Barriers and enablers to providing evidence-based in-hospital urinary continence care: A cross-sectional survey informed by the Theoretical Domains Framework.

AIMS: To identify the barriers and enablers perceived by hospital-based clinicians to providing evidence-based continence care to inpatients. DESIGN: This was a cross-sectional study of inpatient clinicians using a questionnaire. METHODS: Acute care and rehabilitation clinicians from 15 wards that admit patients after stroke at 12 hospitals (NSW = 11, Queensland =1, metropolitan = 4, regional = 8) were invited to complete an online questionnaire. The 58 questions (answered on a 5-point Likert scale) were aligned to 13 of the 14 domains of the Theoretical Domains Framework. Results were dichotomized into 'strongly agree/agree' and 'unsure/disagree/strongly disagree' and proportions were calculated. Data collection occurred between January 2019 and March 2019. RESULTS: The questionnaire was completed by 291 participants with 88% being nurses. Barriers were found in nine domains including knowledge; skills; memory attention and decision making; emotion; environmental context and resources; behavioural regulation; social professional role; intensions, social influences; and beliefs about capabilities. Enablers were found in seven domains including goals; social influences; knowledge; skills; social, professional role and identity; reinforcement and beliefs about consequences. CONCLUSION: This multi-site, multi-professional study that included predominantly nurses highlights the barriers and enablers to inpatient continence care. Future implementation studies in inpatient continence management should address these identified barriers and enablers to improve effectiveness of implementation of evidence-based care. IMPLICATIONS FOR THE PROFESSION: This study highlights that although there are many barriers to ward nurses providing evidence-based continence care, there are also several enablers. Both should be addressed to improve practice. REPORTING METHOD: We adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) (Supplementary File 1). RELEVANCE TO CLINICAL PRACTICE: Establishing barriers to practice gives a broader understanding of why practice does not occur and establishes areas where researchers and clinicians need to address in order to change behaviour.

Improving Practice for Urinary Continence Care on Adult Acute Medical and Rehabilitation Wards: A Multi-Site, Co-Created Implementation Study.

Many adult inpatients experience urinary continence issues; however, we lack evidence on effective interventions for inpatient continence care. We conducted a before and after implementation study. We implemented our guideline-based intervention using strategies targeting identified barriers and evaluated the impact on urinary continence care provided by inpatient clinicians. Fifteen wards (acute = 3, rehabilitation = 7, acute and rehabilitation = 5) at 12 hospitals (metropolitan = 4, regional = 8) participated. We screened 2298 consecutive adult medical records for evidence of urinary continence symptoms over three 3-month periods: before implementation (T0: n = 849), after the 6-month implementation period (T1: n = 740), and after a 6-month maintenance period (T2: n = 709). The records of symptomatic inpatients were audited for continence assessment, diagnosis, and management plans. All wards contributed data at T0, and 11/15 wards contributed at T1 and T2 (dropouts due to COVID-19). Approximately 26% of stroke, 33% acute medical, and 50% of rehabilitation inpatients were symptomatic. The proportions of symptomatic patients (T0: n = 283, T1: n = 241, T2: n = 256) receiving recommended care were: assessment T0 = 38%, T1 = 63%, T2 = 68%; diagnosis T0 = 30%, T1 = 70%, T2 = 71%; management plan T0 = 7%, T1 = 24%, T2 = 24%. Overall, there were 4-fold increased odds for receiving assessments and management plans and 6-fold greater odds for diagnosis. These improvements were sustained at T2. This intervention has improved inpatient continence care.

Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study.

BACKGROUND: Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care. OBJECTIVE: This study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards. METHODS: This is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47% metropolitan, 8/15, 53% regional) in Australia. Data will be collected at 3 time points: before implementation (T0), immediately after the 6-month implementation period (T1), and again after a 6-month maintenance period (T2). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined. RESULTS: This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T0) was completed in March 2020. As of November 2020, 87% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T1). CONCLUSIONS: Our practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/22902.

A Home- and Community-Based Physical Activity Program Can Improve the Cardiorespiratory Fitness and Walking Capacity of Stroke Survivors.

BACKGROUND: The cardiorespiratory fitness of stroke survivors is low. Center-based exercise programs that include an aerobic component have been shown to improve poststroke cardiorespiratory fitness. This pilot study aims to determine the feasibility, safety, and preliminary efficacy of an individually tailored home- and community-based exercise program to improve cardiorespiratory fitness and walking capacity in stroke survivors. METHODS: Independently ambulant, community-dwelling stroke survivors were recruited. The control (n = 10) and intervention (n = 10) groups both received usual care. In addition the intervention group undertook a 12-week, individually tailored, home- and community-based exercise program, including once-weekly telephone or e-mail support. Assessments were conducted at baseline and at 12 weeks. Feasibility was determined by retention and program participation, and safety by adverse events. Efficacy measures included change in cardiorespiratory fitness (peak oxygen consumption [VO2peak]) and distance walked during the Six-Minute Walk Test (6MWT). Analysis of covariance was used for data analysis. RESULTS: All participants completed the study with no adverse events. All intervention participants reported undertaking their prescribed program. VO2peak improved more in the intervention group (1.17 ± .29 L/min to 1.35 ± .33 L/min) than the control group (1.24 ± .23 L/min to 1.24 ± .33 L/min, between-group difference = .18 L/min, 95% confidence interval [CI]: .01-.36). Distance walked improved more in the intervention group (427 ± 123 m to 494 ± 67m) compared to the control group (456 ± 101m to 470 ± 106m, between-group difference = 45 m, 95% CI: .3-90). CONCLUSIONS: Our individually tailored approach with once-weekly telephone or e-mail support was feasible and effective in selected stroke survivors. The 16% greater improvement in VO2peak during the 6MWT achieved in the intervention versus control group is comparable to improvements attained in supervised, center-based programs.