes, Beliefs, and Practices in Registered Nurses and Care Aids About Urinary Incontinence in Korean Nursing Homes A Cross-sectional Survey Sunah Park
Jennie C. De Gagne
■ ABSTRACT PURPOSE: The purpose of this study was to describe
knowledge, attitudes, beliefs, and practices about urinary incontinence among Korean RNs and care aids and to identify correlates of continence care practices. METHOD: A cross-sectional survey was used to gather selfreported data from 338 nursing staff, including 135 RNs and 203 care aids, from 61 nursing homes in Korea by using an existing instrument adapted for Korean nursing staff. The instrument consists of 18 items designed to measure knowledge about urinary incontinence, 18 items querying attitudes toward continence care, 17 items focusing on beliefs about undesirable consequences to older adults with urinary incontinence, and 28 items querying on continence care practice. RESULTS: Registered nurses had higher knowledge about urinary incontinence and they had more positive attitudes toward continence care practice than care aids. Attitudes, facility bed capacity, and continuing education on urinary incontinence were significantly related (P < .05) to RNs’ continence care practice scores (R2= 0.285; P < .001), while care aids’ practice scores were associated with knowledge and attitudes (R2= 0.163; P < .001). CONCLUSIONS: Attitude plays an important role in continence care practice for both RNs and care aids in Korean nursing homes. In addition, continence care practice of RNs may be influenced by updating clinical competencies. For care aids, continence care practice can be influenced by improving basic knowledge of urinary incontinence. KEY WORDS: attitude, beliefs, knowledge, nursing care, nursing education, nursing homes, urinary incontinence
■ Introduction The elderly population has grown substantially in the past decades. The proportion of older persons living in Korea is expected to reach 20% of the country’s population by
Aeyoung So
Mary H. Palmer
2026.1 This circumstance brought a dramatic growth in the number of long-term care facilities, from 8318 in 2008 to 15,704 in 2013.1 Urinary incontinence (UI) is highly prevalent in long-term care settings in Korea, ranging from approximately 50% to 70%; these prevalence rates are similar to those reported in Western countries.2,3 There is also a growing demand for improvement of the care of residents with UI in long-term care facilities. However, UI has often been an underestimated problem and less well managed than other geriatric syndromes in nursing homes. Findings from a study of Korean nurses revealed that continence care was not considered an important intervention for nursing home residents.4 These results are similar to studies based in the United States (US), where nurses were less likely to perceive themselves as primary caregivers for UI.5 In another US-based study, nurse respondents identified bathing, dressing, and assisting residents to move to the dining room as more important than continence care.6 The most prevalent intervention for UI is containing urine loss via absorbent products,2,7,8 despite evidence that behavioral interventions, such as prompted or scheduled toileting, decrease the frequency of UI in many residents.9,10 Sunah Park, PhD, RN, Red Cross College of Nursing, Chung-Ang University, Seoul, Korea. Jennie C. De Gagne, PhD, DNP, RN-BC, CNE, School of Nursing, Duke University, Durham, North Carolina. Aeyoung So, PhD, MPH, RN, Helen W. and Thomas L. Umphlet Distinguished Professor, Department of Nursing, Gangneung-Wonju National University, Wonju-si, Korea. Mary H. Palmer, PhD, RNC, FAAN, AGSF, School of Nursing, University of North Carolina, Chapel Hill. The authors declare no conflicts of interest. Correspondence: Aeyoung So, PhD, MPH, RN, Department of Nursing, Gangneung-Wonju National University, Namwonro, 150, Wonju-si 220-711, Gangwon-do, Korea (
[email protected]). DOI: 10.1097/WON.0000000000000095
Copyright © 2015 by the Wound, Ostomy and Continence Nurses Society™
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Multiple factors have been associated with continence care practices in long-term care. They include lack of knowledge about how to manage or treat older adults with UI, insufficient training in the area of continence care practice, negative attitudes toward UI management, and false beliefs that UI is a normal or inevitable consequence of aging.6,11-15 These factors interact to impair implementation of more efficient continence care practices.16,17 According to existing theories of behavior and behavior change, knowledge, attitudes, and beliefs are critical antecedents for behavioral change.18 Three hierarchical dimensions, cognitive, affective, and behavioral, underpin the behavioral change model that supports our assertion that knowledge, attitude, and belief are expected to influence clinical practice in a positive manner.19 The purpose of this study was to evaluate associations between demographic factors, institutional characteristics and knowledge, attitudes, beliefs, and reported practices related to continence care. The specific aims of this study were to (1) describe demographics of RNs and care aids along with facility characteristics such as bed capacity; (2) describe levels of knowledge, attitudes, and beliefs among nurses and care aids; and (3) analyze associations among these factors to reported continence care practice in the nursing home setting.
■ Methods Data were collected using a cross-sectional survey method. The target sample comprised RNs and care aids employed in nursing homes in Korea. In Korea, care aids receive 3 months of training in elderly care and are primarily responsible for basic nursing skills such as dressing, bathing, feeding, and transferring. Nursing staff who were not directly involved in continence care practice, such as administrators and directors, were excluded from participation. Respondents were recruited from 61 nursing homes in 8 cities located in Korea; these nursing homes employed both RNs and care aids. Study procedures were reviewed and approved by the institutional review boards of the University of North Carolina at Chapel Hill in the United States and the Gangneung-Wonju National University in Korea. Informed consent was obtained from all participants. A pilot study was carried out to pretest the instrument with 33 RNs and care aids; minor adjustments to the questionnaire were then made.
Instruments The questionnaire comprised 3 sections: (1) Knowledge and Practice Instrument (KPI); (2) Attitudes and Beliefs scale; and (3) demographic characteristics and bed capacity as an organizational variable. Knowledge of UI and reported continence care practices were measured by the KPI, designed specifically for nursing staff in nursing homes by Saxer and colleagues.20 The KPI consists of
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18 knowledge and 28 practice items. The knowledge scale comprises statements about UI and nursing care associated with UI. Response categories are “true,” “false,” and “don’t know.” The response “true” was scored as 1 (correct answer), and the “false” and “don’t know” responses were scored as 0 (incorrect answer). The range of scores was 0 to 18. Higher knowledge scores indicate more knowledge of UI and its management. Internal reliability of the instrument measured using the study sample was 0.823 (the Cronbach’s alpha). The practice scale comprises 4 subscales: (1) drinking habits and excretion (10 items); (2) assessment and information (6 items); (3) documentation (4 items); and (4) support (8 items). Each item is scored using a 4-point Likert scale, where 1 = never, 2 = sometimes, 3 = often, and 4 = always. A cumulative score was calculated based on all 28 items; subscale scores were also calculated; the range of scores for each subscale is 1 to 4. Higher scores reflected better continence care practices. The internal reliability of the original practice subscales was 0.77 for drinking habits and excretion, 0.81 for assessment and information, 0.74 for documentation, and 0.69 for support; all were evaluated using the Cronbach’s alpha. In this study, Cronbach’s alpha was 0.89 for drinking habits and excretion, 0.84 for assessment and information, 0.85 for documentation, and 0.85 for support. The internal reliability of total practice scale of this study was 0.94. Urinary incontinence–related attitudes and beliefs were measured by the Attitude and Belief scale, developed by Henderson.21 The attitude subscale consists of 18 items that measure nurses’ attitudes toward incontinence care for older adults. Items responses are a 6-point Likert scale, ranging from 1 (“strongly disagree”) to 6 (“strongly agree”). The attitude score was calculated using the mean for 18 items. The mean score range was 1 to 6 with higher average scores on the attitude scale, indicating more positive attitudes toward continence care practice. The internal reliability of this scale was measured via the Cronbach’s alpha; it was 0.84 when originally developed, and 0.76 in our study. The Belief subscale has 17 items rated on a 6-point Likert scale, ranging from 1 (“strongly disagree”) to 6 (“strongly agree”). This scale was used to measure nurses’ beliefs about undesirable consequences of UI. Most of the items were negatively phrased statements (ie, “Having UI is humiliating for those who have it.”). Negatively phrased items were reverse coded so that higher scores indicated more positive beliefs toward consequences of UI. The score of the belief was calculated with the mean of the 17 items and the score range was 1 to 6, when the internal reliability measured during this study was 0.86. The questionnaire was translated into Korean by the 3 first authors (S.P., J.C.D., and A.S.) with permission. A back-translation was made by a researcher who primarily speaks English and Korean as a second language; this backtranslation was verified by a bilingual-bicultural researcher.
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After comparing the original English and the backtranslated English versions, we finalized the instrument to be used in our survey study.
Study Procedures Participants were recruited between April and June 2012. Administrators or directors of nursing homes located in different sizes of Korean cities were contacted by e-mail to explain the study outline; telephone calls followed to confirm their intention to participate. After a participation agreement was obtained, the survey packets were distributed to nursing homes by the researcher who met with staff members of facilities and explained study objectives. The participants were asked to complete the surveys before or after work or on breaks. They were also asked to place the complete questionnaire in a sealed envelope placed in a secured place. The researcher picked up completed surveys on a regular basis. When physical distance of nursing homes became an issue, the survey packets were distributed and returned by mail. The senior staff of the nursing homes were asked to act as contact persons and were given information about the purpose and procedure of the study. After the participants completed the questionnaire and placed them in sealed envelopes, the senior staff sent the questionnaires to the researchers by mail.
Data Analysis Data were analyzed using SPSS 18.0 for Windows (Statistical Package for Social Sciences Inc, Chicago, Illinois). Analysis of data was conducted using the following approaches: (1) descriptive statistics for investigating general characteristics of RNs and care aids along with bed capacity; (2) descriptive statistics for levels of knowledge, attitudes, beliefs, and practice; and (3) bivariate analyses for examining which factors were related with continence care practice among RNs and care aids, using analysis of
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variance, Scheffe post hoc tests, t tests, and the Pearson correlations. Stepwise multiple regression analyses were used to determine factors associated with continence care practice. The separate regression analyses were conducted for RNs and care aids. Continence care practices were operationalized as the mean score of all the practice items of the KPI.
■ Results Four hundred forty (440) questionnaires were equally distributed between RNs and care aids; 160 (73%) were returned by RNs and 210 (95%) by care aids, yielding a global response rate of 84%. An additional 32 responses were excluded for missing or incomplete data, resulting in 338 evaluable responses (135 RNs and 203 care aids). The majority of respondents were female (96.7%). The mean age of RNs and care aids was 45.1 ± 8.35 years and 51.4 ± 6.67 (mean ± SD) years, respectively; this difference was statistically significant (t = 7.37; P < .001). Registered nurses had a higher level of education (100% had completed at least college) whereas 84% of care aids had a high school or lower level of education. Registered nurses had significantly more work experience than care aids (5.1 ± 3.81 vs 4.3 ± 2.94; t = 1.98; P = .049). Less than 20% of RNs and care aids reported received any continuing education focusing on UI (17.2% and 19.7%, respectively). Sixty-one nursing homes agreed to enable data collection from their staff. Of the 61 nursing homes, 19 (31.1%) had fewer than 30 beds, 13 (21.3%) had 30 to 59 beds, 16 (26.3%) had 60 to 119 beds, and 13 (21.3%) had more than 120 beds. Table 1 summarizes knowledge, attitudes, beliefs, and continence care practice scores of RNs and care aids. Registered nurses showed statistically significant higher scores knowledge and attitude scores than did care aids (P < .001, respectively). In contrast, care aids had
TABLE 1.
Comparison of Knowledge, Attitudes, Beliefs, and Practice Scores Between RNs and Care Aids (N ⴝ 338) Range
RNs (n ⴝ 135)
Care Aids (n ⴝ 203)
Knowledge, median (IQR)
0-18
11.0 (13-9)
7.0 (10-5)
11.01 (