Recently, I had the privilege of participating in an eclectic meeting of scholars and clinicians addressing issues in continence practice and research.1 I was part of a group asked to respond to a paper entitled Patient centered interventions,2 and my focus was on the topic related to men. The term, patient-tailored interventions or patient-centered care, begs the following question, "Have we not always done this-Do we not individualize all care? Surely this is the essence of nursing." Yet, is this indeed the case? Nightingale advocated listening to the patient, but she did not consider negotiating or goal setting with the patient as part of nursing care. She wrote: "Do for the patient what he cannot do for himself," and this attitude of "doing for" continued in nursing education until recently. Now we teach our students to think critically, to negotiate, and to set goals with the patient (client came about, in part, because the person was receiving services as a customer-the business model). The patient-I was pleased to read Dr Lauver speak of patient rather than client-wants an informed health professional who can problem solve and assist in decision making for best care. However, cuts, shortages, and long hours mean that problem solving and individualized care become a challenge. Paths of least resistance are resorted to-for example, the algorithm.
Do algorithms of continence, guidelines for practice, and evidence-based protocols overlook the individual? The business model of the 1990s meant that individual differences were uneconomical-they were set aside for clean, mean, and efficient-nurses lost their jobs and patients lost negotiating rights. We can blame the politicians of the 1990s for the change in attitude, but was care of the male with urinary incontinence truly individualized before the 1990s or have we been more prescriptive than we will readily admit?
The temptation to be prescriptive is strong, and "evidence" (and I use the term with respect to the randomized controlled trial [RCT]-although one could argue evidence is more than RCT results)-is cited as necessary before program funding is considered. In Alberta, one regional district funds continence care by physiotherapists; another does not, stating as a rationale that the evidence is modest at best.
Evidence-based practice without consideration of the subjective/individual evidence does the patient a significant disservice, as Brenda Roe, another member of the meeting, has articulated3; Cochrane members are often criticized for their adherence to the RCT as the gold standard. However, we do need the basic evidence. Our evidence-based report cards are a key element in keeping JWOCN on top of practice-related issues.
What is the evidence about treatment of incontinence in men? For purposes of the discussion, I focused on incontinence after prostatectomy (radical and transurethral resection), but, of course, the incidence of overactive bladder and other bladder dysfunction is equally problematic in the older man as it is in the older woman.
The most recent Cochrane review of treatment of urinary incontinence postradical prostatectomy shows some benefit of pelvic floor muscle exercises (PFME) immediately postoperatively in one study but not in another.4 However, the study showing no significant difference between control and treatment groups had significant impact on the subjective aspects of care-the men who participated were enormously grateful for the support and encouragement provided by both the study coordinator and the physiotherapist. Is this the tailored intervention Dr Lauver considers when she asks: What are the critical dimensions of patient centered interventions?
In keeping with Dr Lauver's question, Jill Milne, a recent PhD graduate from the University of Calgary, explored why men or women did or did not adhere to recommended incontinence treatment strategies.5 Insufficient information, challenging exercises, competing interests, and cost were all important. Moreover, the participants' major self-care goal was maintaining a normal lifestyle, but the therapist's goal was continence. Patients perceived the PFME program as lengthy and time consuming. They consistently reported difficulty maintaining strategies that were personally disruptive; those who had been advised to perform PFME several times a day were more likely to have altered this routine than their lifestyles.
Notably, participants who were no longer able to pursue a normal lifestyle, particularly those who described incontinence as a "dominating force," became more assertive in their personal therapeutic efforts. Such diligence to treatment is reflected in men with incontinence after postprostatectomy. Yet, as Ashworth and Hagan also noted, pelvic floor exercises can be a "major life project in themselves,"6(p470) and practitioners must be cognizant of the commitment required to adhere to what is effectively a lifestyle change as difficult as dieting or smoking cessation. Practitioners must consider what is realistic for the patient, the patient's readiness to learn, and the use of the information provided. Yet, curiously, in a review of the literature on patient-tailored interventions, Ryan and Lauver conclude that the evidence to support prescriptive/standard care vs patient-tailored care is weak.7 Nevertheless, some clear guidelines for practice arose from their review and fit with all continence care: (1) setting realistic goals and expectations for outcomes, (2) giving the patient positive affirmation and feedback, (3) providing follow up for encouragement and support, and (4) assisting the patient to strategize how treatment can fit into a busy daily routine.
In conclusion, the nature of adherence, the level of commitment, and interactive function are negotiated and specifically tailored to patient needs.
In 2004, the articles we publish with our new publisher, Lippincott Williams & Wilkins (LWW), strive to provide information that is tailored to JWOCN readers, giving them the best evidence placed in a context of individualized care. Let us remain conscious of the challenges patients face and aid them in meeting those challenges when trying to balance lifestyle changes, such as PFME, with busy and competing life schedules. If we are able to do this, we are more likely to effect change and positive outcomes.
References