Step 3: Time-Saving Strategies

Having completed basic evaluations of incontinent residents and determined who among them is most responsive to prompted voiding you are now in a position to make informed decisions about how to efficiently use what may be your facility’s most valuable resource: staff time. 

Lack of staff time is one of, if not THE biggest barrier to implementing prompted voiding programs.  The problem is not that prompted voiding consumes more time per episode than regular toileting assistance.  We timed both interventions; on average, the first took just 12 seconds longer per episode to implement than the second.  But toileting assistance in any form is more time-consuming to provide than checking and changing (5.5 minutes per episode), the usual care given to incontinent residents.  In addition, prompted voiding must be offered every two hours, preferably between 7am and 7pm every day, if residents are to stay dry.  By comparison, most nursing home staff provide toileting assistance less than twice a day to residents and check-and-change schedules tend to occur at times most convenient for staff, rather than when a resident needs it.

We estimate that nursing homes need a staffing ratio of 5-7 residents to one nurse aide to effectively provide prompted voiding of all responsive residents.  In comparison, the ratio in most facilities is 10 or more residents to one nurse aide between 7am and 7pm.  With such severely restricted staff resources, nursing homes must work smarter to make the most of their resources.  The recommendations that follow can help. 

Keep in mind that not every recommendation will work well in every facility.  You should decide which to implement based on your residents’ needs and your facility’s staff resources.  Also, please note: We’ve started our list with the least restrictive recommendations.  You should consider implementing these first. 

Nurse aides who consistently work with the same residents each day grow familiar with the residents’ daily routines and preferences. Such knowledge can make it easier to offer timely toileting assistance that helps keep residents drier. 

In the only study of its kind to date, we showed that prompted voiding does not improve continence at night.  So don’t bother to offer it.  Instead, nighttime care should be individualized, with the goals of minimizing sleep disruption and protecting at-risk incontinent residents from skin problems.  Prompted voiding and other toileting assistance interventions should be reserved for those residents who are bothered by nighttime incontinence and who demonstrate their willingness to toilet at night.  In our study, we attempted a nighttime toileting assistance program with 61 incontinent nursing home residents.  Wetness rates remained relatively high at night—49%--while appropriate toileting rates were low—18%.    Ideally, wetness rates should drop below 20% and appropriate toileting rates should be above 66%.  The poorest response rate was primarily observed between 10pm and 6am. Even residents who responded well to daytime prompted voiding showed poor results at night.  

Assign time-consuming tasks that are typically the responsibility of nurse aides to non-traditional care providers, including volunteers, social service staff, even administrative personnel, so that nurse aides have more time to provide prompted voiding. Some mealtime chores and between-meal snack deliveries, for example, can be handled by non-traditional staff. See our weight loss preventions, especially Step 3, for tips on redeploying staff at mealtimes.

Ideally, incontinent residents should be offered prompted voiding every two hours between 7am and 7pm.  Realistically?  Between 8am to 4pm will do.  With this schedule, residents will receive toileting assistance four times a day, enough to stay dry during that period.  They are also more likely to receive the assistance they need because nursing homes are typically better staffed during the day shift than the evening and graveyard shifts.  We’ve also noticed that, once residents are offered routine toileting assistance, many begin to tell staff when they need to go (otherwise referred to as “self-initiating” toileting).  So, as long as staff respond in a timely manner to resident requests for assistance during the evening hours (4pm-7pm), many are likely to remain dry. 

As a last resort, use more restrictive criteria to target the prompted voiding intervention to the most responsive residents. Instead of using an appropriate toileting rate of 66% or higher, raise the rate to above 75%, for example. Step 2 explains how to calculate this rate.  This targeting approach, unfortunately, will exclude some residents who could benefit from prompted voiding. Nevertheless, despite this serious drawback, it is ethically and clinically preferable to providing sub-optimal assistance to all incontinent residents or targeting assistance based on invalid resident characteristics such as cognitive status, both of which are common practices in nursing homes.

Some residents will purposely restrict their fluid intake in an attempt to improve their continence.  For the same reason, some nursing homes will do the same for residents.  In both cases, it’s a bad idea, and potentially harmful to a resident’s health.  Studies show that the majority of nursing home residents are already at high risk for dehydration due to inadequate fluid intake, a condition associated with numerous adverse clinical outcomes for residents, including hospitalization and the ultimate: death.

Far from an opportune time to limit fluids, the start of a prompted voiding program is the ideal time to offer extra fluids to residents.  Incontinent residents may be more likely to drink more if they know they can count on help to the toilet.  Additionally, it will take staff next to no extra time to offer the extra care because they have to attend to the residents in any case. 

Experts recommend that nursing home staff offer all residents extra fluids multiple times per day between meals.  For more information about strategies to increase residents’ fluid intake, visit our weight loss preventions ,especially the FAQs.