Ethical challenges associated with providing continence care in residential aged care facilities: Findings from a grounded theory study

A person-centred approach to care in residential aged care facilities should uphold residents’ rights to independence, choice, decision-making, participation, and control over their lifestyle. Little is known about how nurses and personal care assistants working in these facilities uphold these ideals when assisting residents maintain continence and manage incontinence. The overall aim of the study was to develop a grounded theory to describe and explain how Australian residents of aged care facilities have their continence care needs determined, delivered and communicated. This paper presents and discusses a subset of the findings about the ethical challenges nurses and personal care assistants encountered whilst providing continence care. Grounded theory methodology was used for in-depth interviews with 18 nurses and personal care assistants who had experience of providing, supervising or assessing continence care in any Australian residential aged care facility, and to analyse 88 hours of field observations in two facilities. Data generation and analysis occurred simultaneously using open coding, theoretical coding, and selective coding, until data were saturated. While addressing the day-to-day needs of residents who needed help to maintain continence and/or manage incontinence, nurses and personal care assistants struggled to enable residents to exercise choice and autonomy. The main factor that contributed to this problem was that the fact that nurses and personal care assistants had to respond to multiple, competing, and conflicting expectations about residents’ care needs. This situation was compounded by workforce constraints, inadequate information about residents’ care needs, and an unpredictable work environment. Providing continence care accentuated the ethical tensions associated with caregiving. Nurses’ and personal care assistants’ responses were mainly characterised by highly protective behaviours towards residents. Underlying structural factors that hinder high quality continence care to residents of aged care facilities should be urgently addressed.