An individualized voiding program in this study is a program unique to Japan developed by researchers based on previous studies. The program outline was created as the framework of the program, and the program guide was created to support care workers in effectively implementing urination guidance. The program guide included knowledge to help perform micturition induction, assessment points, and care instructions(Table 1).

Program outline (Figure 1)

The purpose of this program is to improve functional urinary incontinence in older people and enable them to urinate according to their urinary urgency (improvement of the sense of micturition control) through the implementation of micturition induction by nurses and long-term care workers based on micturition assessment.

According to a previous study by Katagami et al. [8] and Nakamura et al. [14], an individualized voiding program consists of the following: 1) selection of recipients, 2) assessment of lower urinary tract symptoms and micturition behavior

Table 1. Outline of the program guide of the individualized voiding program in Japan aimed at improving the sense of micturition control in older people with functional urinary incontinence.

and capability, 3) framing and implementation of a plan for effective execution, 4) monitoring urinary urgency complaints, and 5) changes in lower urinary function and evaluation of the intervention. This program aims to improve the sense of micturition control in older people with dementia by applying the components of “assessment of lower urinary tract symptoms and micturition behavior and capability” through multidisciplinary collaboration and individualized “framing and implementation of a plan for effective execution” in facilities for older people receiving individualized care. Of the program implementation period, the baseline period (before implementation) and evaluation period (after implementation) took three days each, while the intervention period was four weeks. Monitoring was conducted in the second week of the implementation period.

Program components

Selection of recipients:Older people with urinary incontinence caused by cognitive decline or motor dysfunction and people whose primary treatment/ care is micturition induction were selected. Those with suspected overflow incontinence were excluded.

Assessment of lower urinary tract symptoms and micturition behavior andcapability:The possibility of improving urinary incontinence and regaining the ability to voluntarily urinate was assessed through a collaborative system of nurses and long-term care workers. The assessment of lower urinary tract symptoms involved checking the daily micturition status for three days and referring to previous evaluation reports [18] to ensure reliable assessment. During the assessment, recipients were allowed to wear diapers so that they were not psychologically burdened. It was necessary to conduct an individualized assessment as recipients suffer from behavioral disorders caused by dementia. Excretion is an activity of daily living repeated several times a day to which the caregiver can easily get accustomed. However, changes in behavioral disorders related to excretion in the early stages of dementia are subtle and difficult to grasp.

Framing and implementation of a plan for effective execution:This component involves the creation of a plan by referring to the micturition induction method based on urinary urgency confirmation by Katagami et al. [14] and prompted voiding protocol for the deterioration of cognitive function and motivation. Respecting the urinary urgency complaints of older people, micturition was to be induced based on such complaints. Environmental adjustment, which is based on observation of cognitive function and transfer/movement ability of older people, and functional training, which is based on the physical function of older people during micturition induction, were to be implemented to prevent deterioration of physical function. All caregivers engaged in the program would jointly determine changes necessary to the excretion aids being used after examining changes in the movement/transfer method. Further, they would create and implement a micturition induction plan that utilized the potential of the selected recipients. Thus, the sense of micturition control would improve older people with dementia by respecting their urinary urgency and encouraging independence despite the assistance required for excretion.

Monitoring urinary urgency complaints and changes in lower urinary function:If possible, before incontinence occurs, micturition guidance was to be performed, and the manner of urinary urgency complaints and changes in the lower urinary tract symptoms monitored at micturition intervals according to the lower urinary tract function of the recipient. Caregivers would have discussions with the recipients, their families, and if required, professionals, to understand their social and financial problems caused by urinary incontinence and try to find solutions.

Evaluation of intervention:Comparing to pre-admission conditions, changes in urinary incontinence rate of older people, toilet micturition success rate, voluntary urinary urgency complaint, lower urinary tract function, level of micturition independence, FIM, and motivation would be analyzed and evaluated. Also, the staff would exchange thoughts on program implementation that would later be taken into account during the evaluation of the intervention.

The participants were nurses and long-term care workers employed in rehabilitative facilities for older people (recovery rehabilitation hospital and long-term care facility), who play a key role in the implementation and examination of micturition induction. We contacted facility nurses and long-term care supervisors who had participated before in case studies in excretion care research where this researcher was the sponsor. After providing an overview of the study and acquiring consent, we requested nurses and long-term care supervisors to select the micturition induction recipients for the program. Among the ten participants who consented to the study, one was male and nine were female. There were five nurses and five long-term care workers all of whom had at least five years of experience in the field. Six participants were staff members at a long-term care facility and four were staff members at a recovery rehabilitation hospital. There were two groups, one group consisting of 6 people from the long-term care facility and the other group consisting of 4 people from the recovery rehabilitation hospital. Each group had half the nurses and half the care workers. They were practitioners who were considerate of the elderly and familiar with urination care.

This is a qualitative descriptive study and data was collected from November to December 2020. Focus group interviews (FGIs) were used to collect data in this study. FGIs were performed once in two groups according to the desired interview schedule of participants. Before conducting the interview, I explained the purpose of the research and distributed the program and program guide. The contents of the semistructured interview guide are 1) clarity of the purpose of the program, 2) contents and methods of implementation in the outline of the program and other things to be added, 3) clarity and improvement points of the program guide, and 4) feasibility of this program and further improvements when implementing. First of all, we gave an opening greeting and an orientation for the participants. Next, we asked participants about their experience as a nurse or care worker, the characteristics of the ward, and what they feel about urination care for the elderly. A group of four to six people discussed for around 60 minutes the purpose and content of the program, as well as the perspicuity of the guide. Discussion was refocused to the intended topic when the discussion digressed. The sessions began with the open question. The moderator was careful to promote and focus on the interaction of the participants. Remote interviews were conducted using a conference system because COVID-19 restrictions made it difficult to physically visit facilities for older people. We asked the facility supervisors to allow us to use separate rooms in the target facilities to ensure privacy. The FGI environment in which the interviews were held was private. Only the participants and researchers were included in the sessions. The researchers provided the computers and internet connection to conduct the remote interviews, which were recorded on a digital voice recorder with the consent of the participants for recording and use.

Data were analyzed using a qualitative descriptive approach according to content analysis guidelines by Yatsu [19]. The verbatim transcript of the recorded interviews was used as descriptive data for analysis. First, the transcribed interviews were read through several times. The verbatim transcript of each group was carefully read and the content related to suggested improvements in the micturition induction program, such as comments on the program purpose, program content, and the perspicuity of the guide, was extracted. In the second, keeping in mind content relevant to the purpose of the study and using each participant’s words as much as possible, the content was coded to be faithful to its meaning and then checked by a fellow researcher. We classified coded content by comparing similarities and differences, summarized them into several codes, labeled them, and then extracted categories and subcategories. Finally, during the categorization process, we returned to the data to check content validity to name the categories to show semantic content.

The purpose of the study, a method to be used, protection of personal information, voluntary participation in the study, the assurance that the participant will not bear disadvantages because of non-participation, and storage and disclosure of information were explained to the participants using the request form. Further, the participants were also informed that consent cannot be withdrawn after the analysis of the interview since the information acquired in this study is anonymized. Next, the written consent of the participants was acquired. This study was conducted after obtaining the approval of the Ethics Review Board of Osaka Medical College (Nursing 146-2890).

While determining the purpose of the micturition induction program, we extracted the category “enabling caregivers to work as a well-coordinated team to humanely facilitate excretion independence in older people which is essential for living with dignity.” Upon recognizing the importance of rehabilitation, the study participants focused on the objective of this program—that is, improving the post-home return life of recipients—and strived to find solutions to lessen the burden of long-term care for the family. Believing that support for excretion independence would lead to a better life for older people, we searched for ways to improve the morale of the caregivers while hoping to improve the quality of geriatric care provided by the entire team as a whole. We believe that we were able to establish a common understanding of the importance of helping older people maintain a sense of urination control to improve their life.

In the outline of an individualized voiding program, the category “setting selection criteria for recipients considering the status of micturition induction” corresponded to the first component of a selection of recipients. Regarding this category, in consideration of older people with dementia, we confirmed that it is ideal to avoid micturition induction immediately after admission and only perform it after a relationship has been established between the caregiver and the recipient. People who require the assistance of two or more people during excretion, due to conditions that require treatment or physical dysfunction, etc., were excluded from the program. Long-term care reluctance has been identified as a factor that increases the burden on the caregiver during micturition induction. This is an unpleasant experience for both the older person and caregiver. This reluctance was added in the exclusion criteria presuming that it is not only caused by excretion. However, if this reluctance occurs during the implementation of the program, it is necessary to be with the older person and prioritize their safety and comfort. The categories “careful information collection and assessment of lower urinary tract symptoms in older people in case of environmental change” and “examination of assessment methods for lower urinary tract symptoms according to the facility environment” correspond to the second component—assessment of lower urinary tract symptoms and micturition behavior and capability. While analyzing the category “careful information collection and assessment of lower urinary tract symptoms in older people in case of environmental change,” we found that older people with dementia may have difficulty in adapting to an unfamiliar environment. Further, based on the relationship between lower urinary tract symptoms and mental state, we ascertained the timing of mental instability episodes to avoid inducing Behavioral Psychological Symptoms of Dementia (BPSD). The speech, conduct, and presence of the caregiver are also part of the environment. In Japan, the Professional Environmental Assessment Protocol (PEAP) is also used as it shows the mentality and policies for older people with dementia [20].

The eight dimensions of environmental support comprise an important component in excretion care. These are orientation support, support for functional ability, quality, and coordination of environmental stimuli, support for safety and comfort, support of the continuation of life, support for self-selection, ensuring privacy, and promotion of rapport with the recipient. The study participants were nurses and long-term care workers in recovery rehabilitation wards and long-term care facilities—all of which are facilities that provide support for excretion independence so that older people can return home. However, under “examination of assessment methods for lower urinary tract symptoms according to the facility environment”, we found that the measurement method of residual urine volume varies depending on the availability of an ultrasound bladder volume device that allows non-invasive measurement. This measuring instrument is widely used in specialized fields and is effectively used in practice [21]. However, many facilities do not have this instrument owing to the high cost and relatively infrequent use and because it requires special training to use the device. It is necessary to modify the method of assessing lower urinary tract symptoms depending on the availability of the residual urine volume measuring device. The results of the interviews indicated that all the caregivers felt competent to perform residual urine measurement using the ultrasound bladder volume device. However, it has been reported that residual volume measurements at facilities for older people were performed more significantly by nurses than by care workers [8]. Based on this report, the assessment of lower urinary tract symptoms provides important clues in determining the direction of care. Considering the specialty of nurses in collaboration with other workers and the staffing in facilities for older people, nurses need to lead the assessment of lower urinary tract symptoms.

The category “confirmation of the recipient’s urination habits and request for assistance” corresponds to the component of “framing and implementing a plan for effective execution.” Although this was not particularly presented in the program, this topic was added since we realized that it is necessary information for effective micturition induction. The category “conducting necessary examination for setting the intervention period and evaluation period according to target condition” corresponds to components “framing and implementation of a plan for effective execution” and “monitoring urinary urgency complaints and changes in lower urinary function and evaluation of the intervention.” In this category, the subjects felt that a five-week program implementation period was too long. They also said that the efficacy of the intervention can be evaluated by monitoring in the second week. In a previous study [14], a four-week intervention period was set and efficacy was noted on several recipients during the second week. For this reason, we decided to perform monitoring in the second week of the program. Although we believe that the sustainability of the program should be examined, the intervention period must be reviewed by analyzing the level of efficacy by monitoring in the second and fourth week. There is also a study on the sustainability of prompted voiding intervention performed by staff which has not been verified to date [22]. Moving forward, after developing a micturition induction program and verifying its effectiveness in Japan, there is a need to build a system that can effectively, efficiently, and sustainably execute the program.

From the participant’s comments on the program guide, we extracted the category “specific successful cases help frame and implement the micturition induction plan”. The subjects expressed positive opinions toward the program’s content saying that it was easy to understand and would be immediately useful when framing the micturition induction plan. The examples of excretory behavioral disorders caused by dementia were also easy to understand, but some participants opined that more examples need to be presented. There are several difficult cases and few successful experiences in the practice of micturition induction in facilities for older people. Therefore, the participants felt that presenting successful cases would motivate the team.

The interviewees gave suggestions for improving the program. To the best of our knowledge, our study of the feasibility of a micturition induction program in Japan for the improvement of the sense of control in older people with functional urinary incontinence is the first in this domain. However, since the causes of functional urinary incontinence are diverse and complex, verifying the efficacy of the refined program in the future is essential. Also, by verifying the effectiveness of the program, we believe that care methods according to the cause of functional urinary incontinence will be clarified.

In the data on status and issues in an individualized voiding program, we found that the practice of performing timed induction without considering the micturition intention and status of older people is difficult to correct as it the result of a heavy workload. However, taking the micturition intention and status of older people into account during timed inductions, designating a place for information and opinion sharing using ordinary communication methods, and including therapists and care managers in the collaboration system in addition to nurses and long-term care, workers have been proposed as specific measures for the effective implementation of this program. Based on this feedback, we determined that implementation is possible provided that the strengths cultivated so far could be demonstrated. However, the concern about “inability to reliably implement the program while struggling with caring for several older people requiring long-term care” was also identified. As such, due consideration is necessary when setting a feasible number of people to avoid increasing the staff’s workload. We were able to reconfirm the implementation of the program within the current set-up where a small staff is in charge of several older people requiring long-term care.