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A study of the effect of stress incontinence and bladder retraining on older women's perceived self-esteem Pierson, Wanda Jane 1988

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STUDY OF THE EFFECT OF STRESS INCONTINENCE AND BLADDER RETRAINING ON OLDER WOMEN'S PERCEIVED SELF-ESTEEM By WANDA JANE PIERSON BSN., The U n i v e r s i t y of B r i t i s h Columbia, 1983 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES SCHOOL OF NURSING We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA October 1988 © Wanda Jane P i e r s o n , 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Nursing The University of British Columbia Vancouver, Canada Date October 6, 1988 DE-6 (2/88) A b s t r a c t The purpose of t h i s d e s c r i p t i v e study was to determine the e x i s t e n c e o f a r e l a t i o n s h i p between p e r c e p t i o n s o f g l o b a l s e l f - e s t e e m and s t r e s s i n c o n t i n e n c e episodes i n a group of o l d e r women p a r t i c i p a t i n g i n a bladder r e t r a i n i n g p r o t o c o l . A convenience sample of f i f t e e n o l d e r women was obtained. The p a r t i c i p a n t s c o n s t i t u t e d a group o f we l l o l d e r women who ranged i n age from 63 years to 82 years. A l l p a r t i c i p a n t s were l i v i n g i n the community and e x p e r i e n c i n g u r i n a r y i n c o n t i n e n c e . The U n i v e r s i t y o f B r i t i s h Columbia Model f o r Nursing was the conceptual framework which guided the focus o f the study. The model views the i n d i v i d u a l as a b e h a v i o u r a l system composed of nine i n t e r r e l a t e d and interdependent subsystems. This study focused on the i n t e r r e l a t i o n s h i p o f the e x c r e t o r y and e g o - v a l u a t i v e subsystems. The theory o f s e l f - e f f i c a c y , as o u t l i n e d by Bandura provided the method by which t h i s study was o p e r a t i o n a l i z e d . S e l f - e f f i c a c y i s the product o f pers o n a l e f f i c a c y — a n i n d i v i d u a l ' s judgement o f the e f f e c t i v e n e s s o f an executed course o f a c t i o n i n a c h i e v i n g a d e s i r e d outcome. The e n a c t i v e , p e r s u a s i v e , and emotive modes of i n f l u e n c e were u t i l i z e d to provide e f f i c a c y i n f o r m a t i o n . Data were c o l l e c t e d on three o c c a s i o n s u s i n g four instruments. The f i r s t instrument i n v o l v e d c o l l e c t i o n o f s e l e c t e d demographic v a r i a b l e s and was completed d u r i n g the i n i t i a l i n t e r v i e w . A continence assessment and the Rosenberg s e l f - e s t e e m s c a l e were completed d u r i n g the i n i t i a l and f i n a l i n t e r v i e w s . An i n t e r v i e w guide was used d u r i n g a telephone i i i c o n t a c t . The telephone c o n t a c t o c c u r r e d four days f o l l o w i n g the f i r s t i n t e r v i e w ; the f i n a l i n t e r v i e w o c c u r r e d f o u r t e e n days a f t e r the f i r s t . The data were summarized, compared and d e s c r i b e d u s i n g measures of c e n t r a l tendency and frequency d i s t r i b u t i o n s . P a i r e d t - t e s t s were performed on s e l e c t e d v a r i a b l e s to determine i f there was a d i f f e r e n c e between pre and post i n t e r v e n t i o n i n t e r v i e w score. These t e s t s demonstrated no s i g n i f i c a n t d i f f e r e n c e s i n sc o r e s . Study f i n d i n g s i n d i c a t e d t h a t a t the end o f the two week t r i a l 53% of the women were able to i d e n t i f y a change i n t h e i r v o i d i n g h a b i t s . Four o f the p a r t i c i p a n t s (26.7%) s t a t e d t h a t they were completely c o n t i n e n t a t the completion o f the two week t r i a l and four other p a r t i c i p a n t s (26.7%) i n d i c a t e d t h a t $ some type o f p o s i t i v e change had occurr e d . Three women (20%) i d e n t i f i e d a negative change i n t h e i r continence s t a t u s . G l o b a l s e l f - e s t e e m s c o r e s , as measured by the Rosenberg s e l f - e s t e e m s c a l e , remained r e l a t i v e l y s t a b l e d u r i n g the two week t r i a l p e r i o d . Scores appeared to be u n a f f e c t e d by a change i n continence s t a t u s . T h i s may be due to the many s u c c e s s f u l n o r m a l i z i n g s t r a t e g i e s s u b j e c t s had developed to hide the evidence o f the symptom of u r i n a r y i n c o n t i n e n c e . i v TABLE OF CONTENTS A b s t r a c t i i Table o f Contents i v L i s t of Tables v i Acknowledgements v i i i CHAPTER ONE I n t r o d u c t i o n Context of the Problem 1 Conceptual Framework 4 The U n i v e r s i t y of B r i t i s h Columbia Model f o r Nursing 4 S e l f - e f f i c a c y 6 Statement of Purpose 8 Research Questions 8 V a r i a b l e s 9 D e f i n i t i o n of Terms 9 L i m i t a t i o n s 10 O r g a n i z a t i o n o f the F o l l o w i n g Chapters 11 CHAPTER TWO Review of the Rel a t e d L i t e r a t u r e I n t r o d u c t i o n 12 The E x c r e t o r y Subsystem 12 Mechanisms of U r i n a r y Continence 12 Forces 15 The E g o - v a l u a t i v e Subsystem 19 Self-esteem 20 Forces 22 Summary 24 CHAPTER THREE Methodology I n t r o d u c t i o n 25 Process o f O b t a i n i n g Study P a r t i c i p a n t s 25 C r i t e r i a f o r P a r t i c i p a n t S e l e c t i o n 27 Data C o l l e c t i o n 27 Data C o l l e c t i o n Instruments 29 Demographic Inf o r m a t i o n 29 Continence Assessment 30 The Rosenberg Self-esteem Scale 31 The Telephone Interview Guide 33 Data A n a l y s i s 33 E t h i c a l C o n s i d e r a t i o n s 33 Summary 34 V CHAPTER FOUR P r e s e n t a t i o n and D i s c u s s i o n of F i n d i n g s I n t r o d u c t i o n 35 C h a r a c t e r i s t i c s o f the P a r t i c i p a n t s 35 Continence Assessment 38 The Rosenberg Self-esteem Scale 53 D i s c u s s i o n 57 The E x c r e t o r y Subsystem 57 The E g o - v a l u a t i v e Subsystem 59 Summary 63 CHAPTER FIVE Summary, C o n c l u s i o n s , and I m p l i c a t i o n s f o r Nursing Summary 65 Con c l u s i o n s 69 I m p l i c a t i o n s f o r Nursing 70 B i b l i o g r a p h y 74 Appendices A Advertisement 82 B Inf o r m a t i o n L e t t e r 83 C Consent Form 85 D Demographic Information 86 E Continence Assessment 88 F Self-esteem Scale 91 G Bladder R e t r a i n i n g P r o t o c o l 93 H Interview Guide f o r Telephone Contact 94 I Tables o f P e r c e i v e d Changes i n Frequency of In c o n t i n e n t Episodes During P e r i o d s o f Increased Intra-abdominal Pressure a t Pre and Post I n t e r v e n t i o n Interview Times 95 J Tables o f Frequency of Responses to Rosenberg Self-esteem Q u e s t i o n n a i r e Items a t Pre and Post I n t e r v e n t i o n Interview Times 99 K L e t t e r o f Per m i s s i o n to Use the Rosenberg Self-esteem Scale 109 v i LIST OF TABLES Table I P e r c e i v e d Changes i n D a i l y V o i d i n g Frequency a t Pre and Post I n t e r v e n t i o n Interview Times 39 II P e r c e p t i o n s of N o c t u r i a a t Pre and Post I n t e r v e n t i o n Interview Times 40 I I I P e r c e i v e d Changes i n Frequency of Episodes of T o t a l Loss of U r i n a r y C o n t r o l a t Pre and Post I n t e r v e n t i o n Interview Times 41 IV P e r c e i v e d Changes i n Frequency of S t r e s s Incontinence Episodes a t Pre and Post I n t e r v e n t i o n Interview Times 42 V P e r c e i v e d Changes i n Urgency a t Pre and Post I n t e r v e n t i o n Interview Times N 43 VI P e r c e i v e d Changes i n Frequency of Incomplete Bladder Emptying a t Pre and Post I n t e r v e n t i o n Interview Times 44 VII P e r c e i v e d Changes i n Frequency of F e e l i n g of F u l l n e s s Post Void a t Pre and Post I n t e r v e n t i o n Interview Times 44 VIII P e r c e i v e d Changes i n Frequency o f I n c o n t i n e n t Episodes by Category of Incontinence a t Pre and Post I n t e r v e n t i o n Interview Times 46 IX C r o s s - t a b u l a t i o n of Frequency of I n c o n t i n e n t Episodes by P a r t i c i p a n t a c c o r d i n g to Category of Incontinence a t Pre and Post I n t e r v e n t i o n Interview Times 47 X P e r c e i v e d Changes i n the Amount of Urine Released During I n c o n t i n e n t Episodes a t Pre and Post I n t e r v e n t i o n Interview Times 48 XI Use of P r o t e c t i v e Undergarment Products at Pre and Post I n t e r v e n t i o n Interview Times 52 XII Sums of P a r t i c i p a n t ' s Scores on the Rosenberg Self-esteem Scale at Pre and Post I n t e r v e n t i o n Interview Times 53 XIII Frequency of Responses to Question 8 "I wish I c o u l d have more r e s p e c t f o r myself" on the Rosenberg Self-esteem Scale a t Pre and Post I n t e r v e n t i o n Interview Times 55 v i i XIV Comparisons of Changes i n Self-esteem Scores to Changes i n Continence Status a t Pre and Post I n t e r v e n t i o n Interview Times 56 XV P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t Episodes when Coughing a t Pre and Post I n t e r v e n t i o n Interview Times 95 XVI P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t Episodes when Sneezing a t Pre and Post I n t e r v e n t i o n Interview Times 96 XVII P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t Episodes when Laughing at Pre and Post I n t e r v e n t i o n Interview Times 97 XVIII P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t Episodes when L i f t i n g an Object a t Pre and Post I n t e r v e n t i o n Interview Times 98 XVIX I f e e l t h a t I'm a person o f worth, a t l e a s t on an equal plane with o t h e r s . 99 XX I f e e l t h a t I have a number of good q u a l i t i e s . 100 XXI A l l i n a l l , I am i n c l i n e d to f e e l t h a t I am a f a i l u r e . 101 XXII I am able to do t h i n g s as w e l l as most other people. 102 XXIII I f e e l I do not have much to be proud o f . 103 XXIV I take a p o s i t i v e a t t i t u d e towards myself. 104 XXV On the whole, I am s a t i s f i e d with myself. 105 XXVI I wish I c o u l d have more r e s p e c t f o r myself. 106 XXVII I c e r t a i n l y f e e l u s e l e s s at times. 107 XXVIII At times I t h i n k I am no good a t a l l . 108 v i i i Acknowledgements There are a number of people without whose help t h i s study would not have been p o s s i b l e . I wish to thank Helen N i s k a l a and S h e i l a Stanton f o r t h e i r a s s i s t a n c e d u r i n g the beginning of the r e s e a r c h process. I am indebted to my t h e s i s committee f o r a c c e p t i n g the task of g u i d i n g me through the r e s e a r c h process mid-stream. I would l i k e to thank C a r o l J i l l i n g s , c h a i r p e r s o n , f o r her support, encouragement, and i n s i g h t f u l comments; and E t h e l Warbinek f o r her support, i n t e r e s t , and c r i t i c a l a p p r a i s a l . A p p r e c i a t i o n i s a l s o extended to Sue Ng a t the U n i v e r s i t y of B r i t i s h Columbia Computing Centre f o r her w i l l i n g and expert a s s i s t a n c e with the s t a t i s t i c a l a n a l y s i s of the data. S p e c i a l thanks to the women who v o l u n t e e r e d to p a r t i c i p a t e . T h e i r c o o p e r a t i o n i n completing the q u e s t i o n n a i r e s and performing the p r o t o c o l was e s s e n t i a l to the outcome of the study. And f i n a l l y to Anne Johnstone and Penny L u s z t i g , thank-you, f o r your unceasing support and encouragement. :l CHAPTER ONE I n t r o d u c t i o n Context o f the Problem A d u l t s 65 years o f age and o l d e r form the f a s t e s t growing age group w i t h i n Canadian s o c i e t y . During the l a s t h a l f century, the t o t a l Canadian p o p u l a t i o n doubled i n s i z e whereas the s i z e o f the o l d e r p o p u l a t i o n t r i p l e d . P o p u l a t i o n growth p r o j e c t i o n s f o r the next 15 years suggest t h a t t h i s o l d e r p o p u l a t i o n w i l l i n c r e a s e a t a r a t e twice t h a t o f the general p o p u l a t i o n (Stone & F l e t c h e r , 1986). By the year 2001, o l d e r Canadians are expected to comprise 11% of the t o t a l Canadian p o p u l a t i o n , compared to 9% i n 1976 (Vancouver Health Department, 1982, p. 1). Women comprise approximately 57% of the o l d e r p o p u l a t i o n c o h o r t and e x t r a p o l a t i o n o f present growth parameters i d e n t i f i e s a trend toward i n c r e a s e d female l o n g e v i t y . This t r e n d w i l l have major i m p l i c a t i o n s f o r h e a l t h care p r o f e s s i o n a l s as o l d e r a d u l t s use the h e a l t h care system more f r e q u e n t l y than any other a d u l t group, and women use more h e a l t h care s e r v i c e s than men (C h a p p e l l , 1982; F l e t c h e r & Stone, 1982; Scalzo & M i t c h e l l , 1984; Vancouver Health Department, 1982). One of the h e a l t h problems which may b r i n g o l d e r a d u l t s i n t o c o n t a c t with the h e a l t h care system i s u r i n a r y i n c o n t i n e n c e . U r i n a r y i n c o n t i n e n c e i s i d e n t i f i e d as a primary h e a l t h concern of o l d e r a d u l t s , i n v o l v i n g a l l aspects o f an i n d i v i d u a l ' s b i o p s y c h o s o c i a l f u n c t i o n i n g (Green, 1986; Ouslander, 1981; Resnick, 1984). F e e l i n g s o f shame and embarrassment r e l a t e d to u r i n a r y i n c o n t i n e n c e are d e s c r i b e d as l e a d i n g to a sense of h e l p l e s s n e s s and hopelessness. F u r t h e r consequences of u r i n a r y i n c o n t i n e n c e are i d e n t i f i e d as s o c i a l withdrawal and i s o l a t i o n ( B u t t s , 1979; Glew, 1986; Green, 1986; Hadley, 1986; Wells, 1987; Yu & K a l t r e i d e r , 1987). The a c t u a l prevalence of u r i n a r y i n c o n t i n e n c e i s unknown as the problem i s o f t e n not r e p o r t e d . T h i s may be due to a b e l i e f t h a t i n c o n t i n e n c e i s i n e v i t a b l e — p a r t o f the normal aging process (Glew, 1986; M o r i s h i t a , 1988; Simons, 1985; Jakovac Smith, 1988); or, the l a c k o f r e p o r t i n g may be due to m i s i n t e r p r e t a t i o n o f the medical term " i n c o n t i n e n c e " , as used by h e a l t h care p r o f e s s i o n a l s d u r i n g assessments (Jakovac Smith, 1988). S t i l l , other authors have suggested t h a t f e e l i n g s o f shame and hopelessness are r e s p o n s i b l e f o r t h i s i n s u f f i c i e n t r e p o r t i n g ( B u t t s , 1979; Glew, 1986; Jakovac Smith, 1988; Wells, 1987). I t i s estimated t h a t 10% to 20% of o l d e r a d u l t s l i v i n g i n the community have a continence problem. The c o s t o f u r i n a r y i n c o n t i n e n c e (both human and m a t e r i a l ) on f a m i l y r e s o u r c e s may n e c e s s i t a t e or prolong i n s t i t u t i o n a l care (Green, 1986; Hadley, 1986; Long, 1985; M o r i s h i t a , 1988; S i e r , Ouslander & Orzeck, 1987; Simons, 1985). Within i n s t i t u t i o n s , i t i s estimated t h a t more than 50% of the o l d e r p o p u l a t i o n may s u f f e r with some type of in c o n t i n e n c e (McCormick & Burgio, 1984; S i e r e t a l . , 1987; Simons, 1985; Yu e t a l . , 1987). S e v e r a l types o f u r i n a r y i n c o n t i n e n c e may a f f l i c t o l d e r a d u l t s . These i n c l u d e s t r e s s , urge, overflow and t o t a l i n c o n t i n e n c e . Of these, s t r e s s i n c o n t i n e n c e — t h e i n v o l u n t a r y l o s s of u r i n e d u r i n g p e r i o d s o f i n c r e a s e d intra-abdominal p r e s s u r e — i s a common symptom among o l d e r women. Th i s may be a t t r i b u t a b l e to the anatomical s t r u c t u r e o f the female p e l v i s as w e l l as to the woman's o b s t e t r i c a l h i s t o r y ( B u t t s , 1979; Long, 1985; Simons, 1985; Wells, 1987). E f f e c t i v e b e h a v i o u r a l approaches f o r the management of s t r e s s i n c o n t i n e n c e are documented i n the l i t e r a t u r e (Burgio e t a l . , 1985; Long, 1985), but the c o n c l u s i o n s drawn r e g a r d i n g the p s y c h o s o c i a l e f f e c t s o f s t r e s s i n c o n t i n e n c e on o l d e r women appear to be based i n common sense, r a t h e r than v a l i d a t e d e m p i r i c a l evidence. B r i n k , Wells, and Diokno (1987) i d e n t i f i e d f i v e of the few p u b l i s h e d s t u d i e s which d i s c u s s the e f f e c t s of u r i n a r y i n c o n t i n e n c e on p s y c h o s o c i a l f u n c t i o n i n g . The f i v e s t u d i e s focused on men and women of a l l ages. The l a c k o f a d i s c e r n i b l e r e l a t i o n s h i p between the s e v e r i t y o f in c o n t i n e n c e and the r e s t r i c t i o n of d a i l y a c t i v i t i e s , l e d Br i n k and c o l l e a g u e s to the c o n c l u s i o n t h a t r e a c t i o n s to u r i n a r y i n c o n t i n e n c e are " i n d i v i d u a l and u n p r e d i c t i v e " (p. 115). Simons (1985) i n v e s t i g a t e d the r e l a t i o n s h i p between u r i n a r y i n c o n t i n e n c e and s e l f - c o n c e p t . Study r e s u l t s i n d i c a t e d t h a t o l d e r women p e r c e i v e d i n c o n t i n e n c e as an i n e v i t a b l e r e s u l t of aging. A n a l y s i s demonstrated no s i g n i f i c a n t 4 c o r r e l a t i o n between p e r c e i v e d h e a l t h and s e l f - e s t e e m . These r e s u l t s d i f f e r s i g n i f i c a n t l y from the p i c t u r e d e s c r i b e d i n the l i t e r a t u r e . Consequently, there i s a need to examine the p s y c h o s o c i a l i s s u e s o f s t r e s s i n c o n t i n e n c e i n g r e a t e r depth. No p u b l i s h e d study has been l o c a t e d which d e s c r i b e s the e f f e c t on c l i e n t s ' s e l f - e s t e e m o f implementing a bladder r e t r a i n i n g p r o t o c o l to decrease the frequency o f s t r e s s i n c o n t i n e n c e episodes. T h i s study i n v e s t i g a t e d the r e l a t i o n s h i p between s e l f - e s t e e m and s t r e s s i n c o n t i n e n c e i n a group of o l d e r women i n v o l v e d i n a bladder r e t r a i n i n g program. Conceptual Framework The conceptual framework f o r t h i s study i s based on the U n i v e r s i t y o f B r i t i s h Columbia Model f o r Nursing (Campbell, 1987) and Bandura's theory o f s e l f - e f f i c a c y (1978). The U n i v e r s i t y o f B r i t i s h Columbia Model f o r Nursing The U n i v e r s i t y o f B r i t i s h Columbia Model f o r Nursing i s based on systems theory and views the i n d i v i d u a l as a be h a v i o u r a l system composed of nine i n t e r r e l a t e d and interdependent subsystems. Each of the nine s u b s y s t e m s — a c h i e v i n g , a f f e c t i v e , e g o - v a l u a t i v e , e x c r e t o r y , i n g e s t i v e , p r o t e c t i v e , r e p a r a t i v e , r e s p i r a t o r y and s a t i a t i v e — i s r e s p o n s i b l e f o r the s a t i s f a c t i o n o f one b a s i c human need. S t r u c t u r a l l y , a subsystem i s d i v i d e d i n t o an inner p e r s o n a l r e g i o n and a p s y c h o l o g i c a l environment. The inner p e r s o n a l r e g i o n r e p r e s e n t s a b a s i c human need and the c o g n i t i v e and e x e c u t i v e a b i l i t i e s necessary f o r need s a t i s f a c t i o n . The p s y c h o l o g i c a l environment i n c l u d e s a need-r e l a t e d goal and the p o s i t i v e and negative f o r c e s i n f l u e n c i n g goal achievement. The i n d i v i d u a l seeks to a t t a i n subsystem goal achievement, need s a t i s f a c t i o n , b e h a v i o u r a l system balance and s t a b i l i t y through the use of coping behaviours. Coping behaviours are composed of c o g n i t i v e and e x e c u t i v e a b i l i t i e s and r e p r e s e n t the usual way an i n d i v i d u a l achieves and maintains subsystem goal achievement and need s a t i s f a c t i o n (Campbell, 1987). The r e c i p r o c a l i n t e r a c t i o n and interdependency of the subsystems i n d i c a t e t h a t a change r e l a t e d to goal achievement and need s a t i s f a c t i o n i n any subsystem w i l l produce a change i n the n e e d - r e l a t e d t e n s i o n s of the remaining subsystems. This study focuses p r i m a r i l y on the i n t e r - r e l a t i o n s h i p between two s u b s y s t e m s — t h e e x c r e t o r y , and the e g o - v a l u a t i v e subsystems. The goal of the e x c r e t o r y subsystem i s the "absence of accumulated wastes" (Campbell, 1987, p. 47). In the s i t u a t i o n presented by t h i s study, s t r e s s i n c o n t i n e n c e i s an u n s u i t a b l e coping behaviour i n the e x c r e t o r y subsystem. Though the goal of the subsystem i s achieved as wastes are e x c r e t e d , a l i m i t e d e x e c u t i v e a b i l i t y permits the e x c r e t o r y a c t i o n to occur a t an i n a p p r o p r i a t e time. I n t r o d u c t i o n of a bladder r e t r a i n i n g p r o t o c o l , which i n v o l v e s t e a c h i n g the c l i e n t new c o g n i t i v e and e x e c u t i v e a b i l i t i e s , i s an attempt to f o s t e r the development of a s u i t a b l e coping behaviour i n the e x c r e t o r y subsystem. The goal of the e g o - v a l u a t i v e subsystem i s " s e l f - e s t e e m " (Campbell, 1987, p. 46). S t r e s s i n c o n t i n e n c e i s i d e n t i f i e d as a negative f o r c e on a c l i e n t ' s s e l f - e s t e e m ( B u t t s , 1979; 6 Feneley & B l a n n i n , 1984: Long, 1985; McCormick e t a l . , 1984; Sp i r o , 1978; Yu e t a l . , 1987). Th e r e f o r e , s t r e s s i n c o n t i n e n c e i s a negative f o r c e i n the e g o - v a l u a t i v e subsystem. I f the e f f e c t o f the bladder r e t r a i n i n g p r o t o c o l produces a s u i t a b l e coping behaviour i n the e x c r e t o r y subsystem, then t h i s new coping behaviour may become a p o s i t i v e f o r c e i n the ego-v a l u a t i v e subsystem. The study w i l l d e s c r i b e the r e s u l t s of implementing a bladder r e t r a i n i n g p r o t o c o l with a group of o l d e r women e x p e r i e n c i n g s t r e s s i n c o n t i n e n c e . The bladder r e t r a i n i n g p r o t o c o l (Appendix G) c o n s i s t e d o f m a i n t a i n i n g an adequate f l u i d i n t ake and performing e x e r c i s e s to strengthen the p e l v i c f l o o r musculature. S e l f - e f f i c a c y The theory of s e l f - e f f i c a c y , as o u t l i n e d by Bandura (1978) pr o v i d e d the method by which t h i s study was o p e r a t i o n a l i z e d . S e l f - e f f i c a c y i s an i n d i v i d u a l ' s b e l i e f t h a t the performance o f s p e c i f i c behaviours i n s p e c i f i c circumstances w i l l produce a d e s i r e d outcome. The i n d i v i d u a l b e l i e v e s he has the c a p a b i l i t y to perform the necessary behaviours. S e l f - e f f i c a c y i s the product o f pers o n a l e f f i c a c y --an i n d i v i d u a l ' s judgement of how e f f e c t i v e an executed course of a c t i o n was toward a c h i e v i n g a d e s i r e d outcome. When an i n d i v i d u a l p e r c e i v e s h e r s e l f as l a c k i n g the necessary c a p a b i l i t y to produce a d e s i r e d outcome, the s i t u a t i o n becomes an e f f i c a c y - b a s e d f u t i l i t y . The r e s u l t of t h i s f u t i l i t y may be d e p r e s s i o n (Bandura, 1978). In order to change an e f f i c a c y -7 based f u t i l i t y , e x p e c t a t i o n s o f pers o n a l e f f i c a c y r e q u i r e s t r e n g t h e n i n g . Information which may c r e a t e or stren g t h e n p e r s o n a l e f f i c a c y i s conveyed by four modes of i n f l u e n c e , pr sources o f i n f o r m a t i o n — e n a c t i v e , v i c a r i o u s , p e r s u a s i v e , and emotive. The e n a c t i v e mode i n v o l v e s t e a c h i n g an i n d i v i d u a l the behaviour and c o n v i n c i n g her th a t the behaviour w i l l be s u c c e s s f u l . T h i s mode i s c o n s i d e r e d the s t r o n g e s t of the four sources o f i n f o r m a t i o n as a c t u a l performance and e v a l u a t i o n o the behaviour i s r e q u i r e d . The v i c a r i o u s mode i n v o l v e s o b s e r v i n g o t h e r s , i n s i m i l a r circumstances, performing the d e s i r e d behaviour. The pe r s u a s i v e mode i s used to convince an i n d i v i d u a l t h a t she possesses the necessary c a p a b i l i t i e s to perform the behaviour and master the e f f i c a c y - b a s e d f u t i l i t y . The i n d i v i d u a l ' s b e l i e f s about s e l f and pe r s o n a l c a p a b i l i t i e s are maintained and promoted i n the emotive mode. An e f f i c a c y - b a s e d f u t i l i t y i s changed by u t i l i z i n g the modes of i n f l u e n c e to provide the c l i e n t with the necessary behavio and a sense o f pers o n a l e f f e c t i v e n e s s or competence over a s p e c i f i c s i t u a t i o n (Bandura, 1978). S t r e s s i n c o n t i n e n c e with i t s r e s u l t a n t f e e l i n g s o f h e l p l e s s n e s s and hopelessness ( B u t t s , 1979; Glew, 1986) i s an example of an e f f i c a c y - b a s e d f u t i l i t y . U t i l i z i n g the e n a c t i v e p e r s u a s i v e , and emotive modes of i n f l u e n c e , the bladder r e t r a i n i n g p r o t o c o l p r o v i d e d the c l i e n t with the o p p o r t u n i t y to develop a new coping behaviour or competency as d e l i n e a t e d 8 by Bandura. The e n a c t i v e mode i n v o l v e d t e a c h i n g the c l i e n t the components of the bladder r e t r a i n i n g p r o t o c o l . The pe r s u a s i v e mode i n v o l v e d the i n v e s t i g a t o r a c t i v e l y persuading the c l i e n t to r e a l i z e her pers o n a l c a p a b i l i t y i n t h i s s i t u a t i o n . The emotive mode was used to provide support, reassurance and encouragement. The e f f e c t i v e use of these three modes of i n f l u e n c e may provide the c l i e n t with a new competency by which she may be abl e to produce a d e s i r e d outcome. In t h i s s i t u a t i o n the d e s i r e d outcome was a r e d u c t i o n of i n c o n t i n e n t episodes. Statement o f Purpose The purpose o f t h i s study was to determine i f a r e l a t i o n s h i p e x i s t e d between the l e v e l of s e l f - e s t e e m as measured by the Rosenberg s e l f - e s t e e m s c a l e (1965), and the presence of s t r e s s i n c o n t i n e n c e i n a group of o l d e r women p a r t i c i p a t i n g i n a bladder r e t r a i n i n g program. Research Questions 1. What are the p e r c e p t i o n s o f g l o b a l s e l f - e s t e e m , o f o l d e r women e x p e r i e n c i n g s t r e s s i n c o n t i n e n c e , as measured by the Rosenberg s e l f - e s t e e m s c a l e ? 2. I f the number of s t r e s s i n c o n t i n e n c e episodes are decreased through bladder r e t r a i n i n g do o l d e r women experience a change i n t h e i r p e r c e p t i o n s o f g l o b a l s e l f - e s t e e m as measured by the Rosenberg s e l f - e s t e e m s c a l e ? 9 V a r i a b l e s The independent v a r i a b l e i n t h i s study was the bladder r e t r a i n i n g program. The dependent v a r i a b l e s i n t h i s study were: s t r e s s i n c o n t i n e n c e , and the f e e l i n g o f s e l f - e s t e e m as measured by the Rosenberg s e l f - e s t e e m s c a l e . D e f i n i t i o n o f Terms The f o l l o w i n g d e f i n i t i o n s were used throughout the study: C o g n i t i v e a b i l i t y : "the c a p a c i t y to know the subsystem's p s y c h o l o g i c a l environment" (Campbell, 1987, p. 35). Exec u t i v e a b i l i t y : "the c a p a c i t y to manipulate the subsystem's p s y c h o l o g i c a l environment" (Campbell, 1987, p. 35) . Coping behaviour: "a response t h a t i n d i c a t e s the way i n which a subsystem i s attempting to s a t i s f y a b a s i c human need f o r the system" (Campbell, 1987, p. 35). S u i t a b l e coping behaviour: "a response that s a t i s f i e s a b a s i c human need; the response i s a p p r o p r i a t e to s o c i e t a l e x p e c t a t i o n s and congruent with the degree of and p o t e n t i a l f o r maturation" (Campbell, 1987, p. 35). In the s i t u a t i o n presented by t h i s study, the r e l e a s e o f u r i n e a t s o c i a l l y a p p r o p r i a t e times i s an example of a s u i t a b l e coping behaviour. Force: "a determinant o f movement toward or away from a g o a l ; f o r c e s may a r i s e from the needs and a b i l i t i e s o f the subsystems ( p e r s o n a l ) ; from other b e h a v i o u r a l systems ( s o c i o c u l t u r a l ) ; or from the impersonal aspects of a s i t u a t i o n 10 ( i m p e r s o n a l ) " (Campbell, 1987, p. 36). Forces may be p e r c e i v e d as p o s i t i v e or negative by the subsystems. The p e r s o n a l f o r c e s of aging and s t r e s s i n c o n t i n e n c e were c o n s i d e r e d i n t h i s study. Adequate h y d r a t i o n : a minimum f l u i d i n t ake of 2500 ml. i n 24 hours (Maney, 1976; S p i r o , 1978; Wells, 1975). Bladder r e t r a i n i n g p r o t o c o l : a p r o t o c o l i n v o l v i n g p e l v i c f l o o r e x e r c i s e s and adequate h y d r a t i o n . Well o l d e r women: female p a r t i c i p a n t s 60 years of age and o l d e r , l i v i n g i n the community and independently managing t h e i r a c t i v i t i e s of d a i l y l i v i n g . P e l v i c e x e r c i s e s : t i g h t e n i n g of the r i n g of muscle around the vagina and rectum without t e n s i n g muscles of the lower e x t r e m i t i e s ; and r e p e a t e d l y s t o p p i n g the flow of u r i n e when v o i d i n g (McCormick & Burgio, 1984). Self-esteem: "... a p o s i t i v e or negative a t t i t u d e toward a p a r t i c u l a r o b j e c t , namely, the s e l f " (Rosenberg, 1965, p. 30). In t h i s study, s e l f - e s t e e m was measured u s i n g the Rosenberg s e l f - e s t e e m s c a l e (1965). S t r e s s i n c o n t i n e n c e : Any i n v o l u n t a r y l o s s of u r i n e o c c u r r i n g when coughing, sneezing, l a u g h i n g or l i f t i n g an o b j e c t . U r i n a r y i n c o n t i n e n c e : any i n v o l u n t a r y l o s s of u r i n e (McConnell & Zimmerman, 1983, p. 47). L i m i t a t i o n s Study p a r t i c i p a n t s had a v a r i e t y of medical diagnoses which may have i n f l u e n c e d the type and degree of u r i n a r y i n c o n t i n e n c e they experienced. I t was not p o s s i b l e to c o n t r o l 1 :L f o r t h i s , except to exclude i n d i v i d u a l s with neurogenic bladders due to neuromuscular d i s o r d e r s . As women were responding to an advertisement r e g a r d i n g the study, i t i s p o s s i b l e t h a t an unique subset o f the general aging p o p u l a t i o n was s e l e c t e d . There i s a p o s s i b i l i t y t h a t a group o f women d i d not respond due to fe a r o f exposure. The small sample s i z e and the b r i e f two week, t r i a l p e r i o d l i m i t e d the g e n e r a l i z a b i l i t y o f the study r e s u l t s . O r g a n i z a t i o n o f the F o l l o w i n g Chapters This study r e p o r t i s orga n i z e d i n t o f i v e c h a p t e r s . Chapter one o u t l i n e s the context of the problem and the purpose o f the study. Chapter two presents a review o f s e l e c t e d l i t e r a t u r e r e l a t e d to the need and goal o f the 'e x c r e t o r y and e g o - v a l u a t i v e subsystems. Chapter three d e s c r i b e s the r e s e a r c h methodology, i n c l u d i n g data r e g a r d i n g the sample, data c o l l e c t i o n and a n a l y s i s . Chapter four i s a r e p o r t and d i s c u s s i o n o f the study r e s u l t s . C o n c l u s i o n s are presented i n chapter f i v e with i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n , p r a c t i c e and r e s e a r c h . CHAPTER TWO Review of Rel a t e d L i t e r a t u r e I n t r o d u c t i o n The U n i v e r s i t y o f B r i t i s h Columbia Model f o r Nursing c o n c e p t u a l i z e s the i n d i v i d u a l as a b e h a v i o u r a l system compose of nine interdependent and i n t e r a c t i n g subsystems. The Model d i r e c t s the nurse to determine the presence o f b e h a v i o u r a l system balance and s t a b i l i t y through the assessment o f subsystem goal achievement and need s a t i s f a c t i o n . Subsystem goal achievement and need s a t i s f a c t i o n are determined through the c o l l e c t i o n and a n a l y s i s o f r e l e v a n t data r e l a t e d to c o p i n behaviours and manipulable v a r i a b l e s . S t r e s s i n c o n t i n e n c e i s c i t e d as a predominant problem o f o l d e r women. This chapter w i l l review the c u r r e n t l i t e r a t u r e r e g a r d i n g the experience o f o l d e r women with s t r e s s i n c o n t i n e n c e and i s or g a n i z e d a c c o r d i n g to the s t r u c t u r e and f u n c t i o n o f the i n v o l v e d subsystems. The E x c r e t o r y Subsystem The b a s i c human need r e p r e s e n t e d by the e x c r e t o r y subsystem i s the c o l l e c t i o n and removal o f accumulated wastes The n e e d - r e l a t e d goal i s the absence o f accumulated wastes. Need s a t i s f a c t i o n occurs through a process d i r e c t e d toward goal achievement. Goal achievement can be assessed v i a the mechanisms o f continence. Mechanisms of U r i n a r y Continence U r i n a r y continence r e q u i r e s an i n t a c t and f u n c t i o n a l b l a dder, u r e t h r a , u r e t h r a l s p h i n c t e r s , and p e r i n e a l musculature. The u r i n a r y bladder i s a hollow muscular organ p o s i t i o n e d a n t e r i o r l y to the vagina and uterus. The bladder w a l l c o n s i s t s of a l a y e r of c o n n e c t i v e t i s s u e o v e r l y i n g an i n t e r l a c i n g network of smooth muscle known as the d e t r u s o r muscle, and an i n t e r i o r mucous l i n i n g ( G o s l i n g , 1985). Extending approximately four c e n t i m e t e r s from the base of the bladder to the e x t e r n a l meatus the u r e t h r a i s continuous with the i n t e r i o r mucous l i n i n g of the bladder. Contiguous with the bladder and u r e t h r a , the u r e t h r a l s p h i n c t e r s are p o o r l y d e f i n e d a n a t o m i c a l l y . F u n c t i o n a l l y , the i n t e r n a l u r e t h r a l s p h i n c t e r i s i d e n t i f i e d as the bladder neck, and the e x t e r n a l s p h i n c t e r i s d e f i n e d as the proximal u r e t h r a ( B l a i v a s , 1985; G o s l i n g , 1985; Resnick, 1984). Composed of smooth muscle and e l a s t i c f i b r e s , c l o s u r e of the s p h i n c t e r s i s maintained by compression of the u r e t h r a l mucosa over an adequate l e n g t h of muscular and c o n n e c t i v e t i s s u e . The i n t e r n a l u r e t h r a l s p h i n c t e r , predominantly c o n s t i t u t e d of smooth muscle, i s under autonomic c o n t r o l . The e x t e r n a l u r e t h r a l s p h i n c t e r , s i t u a t e d a t the l e v e l of the u r o g e n i t a l diaphragm and composed of s t r i a t e d muscle, i s s o m a t i c a l l y enervated and under v o l u n t a r y c o n t r o l (Resnick, 1984). The pubococcygeus muscle o r i g i n a t e s i n the pubic arch with the i n s e r t i o n s i t e l o c a t e d a t the t i p of the coccyx. P a s s i n g through the medial p o r t i o n s of the f i v e p e l v i c m u s c u l o f a s c i a l diaphragms, the pubococcygeus muscle p l a y s a s u p p o r t i v e and s p h i n c t e r i c r o l e i n the continence mechanism (Kegel & Powell, 1950) . Continence i s achieved by the maintenance of u r e t h r a l pressure a t a l e v e l g r e a t e r than d e t r u s o r p r e s s u r e . The adequately supported, enervated, and e s t r o g e n i z e d u r e t h r a produces an o c c l u s i v e f o r c e s u f f i c i e n t to maintain u r e t h r a l pressure a t r e s t and d u r i n g sudden i n c r e a s e s i n i n t r a -abdominal or i n t r a v e s i c a l p r e s s u r e s (Stanton, 1986; S t a s k i n , Zimmern, Hadley, Raz, 1985). The pubococcygeus muscle and the u r o g e n i t a l diaphragm provide a d d i t i o n a l support d u r i n g coughing, sneezing, and moments of p h y s i c a l e f f o r t (Stanton, 1986; S t a s k i n e t a l , 1985). The continence mechanism demonstrates the f u n c t i o n of c o g n i t i v e and e x e c u t i v e a b i l i t i e s o f the e x c r e t o r y subsystem. The a b i l i t i e s permit the subsystem to p e r c e i v e bladder d i s t e n s i o n , and i n h i b i t bladder r e l a x a t i o n u n t i l a s o c i a l l y a p p r o p r i a t e time. The a b i l i t i e s g i v e r i s e to p e r s o n a l f o r c e s which a f f e c t subsystem goal achievement. In t h i s i n s t a n c e , the personal f o r c e r e l a t e d to subsystem goal achievement i s the mechanism of v o i d i n g . The Mechanism of V o i d i n g The v o i d i n g mechanism i n v o l v e s p e r c e p t i o n of a d i s t e n d e d bladder and c o r t i c a l modulation of the s a c r a l s p i n a l cord r e f l e x a r c to i n h i b i t bladder c o n t r a c t i o n u n t i l a s o c i a l l y a p p r o p r i a t e p l a c e and time (Whitehead, Burgio & Engel, 1984). At an a p p r o p r i a t e time and p l a c e the i n t r a u r e t h r a l pressure f a l l s due to r e l a x a t i o n of the u r e t h r a l s p h i n c t e r and p e l v i c f l o o r . The bladder neck and base descend and the u r e t h r a l lumen opens. The d e t r u s o r muscle c o n t r a c t s e x p e l l i n g u r i n e . The v o i d i n g c o n t r a c t i o n i s s u s t a i n e d u n t i l the bladder i s empty. At the completion of v o i d i n g , the d e t r u s o r r e l a x e s , and the bladder neck and u r e t h r a c l o s e . The bladder neck and base then r e t u r n to t h e i r o r i g i n a l intra-abdominal p o s i t i o n (Stanton, 1986). The combined e f f e c t i v e f u n c t i o n i n g of the continence and v o i d i n g mechanisms f o s t e r s s u i t a b l e coping behaviours i n the e x c r e t o r y subsystem f a c i l i t a t i n g movement toward goal achievement and need s a t i s f a c t i o n . A l t e r a t i o n i n the e f f e c t i v e f u n c t i o n i n g of the continence and v o i d i n g mechanisms may be a t t r i b u t e d to a v a r i e t y of f o r c e s . Forces which w i l l be examined i n c l u d e the e f f e c t of the b i o l o g i c a l process of aging and s t r e s s i n c o n t i n e n c e . Forces Aging The consequences of the p h y s i o l o g i c a l e f f e c t s of aging on the female g e n i t o u r i n a r y t r a c t predispose many o l d e r women to continence problems. Aging of the female g e n i t o u r i n a r y t r a c t i n v o l v e s a decreased bladder c a p a c i t y and may i n v o l v e the c o n d i t i o n of d e t r u s o r i n s t a b i l i t y (Green, 1986). As w e l l , the bladder becomes i n c r e a s i n g l y s e n s i t i v e with age so t h a t c o n c e n t r a t e d u r i n e may p r e c i p i t a t e i n c o n t i n e n c e (McConnell e t a l . , 1983). An adequate f l u i d i n t ake encourages the bladder to expand to c a p a c i t y and decreases the i r r i t a t i o n caused by c o n c e n t r a t e d u r i n e (Maney, 1976; S p i r o , 1978). There i s a l o s s of muscular e l a s t i c i t y i n the g e n i t o u r i n a r y t r a c t and the p e l v i c musculature i n c l u d i n g the vagina. T h i s l o s s o f muscular e l a s t i c i t y i s o f t e n a s s o c i a t e d with lower post-menopausal es t r o g e n l e v e l s (Green, 1986; Wilcox, Gray, & P r i t c h a r d , 1982; Witty, 1977). The combination of a s m a l l e r bladder c a p a c i t y , d e t r u s o r i n s t a b i l i t y , c o n c e n t r a t e d u r i n e , and l o s s o f muscular e l a s t i c i t y p r e d i s p o s e s o l d e r women to the development o f s t r e s s i n c o n t i n e n c e . S t r e s s i n c o n t i n e n c e S t r e s s i n c o n t i n e n c e "occurs when the i n t r a v e s i c a l p r e s s u r e , as a r e s u l t of an i n c r e a s e i n intra-abdominal p r e s s u r e , exceeds the r e s i s t a n c e produced by the u r e t h r a l c l o s u r e mechanisms, i n the absence o f bladder a c t i v i t y " ( S t a s k i n e t a l . , 1985, p. 271). The symptom of s t r e s s i n c o n t i n e n c e , as r e p o r t e d by women, may have m u l t i p l e causes i n c l u d i n g d e t e r i o r a t i o n of the p e r i n e a l f l o o r muscles, unstable bladder c o n t r a c t i o n s , p o o r l y e s t r o g e n i z e d mucosa, or may be the r e s u l t o f pre v i o u s bladder neck surgery. Regardless of the cause, the consequences are s i m i l a r as an i n v o l u n t a r y l o s s o f u r i n e occurs with coughing, sneezing, l a u g h i n g , l i f t i n g o b j e c t s or p o s i t i o n changes (Witty, 1977). St u d i e s have been completed which i n v e s t i g a t e d the mechanisms of continence and v o i d i n g i n o l d e r women through the use of urodynamic t e s t i n g . The pl a c e o f urodynamic t e s t i n g i n the i n v e s t i g a t i o n and treatment o f in c o n t i n e n c e i s a co n t e n t i o u s i s s u e among a u t h o r i t i e s . While the s o p h i s t i c a t e d measures of urodynamic e v a l u a t i o n provide accurate d i a g n o s i s of the type and degree of in c o n t i n e n c e being experienced, the 17 f e a s i b i l i t y of performing t h i s type o f i n v a s i v e i n v e s t i g a t i o n on o l d e r c l i e n t s i s q u e s t i o n a b l e (Eastwood & W a r r e l l , 1984; H i l t o n & S t a t t o n , 1981; Resnick & V a l l a , 1985). The medical a l t e r n a t i v e to urodynamic t e s t i n g i s an a l g o r i t h m i c approach to treatment. The purpose of t h i s approach i s to i d e n t i f y treatment o p t i o n s . Using the r e s u l t s o f a study i n v o l v i n g one hundred o l d e r women H i l t o n and Stanton (1981) developed an a l g o r i t h m i c approach to the treatment o f i n c o n t i n e n c e . Reported study f i n d i n g s i n d i c a t e d t h a t approximately 60% of the women c o u l d be a c c u r a t e l y separated i n t o a p p r o p r i a t e treatment groups, based on s u b j e c t i v e r e p o r t and the use of simple d i a g n o s t i c t e s t s ( H i l t o n e t a l , 1981). Treatment a l t e r n a t i v e s f o r u r e t h r a l s p h i n c t e r incompetence i n c l u d e surgery, estrogens, and e x e r c i s e s . Surgery i s o f t e n the recommended c h o i c e . Popular s u r g i c a l i n t e r v e n t i o n s i n c l u d e the a n t e r i o r and p o s t e r i o r colporrhaphy, and the Burch co l p o s u s p e n s i o n . The American C o l l e g e o f O b s t e t r i c i a n s and G y n e c o l o g i s t s suggest t h a t the long term cure r a t e r e l a t e d to s u r g i c a l i n t e r v e n t i o n f o r s t r e s s i n c o n t i n e n c e i s 50% to 60% (Witty, 1977, p. 141). Inherent i n a l l s u r g i c a l procedures i s r i s k to the c l i e n t . Besides the usual r i s k s , procedures f o r the c o r r e c t i o n of i n c o n t i n e n c e may l e a d to o p e r a t i v e c o m p l i c a t i o n s i n c l u d i n g i n j u r y to the vagina, bladder, u r e t h r a , and major v e i n s of the p e l v i c s t r u c t u r e s . P o s t - o p e r a t i v e c o m p l i c a t i o n s may i n v o l v e urgency, frequency or d i f f i c u l t y with spontaneous v o i d i n g (Stanton, 1985). IB Other modes of treatment f o r in c o n t i n e n c e i n v o l v e b e h a v i o u r a l approaches. Kegel and Powell (1950) suggested that the causes o f s t r e s s i n c o n t i n e n c e are r e l a t e d to poor f u n c t i o n of the pubococcygeus muscle r a t h e r than p h y s i c a l d e f e c t o f the s p h i n c t e r mechanisms. In t h i s study o f over 300 women with s t r e s s i n c o n t i n e n c e , 70% responded to p h y s i o l o g i c therapy with a perineometer. The perineometer c o n s i s t e d o f a c y l i n d r i c a l diaphragm connected to a manometer which enabled the c l i e n t to see the r e s u l t s when she c o n t r a c t e d her p e r i v a g i n a l muscles. A l l 300 c l i e n t s with s t r e s s i n c o n t i n e n c e were symptom f r e e f o l l o w i n g 2 to 6 weeks use of the perineometer r e s i s t i v e e x e r c i s e . Kegel e t a l . , i d e n t i f i e d s a t i s f a c t o r y muscle recove r y even i n the presence o f u r e t h r o c e l e or moderate c y s t o c e l e (p. 810). S a t i s f a c t o r y r e t u r n o f muscle f u n c t i o n was a l s o apparent i n women who had undergone p r e v i o u s bladder neck surgery, p r o v i d e d the muscular r e l a t i o n o f the u r e t h r a and bladder neck was not s i g n i f i c a n t l y d i s t u r b e d , and f i b r o s i s was not ex c e s s i v e (p. 810). Kegel's e x e r c i s e s continue to be implemented as an i n t e r v e n t i o n f o r o l d e r women with s t r e s s i n c o n t i n e n c e . Henderson and Tay l o r (1987) i n v e s t i g a t e d age as a v a r i a b l e i n the performance o f Kegel's e x e r c i s e s f o r the treatment o f s t r e s s i n c o n t i n e n c e . The e i g h t week study i n v o l v e d o l d e r (over age 55) and younger (under age 55) women who i d e n t i f i e d themselves as s u f f e r i n g with s t r e s s i n c o n t i n e n c e . Subjects were ambulatory, n o n - i n s t i t u t i o n a l i z e d , E n g l i s h - s p e a k i n g , and not e x p e r i e n c i n g any neuromuscular or neurogenic bladder d i f f i c u l t i e s . Each woman completed a weekly continence assessment designed to assess her p e r c e p t i o n of i n c o n t i n e n c e s e v e r i t y . During weekly c l i n i c appointments, the women used the "Personal Perineometer" as a bio-feedback mechanism. Upon completion o f the study, measurement with the "Personal Perineometer" i n d i c a t e d no d i f f e r e n c e i n pubococcygeal s t r e n g t h between the younger and the o l d e r women. At the end of the study, s i x o f the nine o l d e r women, and four o f the f i v e younger women r e p o r t e d themselves to be c o n t i n e n t (Henderson e t a l . , 1987). Other forms o f behaviour management i n v o l v e h a b i t r e t r a i n i n g . The sugg e s t i o n i s th a t the bladder can be reeducated to empty a t scheduled times i f an adequate f l u i d i n t a k e i s maintained, and f a c i l i t i e s are a c c e s s i b l e . T h i s approach a l s o i n v o l v e s i n c r e a s i n g the time i n t e r v a l between v o i d i n g s (Greengold & Ouslander, 1986; Hadley, 1986; S p i r o , 1978). S t r e s s i n c o n t i n e n c e i n o l d e r women i s a well-documented problem and types o f treatment are o u t l i n e d i n the l i t e r a t u r e . There are few s t u d i e s which d i s c u s s implementation of the v a r i o u s approaches. The E g o - v a l u a t i v e Subsystem The inner personal r e g i o n of the e g o - v a l u a t i v e subsystem r e p r e s e n t s the b a s i c human need f o r r e s p e c t of s e l f by s e l f and o t h e r s , as we l l as the c o g n i t i v e and e x e c u t i v e a b i l i t i e s necessary to s a t i s f y t h a t need. The c o g n i t i v e a b i l i t i e s o f the e g o - v a l u a t i v e subsystem p e r c e i v e the need. The e x e c u t i v e a b i l i t i e s a l t e r the need r e l a t e d s e n s a t i o n of t e n s i o n , as f o r c e s and v a r i a b l e s are manipulated to move the subsystem toward or away from goal achievement. The p s y c h o l o g i c a l environment r e p r e s e n t s the n e e d - r e l a t e d goal of s e l f - e s t e e m and the p e r s o n a l , impersonal and s o c i o c u l t u r a l f o r c e s i n f l u e n c i n g goal achievement. Assessment of the goal of s e l f - e s t e e m and the f o r c e s i n f l u e n c i n g goal achievement w i l l be d i s c u s s e d . Self-esteem Self-esteem i s the r e l a t i v e l y s t a b l e sense of s e l f produced by the amalgamation of s e l f - r e s p e c t and r e s p e c t of s e l f by o t h e r s . This s t a b l e , i n t e r n a l sense of s e l f can be c o n s i d e r e d an i n d i v i d u a l ' s g l o b a l sense of s e l f - e s t e e m . Globa s e l f - e s t e e m may be d e s c r i b e d as a l l the p o s i t i v e and negative a t t i t u d e s one holds about one's s e l f , and i n d i c a t e s an i n d i v i d u a l ' s sense of s e l f - w o r t h (Rosenberg, 1965; Stanwyck, 1983). Rosenberg determined s e l f - w o r t h to be a p e r s o n a l b e l i e i n an i n d i v i d u a l ' s v a l u e , her acknowledgement of p e r s o n a l s t r e n g t h s and her acceptance of p e r s o n a l weakness (Rosenberg, 1965). Crouch and Straub expanded Rosenberg's and Stanwyck's t h e o r i e s by e n v i s i o n i n g g l o b a l s e l f - e s t e e m as a p a i r e d arrangement between b a s i c and f u n c t i o n a l s e l f - e s t e e m . B a s i c s e l f - e s t e e m i s a s t a b l e core achieved d u r i n g c h i l d h o o d , and f u n c t i o n a l s e l f - e s t e e m i s a f l u i d element, a l l o w i n g f o r f e e l i n g changes due to s i t u a t i o n a l or m a t u r a t i o n a l events (Crouch & Straub, 1983). As with Crouch and Straub's model. Rosenberg's framework allows an i n d i v i d u a l to experience a change i n p e r s o n a l esteem based on s i t u a t i o n a l and i n t e r p e r s o n a l p e r c e p t i o n s . The q u a l i t a t i v e measurement of s e l f - e s t e e m i s f r e q u e n t l y based on c r i t e r i a i n v o l v i n g p e r c e p t i o n s of the p h y s i c a l s e l f , the i n t e l l e c t u a l s e l f and the s o c i a l s e l f . I n d i c e s r e l a t e d to the p h y s i c a l s e l f i n c l u d e i n d i v i d u a l a t t i t u d e s and f e e l i n g s r e g a r d i n g the mental image h e l d of the s t r u c t u r e , c a p a b i l i t i e s and l i m i t a t i o n s of the p h y s i c a l body. I n d i c e s r e l a t e d to the i n t e l l e c t u a l s e l f i n v o l v e e f f i c a c y behaviours and f e e l i n g s of competence as demonstrated by s u c c e s s f u l performance i n a c h i e v i n g p e r s o n a l g o a l s and o b j e c t i v e s (Bandura, 1978). I n d i c e s r e l a t e d to the s o c i a l s e l f i n v o l v e a sense of s e l f -worth demonstrated by acceptance of s e l f by s e l f and o t h e r s . Behaviours congruent with s o c i e t a l norms and the p s y c h o s o c i a l and m a t u r a t i o n a l development of the i n d i v i d u a l are a l s o components of the s o c i a l s e l f . Coping behaviours i n d i c a t e the usual manner a subsystem attempts to s a t i s f y the need of the subsystem. Coping behaviours i n the e g o - v a l u a t i v e subsystem are h i g h l y i n d i v i d u a l i z e d and are demonstrated through an i n d i v i d u a l s ' s observable behaviour and verbal" e x p r e s s i o n . They may be conscious or unconscious and the i n d i v i d u a l may or may not be aware of the i m p l i c a t i o n of the behaviour. Coping behaviours are i n f l u e n c e d by f o r c e s , and i n t h i s i n s t a n c e the f o r c e s f o r c o n s i d e r a t i o n are aging and s t r e s s i n c o n t i n e n c e . Forces Aging The e i g h t h p s y c h o s o c i a l stage o f E r i c k s o n ' s developmental theory s p e c i f i c a l l y i d e n t i f i e s the task o f t h i s l i f e phase as the achievement o f i n t e g r i t y versus d e s p a i r . T h i s i s a time when i n d i v i d u a l s draw on coping behaviours^ developed d u r i n g e a r l i e r l i f e phases to eval u a t e t h e i r l i v e s and meet the tasks of t h i s l a s t developmental stage. According to Crouch and Straub's premise, f u n c t i o n a l s e l f - e s t e e m may be a l t e r e d as an i n d i v i d u a l ' s p e r s o n a l p e r c e p t i o n s change with aging. G l o b a l s e l f - e s t e e m , as i d e n t i f i e d by Rosenberg may a l s o be a f f e c t e d by i n d i v i d u a l s p e r c e p t i o n s o f pers o n a l change d u r i n g the aging process. S t r e s s i n c o n t i n e n c e S t r e s s i n c o n t i n e n c e i s i d e n t i f i e d as a negative personal f o r c e f o r o l d e r women. F e e l i n g s of low s e l f - w o r t h , low s e l f -esteem, dependency and s o c i a l i s o l a t i o n are a t t r i b u t e d to the experience o f u r i n a r y i n c o n t i n e n c e (Hadley, 1986; Henderson et a l . , 1987; Long, 1985; M o r i s h i t a , 1988). At present, l i t t l e r e s e a r c h has been p u b l i s h e d which e m p i r i c a l l y v a l i d a t e s the emotional impact o f i n c o n t i n e n c e , s p e c i f i c a l l y s t r e s s i n c o n t i n e n c e , on o l d e r women. Simons (1985) s t u d i e d the e f f e c t o f u r i n a r y i n c o n t i n e n c e on s e l f - c o n c e p t . The sample c o n s i s t e d o f 43 women, 60 years of age and o l d e r , who completed d e t a i l e d q u e s t i o n n a i r e s . Data were c o l l e c t e d on demographic v a r i a b l e s , and the i n c i d e n c e o f u r i n a r y i n c o n t i n e n c e i n the sample p o p u l a t i o n . Study p a r t i c i p a n t s a l s o completed the Rosenberg s e l f - e s t e e m s c a l e . Research q u e s t i o n s posed by the study attempted to determine the f o l l o w i n g : the i n c i d e n c e o f u r i n a r y i n c o n t i n e n c e i n a s e l e c t e d p o p u l a t i o n ; the p r o p o r t i o n o f the respondents who had re p o r t e d u r i n a r y i n c o n t i n e n c e to a h e a l t h care p r o v i d e r ; and whether or not o l d e r women with u r i n a r y i n c o n t i n e n c e had a lower s e l f - e s t e e m than s i m i l a r women with no i n c o n t i n e n c e . Study r e s u l t s i n d i c a t e d t h a t there was no d i f f e r e n c e i n the se l f - e s t e e m scores between c o n t i n e n t and i n c o n t i n e n t o l d e r women. The concept of hidden i n c o n t i n e n c e was supported when the 11 s u b j e c t s (50%) who i d e n t i f i e d themselves as i n c o n t i n e n t , i n d i c a t e d t h a t they had not r e v e a l e d the symptom to a h e a l t h care p r o f e s s i o n a l (Simons, 1985, p. 39). Fo s t e r (1987) completed a phenomenological study which d e s c r i b e d the impact l i v i n g with u n t r e a t e d u r i n a r y i n c o n t i n e n c e had on the l i v e s o f nine o l d e r women. Four common rt components were d e s c r i b e d by the women: "1) r e c o g n i z i n g the problem; 2) a v o i d i n g exposure; 3) needing i n f o r m a t i o n ; and 4) r e d e f i n i n g normal" ( F o s t e r , 1987, p. 38). By r e d e f i n i n g t h e i r l i f e s t y l e s , and de v e l o p i n g regimes to hide the evidence of the symptom of u r i n a r y i n c o n t i n e n c e , these women r e d e f i n e d normal i n a manner s i m i l a r to those i n d i v i d u a l s who a d j u s t to the sequela o f c h r o n i c i l l n e s s ( S t r a u s s , C o r b i n , Fagerhaugh, G l a s e r , Mainers, Suczek, Wiener, 1984). S t r e s s i n c o n t i n e n c e may be viewed as an e f f i c a c y - b a s e d f u t i l i t y (Bandura, 1978). Older women are unable to c o n t r o l a d e s i r e d outcome, the s o c i a l l y a p p r o p r i a t e time to pass u r i n e . The l o s s of u r i n a r y c o n t r o l leads to f e e l i n g s o f h e l p l e s s n e s s , hopelessness, s o c i a l i s o l a t i o n , and low s e l f - e s t e e m (Burgio e t a l . , 1985; Butt, 1979; F i e l d , 1979; Hadley, 1986). In order to decrease o l d e r womens• negative f e e l i n g s and low s e l f - e s t e e m , i t i s necessary to f o s t e r p e r s o n a l e f f i c a c y among these women. Accomplishment of t h i s task, may be p o s s i b l e with the use of a bladder r e t r a i n i n g p r o t o c o l . Summary A review o f the l i t e r a t u r e r e v e a l e d a s u b s t a n t i a l amount of medical l i t e r a t u r e i d e n t i f y i n g the causes and s u r g i c a l i n t e r v e n t i o n s f o r the treatment o f s t r e s s i n c o n t i n e n c e . The nu r s i n g l i t e r a t u r e p r o v i d e d d e t a i l e d summaries of the types o f inc o n t i n e n c e and common causes. O u t l i n e s o f treatment i n t e r v e n t i o n s were o f t e n i n c l u d e d , but few s t u d i e s d i s c u s s e d the p s y c h o s o c i a l e f f e c t s of implementing the i n t e r v e n t i o n s . There are few p u b l i s h e d s t u d i e s which have i n v e s t i g a t e d the e f f e c t s t r e s s i n c o n t i n e n c e has on the s e l f - e s t e e m o f o l d e r women, though common sense statements are pro v i d e d r e g a r d i n g the e f f e c t o f in c o n t i n e n c e on se l f - e s t e e m . This study w i l l complement some of the work which has been completed by d e s c r i b i n g the e f f e c t o f s t r e s s i n c o n t i n e n c e on the s e l f - e s t e e m o f o l d e r women i n v o l v e d i n a bladder r e t r a i n i n g p r o t o c o l . CHAPTER THREE Methodology I n t r o d u c t i o n T h i s d e s c r i p t i v e study was designed to i d e n t i f y the r e l a t i o n s h i p s between the v a r i a b l e s of s t r e s s i n c o n t i n e n c e , bladder r e t r a i n i n g , and se l f - e s t e e m . The r e s e a r c h q u e s t i o n s g u i d i n g the study methodology i n c l u d e d : 1) what are the pe r c e p t i o n s o f g l o b a l s e l f - e s t e e m , o f o l d e r women e x p e r i e n c i n g s t r e s s i n c o n t i n e n t episodes, as measured by the Rosenberg s e l f - e s t e e m s c a l e ? and 2) i f s t r e s s i n c o n t i n e n t episodes are decreased through bladder r e t r a i n i n g do o l d e r women experience a change i n t h e i r p e r c e p t i o n of g l o b a l s e l f - e s t e e m as measured by the Rosenberg s e l f - e s t e e m s c a l e ? T h i s chapter w i l l d i s c u s s the process employed to c o l l e c t and analyze data r e g a r d i n g these q u e s t i o n s , beginning with the process of o b t a i n i n g study p a r t i c i p a n t s and the c r i t e r i a f o r p a r t i c i p a n t s e l e c t i o n . The data c o l l e c t i o n instruments are a l s o d i s c u s s e d . E t h i c a l c o n s i d e r a t i o n s and the p r o t e c t i o n o f human r i g h t s w i l l be presented. Process o f Ob t a i n i n g Study P a r t i c i p a n t s I n i t i a l l y , convenience sampling was employed to s e l e c t ten o l d e r women to p a r t i c i p a t e i n t h i s study. Towards the end of the p e r i o d f o r data c o l l e c t i o n , response to the advertisement of the study i n c r e a s e d prompting the d e c i s i o n to enlarge the sample s i z e to f i f t e e n o l d e r women. Recruitment of these f i f t e e n o l d e r women was accomplished by p o s t i n g an advertisement (Appendix A) a t s e n i o r ' s h e a l t h d r o p - i n c e n t e r s , community s e r v i c e agencies, and i n a s e n i o r ' s network p u b l i c a t i o n . The advertisement a l s o appeared i n two community p u b l i c a t i o n s . Response to the advertisements i n the community c e n t r e s , and the community papers was slow. The i n v e s t i g a t o r attended two s e n i o r s h e a l t h watch programs to o u t l i n e the study f o r the women i n attendance. Many women were anxious to d i s c u s s u r i n a r y i n c o n t i n e n c e and seemed i n t e r e s t e d i n the p r o t o c o l , but few vol u n t e e r e d to p a r t i c i p a t e i n the study. A s i g n i f i c a n t number of women d i d v o l u n t e e r to p a r t i c i p a t e f o l l o w i n g the p u b l i c a t i o n o f a s h o r t a r t i c l e by columnist Nadin Asante i n a s e n i o r ' s paper, the E l d e r  Statesman. I n d i v i d u a l s who wished to p a r t i c i p a t e i n the study c o n t a c t e d the i n v e s t i g a t o r by telephone. At th a t time p a r t i c i p a n t s e l e c t i o n c r i t e r i a were c l a r i f i e d , and f u r t h e r i n f o r m a t i o n r e g a r d i n g the study was provided. Women who expressed i n t e r e s t i n the study a t the time of the telephone c o n t a c t were mailed a d e t a i l e d w r i t t e n d e s c r i p t i o n o f the study (Appendix B). F o l l o w i n g r e c e i p t of the i n f o r m a t i o n l e t t e r , those s t i l l wishing to p a r t i c i p a t e c a l l e d the i n v e s t i g a t o r and an appointment was made f o r an i n t e r v i e w . At the time o f the f i r s t telephone c o n t a c t some women expressed a pre f e r e n c e f o r the i n v e s t i g a t o r to b r i n g the i n f o r m a t i o n l e t t e r to the f i r s t i n t e r v i e w . In a l l , 28 women responded to the advertisement or the a r t i c l e by Asante. S i x t e e n women agreed to p a r t i c i p a t e i n the study. One women dropped out of the study a f t e r 4 days because she found the e x e r c i s e s p a i n f u l ; the remaining 15 women completed the two week p r o t o c o l . Those women not accepted i n t o the study were sent a copy o f the p r o t o c o l to do independently. These women had the o p t i o n o f c a l l i n g the i n v e s t i g a t o r a t any time with problems or qu e s t i o n s . The a c t u a l r e c r u i t m e n t p e r i o d spanned s i x months. C r i t e r i a f o r P a r t i c i p a n t S e l e c t i o n The c r i t e r i a f o r p a r t i c i p a n t s e l e c t i o n i n c l u d e d women who were: 1) 60 years of age and over; 2) e x p e r i e n c i n g the i n v o l u n t a r y leakage o f u r i n e when coughing, l a u g h i n g , sneezing, or l i f t i n g an o b j e c t ; 3) e x p e r i e n c i n g s t r e s s i n c o n t i n e n c e not caused by a neurogenic bladder; 4) p r e s e n t l y not being t r e a t e d f o r a u r i n a r y i n f e c t i o n or u r i n a r y i n c o n t i n e n c e ; 5) able to read and speak E n g l i s h . Data C o l l e c t i o n Data were c o l l e c t e d on two occ a s i o n s i n p a r t i c i p a n t ' s homes. This s e t t i n g p r o v i d e d a comfortable and c o n f i d e n t i a l l o c a t i o n f o r the i n t e r v i e w s . The methods of data c o l l e c t i o n i n v o l v e d f a c e - t o - f a c e s e m i - s t r u c t u r e d i n t e r v i e w s and completion of the s e l f - e s t e e m s c a l e . The t o t a l time r e q u i r e d of p a r t i c i p a n t s was approximately one and a h a l f hours. P r i o r to the commencement of the f i r s t i n t e r v i e w the p a r t i c i p a n t s igned a consent form (Appendix C). The i n i t i a l i n t e r v i e w r e q u i r e d about 45 minutes to c o l l e c t s e l e c t e d demographic v a r i a b l e s (Appendix D), to complete the continence assessment (Appendix E ) , and the Rosenberg s e l f - e s t e e m s c a l e (Appendix F ) . During the f i r s t c o n t a c t , the e n a c t i v e mode as o u t l i n e d i n Bandura's theory of s e l f - e f f i c a c y , was u t i l i z e d to provide i n s t r u c t i o n to the p a r t i c i p a n t s r e g a r d i n g the p e l v i c f l o o r e x e r c i s e s and the importance o f adequate h y d r a t i o n . P a r t i c i p a n t s were taught how to perform the p e l v i c f l o o r e x e r c i s e s and p r a c t i c e d an i n i t i a l s e t o f the e x e r c i s e s with the i n v e s t i g a t o r . P a r t i c i p a n t s were cau t i o n e d to av o i d using t h e i r g l u t e a l and abdominal muscles, as w e l l as t h e i r hamstring and quadricep muscles when performing the e x e r c i s e s . Use of acces s o r y muscles, such as the g l u t e a l or t h i g h muscles, l e s s e n s the p h y s i o l o g i c a l e f f e c t i v e n e s s of the p e l v i c f l o o r e x e r c i s e s (Kegel, 1949). To avo i d bladder i r r i t a t i o n , the importance o f adequate h y d r a t i o n to d i s t e n d the bladder and d i l u t e the u r i n e was e x p l a i n e d to a l l p a r t i c i p a n t s (Maney, 1976; S p i r o , 1978; Wells, 1975). As none of the s u b j e c t s i n d i c a t e d t h a t they were m a i n t a i n i n g a r e s t r i c t e d f l u i d i n t ake f o r h e a l t h reasons, p a r t i c u l a r a t t e n t i o n was focused on en s u r i n g t h a t those women with an i d e n t i f i e d low f l u i d i n t a k e understood the r a t i o n a l f o r adequate h y d r a t i o n . P a r t i c i p a n t s were g i v e n a w r i t t e n d e s c r i p t i o n of the p r o t o c o l as a reminder to p r a c t i c e the e x e r c i s e s and mai n t a i n h y d r a t i o n (Appendix G). At t h i s time the i n v e s t i g a t o r a l s o employed the pursuasive mode by d i s c u s s i n g with the p a r t i c i p a n t her a b i l i t y to perform the e x e r c i s e s . The emotive mode was used to o f f e r support, encouragement, and reassurance. P a r t i c i p a n t s had the o p t i o n o f c a l l i n g the i n v e s t i g a t o r a t any time with q u e s t i o n s or problems. A telephone c o n t a c t o c c u r r e d 3 to 4 days f o l l o w i n g the i n i t i a l meeting and r e q u i r e d approximately 15 minutes. The pe r s u a s i v e and emotive modes were u t i l i z e d a t t h i s time to provide support and encouragement to p a r t i c i p a n t s . Data were c o l l e c t e d on the c o n s i s t e n c y and d i f f i c u l t y o f e x e r c i s e performance, and the maintenance of adequate h y d r a t i o n . The f i n a l i n t e r v i e w o c c u r r e d 14 days l a t e r and r e q u i r e d about 30 minutes of the p a r t i c i p a n t s time. T h i s i n t e r v i e w i n v o l v e d completion o f a second continence assessment and s e l f - e s t e e m s c a l e . Data C o l l e c t i o n Instruments Data were c o l l e c t e d u s i n g four t o o l s . The f i r s t t o o l i n v o l v e d c o l l e c t i o n o f s e l e c t e d demographic v a r i a b l e s and was completed d u r i n g the f i r s t i n t e r v i e w . A continence assessment and the Rosenberg s e l f - e s t e e m s c a l e were completed d u r i n g both i n t e r v i e w s . A telephone i n t e r v i e w guide (Appendix H) was used d u r i n g the telephone c a l l to e l i c i t i n f o r m a t i o n r e g a r d i n g the c o n s i s t e n c y o f e x e r c i s e performance, and the maintenance of adequate h y d r a t i o n . Demographic Information The demographic q u e s t i o n n a i r e u t i l i z e d both c l o s e d and open-ended q u e s t i o n s to e l i c i t s e l e c t e d general h e a l t h i n f o r m a t i o n from each p a r t i c i p a n t . Data were c o l l e c t e d r e g a r d i n g p a r t i c i p a n t ' s present h e a l t h s t a t u s , i n c l u d i n g h y d r a t i o n . Information about p r e v i o u s treatment f o r inc o n t i n e n c e was c o l l e c t e d . P a r t i c i p a n t s were asked about past u r i n a r y t r a c t i n f e c t i o n s , as these i n f e c t i o n s may predispose i n d i v i d u a l s to the development o f u r i n a r y i n c o n t i n e n c e (Green, 1986). F u r t h e r data were c o l l e c t e d r e l a t e d to p a r t i c i p a n t ' s bowel e l i m i n a t i o n p a t t e r n s , as c o n s t i p a t i o n may be a c o n t r i b u t i n g f a c t o r to u r i n a r y urgency and l a c k of c o n t r o l (Jakovac Smith, 1988). Information about the p a r t i c i p a n t ' s o b s t e t r i c a l h i s t o r y was a l s o c o l l e c t e d as the trauma o f c h i l d b i r t h may predispose women to the development o f u r i n a r y i n c o n t i n e n c e (Henderson e t a l , 1987; Kegel, 1949). Continence Assessment The continence assessment used open and closed-ended q u e s t i o n s to a c q u i r e i n f o r m a t i o n r e g a r d i n g each p a r t i c i p a n t ' s continence s t a t u s . I n i t i a l q u e s t i o n s d e a l t with s u b j e c t s usual day and n o c t u r n a l v o i d i n g p a t t e r n s and pro v i d e d b a s e l i n e i n f o r m a t i o n r e g a r d i n g v o i d i n g h a b i t s . S p e c i f i c a t t e n t i o n was focused on n o c t u r i a , i n an e f f o r t to i d e n t i f y the women who experienced t h i s c o n d i t i o n , and a l s o to d i f f e r e n t i a t e the c o n d i t i o n from primary s l e e p d i s t u r b a n c e s . N o c t u r i a i s common i n o l d e r a d u l t s as the o l d e r a d u l t ' s kidneys o f t e n continue to produce u r i n e a t the same r a t e d u r i n g both the day and n i g h t . As w e l l , once the o l d e r i n d i v i d u a l i s recumbent, c i r c u l a t i o n to the kidney i s i n c r e a s e d and consequently u r i n e p r o d u c t i o n may i n c r e a s e (Wells, 1975). N o c t u r i a may be confused with primary s l e e p d i s t u r b a n c e s and p a r t i c i p a n t s were asked whether •uJ J. they woke because of the urge to v o i d ( n o c t u r i a ) , or went to the bathroom because they were awake. Study p a r t i c i p a n t s were then asked que s t i o n s r e g a r d i n g t o t a l l o s s of u r i n e , s t r e s s i n c o n t i n e n c e and urgency, as w e l l as u r i n a r y r e t e n t i o n . U r i n a r y overflow was determined with a q u e s t i o n d i r e c t e d toward the problem of d r i b b l i n g . The study p a r t i c i p a n t s a s s o c i a t e d d r i b b l i n g of u r i n e with urgency or u r i n e l o s t d u r i n g episodes of s t r e s s i n c o n t i n e n c e . One p a r t i c i p a n t who p r i m a r i l y experienced u r i n a r y r e t e n t i o n probably d i d a l s o s u f f e r from u r i n a r y overflow. The f i n a l s i x q u e s t i o n s e l i c i t e d responses s p e c i f i c a l l y r e l a t e d to the presence or absence of a bladder i n f e c t i o n . Open ended ques t i o n s were u t i l i z e d to gather i n f o r m a t i o n r e g a r d i n g the self-management s t r a t e g i e s used by the p a r t i c i p a n t s when e x p e r i e n c i n g i n c o n t i n e n c e symptoms. Queries i n v o l v i n g self-management s t r a t e g i e s p r i m a r i l y concerned the use of undergarment p r o t e c t i o n . The Rosenberg Self-esteem Scale The s e l f - e s t e e m s c a l e used i n t h i s study i s a b r i e f , ten item q u e s t i o n n a i r e intended to provide a u n i d i m e n s i o n a l measure of g l o b a l s e l f - e s t e e m . T h i s s c a l e was f i r s t a d m i n i s t e r e d to 5,077 New York s t a t e high school students i n an attempt to understand how a d o l e s c e n t s view themselves (Rosenberg, 1965). Since p u b l i c a t i o n of the s c a l e , i t has been used e x t e n s i v e l y with i n d i v i d u a l s of a l l ages and may be c o n s i d e r e d a " c l a s s i c measure of g l o b a l s e l f - e s t e e m " (George et a l . , 1985, p. 79). George and Bearon (1985) c i t e d f i v e s t u d i e s i n v o l v i n g o l d e r a d u l t s and the use of the Rosenberg s e l f - e s t e e m s c a l e . Simons (1985) used t h i s s c a l e with o l d e r women d u r i n g an i n v e s t i g a t i o n of the e f f e c t of i n c o n t i n e n c e on s e l f - c o n c e p t . R e l i a b i l i t y George and Bearon (1985) e v a l u a t e d the Rosenberg s e l f -esteem s c a l e a c c o r d i n g to i n t e r n a l r e l i a b i l i t y and t e s t - r e t e s t r e l i a b i l i t y . Adequate i n t e r n a l r e l i a b i l i t y o f the t o o l i s demonstrated by a "Guttman s c a l e r e p r o d u c i b i l i t y c o e f f i c i e n t of .92 and a s c a l a b i l i t y c o e f f i c i e n t of .72" (George e t a l . , 1985, p. 83). Evidence of t e s t - r e t e s t r e l i a b i l i t y i s provided by a " c o r r e l a t i o n of .85 between measures admi n i s t e r e d to c o l l e g e students at two week i n t e r v a l s " (George e t a l . , 1985, p. 83). V a l i d i t y To p r o v i d e evidence of the s c a l e ' s v a l i d i t y , Rosenberg u t i l i z e d a c r i t e r i o n - r e f e r e n c e d d e s i g n i n v o l v i n g n u r s i n g and v o l u n t e e r personnel at the N a t i o n a l I n s t i t u t e s of Health. A s i g n i f i c a n t r e l a t i o n s h i p was i d e n t i f i e d between i n d i v i d u a l s e l f - e s t e e m scores and the i d e n t i f i c a t i o n of d e p r e s s i o n i n the s u b j e c t s (Rosenberg, 1965). Fu r t h e r evidence of convergent v a l i d i t y was provided by " S i l b e r and T i p p e t t (1965) who r e p o r t e d c o r r e l a t i o n s ranging from .56 to .83 between the Rosenberg s e l f - e s t e e m s c a l e and other measures of s e l f - e s t e e m " (George, e t a l . , 1985, p. 83). oo The Telephone Interview Guide This t o o l p r o v i d e d a guide to the telephone c o n t a c t with p a r t i c i p a n t s . The purpose was to o b t a i n data r e g a r d i n g the frequency o f the performance of the p e l v i c f l o o r e x e r c i s e s , and to determine i f there was any d i f f i c u l t y p r a c t i c i n g the e x e r c i s e s . I n f o r m a t i o n was a l s o sought r e g a r d i n g the maintenance o f adequate h y d r a t i o n . Data A n a l y s i s The purpose o f a d e s c r i p t i v e study i s to d e s c r i b e the v a r i a b l e s and any s i g n i f i c a n t r e l a t i o n s h i p between the v a r i a b l e s without i n f e r r i n g c a u s a t i o n (Brink. & Wood, 1978). The r e f o r e , data are orga n i z e d and presented u s i n g measures of c e n t r a l tendency and frequency d i s t r i b u t i o n . C r o s s - t a b u l a t i o n s and p a i r e d t - t e s t s were a l s o completed f o r s e l e c t e d v a r i a b l e s . A n a l y s i s was accomplished u s i n g the S t a t i s t i c a l Package f o r S o c i a l Sciences v e r s i o n X ( L a i , 1986). E t h i c a l C o n s i d e r a t i o n s Approval was gained from the U n i v e r s i t y o f B r i t i s h Columbia Beh a v i o u r a l Sciences Screening Committee For Research and Other S t u d i e s I n v o l v i n g Human Subjects p r i o r to the commencement o f the study. P a r t i c i p a n t s ' r i g h t s were f u r t h e r safeguarded i n a v a r i e t y of ways. As women responded to the advertisement, the i n v e s t i g a t o r determined the s u i t a b i l i t y of respondents f o r i n c l u s i o n i n the study. P a r t i c i p a n t s were g i v e n a d e t a i l e d i n f o r m a t i o n l e t t e r o u t l i n i n g the purpose and procedures of the study. P r i o r to commencement of the i n i t i a l i n t e r v i e w 3 4 p a r t i c i p a n t s were asked to s i g n a consent form. A l l i n t e r v i e w s were conducted with the w r i t t e n consent of the p a r t i c i p a n t s . Both the i n f o r m a t i o n l e t t e r and the consent form c l e a r l y s t a t e d t h a t p a r t i c i p a t i o n was v o l u n t a r y and that p a r t i c i p a n t s c o u l d withdraw a t any time without j e o p a r d i z i n g any present or fu t u r e h e a l t h c a r e . C o n f i d e n t i a l i t y o f p a r t i c i p a n t s was maintained by a s s i g n i n g each p a r t i c i p a n t a numerical code and p l a c i n g t h a t code on a l l documents concerning t h a t i n d i v i d u a l . The i d e n t i t y of the p a r t i c i p a n t s was known onl y to the i n v e s t i g a t o r . Coded data were reviewed only by the i n v e s t i g a t o r and members of her t h e s i s committee. At the c o n c l u s i o n of the study, a l l o r i g i n a l data c o l l e c t e d from p a r t i c i p a n t s were destroyed. Summary The methodology used i n t h i s d e s c r i p t i v e study i n v o l v e d four data c o l l e c t i o n instruments. Each t o o l added i n f o r m a t i o n to the data base which was then analyzed a c c o r d i n g to e s t a b l i s h e d s t a t i s t i c a l methods. E t h i c a l c o n s i d e r a t i o n s and the p r o t e c t i o n of the p a r t i c i p a n t ' s human r i g h t s were a l s o d i s c u s s e d . CHAPTER FOUR P r e s e n t a t i o n and D i s c u s s i o n of F i n d i n g s I n t r o d u c t i o n Beginning with the c h a r a c t e r i s t i c s of the p a r t i c i p a n t s , t h i s chapter i s a p r e s e n t a t i o n and d i s c u s s i o n o f the study r e s u l t s . Data are organized and presented a c c o r d i n g to the r e s u l t s o b t a i n e d from the data c o l l e c t i o n instruments. R e s u l t s are d i s c u s s e d a c c o r d i n g to the e x c r e t o r y and e g o - v a l u a t i v e subsystems w i t h i n the framework of the U n i v e r s i t y o f B r i t i s h Columbia Model f o r Nursing. C h a r a c t e r i s t i c s o f the P a r t i c i p a n t s Using the demographic i n f o r m a t i o n instrument, data were gathered r e l a t i n g to the c h a r a c t e r i s t i c s of the p a r t i c i p a n t s . The f i f t e e n study p a r t i c i p a n t s ranged i n age from 63 years to 82 years (M=70.8 y e a r s ) . A l l s u b j e c t s were l i v i n g i n the community, alone or with t h e i r spouse, and i n d i c a t e d t h a t they were independently managing t h e i r a c t i v i t i e s o f d a i l y l i v i n g . Many o f the women were a c t i v e l y i n v o l v e d i n community p r o j e c t s or p e r s o n a l endeavors. A l l o f the p a r t i c i p a n t s i d e n t i f i e d themselves as being i n good h e a l t h although e i g h t were r e c e i v i n g medical treatment f o r h e a l t h concerns. These concerns i n c l u d e d a t l e a s t one of the f o l l o w i n g h e a l t h problems: angina (2), a r t h r i t i s ( 4 ) , asthma (1), back p a i n (1), c a r d i a c arrhythmias (1), coronary a r t e r y d i s e a s e ( 2 ), d e p r e s s i o n (3), g a s t r i c h y p e r a c i d i t y (1), h y p e r t e n s i o n ( 3 ), hypothyroidism (1), o s t e o p o r o s i s ( 3 ), and s c i a t i c a ( 1). Of Treatment f o r these h e a l t h concerns p r i m a r i l y i n v o l v e d the use of p r e s c r i p t i o n medications. Not a l l s u b j e c t s were able to i d e n t i f y the medications they were t a k i n g , nor the reasons f o r which the medications had been p r e s c r i b e d . The i n v e s t i g a t o r asked to see a l l medications being used i n order to o b t a i n a c c u r a t e data. Three women were t a k i n g an estrogen supplement. Two women were t a k i n g d i u r e t i c s and three other women were u s i n g medications which improved kidney e x c r e t i o n f u n c t i o n as a s i d e e f f e c t . A n t i d e p r e s s a n t s were being used by two women. A s i d e e f f e c t o f both a n t i d e p r e s s a n t medications was u r i n a r y r e t e n t i o n . A v a r i e t y o f other medications were being used to t r e a t s p e c i f i c h e a l t h problems. Subjects d i d not i d e n t i f y any changes i n medication usage d u r i n g the t r i a l p e r i o d . The o b s t e t r i c a l h i s t o r y of the women v a r i e d . Three women were n u l l i g r a v i d a . The remaining twelve women had experienced one to e i g h t pregnancies. A l l but two of the women had experienced uncomplicated pregnancies. A l l the women had d e l i v e r e d v a g i n a l l y and onl y one women s t a t e d t h a t f o r c e p s had been used d u r i n g the b i r t h i n g p rocess. Many of the women were unsure whether e p i s i o t o m i e s had been performed d u r i n g the d e l i v e r y process. Two women were sure e p i s i o t o m i e s had not been performed and seven women b e l i e v e d t h a t an episiotomy had been performed d u r i n g at l e a s t one b i r t h . Ten s u b j e c t s were able to i d e n t i f y the l e n g t h o f time they had experienced the symptom of i n c o n t i n e n c e . That p e r i o d ranged from one year to for t y - o n e years (n=10, M=16.9 y e a r s ) . Six women s t a t e d t h a t t h e i r problem with i n c o n t i n e n c e began suddenly, while e i g h t women i d e n t i f i e d a gradual beginning to the problem. Fourteen women a s s o c i a t e d the beginning o f in c o n t i n e n c e with a s p e c i f i c event: s i x women i d e n t i f i e d c h i l d b i r t h as the p r e c i p i t a t i n g f a c t o r , and two women s t a t e d t h a t the in c o n t i n e n c e began f o l l o w i n g s u r g i c a l procedures (bladder surgery, hysterectomy). Other i d e n t i f i e d causes i n c l u d e d c o l d s (1), c y s t i t i s (1), a weak, bladder (1), c a t h e t e r i z a t i o n (1), aging (1), and emotional s t r e s s (1). One women s t a t e d t h a t she had n o t i c e d a worsening o f the i n c o n t i n e n t episodes s i n c e menopause. Subjects were questioned r e g a r d i n g p r e v i o u s treatment f o r inc o n t i n e n c e and u r i n a r y t r a c t i n f e c t i o n s . F i v e women (33.3%) i n d i c a t e d t h a t they had undergone some type o f treatment f o r u r i n a r y i n c o n t i n e n c e . The onl y treatment o p t i o n these women had been o f f e r e d was surgery. Two of these women were^able to i d e n t i f y the s u r g i c a l procedure t h a t had been performed. Two of the f i v e women had experienced three or more s u r g e r i e s f o r the c o r r e c t i o n of i n c o n t i n e n c e . Surgery had been suggested to two other s u b j e c t s . These women had r e f u s e d t h i s o p t i o n and no other suggestions r e g a r d i n g treatment f o r in c o n t i n e n c e had been o f f e r e d . Seven women (46.7%) i n d i c a t e d they had r e c e i v e d treatment f o r bladder i n f e c t i o n s , and two of these women (13.3%) had a l s o experienced bladder stones. Data were c o l l e c t e d from p a r t i c i p a n t s a t the f i r s t and f i n a l i n t e r v i e w s r e g a r d i n g the sig n s and symptoms of u r i n a r y t r a c t i n f e c t i o n s . None of the p a r t i c i p a n t s were e x p e r i e n c i n g any si g n s or symptoms of a u r i n a r y t r a c t i n f e c t i o n a t the commencement of the study or upon r e t e s t i n g two weeks l a t e r . In r e l a t i o n to bowel e l i m i n a t i o n h a b i t s , two women i d e n t i f i e d themselves as being prone to c o n s t i p a t i o n . The remainder o f the s u b j e c t s s t a t e d t h e i r bowel movements were r e g u l a r , every 24 to 36 hours. Data were a l s o c o l l e c t e d r e g a r d i n g p a r t i c i p a n t s ' f l u i d i n t a k e . E l e v e n of the women (73.3%) i n d i c a t e d a f l u i d i n t ake of e i g h t or more cups per day while the remaining four women (26.7%) i n d i c a t e d a f l u i d i n t ake o f l e s s than 4 cups. During the i n i t i a l telephone c o n t a c t a l l p a r t i c i p a n t s responded a f f i r m a t i v e l y to quest i o n s r e g a r d i n g l o s s of u r i n e d u r i n g p e r i o d s o f s t r e s s . At the time of the f i r s t i n t e r v i e w i t became e v i d e n t t h a t one p a r t i c i p a n t s u f f e r e d p r i m a r i l y from u r i n a r y overflow r e l a t e d to r e t e n t i o n . T h i s women expressed a d e s i r e to remain i n the study and she executed the bladder r e t r a i n i n g p r o t o c o l i n the same manner as other p a r t i c i p a n t s . The data from t h i s p a r t i c i p a n t has been i n c l u d e d i n the data a n a l y s i s . In c o n c l u s i o n , the study p a r t i c i p a n t s c o n s t i t u t e d a group of w e l l o l d e r women, l i v i n g i n the community, who were e x p e r i e n c i n g u r i n a r y i n c o n t i n e n c e . Continence Assessment The assessment o f continence o c c u r r e d at both the f i r s t and second i n t e r v i e w times, and i n v o l v e d c o l l e c t i n g data on a l l a s pects o f p a r t i c i p a n t s ' continence s t a t u s . The bladder r e t r a i n i n g p r o t o c o l was implemented a t the time o f the f i r s t i n t e r v i e w . T h e r e f o r e , the data are arranged and presented to demonstrate the changes p a r t i c i p a n t s p e r c e i v e d i n t h e i r v o i d i n g h a b i t s , and the frequency of i n c o n t i n e n t episodes f o l l o w i n g implementation o f the bladder r e t r a i n i n g p r o t o c o l . The i n i t i a l assessment o f continence i n these women i n v o l v e d q u e s t i o n s about usual v o i d i n g h a b i t s . These q u e s t i o n s concerned day and n o c t u r n a l v o i d i n g frequency and determined the s u b j e c t s ' b a s e l i n e v o i d i n g frequency. Table I Pe r c e i v e d Changes i n D a i l y V o i d i n g Frequency a t Pre and Post  I n t e r v e n t i o n Interview Times F i r s t Interview Second Interview V o i d i n g Frequency Frequency Percent Frequency Percent <3x/day 1 (6.7%) 0 3-6x/day 4 (26.7%) 8 (53.3%) >6x/day 10 (66.7%) 6 (40.0%) T o t a l 15 (100.0%) 14 (93.3%) At the time of the second i n t e r v i e w women r e p o r t e d f e e l i n g t h a t t h e i r "bladder was emptying more completely", t h a t they were v o i d i n g "with g r e a t e r f o r c e " , and th a t they had "b e t t e r c o n t r o l over the bladder". 40 Women were asked about n o c t u r i a and waking p a t t e r n s . Some su b j e c t s experienced n o c t u r i a as f r e q u e n t l y as four or f i v e times a n i g h t . Nine s u b j e c t s (60%) i n d i c a t e d t h a t they woke with the urge to v o i d at the time of the f i r s t i n t e r v i e w . Seven women (46.7%) i d e n t i f i e d t h a t they woke with the urge to vo i d a t the time o f the second i n t e r v i e w . Three women (20%) were unsure about t h e i r waking p a t t e r n s , whereas other s u b j e c t s knew they woke f o r other reasons. One woman with a r t h r i t i s s t a t e d "I th i n k the p a i n i n my hi p s wakes me". Another p a r t i c i p a n t s t a t e d t h a t she would get up because o f f e e l i n g " r e s t l e s s " and a t h i r d woman s t a t e d she "wakes up and then goes". Table II Pe r c e p t i o n s o f N o c t u r i a at Pre and Post I n t e r v e n t i o n Interview  Times F i r s t Interview Second Interview N o c t u r i a Frequency Percent Frequency Percent Yes 11 (73.3%) 10 (66.7%) Sometimes 1 (6.7%) 1 (6.7%) No 3 (20.0%) 4 (26.7%) T o t a l 15 (100.0%) 15 (100.0%) The p a r t i c i p a n t s ' p e r c e p t i o n s o f n o c t u r i a and waking because of the urge to v o i d remained r e l a t i v e l y unchanged 0 d u r i n g the two week t r i a l p e r i o d . The p a t t e r n s o f u r i n a r y frequency and n o c t u r i a were c o n s i s t e n t with the symptom of u r i n a r y s t r e s s i n c o n t i n e n c e and the age of t h i s group o f women. Subjects were questioned about complete l o s s o f u r i n a r y c o n t r o l . One women i d e n t i f i e d t h a t she l o s t c o n t r o l o f u r i n e " a l l the time". Two other women a s s o c i a t e d t o t a l l o s s of u r i n a r y c o n t r o l with an ove r d i s t e n d e d bladder and a st r o n g urge. Three women a s s o c i a t e d t o t a l l o s s o f u r i n e with movements such as walking or running, or a change i n p o s i t i o n such as r i s i n g from a c h a i r . The remainder of the women who responded a f f i r m a t i v e l y to t h i s q u e s t i o n i n d i c a t e d t h a t the l o s s o f u r i n e was d i r e c t l y connected to episodes o f s t r e s s , such as coughing, sneezing, l a u g h i n g , or l i f t i n g an o b j e c t . Table I I I Pe r c e i v e d Changes i n Frequency o f Episodes of T o t a l Loss o f  Ur i n a r y C o n t r o l a t Pre and Post I n t e r v e n t i o n Interview Times F i r s t Interview Second Interview T o t a l Loss o f U r i n a r y C o n t r o l Frequency Percent Frequency Percent Yes 5 (33.3%) 3 (20.0%) Sometimes 4 (26.7%) 5 (33.3%) No 6 (40.0%) 7 (46.7%) T o t a l 15 (100.0%) 15 (100.0%) The i n i t i a l assessment of s u b j e c t s ' continence s t a t u s i n c l u d e d s p e c i f i c q u e s t i o n s r e l a t e d to the i n v o l u n t a r y l o s s of u r i n e d u r i n g p e r i o d s of i n c r e a s e d intra-abdominal p r e s s u r e . Table IV presents a summary of the p e r c e i v e d changes i n the frequency o f i n v o l u n t a r y u r i n e l o s s when coughing, sneezing, l a u g h i n g , or l i f t i n g an o b j e c t . A d e t a i l e d examination of the p e r c e i v e d change i n the frequency of the i n v o l u n t a r y l o s s of u r i n e f o r each v a r i a b l e i s presented i n Appendix I. Table IV Pe r c e i v e d Changes i n Frequency of S t r e s s Incontinence Episodes  at Pre and Post I n t e r v e n t i o n Interview Times S t r e s s Incontinence F i r s t Interview Second Interview Frequency Percent Frequency Percent Cough 12 (80.0%) 7 (46.7%) Sneeze 12 (80.0%) 8 (53.3%) Laugh 8 (53.3%) 2 (13.3%) L i f t an Object 2 (13.3%) 1 (6.7%) Note. Subjects responded a f f i r m a t i v e l y to more than one v a r i a b l e . The problem of urgency was a l s o d i s c u s s e d with the p a r t i c i p a n t s . S i x women (40%) i n d i c a t e d t h a t the urge to v o i d was s t r o n g and t h a t they would o f t e n l o s e u r i n e on the way to the bathroom. Table V P e r c e i v e d Changes i n Urgency at Pre and Post I n t e r v e n t i o n  Interview Times F i r s t Interview Second Interview Urgency Frequency Percent Frequency Percent Urgent 6 (40.0%) 3 (20.0%) Wait Minutes 6 (40.0%) 11 (73.3%) Wait Hours 3 (20.0%) 1 (6.7%) T o t a l 15 (100.0%) 15 (100.0%) Two q u e s t i o n s r e g a r d i n g the problem of u r i n a r y r e t e n t i o n were asked of s u b j e c t s . The f i r s t q u e s t i o n concerned f e e l i n g s of emptying the bladder i n c o m p l e t e l y when v o i d i n g . The second q u e s t i o n d e a l t with f e e l i n g s of f u l l n e s s i n the bladder a f t e r v o i d i n g . Table VI P e r c e i v e d Changes i n Frequency of Incomplete Bladder Emptying  at Pre and Post I n t e r v e n t i o n Interview Times F i r s t Interview Second Interview Incomplete Bladder Emptying Frequency Percent Frequency Percent Yes 8 (53.3%) 5 (33.3%) Sometimes 0 1 (6.7%) No 7 (46.7%) 9 (60.0%) T o t a l 15 (100.0%) 15 (100.0%) Table VII P e r c e i v e d Changes i n Frequency of F e e l i n g of F u l l n e s s Post  Void a t Pre and Post I n t e r v e n t i o n Interview Times F i r s t Interview Second Interview F u l l n e s s post v o i d Frequency Percent Frequency Percent Yes 1 (6.7%) 0 Sometimes 1 (6.7%) 1 (6.7%) No 13 (86.7%) 14 (93.3%) T o t a l 15 (100.0%) 15 (100.0%) The i n f o r m a t i o n c o l l e c t e d d u r i n g the f i r s t i n t e r v i e w p r o v i d e d the b a s e l i n e data which were used d u r i n g a n a l y s i s to develop the u r i n a r y i n c o n t i n e n c e s c a l e . I n i t i a l l y , a l l women were c a t e g o r i z e d simply as c o n t i n e n t or i n c o n t i n e n t and the change i n frequency was examined between the two measurement times. I n i t i a l c r o s s - t a b u l a t i o n o f inc o n t i n e n c e by i n t e r v i e w time i n d i c a t e d t h a t 4 women (26.7%) p e r c e i v e d themselves completely r e l i e v e d o f the symptom of inc o n t i n e n c e a f t e r e x e c u t i n g the bladder r e t r a i n i n g p r o t o c o l f o r two weeks. In order to determine which o f the p a r t i c i p a n t s had experienced a change, and to what degree, a u r i n a r y i n c o n t i n e n c e s c a l e was developed. Women were p l a c e d i n t o c a t e g o r i e s a c c o r d i n g to the responses they had pro v i d e d d u r i n g the i n t e r v i e w s . The c a t e g o r i e s developed from the p a r t i c i p a n t ' s responses i n c l u d e d : 1 C o n t i n e n t , (C); 2 S t r e s s i n c o n t i n e n c e . (S); 3 S t r e s s i n c o n t i n e n c e p l u s urgency, ( S+U); 4 S t r e s s i n c o n t i n e n c e p l u s r e t e n t i o n , (S+R); 5 S t r e s s i n c o n t i n e n c e p l u s urgency p i us r e t e n t i o n , (S+U+R); 6 Re t e n t i o n , (R). Table VIII P e r c e i v e d Changes i n Frequency o f I n c o n t i n e n t Episodes by  Category o f Incontinence a t Pre and Post I n t e r v e n t i o n  Interview Times F i r s t Interview Second Interview Category Frequency Percent Frequency Percent 1 (C) 0 4 (26.7%) 2 (S) 5 (33.3%) 4 (26.7%) 3 (S+U) 1 (6.7%) 1 (6.7%) 4 (S+R) 3 (20.0%) 3 (20.0%) 5 (S+U+R) 5 (33.3%) 2 (13.3%) 6 (R) 1 (6.7%) 1 (6.7%) T o t a l 15 (100.0%) 15 (100.0%) This t a b l e i n d i c a t e s t h a t the g r e a t e s t b e n e f i t from the bladder r e t r a i n i n g p r o t o c o l was experienced by those women with s t r e s s i n c o n t i n e n c e p l u s urgency p l u s r e t e n t i o n . Aside from one woman with s t r e s s i n c o n t i n e n c e , the bladder r e t r a i n i n g p r o t o c o l had l i t t l e e f f e c t f o r the other women. Examination o f these data i n d e t a i l allowed i d e n t i f i c a t i o n of the women who a c t u a l l y experienced r e l i e f o f the symptom of u r i n a r y i n c o n t i n e n c e . 47 Table IX C r o s s - t a b u l a t i o n of Frequency o f I n c o n t i n e n t Episodes by  P a r t i c i p a n t a c c o r d i n g to Category of Incontinence at Pre and  Post I n t e r v e n t i o n Interview Times Category Time 1 2 3 4 5 6 (C) (S) (S+U) (S+R) (S+U+R) (R) 1 10 8 3 2 4 12 5 1 7 15 6 9 13 11 14 3 + 4 9 - 1 - 10 - 2 6 + 8 + 5 + 13 2 7 + 12 + 15 11 + 14 + Note. The numbers under i each category are the numerical code f o r the p a r t i c i p a n t . P o s i t i v e and negative symbols beside second i n t e r v i e w numbers i n d i c a t e the type of change th a t o c c u r r e d . The women who b e n e f i t e d from the p r o t o c o l were two wome: with s t r e s s i n c o n t i n e n c e and two women with s t r e s s i n c o n t i n e n c e p l u s urgency p l u s r e t e n t i o n . As we l l one woman (14) with s t r e s s i n c o n t i n e n c e p l u s urgency p l u s r e t e n t i o n r e p o r t e d only s t r e s s i n c o n t i n e n c e a t the end of the two week t r i a l p e r i o d . The other s u b j e c t (5) i n t h i s category moved to the s t r e s s i n c o n t i n e n c e p l u s r e t e n t i o n category i n d i c a t i n g t h a t some b e n e f i t may have o c c u r r e d . Two other p a r t i c i p a n t s (8, 12) who seemed to have b e n e f i t e d are from the s t r e s s i n c o n t i n e n c e p l u s r e t e n t i o n category. These women both 4 8 p e r c e i v e d themselves to have on l y s t r e s s i n c o n t i n e n c e a t the completion o f the two week t r i a l . Of these women, one women (8) i n d i c a t e d d u r i n g the telephone c o n t a c t t h a t she was not performing the e x e r c i s e s c o n s i s t e n t l y , but s t i l l thought t h a t " t h i n g s [were] b e t t e r " . T h i s sense of p o s i t i v e change i s a l s o present i n the p a r t i c i p a n t s ' sense o f the amount of u r i n e r e l e a s e d d u r i n g i n c o n t i n e n t episodes. Table X Pe r c e i v e d Changes i n the Amount o f Urine Released d u r i n g  I n c o n t i n e n t Episodes a t Pre and Post I n t e r v e n t i o n Interview  Times F i r s t Interview Second Interview Amount of Urine Released Frequency Percent Frequency Percent Large O t s p ) 6 (40.0%) 3 (20.0%) Small (<tsp) 7 (53.3%) 7 (53.3%) T o t a l 13 (93.3%) 10 (73.3%) Only three o f the women (20%) c o n s i d e r e d themselves to be l o s i n g an amount of u r i n e g r e a t e r than a teaspoon a t the second i n t e r v i e w . These f i g u r e s a t t e s t to stronger p e l v i c musculature which the p a r t i c i p a n t s c o u l d i d e n t i f y through a r e d u c t i o n i n the amount of u r i n e l o s t d u r i n g i n c o n t i n e n t episodes. Of p a r t i c u l a r i n t e r e s t were the women whose symptoms appeared to worsen over the two week t r i a l p e r i o d . One p a r t i c i p a n t (1) moved from s t r e s s i n c o n t i n e n c e alone to s t r e s s i n c o n t i n e n c e p l u s r e t e n t i o n . Another woman (9) moved from s t r e s s i n c o n t i n e n c e to s t r e s s i n c o n t i n e n c e p l u s urgency and one woman (10) with s t r e s s i n c o n t i n e n c e p l u s urgency moved to s t r e s s i n c o n t i n e n c e p l u s urgency p l u s r e t e n t i o n . Two of these s u b j e c t s (9, 10) i n d i c a t e d d u r i n g the telephone c o n t a c t t h a t they were not performing the e x e r c i s e s as f r e q u e n t l y as suggested. Changes i n continence s t a t u s may a l s o be d i s c u s s e d i n r e l a t i o n to some of the c o l l e c t e d b a s e l i n e data. Two s u b j e c t s (5, 6) i n d i c a t e d t h a t they were t a k i n g a n t i d e p r e s s a n t medication. A s i d e e f f e c t o f both medications being used was u r i n a r y r e t e n t i o n . Both s u b j e c t s experienced a p o s i t i v e change i n t h e i r continence s t a t u s . One s u b j e c t (5) moved from s t r e s s i n c o n t i n e n c e p l u s urgency p l u s r e t e n t i o n to s t r e s s i n c o n t i n e n c e p l u s r e t e n t i o n . The other s u b j e c t (6) i n d i c a t e d t h a t the symptom of u r i n a r y i n c o n t i n e n c e was completely a l l e v i a t e d a t the end of the two week t r i a l . Among the women t a k i n g e s t r o g e n supplements, v a r i o u s changes i n continence s t a t u s o c c u r r e d . One s u b j e c t (11) i n d i c a t e d t h a t she was c o n t i n e n t a t the completion o f the two week t r i a l , while another s u b j e c t (15) experienced no change i n c ontinence s t a t u s . The t h i r d s u b j e c t (9) u s i n g an es t r o g e n supplement experienced a negative change moving from s t r e s s i n c o n t i n e n c e to s t r e s s i n c o n t i n e n c e p l u s urgency. 50 Of the two women t a k i n g d i u r e t i c s , one s u b j e c t (4) experienced no change i n continence, while the other s u b j e c t (1) moved from s t r e s s i n c o n t i n e n c e to s t r e s s i n c o n t i n e n c e p l u s r e t e n t i o n . Two women i d e n t i f i e d themselves as being prone to c o n s t i p a t i o n . One s u b j e c t (8) experienced a p o s i t i v e change i n continence s t a t u s moving from s t r e s s i n c o n t i n e n c e p l u s r e t e n t i o n to s t r e s s i n c o n t i n e n c e , while the other s u b j e c t (15) experienced no change i n continence s t a t u s . Four s u b j e c t s had i d e n t i f i e d themselves as having a low f l u i d i n t a k e . These women had i n d i c a t e d a t the time o f the telephone c o n t a c t , and a t the time o f the second i n t e r v i e w , t h a t they were attempting to maintain an intake of a l e a s t 8 cups of f l u i d a day. Two of these s u b j e c t s (7, 14) experienced a p o s i t i v e change i n continence. One women (7) i d e n t i f i e d h e r s e l f as c o n t i n e n t a t the end of the two week t r i a l , while the other women (14) moved from s t r e s s i n c o n t i n e n c e p l u s urgency p l u s r e t e n t i o n , to s t r e s s i n c o n t i n e n c e . One p a r t i c i p a n t (4) experienced no change i n continence while the other s u b j e c t (9) moved from s t r e s s i n c o n t i n e n c e to s t r e s s i n c o n t i n e n c e p l u s urgency. F i v e women i n d i c a t e d that they had undergone surgery f o r the treatment o f s t r e s s i n c o n t i n e n c e . Three o f these s u b j e c t s experienced a p o s i t i v e change i n continence s t a t u s . Two women (3, 6) i n d i c a t e d t h a t they were c o n t i n e n t at the completion the two week t r i a l . A t h i r d s u b j e c t (5) moved from s t r e s s i n c o n t i n e n c e p l u s urgency p l u s r e t e n t i o n to s t r e s s 51 i n c o n t i n e n c e p l u s r e t e n t i o n . One s u b j e c t (13) experienced no change i n continence and another women (9) experienced a negative change moving from s t r e s s i n c o n t i n e n c e to s t r e s s i n c o n t i n e n c e p l u s urgency. Assessment o f the e x c r e t o r y subsystem o f the f i f t e e n p a r t i c i p a n t s i n c l u d e d data c o l l e c t i o n r e g a r d i n g the s e l f -management s t r a t e g i e s , or the coping behaviours, u t i l i z e d by these women to manage u r i n a r y i n c o n t i n e n c e . Many of the women used some type o f p r o t e c t i v e undergarment product on a r e g u l a r b a s i s . One women used an i n c o n t i n e n t product "Depends (R)" and another made her own a i d s from sheets. One women washed and reused the commercial p r o t e c t i o n product as o f t e n as three times. Those women who d i d not use a i d s , or attempted to extend the wear of p r o t e c t i v e products d i d so because they found the c o s t o f the products p r o h i b i t i v e . Table XI Use of P r o t e c t i v e Undergarment Products a t Pre and Post I n t e r v e n t i o n Interview Times F i r s t Interview Second Interview Use o f P r o t e c t i v e Product Frequency Percent Frequency Percent Yes 6 (40.0%) 6 (40.0%) Sometimes 8 (53.3%) 3 (20.0%) No 1 (6.7%) 6 (40.0%) T o t a l 15 (100.0%) 15 (100.0%) The m a j o r i t y o f the s u b j e c t s s t a t e d t h a t the undergarment p r o t e c t i o n product used was e f f e c t i v e . Other s t r a t e g i e s used by these women to manage u r i n a r y i n c o n t i n e n c e i n c l u d e d l i m i t i n g t h e i r f l u i d i n t a k e , e s p e c i a l l y c o f f e e and tea . Some women attempted to maintain an empty bladder by emptying the bladder f r e q u e n t l y , but none of the study p a r t i c i p a n t s i d e n t i f i e d t h a t u r i n a r y i n c o n t i n e n c e i n any way curbed t h e i r d a i l y a c t i v i t i e s . The continence assessment y i e l d e d d e t a i l e d data r e l a t e d to u r i n a r y t r a c t f u n c t i o n . I n i t i a l data were compared with data obtained two weeks l a t e r , f o l l o w i n g implementation o f the bladder r e t r a i n i n g p r o t o c o l . The Rosenberg Self-esteem Scale The Rosenberg s e l f - e s t e e m s c a l e i s a ten item q u e s t i o n n a i r e which scores items on a four p o i n t s c a l e . Answer op t i o n s i n c l u d e : 1) s t r o n g l y agree, 2) agree, 3) d i s a g r e e , and 4) s t r o n g l y d i s a g r e e . Each o p t i o n was scored a c c o r d i n g to i t s numerical placement on the s c a l e . Scores were f i r s t summed and then means were compared. Table XII Sums o f P a r t i c i p a n t s ' Scores on the Rosenberg Self-esteem  Scale a t Pre and Post I n t e r v e n t i o n Interview Times Sums of Scores P a r t i c i p a n t Interview 1 Interview 2 Change 1 23 18 -5 2 28 27 -1 3 27 26 -1 4 24 25 + 1 5 25 24 -1 6 24 27 + 3 7 25 25 N/Ca 8 24 23 -1 9 25 24 -1 10 25 25 N/C 11 20 25 +5 12 26 25 -1 13 24 25 + 1 14 25 22 -3 15 25 25 N/C Note • T-value = -0.68, df = 14, p_ = 0.5 t w o - t a i l e d . aN/C = no change. Scores on the s e l f - e s t e e m s c a l e ranged from 20 to 27 (M=24.66) a t the time o f the f i r s t i n t e r v i e w and from 18 to 25 (M=24.40) at the time o f the second i n t e r v i e w . E i g h t women 54 experienced a negative change i n t h e i r s c o r e s , four women experienced a p o s i t i v e change and the scores o f three women remained the same. There i s no s i g n i f i c a n t d i f f e r e n c e between the means o f the scores a t the f i r s t and second i n t e r v i e w times. Though some women experienced a negative change i n t h e i r s c o r e , the measurement of g l o b a l s e l f - e s t e e m f o r t h i s group of o l d e r women remained r e l a t i v e l y unchanged. D e t a i l e d t a b l e s are presented i n Appendix J d e p i c t i n g the changes i n response f r e q u e n c i e s of each score, f o r each q u e s t i o n on the Rosenberg s e l f - e s t e e m s c a l e , a t both pre and post i n t e r v e n t i o n i n t e r v i e w times. Question number e i g h t i n the s e l f - e s t e e m s c a l e s p e c i f i c a l l y concerned s e l f - r e s p e c t . S e l f - r e s p e c t i s a component of the b a s i c human need of the e g o - v a l u a t i v e subsystem, and a summary of the responses to t h i s q u e s t i o n are presented. 55 Table XIII Frequency of Responses to Question 8 "I wish I c o u l d have more  r e s p e c t f o r myself" on the Rosenberg Self-esteem Scale a t Pre  and Post I n t e r v e n t i o n Interview Times Response F i r s t Interview Second Interview Frequency Percent Frequency Percent 1 2 3 ( 2 0 . 0 % ) 3 12 ( 8 0 . 0 % ) 14 ( 9 3 . 3 % ) 4 1 ( 6 . 7 % ) T o t a l 15 ( 1 0 0 . 0 % ) 15 ( 1 0 0 . 0 % ) Note. At i n t e r v i e w time 1, Mj=2.8; a t i n t e r v i e w time 2, £1=3.0. A p o s i t i v e s h i f t i n the responses of the women a t the time of the second i n t e r v i e w was e v i d e n t . This cannot be a t t r i b u t e d to the e f f e c t of the bladder r e t r a i n i n g p r o t o c o l without f u r t h e r q u e s t i o n i n g and v a l i d a t i o n of the p a r t i c i p a n t s thoughts and f e e l i n g s . The p e r c e p t i o n s o f s e l f - e s t e e m i n t h i s group o f o l d e r women e x p e r i e n c i n g s t r e s s i n c o n t i n e n c e remained r e l a t i v e l y s t a b l e d u r i n g the two week t r i a l p e r i o d . In an attempt to determine i f the bladder r e t r a i n i n g p r o t o c o l had any e f f e c t on the s e l f - e s t e e m scores of the p a r t i c i p a n t s , s e l f - e s t e e m scores and changes i n continence s t a t u s were examined. Comparisons of the changes i n s e l f - e s t e e m scores and changes i n continence s t a t u s are summarized f o r each p a r t i c i p a n t . Table XIV Comparisons of Changes i n Self-esteem Scores to Changes i n  Continence Status a t Pre and Post I n t e r v e n t i o n Interview Times Interview 1 Interview 2 Changes i n Changes i n Self-esteem Incontinence Self-esteem Incontinence Score Category Scores Category 1 23 2 18 - 4 -2 28 6 27 - 6 N/Ca 3 27 5 26 - 1 + 4 24 2 25 + 2 N/C 5 25 5 24 — 3 + 6 24 5 27 + 1 + 7 25 2 25 N/C 1 + 8 24 4 23 - 2 + 9 25 2 24 - 3 -10 25 3 25 N/C 5 -11 20 2 25 + 1 + 12 26 4 25 - 2 + 13 24 5 25 + 5 N/C 14 25 5 22 - 2 + 15 25 4 25 N/C 4 N/C Note. The p o s i t i v e and negative s i g n s i n d i c a t e the type of change t h a t o c c u r r e d . aN/C = no change. Evidence of a p a t t e r n between s e l f - e s t e e m scores and change i n continence s t a t u s was not e v i d e n t . P a r t i c i p a n t s ' p e r c e p t i o n s of g l o b a l s e l f - e s t e e m remained e s s e n t i a l l y s t a b l e d e s p i t e any p o s i t i v e or negative change i n continence s t a t u s . 57 D i s c u s s i o n The E x c r e t o r y Subsystem Assessment o f the e x c r e t o r y subsystem i n v o l v e d c o l l e c t i n g data about an i n d i v i d u a l ' s usual e l i m i n a t i o n p a t t e r n s . Assessment o f s u b j e c t s i n v o l v e d c o l l e c t i n g data on past and present lower g a s t r o i n t e s t i n a l and u r i n a r y t r a c t f u n c t i o n i n g . Data were a l s o c o l l e c t e d on some of the self-management s t r a t e g i e s , or coping behaviours, u t i l i z e d by the p a r t i c i p a n t s to manage u r i n a r y i n c o n t i n e n c e . Subjects i d e n t i f i e d u r i n a r y symptoms congruent with t h e i r age and the symptom of s t r e s s i n c o n t i n e n c e . E l e v e n o f the women i n d i c a t e d t h a t they experienced mixed i n c o n t i n e n c e . Mixed i n c o n t i n e n c e i s not an uncommon occurrence among o l d e r women as i n s u f f i c i e n t s p h i n c t e r c l o s u r e p l u s d e t r u s o r i n s t a b i l i t y may l e a d to mixed i n c o n t i n e n c e types (Hadley, 1986). A t r e n d toward p o s i t i v e change i n continence s t a t u s was ev i d e n t f o l l o w i n g implementation of the bladder r e t r a i n i n g p r o t o c o l . At the two week p o i n t , e i g h t women (53.3%) i n d i c a t e d t h a t they c o u l d i d e n t i f y some type of change i n t h e i r v o i d i n g h a b i t s . At t h i s time, some s u b j e c t s commented on improved c o n t r o l over t h e i r b l adder, and t h a t they were l o s i n g c o n t r o l of t h e i r u r i n e l e s s f r e q u e n t l y . The trend toward p o s i t i v e change i n these women, e s p e c i a l l y the women s u f f e r i n g with mixed i n c o n t i n e n c e types, demonstrates the e f f e c t o f c o r r e c t l y performed Kegel's e x e r c i s e s to improve "the muscle tone i n a l l 5 8 muscles o f the p e l v i c s l i n g and e l e v a t e the u r e t h r a and bladder neck" (Witty, 1977, p. 137). The p o s i t i v e t rend towards the development o f continence i s congruent with f i n d i n g s i n the l i t e r a t u r e . Long (1985) r e p o r t e d a 79% success r a t e f o l l o w i n g a h a b i t t r a i n i n g program, and McCormick e t a l . (1984) i d e n t i f i e d a 75% improvement u s i n g biofeedback techniques with o l d e r c l i e n t s to t r e a t s t r e s s and urge i n c o n t i n e n c e . Henderson e t a l . (1987) e l i m i n a t e d s t r e s s i n c o n t i n e n c e i n 67% of a sample o f o l d e r woman (n=9) u t i l i z i n g a biofeedback mechanism d u r i n g an e i g h t week program. F i g u r e s obtained from the present study are not as s i g n i f i c a n t . T h i s may be a f u n c t i o n o f the two week t r i a l p e r i o d . Extending the study p e r i o d s i x weeks or longer as suggested by Hurd (1980), and Henderson e t a l . (1987) may le a d to g r e a t e r changes i n continence s t a t u s . Biofeedback i n s t r u m e n t a t i o n was not used with the implementation o f the p e l v i c e x e r c i s e s i n the present study. Biofeedback t r a i n i n g , used i n c o n j u n c t i o n with the p e l v i c e x e r c i s e s , as suggested by Henderson e t a l . (1987) may have f a c i l i t a t e d s u b j e c t s ' p r o g r e s s . The c u r i o u s response o f the s u b j e c t s who r e p o r t e d a worsening o f in c o n t i n e n c e symptoms f o l l o w i n g implementation o f the bladder r e t r a i n i n g p r o t o c o l , r a i s e s q u e s t i o n s concerning the p a r t i c i p a n t s ' understanding of the quest i o n s d u r i n g the i n t e r v i e w times. The i n v e s t i g a t o r may not have c o r r e c t l y i n t e r p r e t e d or coded these womens' responses to the i n t e r v i e w q u e s t i o n s . The f i r s t i n t e r v i e w may have s e n s i t i z e d these women to c o n s i d e r t h e i r u r i n a r y h a b i t s r e s u l t i n g i n them p r e s e n t i n g more d e t a i l e d i n f o r m a t i o n d u r i n g the the second i n t e r v i e w . When the data obtained p r i o r to implementing the bladder r e t r a i n i n g p r o t o c o l are compared to data obtained two weeks f o l l o w i n g implementation of the p r o t o c o l , r e s u l t s i n d i c a t e t h a t some of the s u b j e c t s may have an improved e x e c u t i v e a b i l i t y r e l a t e d to bladder emptying. The consequence of t h i s improved a b i l i t y i s a p e r s o n a l f o r c e i n the e x c r e t o r y subsystem which f o s t e r e d the development of a s u i t a b l e coping behaviour and f a c i l i t a t e d movement toward goal achievement. The r e s u l t i s goal achievement and need s a t i s f a c t i o n i n the e x c r e t o r y subsystem as evidenced by an i n c r e a s e d a b i l i t y to c o n t r o l a d e s i r e d outcome—the r e l e a s e of u r i n e a t s o c i a l l y a p p r o p r i a t e times. The E g o - v a l u a t i v e Subsystem Assessment of the e g o - v a l u a t i v e subsystem i n v o l v e d c o l l e c t i n g data on an i n d i v i d u a l ' s observable behaviours which le a d to evidence of goal achievement and need s a t i s f a c t i o n , or l a c k of goal achievement and need s a t i s f a c t i o n . The primary data c o l l e c t i o n instrument f o r the goal of the e g o - v a l u a t i v e subsystem i n t h i s study was the Rosenberg s e l f - e s t e e m s c a l e . T h i s s c a l e p r o v i d e d a measure of g l o b a l s e l f - e s t e e m and s e l f -worth. D e t a i l e d examination of the s e l f - e s t e e m scores f o r study p a r t i c i p a n t s i n d i c a t e d t h a t e i g h t s u b j e c t s experienced a negative change i n t h e i r score a t the end of the two week t r i a l . There are s e v e r a l p o s s i b l e reasons f o r the lower s e l f -60 esteem scores d u r i n g the second i n t e r v i e w . Other events o c c u r r i n g i n the l i v e s o f the p a r t i c i p a n t s d u r i n g the two week t r i a l p e r i o d may have i n f l u e n c e d t h e i r responses to q u e s t i o n n a i r e items. As w e l l , the two week t r i a l p e r i o d may have been an i n f l u e n c i n g f a c t o r . Women were s e n s i t i z e d to the ques t i o n s d u r i n g the i n i t i a l i n t e r v i e w and had two weeks to f u r t h e r r e f l e c t on t h e i r thoughts and f e e l i n g s . T h i s p e r i o d of r e f l e c t i o n may have i n f l u e n c e d responses to the q u e s t i o n n a i r e items d u r i n g the second i n t e r v i e w . For example, the f i r s t p a r t i c i p a n t whose s e l f - e s t e e m score decreased by f i v e p o i n t s , was unable to respond to three o f the s c a l e items d u r i n g the second i n t e r v i e w r e s u l t i n g i n a lower t o t a l s c o r e . She s t a t e d t h a t s e r i o u s r e f l e c t i o n and c o n s i d e r a t i o n had oc c u r r e d r e g a r d i n g those items she was unable to answer. A l s o , the e f f e c t o f the bladder r e t r a i n i n g p r o t o c o l , though showing a p o s i t i v e t r e n d f o r most p a r t i c i p a n t s , was not completely e f f e c t i v e f o r a l l women a t the completion o f the study. Th i s may have a f f e c t e d some of the s u b j e c t s ' sense o f perso n a l e f f i c a c y which was manifested by a negative change i n t h e i r score a t the time o f the second i n t e r v i e w . G e n e r a l l y , the s e l f - e s t e e m scores were r e l a t i v e l y s t a b l e , and there i s no d i s c e r n i b l e r e l a t i o n s h i p between these scores and any change i n continence s t a t u s . At a s u p e r f i c i a l l e v e l , t h i s r e s u l t may i n d i c a t e t h a t s t r e s s i n c o n t i n e n c e i s not a t h r e a t to i n d i v i d u a l f e e l i n g s o f s e l f - e s t e e m or s e l f -worth, so t h a t study p a r t i c i p a n t s were able to accept themselves p o s i t i v e l y d e s p i t e any change i n continence s t a t u s . 61 I t would appear t h a t i n t h i s group o f women, the p o s i t i v e e v a l u a t i o n o f s e l f was u n a f f e c t e d by the negative f o r c e of s t r e s s i n c o n t i n e n c e . T h i s f i n d i n g i s s i m i l a r to the r e s u l t s documented by Simons (1985) who r e p o r t e d t h a t s e l f - c o n c e p t was not a d v e r s e l y a f f e c t e d by i n c o n t i n e n c e . However, the r e l a t i v e l y s t a b l e s e l f - e s t e e m s c o r e s , and the lack, o f r e l a t i o n s h i p to the negative f o r c e o f s t r e s s i n c o n t i n e n c e may i n d i c a t e t h a t the Rosenberg s c a l e l a c k s the s e n s i t i v i t y to q u a n t i f y the pe r s o n a l i n d i c e s i n d i v i d u a l s u t i l i z e to q u a l i t a t i v e l y determine t h e i r sense o f se l f - e s t e e m . These study r e s u l t s , which i n d i c a t e d no r e l a t i o n s h i p between s e l f - e s t e e m and s t r e s s i n c o n t i n e n c e , d i f f e r from the p i c t u r e o f d e p r e s s i o n and i s o l a t i o n presented i n the l i t e r a t u r e (Burgio e t a l . , 1985; Butt , 1979; F i e l d , 1979; Hadley, 1986). The p o s s i b i l i t y e x i s t s t h a t women who would respond to an advertisement seeking study p a r t i c i p a n t s with i n c o n t i n e n c e form a unique subset o f the o l d e r female p o p u l a t i o n with u r i n a r y i n c o n t i n e n c e . These women may have a str o n g sense o f s e l f - e s t e e m and s e l f - r e s p e c t . At the same time, these women d i d express concern and an x i e t y r e g a r d i n g i n c o n t i n e n t episodes. One p a r t i c i p a n t s t a t e d , "even one drop o f u r i n e i n your p a n t i e s can make you unhappy" and another s u b j e c t s t a t e d , "even l o s i n g a l i t t l e b i t of u r i n e makes you uneasy". The primary concern o f many women was odour. Some of the women questioned the i n v e s t i g a t o r d u r i n g the i n t e r v i e w s as to whether an odour was n o t i c e a b l e . For other women, the concern was the l o c a t i o n o f the nearest bathroom f a c i l i t y . As one p a r t i c i p a n t i d e n t i f i e d "[I'm] a f r a i d I won't make i t to the bathroom i n time". Another s u b j e c t s t a t e d , "I f e e l l i k e I'm always l o o k i n g f o r a bathroom", and another women s t a t e d she knew the placement o f the bathroom f a c i l i t i e s i n a l l the s t o r e s where she shopped. Most women wore some type of undergarment p r o t e c t i o n when away from home, f o r a " f e e l i n g of p r o t e c t i o n " or " s a f e t y " . The p a r t i c i p a n t s denied t h a t u r i n a r y i n c o n t i n e n c e i n any way a f f e c t e d t h e i r d a i l y a c t i v i t i e s . T h i s may be due to the s u c c e s s f u l a b i l i t y o f these women to develop s t r a t e g i e s to normalize the symptom of u r i n a r y i n c o n t i n e n c e through the evolvement o f techniques to hide the evidence of the symptom (Strauss e t a l . , 1984). The use of undergarment p r o t e c t i o n , the attempt to maintain an empty bladder, and the use of f l u i d r e s t r i c t i o n s are s t r a t e g i e s used by these women to normalize the symptom of u r i n a r y i n c o n t i n e n c e . The a b i l i t y to s u c c e s s f u l l y normalize the symptom may have a s s i s t e d these women i n m a i n t a i n i n g t h e i r sense o f s e l f - e s t e e m and s e l f -r e s p e c t . The techniques these women developed to normalize i n c o n t i n e n c e are a l s o i n d i c a t i v e of pers o n a l e f f i c a c y behaviours. Though unable to c o n t r o l the e f f i c a c y - b a s e d f u t i l i t y of s t r e s s i n c o n t i n e n c e , s u b j e c t s developed behaviours which they judged to be e f f e c t i v e i n c o n t r o l l i n g the evidence of the symptom. These behaviours may have pr o v i d e d the s u b j e c t s with a sense o f pers o n a l e f f i c a c y , and may have c o n t r i b u t e d to m a i n t a i n i n g the s u b j e c t s ' sense of pe r s o n a l sense of esteem. Summary Study r e s u l t s i n t h i s chapter were r e p o r t e d a c c o r d i n g to the data c o l l e c t i o n instruments and r e s u l t s were d i s c u s s e d i n r e l a t i o n to the e x c r e t o r y and e g o - v a l u a t i v e subsystems. E l e v e n of the study p a r t i c i p a n t s experienced some type o f change i n t h e i r continence s t a t u s . E i g h t o f these women experienced a p o s i t i v e change. The new c o g n i t i v e and ex e c u t i v e a b i l i t i e s f o s t e r e d by the bladder r e t r a i n i n g p r o t o c o l may have l e d to the development of a p o s i t i v e p e r s o n a l f o r c e f o r some of the s u b j e c t s . T h i s p o s i t i v e f o r c e i n f l u e n c e d the development o f a s u i t a b l e coping behaviour which f a c i l i t a t e d goal achievement, and u l t i m a t e l y , need s a t i s f a c t i o n i n the e x c r e t o r y subsystem. The i n c r e a s e d u r i n a r y c o n t r o l allowed some of the p a r t i c i p a n t s to overcome the e f f i c a c y - b a s e d f u t i l i t y o f l o s s of u r i n a r y c o n t r o l a t s o c i a l l y i n a p p r o p r i a t e times. The l a c k of a r e l a t i o n s h i p between the s e l f - e s t e e m scores and the change i n continence s t a t u s does not l e a d to the c o n c l u s i o n t h a t p e r s o n a l e f f i c a c y was i n c r e a s e d by the a b i l i t y to c o n t r o l a d e s i r e d outcome. The study r e s u l t s p rovide no evidence t h a t a s u i t a b l e coping behaviour i n the e x c r e t o r y subsystem became a p o s i t i v e f o r c e i n the e g o - v a l u a t i v e subsystem. In response to the r e s e a r c h q u e s t i o n s g u i d i n g t h i s study the f o l l o w i n g c o n c l u s i o n s can be drawn: Self-esteem, as measured by the Rosenberg s e l f - e s t e e m s c a l e , i s e s s e n t i a l l y s t a b l e i n t h i s group of o l d e r women; there i s no s i g n i f i c a n t r e l a t i o n between s e l f Rosenberg s e l f - e s t e e m s t a t u s , i n t h i s group esteem s c o r e s , as measured by the s c a l e , and a change i n continence of o l d e r women. CHAPTER FIVE Summary, C o n c l u s i o n s , and I m p l i c a t i o n s f o r Nursing Summary The purpose of t h i s study was to determine the e x i s t e n c e of a r e l a t i o n s h i p between the l e v e l o f se l f - e s t e e m , as measured by the Rosenberg s e l f - e s t e e m s c a l e , and the presence of s t r e s s i n c o n t i n e n c e i n a group o f o l d e r women p a r t i c i p a t i n g i n a bladder r e t r a i n i n g p r o t o c o l . A review o f the l i t e r a t u r e r e g a r d i n g u r i n a r y i n c o n t i n e n c e and treatment o p t i o n s f o r women d i r e c t e d the formation o f the r e s e a r c h q u e s t i o n s . U r i n a r y i n c o n t i n e n c e i s i d e n t i f i e d as a s i g n i f i c a n t h e a l t h concern f o r o l d e r women, cau s i n g p h y s i c a l and emotional d i s c o m f o r t . Estimates of the a c t u a l prevalence o f u r i n a r y i n c o n t i n e n c e among women are c o n s i d e r e d i n a c c u r a t e due to a l a c k o f r e p o r t i n g o f the problem. This l a c k of in c o n t i n e n c e symptom r e p o r t i n g may be due to f e e l i n g s o f embarrassment, hopelessness, and shame. I t i s a l s o suggested t h a t the l a c k of r e p o r t i n g i s due to a b e l i e f by some women, th a t u r i n a r y i n c o n t i n e n c e i s a normal p a r t o f the aging process. Lack o f symptom r e p o r t i n g may a l s o be due to m i s i n t e r p r e t a t i o n of the term i n c o n t i n e n c e , used by h e a l t h care p r o f e s s i o n a l s , d u r i n g h e a l t h assessments. The l i t e r a t u r e review i d e n t i f i e d s e v e r a l treatment o p t i o n s f o r women i n c l u d i n g medications, surgery and be h a v i o u r a l i n t e r v e n t i o n s . S t u d i e s i n v o l v i n g the use of be h a v i o u r a l i n t e r v e n t i o n s focused on the u t i l i z a t i o n o f b i o -feedback techniques with Kegel's e x e r c i s e s . Study r e s u l t s ( 66 i n d i c a t e d a s i g n i f i c a n t r a t e o f symptom a l l e v i a t i o n among o l d e r i n c o n t i n e n t women. Other s t u d i e s i n d i c a t e d t h a t the use of bladder r e t r a i n i n g programs, p r i m a r i l y h a b i t t r a i n i n g programs, without the use of the bio-feedback, techniques were a l s o e f f e c t i v e . The l i t e r a t u r e review r e v e a l e d many common sense statements r e g a r d i n g the e f f e c t u r i n a r y i n c o n t i n e n c e has on the s e l f - e s t e e m o f o l d e r women. However, few p u b l i s h e d r e s e a r c h s t u d i e s e m p i r i c a l l y v a l i d a t e d the emotional impact of any type o f u r i n a r y i n c o n t i n e n c e on o l d e r women. The r e f o r e , a d e s c r i p t i v e study was designed to compliment e x i s t i n g r e s e a r c h by d e s c r i b i n g the e f f e c t o f s t r e s s i n c o n t i n e n c e on the s e l f -esteem o f o l d e r women i n v o l v e d i n a bladder r e t r a i n i n g p r o t o c o l . A convenience sample o f f i f t e e n women was obtained by p o s t i n g an advertisement i n s e n i o r s ' h e a l t h d r o p - i n c e n t r e s , community s e r v i c e agencies, and a s e n i o r s ' network p u b l i c a t i o n . The advertisement a l s o appeared i n two community papers. The p a r t i c i p a n t s c o n s t i t u t e d a group o f w e l l o l d e r women who ranged i n age from 63 years to 82 years. A l l p a r t i c i p a n t s were l i v i n g i n the community and e x p e r i e n c i n g u r i n a r y i n c o n t i n e n c e . The conceptual framework which guided the study was the U n i v e r s i t y o f B r i t i s h Columbia Model f o r Nursing. The model views the i n d i v i d u a l as a b e h a v i o u r a l system composed of nine i n t e r r e l a t e d and interdependent subsystems. This study focused on the i n t e r r e l a t i o n s h i p between the e x c r e t o r y and ego-67 v a l u a t i v e subsystems. The theory o f s e l f - e f f i c a c y p r o v i d e d the method by which t h i s study was o p e r a t i o n a l i z e d . S e l f - e f f i c a c y i s an i n d i v i d u a l ' s b e l i e f t h a t the performance of s p e c i f i c behaviours i n s p e c i f i c circumstances w i l l produce a d e s i r e d outcome. S e l f - e f f i c a c y i s the product o f pers o n a l e f f i c a c y — a n i n d i v i d u a l ' s judgement o f the e f f e c t i v e n e s s of an executed course o f a c t i o n i n a c h i e v i n g a d e s i r e d outcome. E f f i c a c y i n f o r m a t i o n which may c r e a t e or stren g t h e n p e r s o n a l e f f i c a c y i s conveyed by four modes of i n f l u e n c e . Three of the four m o d e s — e n a c t i v e , p e r s u a s i v e , and emotive-were used to provide e f f i c a c y i n f o r m a t i o n i n t h i s study. Data were c o l l e c t e d from f o u r t e e n o l d e r women e x p e r i e n c i n g s t r e s s i n c o n t i n e n c e , and one o l d e r women who experienced r e t e n t i o n with overflow. Data c o l l e c t e d were p r i m a r i l y q u a n t i t a t i v e i n nature. Four instruments were used to c o l l e c t data on three d i f f e r e n t o c c a s i o n s . During the i n i t i a l i n t e r v i e w data were c o l l e c t e d with regard to s e l e c t e d demographic v a r i a b l e s . A continence assessment was completed f o l l o w e d by the Rosenberg s e l f - e s t e e m s c a l e . During t h i s i n i t i a l i n t e r v i e w , the n e c e s s i t y o f adequate h y d r a t i o n , and the p e l v i c f l o o r e x e r c i s e s were e x p l a i n e d . A w r i t t e n d e s c r i p t i o n o f the p e l v i c f l o o r e x e r c i s e s was l e f t with the p a r t i c i p a n t s as a reminder to p r a c t i c e the e x e r c i s e s . The second c o n t a c t by telephone, approximately three days l a t e r , a s c e r t a i n e d whether the s u b j e c t s were able to perform the e x e r c i s e s and i n c r e a s e or maintain t h e i r f l u i d i n t a k e . The f i n a l c o n t a c t was another f a c e - t o - f a c e i n t e r v i e w i n v o l v i n g completion o f the same continence assessment and the Rosenberg s e l f - e s t e e m s c a l e . The data were summarized, compared, and d e s c r i b e d u s i n g measures of c e n t r a l tendency and frequency d i s t r i b u t i o n s . Data from the continence assessments r e v e a l e d t h a t women s u f f e r e d from more than one type o f i n c o n t i n e n c e . Data were separated i n t o c a t e g o r i e s developed from the s u b j e c t s ' responses to the q u e s t i o n n a r i e items. The t - t e s t s t a t i s t i c was used to determine i f a d i f f e r e n c e e x i s t e d between pre and post i n t e r v e n t i o n s e l f -esteem s c o r e s . The r e s u l t s o f the t - t e s t i n d i c a t e d t h a t there was no s i g n i f i c a n t change i n s u b j e c t s ' s e l f - e s t e e m scores f o l l o w i n g implementation of the bladder r e t r a i n i n g p r o t o c o l . Study f i n d i n g s i n d i c a t e d t h a t a t the end of the two week t r i a l , 53% of the women were able to i d e n t i f y a change i n t h e i r v o i d i n g h a b i t s . A small number of the p a r t i c i p a n t s (26.7%) s t a t e d t h a t they were completely c o n t i n e n t a t the completion o f the two week t r i a l and four other p a r t i c i p a n t s (26.7%) i n d i c a t e d t h a t some type o f p o s i t i v e change had occu r r e d . Three women (20%) i d e n t i f i e d a negative change i n t h e i r continence s t a t u s . G l o b a l s e l f - e s t e e m scores as measured by the Rosenberg s e l f - e s t e e m s c a l e remained r e l a t i v e l y s t a b l e d u r i n g the two week t r i a l p e r i o d . Scores appeared to be u n a f f e c t e d by a change i n continence s t a t u s . C o n c l u s i o n s The f i n d i n g o f the study suggest the f o l l o w i n g c o n c l u s i o n s : 1. Older women who c o r r e c t l y l e a r n e d and c o n s i s t e n t l y performed Kegel's e x e r c i s e s demonstrated a p o s i t i v e t r e n d toward continence a t the end of two weeks. 2. The bladder r e t r a i n i n g p r o t o c o l improved the e x e c u t i v e a b i l i t y of the e x c r e t o r y a c t i o n o f the bladder, and gave r i s e to the development o f a p o s i t i v e p e r s o n a l f o r c e and need s a t i s f a c t i o n . The p o s i t i v e personal f o r c e i n f l u e n c e d the development o f a s u i t a b l e coping behaviour i n the e x c r e t o r y subsystem and f a c i l i t a t e d movement toward goal achievement. 3. G l o b a l s e l f - e s t e e m as measured by the Rosenberg s e l f -esteem s c a l e , d i d not s i g n i f i c a n t l y change when the number of s t r e s s i n c o n t i n e n t episodes decreased. There i s no evidence t h a t the e f f e c t o f the bladder r e t r a i n i n g p r o t o c o l became a p o s i t i v e f o r c e i n the e g o - v a l u a t i v e subsystem. 4. Three modes of i n f l u e n c e — e n a c t i v e , p u r s u a s i v e , and emotive—were u t i l i z e d to a s s i s t study p a r t i c i p a n t s to streng t h e n t h e i r sense o f pers o n a l e f f i c a c y through a c t i v i t i e s r e l a t e d to the bladder r e t r a i n i n g p r o t o c o l . Though some women were able to overcome the e f f i c a c y - b a s e d f u t i l i t y o f s t r e s s i n c o n t i n e n c e , there was no evidence t h a t p e r s o n a l e f f i c a c y was changed. 70 I m p l i c a t i o n s f o r Nursing  I m p l i c a t i o n s f o r Nursing E d u c a t i o n As the age of the Canadian p o p u l a t i o n i n c r e a s e s , n u r s i n g c u r r i c u l a need to devote a t t e n t i o n to the unique needs and is s u e s surrounding the care o f the o l d e r i n d i v i d u a l . Continence i s one c r i t i c a l i s s u e . I t i s w i t h i n the scope o f present n u r s i n g c u r r i c u l a to impart to students an understanding o f the continence and v o i d i n g mechanisms i n the o l d e r i n d i v i d u a l , and the f o r c e s which i n f l u e n c e those mechanisms. The accurate assessment o f cont i n e n c e , and the knowledge of s t r a t e g i e s f o r t r e a t i n g d i f f e r i n g types o f in c o n t i n e n c e a l s o needs to be communicated to p o t e n t i a l p r a c t i t i o n e r s . Implementation o f Kegel's e x e r c i s e s l i e w i t h i n the realm of independent n u r s i n g a c t i o n , and nurses should be aware of the proper method to implement these e x e r c i s e s with c l i e n t s . Kegel's e x e r c i s e s , p r o p e r l y taught and c o n s i s t e n t l y performed, are e f f e c t i v e i n improving and/or e l i m i n a t i n g s t r e s s i n c o n t i n e n c e and mixed i n c o n t i n e n c e i n some o l d e r women. I m p l i c a t i o n s o f Nursing P r a c t i c e Nurses i n v o l v e d i n the care of o l d e r c l i e n t s , e s p e c i a l l y o l d e r women, should a n t i c i p a t e the presence o f some type o f u r i n a r y i n c o n t i n e n c e . In order to e f f e c t i v e l y respond to t h i s c l i e n t concern, nurses must be able to a c c u r a t e l y assess c l i e n t needs, and then develop and implement a p l a n designed to a s s i s t the c l i e n t i n a c h i e v i n g or m a i n t a i n i n g optimal h e a l t h . Kegel's e x e r c i s e s can a s s i s t many o l d e r women i n 71 a c h i e v i n g a higher l e v e l o f s t a b i l i t y and i n c r e a s e d movement towards optimal h e a l t h . Kegel's e x e r c i s e s , although not the only treatment f o r s t r e s s i n c o n t i n e n c e , do f a l l w i t h i n the realm o f independent n u r s i n g p r a c t i c e . Bladder r e t r a i n i n g programs, i n c l u d i n g implementation o f Kegel's e x e r c i s e s are inexpensive, n o n - i n v a s i v e , and promote s e l f - c a r e . They are an e f f e c t i v e t o o l f o r the p r a c t i c i n g nurse to use with i n c o n t i n e n t c l i e n t s . The i n v e s t i g a t o r has continued to r e c e i v e telephone c a l l s from women wishing to p a r t i c i p a t e i n the study. These women have been sent a copy o f the p r o t o c o l to do on t h e i r own, and may c a l l the i n v e s t i g a t o r i f they have any concerns. C a l l s have a l s o been r e c e i v e d from p a r t i c i p a n t s who are c o n t i n u i n g to experience i n c o n t i n e n t episodes, and who wish f u r t h e r a s s i s t a n c e . These women have been r e f e r r e d to a u r o g y n e c o l o g i c a l c l i n i c . The continued c o n t a c t and response o f o l d e r women e x p e r i e n c i n g i n c o n t i n e n t episodes speaks to the need f o r a c l i n i c a l nurse s p e c i a l i s t . A community-based continence nurse s p e c i a l i s t c o u l d a s s i s t with the assessment of o l d e r women's continence s t a t u s , and i n s t i t u t e a p p r o p r i a t e treatment or r e f e r r a l . A c l i n i c a l nurse s p e c i a l i s t f o c u s i n g on continence problems c o u l d a l s o a s s i s t i n s t i t u t i o n s i n dev e l o p i n g programs to a i d c l i e n t s and s t a f f i n the management of u r i n a r y i n c o n t i n e n c e . I m p l i c a t i o n s f o r Research This study demonstrated a p o s i t i v e t r e n d toward continence i n o l d e r women e x p e r i e n c i n g s t r e s s i n c o n t i n e n c e . 7 2 The t r i a l p e r i o d was two weeks i n l e n g t h . Extending the time of the study may have allowed f o r a g r e a t e r degree of change i n continence s t a t u s . Follow-up o f the p a r t i c i p a n t s over time would a l s o p r o v i d e u s e f u l i n f o r m a t i o n r e g a r d i n g the e f f e c t i v e n e s s o f the bladder r e t r a i n i n g p r o t o c o l . T h i s study demonstrated no r e l a t i o n between g l o b a l s e l f -esteem as measured by the Rosenberg s e l f - e s t e e m s c a l e and a change i n continence s t a t u s . T h i s r e s u l t i s d i f f e r e n t from the p i c t u r e presented i n the l i t e r a t u r e r e g a r d i n g the emotional impact o f s t r e s s i n c o n t i n e n c e on o l d e r women. Fu r t h e r s t u d i e s need to be completed which i n v o l v e the use of more s e n s i t i v e s e l f - e s t e e m measurement t o o l s so t h a t an understanding o f the emotional impact of s t r e s s i n c o n t i n e n c e on o l d e r women can be reached. There i s the p o s s i b i l i t y t h a t the sample i n t h i s study formed a unique subset of o l d e r i n c o n t i n e n t women because o f t h e i r d e s i r e to p a r t i c i p a t e . F u r t h e r s t u d i e s employing random sampling methods with l a r g e r samples need < to be completed i n order f o r there to be g e n e r a l i z a b i l i t y to the o l d e r p o p u l a t i o n . S t u d i e s need to be completed which demonstrate the e f f e c t o f d i f f e r e n t techniques f o r managing d i f f e r e n t types of in c o n t i n e n c e i n order to i n c r e a s e the s t r a t e g i e s a v a i l a b l e f o r nurses to implement with c l i e n t s . Continence s t u d i e s a l s o need to be completed on both o l d e r men and women. The use of Kegel's e x e r c i s e s with o l d e r men i s s p a r s e l y documented. Continence i s a c r i t i c a l i s s u e f o r o l d e r a d u l t s . U r i n a r y i n c o n t i n e n c e causes p h y s i c a l and emotional d i f f i c u l t i e s f o r those who experience the problem. The p h y s i c a l d i s c o m f o r t o f the i n v o l u n t a r y l o s s of u r i n a r y c o n t r o l i s coupled with f e e l i n g s o f low s e l f - e s t e e m and s e l f - w o r t h . S o c i a l i s o l a t i o n or i n s t i t u t i o n a l i z a t i o n may r e s u l t from the p h y s i c a l and emotional c o s t of u r i n a r y i n c o n t i n e n c e . The e f f e c t s o f u r i n a r y i n c o n t i n e n c e can be a l l e v i a t e d or minimized through e f f e c t i v e n u r s i n g management. T h i s i n v o l v e s independent n u r s i n g a c t i o n s , i n c l u d i n g complete and ac c u r a t e assessment of c l i e n t s ' continence s t a t u s , p l u s the implementation o f a p p r o p r i a t e p r o t o c o l s . Nurses are then able to nurture the c l i e n t i n the development of s u i t a b l e coping behaviours. 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Promoting u r i n a r y continence i n the e l d e r l y i n h o s p i t a l . Nursing Times, 71, (48), 1908-1909. Wells, T. (1987). Diagnosing i n c o n t i n e n c e type. Nursing Times. 83, (15), 89-91. Whitehead, W.E., Burgio, K.L., Engel, B.T., (1984). Beh a v i o u r a l methods i n the assessment and treatment of u r i n a r y i n c o n t i n e n c e . In J.C. B r o c k l e h u r s t (Ed.) Urology i n the e l d e r l y . ( p p . 74-91). Edinburgh: C h u r c h i l l L i v i n g s t o n e . Whitman, S. & Kursh, E.D. (1987). Curbing i n c o n t i n e n c e . J o u r n a l o f G e r o n t o l o g i c a l Nursing, 13, (4), 35-40. Wilcox, G.K., Gray, J.A.M., P r i t c h a r d , P.M.M. (1982). G e r i a t r i c problems i n general p r a c t i c e . Oxford ge n e r a l p r a c t i c e s e r i e s 2. Oxford: Oxford U n i v e r s i t y P r e s s . 8:1. Witty, D.L. (19.77). Managing i n c o n t i n e n c e i n women. P a t i e n t Care. 11, 120-122; 127-133; 137-141. Yu, L. C. & K a l t r e i d e r , D. L. (1987). S t r e s s e d nurses d e a l i n g with i n c o n t i n e n t p a t i e n t s . J o u r n a l of G e r o n t o l o g i c a l Nursing, 13, (1), 27-30. Appendix B A study of the e f f e c t s of s t r e s s i n c o n t i n e n c e and bladder  r e t r a i n i n g on o l d e r women's p e r c e i v e d s e l f - e s t e e m  Information L e t t e r My name i s Wanda P i e r s o n and I am a R e g i s t e r e d Nurse i n the Master's i n Nursing program at the U n i v e r s i t y of B r i t i s h Columbia. I am conducting a study to determine i f s t r e s s i n c o n t i n e n c e (the i n v o l u n t a r y leakage of u r i n e when coughing, sneezing, laughing or l i f t i n g an o b j e c t ) can be reduced or stopped by performing e x e r c i s e s to s t r e n g t h e n the p e l v i c muscles. I am a l s o i n t e r e s t e d i n your f e e l i n g s r e g a r d i n g the experience of s t r e s s i n c o n t i n e n c e and, i f those f e e l i n g s change, i f your experience with s t r e s s i n c o n t i n e n c e changes. I f you are i n t e r e s t e d i n p a r t i c i p a t i n g i t w i l l r e q u i r e about one and a h a l f hours of your time. The f o l l o w i n g l i s t o u t l i n e s the events of the study: -At a time convenient f o r you, I w i l l v i s i t your home and ask you a few q u e s t i o n s about your v o i d i n g h a b i t s and you w i l l complete a 10 item q u e s t i o n n a i r e . I w i l l e x p l a i n the p e l v i c e x e r c i s e s a t t h i s time. Time r e q u i r e d f o r t h i s i n t e r v i e w i s about 45 minutes. -I w i l l phone you 2 to 3 days l a t e r to see how you managing. -The l a s t i n t e r v i e w w i l l occur 2 weeks l a t e r , i n your home, at a time convenient f o r you. I w i l l a g a i n ask you a few q u e s t i o n s about your v o i d i n g h a b i t s and have you complete the same 10 item q u e s t i o n n a i r e . 8 6 Appendix D No. A study o f the e f f e c t s o f s t r e s s i n c o n t i n e n c e and bladder  r e t r a i n i n g on o l d e r women's p e r c e i v e d s e l f - e s t e e m I would l i k e to ask you some general q u e s t i o n s about your past and present h e a l t h ? Demographic Information Age Are you p r e s e n t l y t a k i n g any medication? I f yes, please i d e n t i f y the m e d i c a t i o n ( s ) . Please i d e n t i f y any h e a l t h problems you are p r e s e n t l y being t r e a t e d f o r , by any h e a l t h p r o f e s s i o n a l . What would you estimate the amount of your d a i l y f l u i d i n t ake to be? What types of f l u i d s do you u s u a l l y d r i n k ? Past H i s t o r y Have you ever been t r e a t e d f o r i n c o n t i n e n c e before? I f yes, ple a s e d e s c r i b e the treatment. Have you ever been t r e a t e d f o r bladder i n f e c t i o n s b efore? I f yes, when? What was the treatment? How o l d were you when you had your f i r s t baby? How many c h i l d r e n have you had? 8 7 As f a r as you know, were the pregnancies normal? (Did you c a r r y the c h i l d to f u l l term without c o m p l i c a t i o n s ? ) As f a r as you know, were the d e l i v e r i e s u n e v e n t f u l ? (Cesarean s e c t i o n or episiotomy) Bowel P a t t e r n How o f t e n do your bowels move? Is t h i s a r e g u l a r p a t t e r n f o r you? Do you f o l l o w a s p e c i f i c r o u t i n e to keep your bowels r e g u l a r ? I f yes, please d e s c r i b e . 8 8 Appendix E No. Interview No. A study o f the e f f e c t o f s t r e s s i n c o n t i n e n c e and bladder  r e t r a i n i n g on o l d e r women's p e r c e i v e d s e l f - e s t e e m I would l i k e to ask you a few qu e s t i o n s about your usual v o i d i n g p a t t e r n s ? Continence Assessment Frequency of v o i d i n g How o f t e n do you v o i d d u r i n g the day? How o f t e n do you v o i d d u r i n g the ni g h t ? Do you wake up because of the urge to go to the bathroom? Have you n o t i c e d any r e c e n t change i n v o i d i n g ? I f yes, ple a s e d e s c r i b e the change. Continence Do you ever loose c o n t r o l o f your u r i n e ? I f yes when? Is your u r i n e r e l e a s e d when you cough sneeze , laugh , or l i f t an o b j e c t ? I f yes, i s i t a small amount? or a l a r g e amount? Do you ever experience d r i b b l i n g o f u r i n e ? I f yes, please d e s c r i b e t h i s . 8 9 How soon do you have to go the bathroom a f t e r you experience the urge? minutes? or hours? How many times a day are you i n c o n t i n e n t x l x2 x3 >3 How long have you had the symptom o f in c o n t i n e n c e ? days? months? years? Did i t s t a r t suddenly? or g r a d u a l l y ? Was i t a s s o c i a t e d with any p a r t i c u l a r event? I f yes, please d e s c r i b e . Do you use a i d s or pads? Type? Number used per day? Are they e f f e c t i v e ? I f not e f f e c t i v e , please d e s c r i b e problem. R e t e n t i o n Do you ever f e e l t h a t you have not emptied your bladder f u l l y when you void? Do you have a sense of f u l l n e s s i n your bladder a f t e r v o i d i n g ? What do you do about t h i s ? P a i n Do you ever experience any p a i n when you v o i d ? _ I f yes, ple a s e d e s c r i b e i t . Do you ever experience any burning when you void? I f yes, ple a s e d e s c r i b e i t . Urine Have you ever seen c r y s t a l s or p a r t i c l e s i n your u r i n e ? I f yes, when Is your u r i n e c l e a r as tap water or i s i t cloudy? I f cloudy, when does t h i s occur? Does your u r i n e every have a s t r o n g odour? Please d e s c r i b e the odour. Is your u r i n e ever d i s c o l o r e d ? Please d e s c r i b e the c o l o r . Appendix F A study of the e f f e c t of s t r e s s i n c o n t i n e n c e and bladder  r e t r a i n i n g on o l d e r women's p e r c e i v e d s e l f - e s t e e m No. Self-Esteem Scale Interview No Incontinence may a f f e c t the way people f e e l about themselves. I would l i k e to ask you a few q u e s t i o n s about ho you f e e l about y o u r s e l f . 1. I f e e l t h a t I'm a person of worth,at l e a s t on an equal plane with o t h e r s . 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 2. I f e e l t h a t I have a number of good q u a l i t i e s . 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 3. A l l i n a l l , I am i n c l i n e d to f e e l t h a t I am a f a i l u r e . 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 4. I am a b l e to do t h i n g s as w e l l as most other people. 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 5. I f e e l I do not have much to be proud of. 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 9 2 6. I take a p o s i t i v e a t t i t u d e towards myself. 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 7. On the whole, I am s a t i s f i e d with myself. 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 8. I wish I c o u l d have more r e s p e c t f o r myself. 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 9. I c e r t a i n l y f e e l u s e l e s s a t times. 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e 10.At times I t h i n k I am no good a t a l l . 1. S t r o n g l y agree 2. Agree 3. Disagree 4. S t r o n g l y d i s a g r e e Rosenberg, M. (1965). S o c i e t y and the a d o l e s c e n t s e l f - i m a q e . P r i n c e t o n : P r i n c e t o n U n i v e r s i t y Press. Self-esteem s c a l e . Appendix D, pp. 305-319 r e p r i n t e d by p e r m i s s i o n o f P r i n c e t o n U n i v e r s i t y Press. 9 4 Appendix H Interview Guide f o r Telephone Contact 1. Have you been able to do the e x e r c i s e s as we di s c u s s e d ? 2. Are you having any d i f f i c u l t y performing the e x e r c i s e s ? I f yes, pl e a s e d e s c r i b e . 3. How much f l u i d have you been able to take i n d a i l y ? 4. Do you have any q u e s t i o n s , a t t h i s time? Appendix I Tables of P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t  Episodes During P e r i o d s of Increased Intra-abdominal Pressure  at Pre and Post I n t e r v e n t i o n Interview Times Table XV P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t Episodes when  Coughing a t Pre and Post I n t e r v e n t i o n Interview Times F i r s t Interview Second Interview Cough Frequency Percent Frequency Percent Yes 12 (80.0%) 7 (46.7%) Sometimes 1 (6.7%) 1 (6.7%) No 1 (6.7%) 7 (46.7%) N/A 1 (6.7%) 0 T o t a l 15 (100.0%) 15 (100.0%) Table XVI P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t Episodes when  Sneezing a t Pre and Post I n t e r v e n t i o n Interview Times F i r s t Interview Second Interview Sneeze Frequency Percent Frequency Percent Yes 12 (80.0%) 8 (53.3%) Sometimes 0 2 (13.3%) No 2 (13.3%) 5 (33.3%) N/A 1 (6.7%) 0 T o t a l 15 (100.0%) 15 (100.0%) 37 Table XVII P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t Episodes when  Laughing a t Pre and Post I n t e r v e n t i o n Interview Times Laugh F i r s t Interview Second Interview Frequency Percent Frequency Percent Yes 8 (53.3%) 2 (13.3%) Sometimes 1 (6.7%) 0 No 5 (33.3%) 13 (86.7%) N /A 1 (6.7%) 0 T o t a l 15 (100.0%) 15 (100.0%) 9 8 Table XVIII P e r c e i v e d Changes i n Frequency of I n c o n t i n e n t Episodes when  L i f t i n g an Object a t Pre and Post I n t e r v e n t i o n Interview Times F i r s t Interview Second Interview L i f t i n g an Object Frequency Percent Frequency Percent Yes 2 (13.3%) 1 (6.7%) Sometimes 0 0 No 12 (80.0%) 14 (93.0%) N/A 1 (6.7%) 0 T o t a l 15 (100.0%) 15 (100.0%) Appendix J Tables of Frequency of Responses to Rosenberg Self-esteem  Q u e s t i o n n a i r e Items a t Pre and Post I n t e r v e n t i o n Interview Times When completing the s e l f - e s t e e m s c a l e women would o f t e n stop and s e r i o u s l y r e f l e c t on t h e i r l i f e c ircumstances. Although the i n f o r m a t i o n i s not r e l e v a n t to the d i s c u s s i o n o f u r i n a r y i n c o n t i n e n c e , many of the comments are note-worthy. Some o f these comments have been i n c l u d e d here, under the s p e c i f i c q u e s t i o n s to which the comments r e l a t e d . Note: Responses are i d e n t i f i e d a c c o r d i n g to the s c a l e used i n the q u e s t i o n n a i r e ; 1 s t r o n g l y agree, 2 agree, 3 d i s a g r e e , 4 s t r o n g l y d i s a g r e e . Table XVIX I f e e l t h a t I'm a person o f worth, a t l e a s t on an equal plane  with o t h e r s . Response F i r s t Interview Second Interview Frequency Percent Frequency Percent 1 5 (33.3%) 2 (13.3%) 2 10 (66.7%) 13 (86.7%) 3 4 T o t a l 15 (100.0%) 15 (100.0%) 100 Table XX I f e e l t h a t I have a number of good q u a l i t i e s . Response F i r s t Interview Second Interview Frequency Percent Frequency Percent 1 4 (26.7%) 2 (13.3%) 2 11 (73.3%) 13 (86.7%) 3 4 T o t a l 15 (100.0%) 15 (100.0%) 1.01 Table XXI A l l i n a l l , I am i n c l i n e d to f e e l t h a t I am a f a i l u r e . Response F i r s t Interview Second Interview Frequency Percent Frequency Percent 1 2 3 13 (86.7%) 14 (93.3%) 4 2 (13.3%) 1 (6.7%) T o t a l 15 (100.0%) 15 (100.0%) Three women f e l t inadequate because they had not pursued t h e i r e d u c a t i o n a t a u n i v e r s i t y l e v e l . These women a l s o s t a t e d they f e l t inadequate because they d i d not have a p r o f e s s i o n a l c a r e e r . Table XXII I am able to do t h i n g s as w e l l as most other people. Response F i r s t Interview Second Interview Frequency Percent Frequency Percent 1 2 (13.3%) 1 (6.7%) 2 10 (66.7%) 10 (66.7%) 3 3 (20.0%) 3 (20.0%) 4 T o t a l 15 (100.0%) 14 (93.4%) 1 0 3 Table XXIII I f e e l I do not have much to be proud o f . Response F i r s t Interview Second Interview Frequency Percent Frequency Percent 1 2 2 (13.3%) 2 (13.3%) 3 11 (73.3%) 10 (66.7%) 4 2 (13.3%) 2 (13.3%) T o t a l 15 (100.0%) 14 (93.3%) S a t i s f a c t i o n with t h e i r a b i l i t y to nurture t h e i r f a m i l i e s was i d e n t i f i e d by three s u b j e c t s as being a source of p r i d e . 104 Table XXIV I take a p o s i t i v e a t t i t u d e towards myself. Response F i r s t Interview Frequency Percent Second Interview Frequency Percent 1 2 3 4 1 (6.7%) 12 (80.0%) 2 (13.3%) 1 (6.7%) 13 (86.7%) 1 (6.7%) T o t a l 15 (100.0%) 15 (100.0%) 105 Table XXV On the whole, I am s a t i s f i e d with myself. F i r s t Interview Second Interview Response Frequency Percent Frequency Percent 1 0 1 (6.7%) 2 12 (80.0%) 9 (60.0%) 3 3 (20.0%) 4 (26.7%) 4 T o t a l 15 (100.0%) 14 (93.4%) Two p a r t i c i p a n t s i d e n t i f i e d t h a t they d i d not f e e l s a t i s f i e d with themselves because they were always " s t r i v i n g " and "reaching f o r something b e t t e r " . Table XXVI I wish I c o u l d have more r e s p e c t f o r myself. F i r s t Interview Second Interview Response Frequency Percent Frequency Percent 1 0 0 2 3 (20.0%) 0 3 12 . (80.0%) 14 (93.3%) 4 0 1 (6.7%) T o t a l 15 (100.0%) 15 (100.0%) 107 Table XXVII I c e r t a i n l y f e e l u s e l e s s a t times. Response F i r s t Interview Second Interview Frequency Percent Frequency Percent 1 0 0 2 5 (33.3%) 5 (33.3%) 3 6 (40.0%) 8 (53.3%) 4 3 (20.0%) 1 (6.7%) T o t a l 14 (93.3%) 14 (93.3%) This q u e s t i o n caused t h o u g h t f u l r e f l e c t i o n on the p a r t of most p a r t i c i p a n t s . One woman s t a t e d t h a t she d i d n ' t f e e l u s e l e s s but t h a t she f e l t "meaningless". Three other women i n d i c a t e d t h a t they f e l t u s e l e s s " o c c a s i o n a l l y " . 108 Table XXVIII At times I think. I am no good a t a l l . Response F i r s t Interview Second Interview Frequency Percent Frequency Percent 1 0 0 2 1 (6.7%) 1 (6.7%) 3 8 (53.3%) 11 (73.3%) 4 6 (40.0%) 3 (20.0%) T o t a l 15 (100.0%) 15 (100.0%) 109 Appendix K L e t t e r of P e r m i s s i o n to Use the Rosenberg Self-esteem Scale 

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