Volume 43 Number 4

Introduction

Absorbent pads or incontinence diapers are sanitary products that are used for personal hygiene in the presence of urinary or faecal incontinence. Correct use of these products contributes to the containment and absorption of urine and faeces¹ by wicking fluids away from the skin². Nevertheless, it is becoming apparent in some healthcare facilities that nurses are unjustifiably using these continence aids on continent people³. Even studies like Zisberg (2011) show the high tendency among hospital staff to use incontinence diapers in patients whose condition do not require such intervention⁴.

Diaper use in older adults is associated with multiple adverse outcomes. For example, studies have found that diaper use: negatively influences self-esteem and perceived quality of life⁴; may lead to urinary or faecal incontinence⁵; increases dependency to carry out day-to-day activities⁶; and leads to the appearance of moisture-associated skin injuries^7–9 and pressure injuries or urinary tract infections¹⁰ that complicate the patients’ health status, or even cause their death¹¹. The adverse effects impair the quality of the health system and generate financial impacts due to the additional costs and the increase in hospital stays for the treatment of the skin damage incurred³. Additionally, the use of absorbent pads generates waste that pollutes the ecosystem^12,13, and they can also pose additional medical expenses for the patient and/or their family^14,15. Furthermore, they generate an increased burden of care for health personnel and/or family members due to the time and effort spent on changing absorbent products, hygiene and skin care³.

Studies indicate that this practice is utilised due to a lack of assessment and nursing interventions, other than application of an incontinence pad¹⁶. A study by Zurcher et al. (2011) found that nursing records mentioned the use of absorbent products without documenting a prior assessment of urinary continence¹⁷. Other studies show that health personnel have beliefs that relate incontinence to ageing¹⁶ and the use of diapers as the only hygiene treatment for the elderly¹⁸. They also mention the low use of elimination intervention strategies such as scheduled urination in nursing homes, a strategy that has more benefits compared to diaper use since it maintains continence, and promotes mobility and independence^15,19.

Although the literature describes many problems related to the wearing of unnecessary absorbent incontinence products, the effects associated with the quality of life and experiences of people have not been thoroughly studied. During her clinical duties, the researcher observed in diaper-wearing continent people feelings of revulsion, discomfort and dissatisfaction with the care provided. However, when examining the literature, few studies address these factors. One example is the study by Alves et al. (2013)¹⁸ that describes nurses’ perceptions of how users of diapers where there was no valid clinical indication for their use, evidenced mistrust, insecurity, stress, sadness and discomfort, among others. Study data is based only on the perception of nurses and does not document the patients’ perspective.

The rationale for the current study therefore was to further investigate, explain and share continent patients ‘lived experiences’ of having to wear incontinence diapers or absorbent pads when they wished to be toileted whilst being treated as inpatients within a high-complexity hospital in Bogotá, Colombia.

Methodology

Research methods

A qualitative research technique was used to interview patients about their feelings of having to use incontinence diapers or absorbent pads as opposed to being assisted to the toilet to maintain their current state of urinary or faecal continence. The following questions were asked of patients recruited to the study:

1. How do you describe your experience when using a diaper?
2. What feelings has the diaper use generated in you?
3. What factors do you think influenced your experience regarding diaper use?

Data collection was carried out by pilot testing on two patients and was assessed using the Creswell criteria²⁰ to confirm the operation of the interview guide (Figure 1) and the aspects that could be improved to incorporate them into the data collection process²⁰.

The interviews were conducted by the researcher in a private place, and the data was collected via voice recordings and field notes that included information on non-verbal expressions²⁰. During the session, the participant described their experience, additional questions were introduced to specify what they were reporting and, subsequently, the interview ended when data saturation was reached²⁰.

Selection and recruitment criteria

Selection criteria included continent people without previous use of absorbent pads or incontinence diaper products and without disability or with a mild disability according to the PULSES profile.

Seven participants were selected and recruited from an internal medicine service of a high-complexity hospital in Bogotá, Colombia. Recruited patients were informed of the research study’s objectives, privacy and security measures and the option to withdraw at any moment without any compromise to clinical care provided. Written informed consent to participate in the study were obtained.

Sample size and data saturation

The sampling was theoretical (or purposeful) for the purpose of better understanding the issues central to the current study²¹. The interview was considered complete when the data collected described the phenomenon identified in the guiding questions and the total of interviews were adequate when data saturation occurred, that is to say, the data included enough information to replicate the study, no new information was being obtained in the interviews and further coding no longer deemed feasible²².

Data analysis

The interviews were transcribed, stored and classified by a number to maintain patient anonymity. The tool used was  ATLAS.ti program version 6.0 (2003–2010, ATLAS.ti Scientific Software Development GmbH, Berlin. Author: Dr Susanne Friese) for the organisation, coding and analysis of information²³. Analysis was done according to Husserlian phenomenology since this allowed us to understand the lived experience of persons related to the phenomenon²⁴. Fundamentally, this analysis directs nursing research away from personal preference, and directs it towards a purer return²⁵, it allows us to know the phenomenon as it is lived by a person²⁶ and produces an unbiased scientific knowledge that reinforces the principles and practices of nursing and contributes therefore to professional development²⁷.

In the study, a constant immersion in the data was carried out in order to understand what is happening²⁸. The researcher of this study constantly evaluated herself to neutralise preconceptions and not influence the object of study²⁶. Based on participants’ statements, meaningful references, text excerpts or descriptors, and nominal codes, categories to describe the phenomenon were created. A second researcher was involved in validating data that was transcribed, contributing to the accuracy of the data process. Each resulting category was compared to the original descriptions for validation purposes.

Results

The study included seven continent people without a previous diagnosis of urinary or faecal incontinence and who had not previously used absorbent products or continence diapers. The average age of participants was around 74 years old and most were from a low socioeconomic background and had a low level of education. Upon further enquiry about reasons to use diapers, participants referred to having mobility difficulties to go to the bathroom, visual disability, dizziness, and alteration in lower extremities movements. All of them had a mild disability according to the PULSES profile and were able to go to the bathroom with assistance with walking or by using a walker device or a wheelchair.

From the data analysis, significant statements were identified, meanings were formulated and these were grouped in five common categories: getting into an unknown world; looking for care; submitting to using an absorbent continence product; my body’s reaction to using an absorbent continence product; and adapting or trying to recuperate my independence. Further descriptors and patient experiences under these categories are provided below.

Getting into an unknown world

This category expresses the transition the patient experienced when they were admitted as an inpatient to the hospital and how the admission affected their elimination pattern. At home, patients can go to the bathroom in an independent, private  and peaceful way but the situation changes when they are admitted to hospital. Going to the bathroom while in hospital is difficult due to their health situation and that is why they seek the accompaniment of health personnel. However, as they do not find support in these people, the only option that they receive is to relieve themselves in the diapers.

A continent person with mobility problems attempting to go to the bathroom, secondary to visual impairment, reports:

While I was here, at the hospital, it was when I had to use the diaper… When I entered, they did not ask me if I wanted, they did it without asking, they told me: You need a diaper; you must wear it... and I said: Alright. Let’s do it... and since then I’ve been wearing the diaper. But it is better to go to the bathroom, it’s more hygienic, to go to the bathroom, I have to ask for help because I see shadows, sometimes they assist me, but other times they are busy with other patients and I have to wait – E6.

Looking for care

This category describes how these subjects tried to avoid diaper usage and decided to look for help to go to the bathroom. As provision of such assistance was not timely, and sometimes took hours, the patients’ capacity to contain urine or faecal elimination was limited, and a sense of urgency occurred. In the desire to contain elimination needs, they also expressed suffering, shame, resignation, discomfort, insomnia, abdominal pain and bloating. These sensations subsided after elimination. In this category a person describes:

I had a thrombosis. This whole side became paralyzed (points to the right side of the body), (...) I’m already using the walker... but still, I cannot go to the bathroom alone. The thing is that I’m afraid of falling… When I must go to the bathroom, I call them and tell them: take me to the bathroom! but sometimes they don’t have time... and (grunts)! (points to the abdomen and simulates pain). Last night, for instance, I had such horrible colic... it was because I asked them during two hours to come and take me to the bathroom and I was very hurried – E2.

Although patients tried to wait, eventually they reached a point where they could not resist the urge to eliminate. They then resigned themselves to excrete in the absorbent pad/incontinence diaper and experienced a momentary sense of relief.

Occasionally, the nursing team takes care of their urge to go to the bathroom on time. Someone mentions:

I have gone to the bathroom to relieve myself. Normally a nurse assists me. Yesterday, she took me to the bathroom, she helped me to sit and be comfortable... She is attentive; takes care of me; she always says: What do you want? What do I do? They all are very attentive; when they assist us, they do it with so much affection – E4.

Submitting to using an absorbent continence product

The category relates to those subjects who did not need to use diapers, but felt they ‘had’ to. They wanted to relieve themselves in the bathroom, but they did not receive any assistance despite insisting repeatedly to receive it. For that reason, they had to forgo their wants and decide to relieve themselves in absorbent pads/incontinence diapers. Over time, the patients stopped calling the nursing staff to be taken to the bathroom and they resigned themselves to wearing an absorbent pad/incontinence diaper. The patients feel at the mercy of the health personnel who have little time and are also experiencing a shortage of staff. As a result, this makes them feel restricted and vulnerable. The patients have made the following comments:

Well, I have to wear a diaper, but I don’t need it… wearing a diaper is uncomfortable, but this is what I had to do. Regardless, I like to go to the bathroom and try to find someone who helps me, they just don’t assist me – E1.

I feel like an impediment to wear a diaper; it doesn’t feel good… I feel dependent on the will of the people – E6.

My body’s reaction to using an absorbent continence product

This category describes the patients’ expressed and unpleasant feelings about wearing an absorbent continence product. They used terms such as: moisture; warmth, load; burning sensation; dirt, chafe or discomfort; and even the loss of sleep. Furthermore, they worried about expenses incurred by their families when they had to buy absorbent pads or incontinence diapers. Another issue they worried about was skin injuries due to diaper change delay. People made these comments about this category:

When I wear a diaper, I feel dirty… too warm; you try to sweat. Further, the diaper makes me feel annoyed, cold, wet; I feel bad. That’s why I take it off or I tell the nurse to change it for me. I can last for hours with the diaper wet... and sometimes that produces some kind of peeling, scorching… that is annoying – E6.

Now I am burned… because they took too long to change my diaper; I burn completely, that’s why they are putting ointment on – E7.

I feel that wearing a diaper alters my sleep. I feel uncomfortable and I can’t rest properly because of the dampness – E4.

I think buying diapers affects me financially… Sometimes my husband has no money for diapers, and he has to borrow some money, then he comes and buys them – E2.

Adapting or trying to recover my independence

The category refers to how either patients adopted to the habit of relieving themselves in the absorbent pad or incontinence products without a clinical diagnosis of incontinence or other physical or reason to do so, just because there is no nursing assistance to enable them to go to the toilet. Other people persisted in avoiding the use of incontinent devices and tried to recover their independence by doing activities that helped them to mobilise or even going by themselves to the bathroom, increasing falls and injury risks. Some people mentioned:

I don’t feel bad for wearing a diaper, one gets used to it… now I ask that they put the diaper on me… I like to go to the bathroom, but I ask to be placed (in the diaper) due laziness! – E6.

So when I go to the bathroom at least I walk a little bit, and also I kind of feel life as before. I want to go back to my old life, go to the bathroom, normal – E5.

I tried to go to the bathroom alone because sometimes assistants are busy with other patients. I always hit against walls because I do not see. Yesterday I went to the bathroom... they didn’t even notice it – E6.

Discussion

This small selective sample size qualitative study describes patients’ experience of having to use absorbent pads/incontinence diapers without a valid clinical indication for their use as a shocking experience. In this study the patients felt obliged to use these types of devices because they had no other option, which generated negative consequences on a physical and personal level that could have been avoided.

Studies like Zisberg (2011) show the high tendency among hospital staff to use incontinence diapers in patients whose condition does not require such intervention⁴. This is due to the shortage of personnel, the lack of time to build better patient care planning¹⁶, and the delegation of care to technical personnel without adequate supervision¹⁸. Within the hospital in which this study was held, a similar situation was found – nursing staff delegate the task of needs relating to elimination to the technician or ancillary staff and do not supervise the type of people who are being provided with diapers.

However, regardless of whether patients are continent or have the possibility of going to the bathroom with assistance, it is becoming increasingly common for health personnel to routinely use diapers for hygiene purposes in the elderly¹⁸ or people with functional disabilities¹⁵. This occurs because health personnel do not assess continence, they associate urinary incontinence with ageing^18,29, and they believe that people with functional disabilities need to wear diapers¹⁵.

This study also observed that at home patients can go to the bathroom in an independent manner; however, this situation changes when they are admitted to hospital since the only option they are given is to relieve themselves in a diaper. This is not best practice since continent people should use the bathroom. According to studies, even semi-dependent patients should not use a diaper to relieve themselves. On the contrary, they need to go to the bathroom to help stimulate their mobility and independence^15,30.

In this study the patients who felt an urge to go to the bathroom and needed nursing assistance to do so tried to resist the use of absorbent pads/incontinence diapers. However, as the hours went by without any nursing assistance, they had no other option but to give way and relieve themselves within the diapers. In the desire to contain elimination needs, they also expressed suffering, shame, resignation, discomfort, insomnia, abdominal pain and bloating. These sensations subsided after elimination. When searching the literature, no studies were found that describe in detail this resistance of continent patients to the use of a diaper. For this reason, the current study allowed a greater insight into patient experiences.

Furthermore, as outlined above, although patients tried to wait, eventually they reached a point where they could not resist the urge to eliminate. They then resigned themselves to excrete in the absorbent pad/incontinence diaper and experienced unpleasant sensations. They described discomfort and unpleasantness from being in prolonged contact with their faeces or urine. The feelings verbalised were ones of restlessness, frustration, hopelessness and in particular the loss of independence. They also felt uncomfortable with the sensation of humidity, heat and pressure in addition to effects on their skin such as burning and pain from dermatitis associated with incontinence. When examining the literature, few studies address these factors; however, some results are similar. One study is by Alves et al. (2013) that describes nurses’ perceptions of diaper users where there is no validated clinical indication for their use. The findings are distrust, insecurity, stress, sadness and discomfort, in addition to the loss of identity, dependency or fragility due the use of diapers¹⁸. In another study on the perception of hospitalised elderly people, they mention the feeling of discomfort, low self-esteem, revulsion, itching, pain, inefficiency, heat and motor restriction⁶.

After being exposed to these sensations, some patients adopt the habit of relieving themselves in the absorbent pad or incontinence products. The study of Zisberg (2011) says that, even among continent patients, diaper use may be “addictive,” at least in the short term, which may explain the behaviour of these patients⁴. On the other hand, other people persisted in avoiding the use of incontinent devices and tried to recover their independence by doing activities that helped them to mobilise or even going by themselves to the bathroom, increasing falls and injury risks.

The literature has similar results; however, there is little research, and this allows the current study to provide a greater insight into the patients’ experiences of being forced into using diapers unnecessarily. This practice exposes patients to potential skin damage and psychological trauma that can mean a problematic or longer recovery time³¹. People who are continent of urine seek nursing assistance to go to the bathroom and maintain their level of independence. However, this study found that on most occasions they do not get support from these people and the only option that they receive is to relieve themselves in the diapers.

In these cases, the absorbent pad is used unnecessarily and can be replaced by other methods. According to Jonasson et al. (2016), there is a need to move towards a more person-centred approach as far as possible¹⁶, using methods such as scheduled assistance when going to the bathroom to help to strengthen mobility, improve autonomy and independence^30,32, and maintain health and wellbeing¹⁶.

For these methods to be implemented by hospital staff, a change in practice is necessary. A study by Bernard et al. (2020) outlines how nurse educator and administration support can contribute to reduce diapers use to improve the patient care experience. Nurse educators can teach proper toileting, explain how to assess the patients’ continence and how to use the patients’ toileting schedules, and select appropriate collection/containment devices. Also, administrative support contributes to the implementation of programs and protocols on best practices in continence care, restricts the use of absorbent pads, increases the availability of optional urinary/faecal containment devices and provides tools to support toileting, such as adequate facilities and nurses and physiotherapists trained in continence management³³.

Conclusions

The results of the study show that the Colombian health system does not always respond efficiently to the clinical needs of patients with mild disabilities to maintain independence with urinary and faecal continence. The provision of assistance nursing was not timely and forced patients to wear diapers unnecessarily and involuntarily, which undermined self-confidence, patient safety, and caused physical and psychological consequences. There were also economic implications that affect the family and health institutions with the increase in treatment costs. This study shows how health institutions do not always consider physical and social functionality and the preference of users regarding their elimination needs, thereby generating dissatisfaction, discomfort, vulnerability and loss of dependency.

In this sense, phenomenological studies such as this one are a window for reflection and a path to achieve a better quality of care³⁴. Health professionals, whilst under time and other constraints, need to understand the patients’ perspective and maintain independence regarding their elimination needs when in hospital. That is why individualised holistic care¹⁶ is needed to offer care beyond the usual care procedures, considering the priorities and elimination needs of patients.

Limitations

This research study had a very small theoretical sample size. Therefore, the results of the study should not be generalised to all health facilities. More research is needed on this phenomenon.

Acknowledgements

We would like to thank all the study participants for their cooperation.

Conflict of interest

There are no conflicts of interest to declare.

Ethics statement

This study was endorsed by the Faculty of Nursing Ethics Committee, National University of Colombia: approval (021-18) and the Research Ethics Committee in health facility, approval (119/18).

Funding

The authors received no funding for this study.

Author(s)

Sandra Guerrero Gamboa
PhD MN ETN RN
Associate Professor, Faculty of Nursing, National University of Colombia, Bogotá, Colombia

Angie Viviana Ariza Garzón*
MN RN
National University of Colombia, Bogotá, Colombia
Email avarizag@unal.edu.co

* Corresponding author

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