title: Evaluating a systematic voiding programme for patients with urinary incontinence after stroke in secondary care using soft systems analysis and Normalisation Process Theory: findings from the ICONS case study phase.
abstract: BACKGROUND
  Urinary incontinence (UI) affects between 40 and 60% of people in hospital after stroke, but is often poorly managed in stroke units.
  
  
  OBJECTIVE
  To inform an exploratory trial by three methods: identifying the organisational context for embedding the SVP; exploring health professionals' views around embedding the SVP and measuring presence/absence of UI and frequency of UI episodes at baseline and six weeks post-stroke.
  
  
  METHODS
  A mixed methods single case study included analysis of organisational context using interviews with clinical leaders analysed with soft systems methodology, a process evaluation using interviews with staff delivering the intervention and analysed with Normalisation Process Theory, and outcome evaluation using data from patients receiving the SVP and analysed using descriptive statistics.
  
  
  METHODS
  An 18 bed acute stroke unit in a large Foundation Trust (a 'not for profit' privately controlled entity not accountable to the UK Department of Health) serving a population of 370,000.
  
  
  METHODS
  Health professionals and clinical leaders with a role in either delivering the SVP or linking with it in any capacity were recruited following informed consent. Patients were recruited meeting the following inclusion criteria: aged 18 or over with a diagnosis of stroke; urinary incontinence (UI) as defined by the International Continence Society; conscious; medically stable as judged by the clinical team and with incontinence classified as stress, urge, mixed or 'functional'. All patients admitted to the unit during the intervention period were screened for eligibility; informed consent to collect baseline and outcome data was sought from all eligible patients.
  
  
  RESULTS
  Organisational context: 18 health professionals took part in four group interviews. Findings suggest an environment not conducive to therapeutic continence management and a focus on containment of UI. Embedding the SVP into practice: 21 nursing staff took part in six group interviews. Initial confusion gave way to embedding of processes facilitated by new routines and procedures. Patient outcome: 43 patients were recruited; 28 of these commenced the SVP. Of these, 6/28 (21%) were continent at six weeks post-stroke or discharge.
  
  
  CONCLUSIONS
  It was possible to embed the SVP into practice despite an organisational context not conducive to therapeutic continence care. Recommendations are made for introducing the SVP in a trial context.
authors.affiliation: School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK. Electronic address: lhthomas@uclan.ac.uk.
authors.forename: L H
authors.initials: LH
authors.lastname: Thomas
authors.affiliation: School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK.
authors.forename: B
authors.initials: B
authors.lastname: French
authors.affiliation: School of Health Care Sciences, Bangor University, Gwynedd LL57 2EF, UK.
authors.forename: C R
authors.initials: CR
authors.lastname: Burton
authors.affiliation: School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK.
authors.forename: C
authors.initials: C
authors.lastname: Sutton
authors.affiliation: School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK.
authors.forename: D
authors.initials: D
authors.lastname: Forshaw
authors.affiliation: School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK.
authors.forename: H
authors.initials: H
authors.lastname: Dickinson
authors.affiliation: School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK.
authors.forename: M J
authors.initials: MJ
authors.lastname: Leathley
authors.affiliation: Division of Primary Care, University of Liverpool, Brownlow Street, Liverpool L69 3GL, UK.
authors.forename: D
authors.initials: D
authors.lastname: Britt
authors.affiliation: Evidence-Based Practice Research Centre, Edge Hill University, St Helens Road, Ormskirk L39 4QP, UK.
authors.forename: B
authors.initials: B
authors.lastname: Roe
authors.affiliation: School of Nursing Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK.
authors.forename: F M
authors.initials: FM
authors.lastname: Cheater
authors.affiliation: School of Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK.
authors.forename: J
authors.initials: J
authors.lastname: Booth
authors.affiliation: School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK.
authors.forename: C L
authors.initials: CL
authors.lastname: Watkins
mesh_terms: D006801:Humans; D020521:Stroke / Q000150:complications*; D014549:Urinary Incontinence / Q000209:etiology / Q000503:physiopathology*
keywords: Case study; Normalisation Process Theory; Soft systems methodology; Stroke; Urinary incontinence