Capstone Project Change Proposal for Bowel and Urinary Incontinence Prevention and Care in ICU

Background

Bowel and urinary incontinence syndrome (BUI) is a very widespread condition that is frequently encountered in the ICU. According to Stokes, Crumley, Taylor-Thompson, and Cheng (2016), the prevalence of BUI in intensive care ranges between 9% to 37%. These numbers are mirrored by Aguiar and Franco (2018), who bring up the prevalence of 8.7%-40% worldwide. The disease occurs in women more so than men, due to various physiological differences, one of which includes childbirth. Therefore, nurses are familiar with BUI encounters. At the same time, the levels of their knowledge about the disease and its effect on the patient and overall healthcare system remain low (Stokes et al., 2016). Nurses do not apply in-depth knowledge in treating and preventing the condition, resulting in mediocre results and increased chances of rehospitalization or hospital-acquired infection in patients (Stokes et al., 2016). One of the most frequent diseases to accompany BUI includes perineal dermatitis in the areas surrounding the urinal or anal cavity (Mohammed & Nadr, 2018).

Clinical Problem Statement

Bowel and urinary incontinence syndrome (BUI) presents a significant threat to the wellbeing of patients and the integrity of the hospital system. It is a gateway to numerous other hospital-acquired infections, is deeply disconcerting for the patient, and requires significant time resources on the part of the hospital to treat. Some of these cases are unavoidable, such as in trauma and post-birth ICU patients. But many individuals acquire the condition or exacerbate the existing one while in hospital care. Preventing such eventualities will help decrease the negative effects of the disease on the patient, reduce the pressure on nurses, and contribute to the overall quality of care.

Purpose

The purpose of the change proposal is to improve the quality of patient care by increasing the state of nursing knowledge about BUI, methods of treatment, and its impact on the healthcare system. As indicated by Stokes et al. (2016), the state of knowledge of the disease in nurses is mostly cursory and does not extend beyond providing immediate treatment, despite nurses’ familiarity with the condition (Aguiar & Franco, 2018). At the same time, the increases in nursing knowledge have been shown to have a connection with patient satisfaction and quality of care (Donnelly et al., 2018). Therefore, the proposed solution is to implement changes that would improve the levels of knowledge of BUI in the ICU unit.

PICOT Question

  • P (Population): ICU populations suffering from bowel and urinary incontinence;
  • I (Intervention): Information campaign providing knowledge on BUI, its effects on the hospital system, potential infections, and various outcomes;
  • C (Comparison): Baseline with no dedicated interventions aimed towards them;
  • O (Outcome): Improved quality, reduced rehospitalization rates, reduced HAI rates;
  • T (Time): 12 months.

Literature Search Strategy Employed

The literature search strategy involved the research and analysis of articles relevant to the current subject, extracted from various databases, such as Medlab, CINAHL, Cochrane, Elsevier, as well as the university library. The initial article search was performed utilizing the following keywords: bowel, urinary, incontinence, syndrome, intensive care unit, ICU, prevention, education. The articles were set to have been published in peer-reviewed sources within the last 5 years, in order to account for the relevancy of findings. The initial articles were extracted and then evaluated manually, in order to determine the relevancy of their subject and findings to the study. Out of about 50 articles that passed through stage 1, the total list was narrowed down to 8 articles to provide information for the initial proposal. In the scope of informing the ongoing research, more literature sources will be warranted.

Evaluation of the Literature

Literature sources acquired as a result of the earlier searches were evaluated in order to identify the potential gaps of knowledge as well as similarities and differences in terms of methods, samples, research questions, and other defining traits that could inform the proposed study. It was discovered that the primary gap of knowledge lied in the lack of data regarding the effectiveness of nursing education in reducing BUI morbidity (Brown et al., 2019). The studies were split into four different types based on their methodology and scope. Large “state of knowledge” studies were essentially expanded literature reviews with a broad scope of assessment, but no creation of actual knowledge (Danielis, Palese, Terzoni, & Destrebecq, 2020). RCTs were usually small in scope and sample size, and lacking in representation, but provided important data on the effectiveness of programs in countering BUI (Donnelly et al., 2018). There was a distinct lack of RCTs dedicated to nursing education on the matter. Incidence and prevalence studies helped inform the existing research about the scope of the issue (Kawanabe, Suzuki, Tanaka, Sasaki, & Hamaguchi, 2018). Finally, guidelines attempted to tackle the issue of nursing knowledge and could be used in the recent study.

Applicable Change Theory

In order to facilitate the learning and implementation of nursing knowledge provided in the scope of the intervention, Lewin’s change theory was utilized. It is a three-stage process that includes Unfreezing, Implementing Changes, and Refreezing as distinct steps in applying changes (Sullivan, 2019). The unfreezing stage will occur during the initial lessons and lectures, where the state of knowledge in participants would be evaluated, while misconceptions and strong (but inaccurate) beliefs about BUI would be dismantled. The change implementation will include the provision of factual and up-to-date knowledge and recommendations on how to conduct patient treatment. Finally, the refreezing stage will involve nurses practicing their newly-acquired knowledge and cementing the improved operational procedures as the new status quo.

Proposed Implementation Plan with Outcome Measures

The proposed implementation plan includes the following steps (Sullivan, 2019):

  • Assessment of the existing nursing knowledge: Tests will be conducted to learn at what stage is the knowledge levels in nurses participating in the study.
  • Educational intervention: Nurses will be taught about BUI, the newest methods of handling and maintenance, and the overarching importance of treating it efficiently.
  • Secondary assessment: Nurses will be asked to pass another test, to see how well they have retained the material. Outcome measure: Score improvements compared to the first test.
  • Implementation stage: Nurses will return to work and apply their newfound knowledge to practice. Outcome measure: reduction of BUI and BUI-associated factors in patients and hospital statistics.
  • Tertiary assessment. Approximately 6 months after the end of the active phase of the intervention, a third test will be conducted to see how well was the knowledge retained over time.

Use of Evidence-Based Practice in the Intervention Plan

EBP guidelines were utilized in creating the intervention plan. The blueprint mirrors the methodology of other educational interventions utilized in the chosen area. The background and literature review section is based on recently-published articles. The plan for nurse education is based on expert recommendations and guidelines dedicated to the subject of BUI and fecal incontinence (Garcia et al., 2015). Finally, the choices of evaluation methods are based on the recommendations for nursing research by Sullivan (2019). The overarching theoretical framework (Lewin’s change theory) is also supported by numerous implementations in change plans and has proven to be efficient in guiding interventions such as this one.

Evaluation Plan

The study will use two types of evaluation, including theoretical and practical assessments of the effectiveness of the intervention (Kramer & Rubinstein, 2020). The theoretical part will be evaluated by the use of tests and marks to highlight the effectiveness (or failure) of the intervention to improve the state of knowledge in nurses. The practical effectiveness of the intervention will be demonstrated by the comparison of BUI statistics in the chosen ICU unit prior, during, and after the intervention, to see a clear correlation between the increase in nursing knowledge and decrease in BUI and rehospitalization rates, if there are any.

Potential Barriers

Some of the potential barriers to the plan implementation include the lack of financial resources to conduct the research, the lack of human resources needed to conduct the educational part of the intervention, and the lack of representation in either the nurses or the patients (Sullivan, 2019). The first one is addressed by the chosen methodology of research, which does not require as many financial resources as other types of interventions. The lack of human resources could be addressed with the use of volunteers, as it is possible to convince nurses with high points in BUI knowledge to act as mentors for other nurses. Finally, the issue with representation is common in these types of research, and it will be dealt with by limiting the scope of the study.

References

Aguiar, L. M., & Franco, I. (2018). Bladder bowel dysfunction. Urologic Clinics, 45(4), 633-640.

Brown, H. W., Braun, E. J., Wise, M. E., Myers, S., Li, Z., Sampene, E.,… Rogers, R. G. (2019). Small-Group, community-member intervention for urinary and bowel incontinence: A randomized controlled trial. Obstetrics and Gynecology, 134(3), 600-611.

Danielis, M., Palese, A., Terzoni, S., & Destrebecq, A. L. L. (2020). What nursing-sensitive outcomes have been studied to date among patients cared for in intensive care units? Findings from a scoping review. International Journal of Nursing Studies, 102, 103491.

Donnelly, D. W., Donnelly, C., Kearney, T., Weller, D., Sharp, L., Downing, A.,… Cross, W. R. (2018). Urinary, bowel and sexual health in older men from Northern Ireland. BJU International, 122(5), 845-857.

García, C. B., Binks, R., De Luca, E., Dierkes, C., Franci, A., Gallart, E.,… Gibot, S. (2015). Expert recommendations for managing acute fecal incontinence with diarrhea in the intensive care unit. Journal of the Intensive Care Society, 14(4_suppl), 1-9.

Kawanabe, E., Suzuki, M., Tanaka, S., Sasaki, S., & Hamaguchi, T. (2018). Impairment in toileting behavior after a stroke. Geriatrics & Gerontology International, 18(8), 1166-1172.

Kramer, C. L., & Rabinstein, A. A. (2020). Evidence-based critical care. Cham, Switzerland: Springer.

Mohammed, H. M., & Nadr, M. (2018). Perineal dermatitis: A neglected problem in patients at Critical Care Unit. EPH-International Journal of Medical and Health Science (ISSN: 2456-6063), 4(2), 66-71.

Stokes, A. L., Crumley, C., Taylor-Thompson, K., & Cheng, A. L. (2016). Prevalence of fecal incontinence in the acute care setting. Journal of Wound, Ostomy and Continence Nursing, 43(5), 517-522.

Sullivan, D. A. (2019). How to choose and conduct a research project: Some advice for young investigators. Arquivos Brasileiros De Oftalmologia, 82(1), 1-10.