Incontinence is a widespread disorder ranging in severity from irregular and episodic urinary leaks to complete loss of bladder and/or bowel control. The likelihood of developing this condition increases with age and is a major reason for admission to long-term care facilities. If not properly managed and assessed, it can negatively impact psychological wellbeing and health-related quality of life (Kehinde, 2016; Buckley, 2019; Sayabalian et al, 2019). Prolonged exposure of the skin to urine, faeces, or both, as a consequence of incontinence, can lead to moist skin that is vulnerable to injury and the development of incontinence-associated dermatitis (IAD) (Coyer and Campbell, 2018). IAD is a complex and painful condition characterised by inflammation and erythema, which may present as blisters and erosions (Campbell et al, 2016). Subsequently, IAD increases susceptibility to secondary skin infections and pressure ulcers (Raepsaet et al, 2021).
Long-term skin exposure to moisture due to incontinence, as well as chemical or physical irritants, disrupts the skin barrier function. Normal skin pH, ranging from 4 to 6, provides an acidic mantle that inhibits bacterial invasion and colonisation. However, skin pH can be influenced by a wide variety of factors such as skin moisture, sweat, sebum, anatomic site, and age (Schmid-Wendtner and Korting, 2006; Coyer and Campbell, 2018). Higher skin pH levels contribute to increased skin permeability, which in turn leads to inflammation, a burning sensation, and pain (Nakagami et al, 2006; Coyer and Campbell, 2018). Ageing skin has a lower baseline function and is more susceptible than the skin of younger people to damage from chronic exposure to irritants such as urine or stool. Consequently, older adults are at a higher risk of developing IAD than younger adults (Gray et al, 2007; Van Damme et al, 2018).
A wide range of interventions is available to treat the cause of, or manage, incontinence. Absorbent incontinence products are the most commonly used daily management option for individuals with incontinence. To meet the various needs of users and their lifestyles, several continence products are available on the market, differing in terms of design, size and absorbency (DeMarinis et al, 2018; Sacco et al, 2018; Sanaeifar et al, 2023). However, with the bewildering range of products, sufficient guidance is not available to aid patients, family, caregivers, and professionals in making informed purchase choices (Knifton et al, 2018). In addition, the number of studies on absorbent incontinence product evaluation is too small to help users select an appropriate product.
There is no single best absorbent incontinence product that is appropriate and effective for all users; therefore, it is important that healthcare providers identify the right product for each individual (Sacco et al, 2018). Using the correct product can enhance comfort and reduce unnecessary changes, particularly at night. This minimises sleep fragmentation and allows residents to sleep better (Sayabalian et al, 2019).
The choice of absorbent incontinence products should depend on the volume of urine leakage, the frequency of leakage, and the user's ability to apply the product. Products should have a suitable absorbency level with the highest possible flow rate and should be able to hold urine without leakage to ensure the skin's exposure to urine and faeces is minimised (Doherty, 2003; DeMarinis et al, 2018; Sayabalian et al, 2019). The ability of the product to effectively wick moisture away from the skin, draw urine in, and transmit it to the lower absorbent layer results in a dry skin micro-environment. These features promote a healthy microclimate between the product and the skin and diminish skin complications. The containment of odour and softness are other important considerations for users that provide comfort and prevent unnecessary changes (Buckley, 2019). This allows for more restful sleep and decreased disturbances during night-time hours.
The benefits for healthcare providers include the need for fewer changes in clothing and bedding due to leaks, thereby relieving some of the burden of incontinence in daily care (Sayabalian et al, 2019). For people with mobility issues, other characteristics, including the ease of opening the pack and putting on the product, are considered important (Getliffe et al, 2007).
In the present study, the authors aimed to investigate the experiences of nurses in nursing homes using the newly introduced MoliCare Premium Elastic for patients with incontinence compared with the former MoliCare product design using a quantitative questionnaire focusing on the key performance features of the absorbent incontinence product.
For the purposes of this article, the term ‘nurses’ is used when referring to the nursing home specialist caregivers. In nursing homes in Germany, such caregivers are responsible for all aspects of nursing care from administration, care planning and daily care to wound treatment.
Methods
Study design
Forty-three qualified nurses responsible for elderly and disabled people working different shifts in five nursing homes with patients with incontinence (urinary, faecal, or both) and/or dementia in Germany participated in this study. The product manufacturer's continence adviser provided nurses with MoliCare Premium Elastic products, and the correct usage and fitting of these products were taught in a training session. The nursing homes tested MoliCare products with their residents for approximately 10 days.
A quantitative questionnaire comprising the key performance characteristics of an absorbent incontinence product was administered to the nurses to assess their opinions on the use of MoliCare Premium Elastic products.
Ethical considerations
The study complied fully with ethical, governance, and data protection requirements.
Development of the questionnaire
The questionnaire began with a brief introduction to the new changes and modifications to the design characteristics of the MoliCare Premium Elastic product and its packaging. The second section of the questionnaire asked participants about the name of their institution, type of shift, and the special characteristics of the residents (for example, faecal incontinence, dementia, and medication). Subsequently, the nurses were asked about the overall acceptability of the product. Statements were designed to evaluate the packaging and handling of the product. This was followed by items describing the key performance features of the new product. These key features were based on important parameters indicating whether absorbent products are regarded as effective and acceptable by users and were identified through a literature review (Getliffe et al, 2007; Buckley, 2019). Afterwards, these factors were turned into statements where the nurses could indicate their level of agreement with each one. Respondents were also asked to rate statements to compare the new MoliCare design with the previous MoliCare product in terms of performance and user preference.
The nurses were required to grade their level of satisfaction with the products on a scale of 1 to 5, where 5 indicated the highest possible level of satisfaction and 1 indicated the strongest level of dissatisfaction. However, in this study, a three-point scale (Good, OK, Poor, or Higher/Better, Neutral, Worse) was used. Good or Higher/Better, the sum of ratings 5 and 4, signified that the product worked well and the participants wished to use it again; OK or Neutral (rating of 3) indicated that the product worked fairly well and the nurses would consider using it; and Poor or Worse was the sum of 2 and 1 ratings, showing that the product did not meet their expectations and they would not continue using it.
MoliCare Premium Elastic products
MoliCare Premium Elastic is an incontinence product with two wide, extendable and elastic inserts on the side panels and two wide, re-closable adhesive strips that can be reattached to reposition the product. This product is suitable for moderate-to-severe urinary and/or faecal incontinence in both active patients and those confined to bed. The elasticated cuffs on the sides of the product can contain large and sudden flows of urine to prevent leakage.
Improved technology in the absorbent core of the product provides dryness and leakage protection. The product contains cellulose fluff and superabsorbent polymers (SAPs) that absorb and transmit urine to the inner absorbent layer, minimising skin wetness and allowing for the absorbance of multiple incontinence episodes. Modification of specially processed cellulose fibres with citric acid creates an acidic surface environment when wet (Beguin et al, 2010).
The key feature of the new design is a channel-shaped cavity at the most probable urine entry point of the product. This leads to accelerated urine absorption and assists in quick movement and distribution of the liquid throughout the product. The new MoliCare SkinGuard absorbent core technology is designed to offer leakage protection, provide an instant dry feeling due to the improved absorbent core, and maintain healthy skin that helps prevent skin irritation. Figure 1 shows the design of the new product.
Data analysis
The data were summarised using Microsoft Excel.
Findings
Figure 2 shows the percentage of nurses (n=43) who evaluated the key performance aspects of the new MoliCare Premium Elastic design as ‘Good’, ‘OK’, or ‘Poor’. More than 80% of the nurses considered the overall acceptance of the new design as ‘Good’, and only 4% rated this as ‘Poor’. The ease of use of the product was rated as ‘Good’ by 74% of respondents, while 16% and 10% found this aspect to be ‘OK’ or ‘Poor’, respectively. Seventy-four per cent of nurses rated absorbency and leakage protection as ‘Good’, and 12% considered these features as ‘Poor’. Seventy-two per cent of the respondents found the ability of the product to maintain healthy skin, surface softness, and the fit of the product to be ‘Good’, and the rest rated these features as ‘OK’ and ‘Poor’. Most participants rated the absorption speed, odour containment, and surface dryness of the product as ‘Good’, whereas approximately 10% considered these features as having ‘Poor’ performance.
The nurses also ranked statements describing the ergonomic aspects of the new MoliCare Premium Elastic product (Figure 3). Seventy per cent of the participants rated the ergonomic handling of the new design, adhesion of the tapes, as well as time-saving due to the ergonomic fast handling of the product as ‘Good’, and only 9% considered these features as ‘Poor’.
The evaluation of the packaging and handling of the product by nurses of incontinent residents after opening the pack is shown in Figure 4. All packaging features received a ‘Good’ or ‘OK’ rating from all respondents, and none of the nurses rated these features as ‘Poor’. More than 90% of the participants found it easy to open the packaging and remove the product. The ease of unfolding was rated as ‘Good’ by the highest percentage of nurses (98%), and the condition of absorbent core after unfolding was considered ‘Good’ by 86% of the respondents.
Nurses also compared the key performance aspects of the new MoliCare Premium Elastic with the former product (Figure 5). The new MoliCare product was considered easier to use and to have a softer surface by 72% of the respondents, and only 9% found the old design to be a better-performing product in these features. Seventy-four per cent of respondents agreed that the new design performed better in terms of absorbency, leakage protection, skin health maintenance, absorption speed, and odour containment. The new design was considered to have a better fit and to be more comfortable by 77% of the participants; 84% stated that the new product design had a drier feeling. Consequently, 74% of the participants agreed that the wetness indicator of the new design performed as well as the old product, and 12% found this feature to be ‘Poorer/Worse’.
Additionally, nurses provided their opinions on the overall preferences for using the new and old product designs. However, six participants did not rate this statement. As shown in Figure 6, 52% voted for the new MoliCare Premium Elastic design, 32% liked both product designs, and 16% preferred the previous design to the new product.
Discussion
The management of residents experiencing incontinence requires a multidisciplinary approach and should not be based exclusively on the supply of absorbent incontinence products. However, despite advances in treatment and therapies for incontinence, there are always residents with severe incontinence who do not respond to treatment. Such patients can effectively manage their incontinence themselves or with the help of nurses using absorbent products (Doherty, 2003; Newman et al, 2004). These include MoliCare Premium Elastic. Improvements have been made to the design and features of this product to meet user preferences and address issues that are important for nurses. By developing a questionnaire comprising the key aspects of a ‘good’ absorbent incontinence product, the authors assessed the experiences of nurses in nursing homes using new and old designs of this product.
The absorbent core of the MoliCare Premium Elastic is designed to provide sufficient absorbency and leakage protection by holding the urine locked within the product. This protects individuals with incontinence against embarrassing visible soiling and reduces related worry and anxiety.
The materials of the MoliCare absorbent core were carefully selected to provide an acidic pH surface adapted to the physiology of the skin, which helps maintain healthy skin (Beguin et al, 2010; Bliss et al, 2017). Acidic pH plays an important role in barrier homeostasis, stratum corneum integrity and cohesion. An increase in skin pH to an alkaline level enhances microbial growth, impairs the skin barrier function, and causes acidic mantle deterioration. In addition, managing skin wetness and keeping the skin as dry as possible are essential for preventing dermatitis (Fujimura et al, 2016; Bender et al, 2017). In both MoliCare designs, the SAP absorbs liquid efficiently, and because the polymer locks the moisture inside, the contact between the skin and liquid is reduced, leading to healthier skin. The so-called ‘channel’, an additional feature in the new design, accelerates liquid absorption speed, providing an instant dry feeling.
The fixation system enables MoliCare Premium Elastic products to be secured around the user's waist and repositioned as required, thereby improving fit and comfort. The product is designed to stay in place while the user/nurse readjusts it. These products are easy and quick to apply, encouraging independence, and reducing patient embarrassment. Owing to the double waist elastic, the slippage and movement of the product is reduced, providing considerable comfort and a better fit for patients. Effective fixation systems have been shown to contribute to the product's effectiveness, comfort and skin health by absorbing urine efficiently (Buckley, 2019). Furthermore, the new product design performed very well in terms of odour neutralisation, and the smell of urine did not appear to be a problem.
One of the major causes of lower back pain among hospital nurses, nursing home staff and caregivers in families is changing continence products and cleaning patients who require long-term care (Kyota et al, 2013). However, the physical stress to which patients and nurses are exposed during the handling of continence products is of great importance to users but less obvious to designers and manufacturers. The optimised MoliCare product was ergonomically designed to have faster, easier, and more convenient handling, with a reduced need for the nurse or other caregiver to adopt stressful postures during the application, change and removal of the product (Schneider and Sanaeifar, 2023).
The new MoliCare Premium Elastic design met user satisfaction requirements and outperformed the old product in all key areas. Most respondents considered using the new product, probably because of its optimised design.
Limitations
This study, conducted in five nursing homes, evaluated the perspectives of nurses caring for patients with incontinence. It would have added to the authors' understanding to gain patients' opinions regarding product assessment. However, in the choice and purchase of adult incontinence products, nurse specialists are the most likely group to provide recommendations to patients; therefore, it is important and appropriate to seek their views.
Conclusions
This study showed that changes made to the newly redesigned MoliCare Premium Elastic enhanced the product's performance characteristics, outperforming the previous product. This is indicative of the high quality, specific features and materials of the product, ensuring that the patient's needs are met, and the criteria for choosing the absorbent continence product are fulfilled. Thus, when selected for appropriate users, the MoliCare Premium Elastic product should have a beneficial effect on patient usage owing to its high level of satisfaction with diverse product performance features.
KEY POINTS
- The new MoliCare SkinGuard absorbent core technology is designed to offer leakage protection and an instant dry feeling
- The acidic pH on the surface of MoliCare Premium Elastic helps maintain healthy skin and prevent skin irritation
- The two wide re-closable adhesive strips on the side panels allow for frequent adjustment and repositioning of the diaper
- Changes made to the new design of MoliCare Premium Elastic enhances the product performance characteristics, outperforming the previous design
CPD reflective questions
- What are the important factors that influence the effectiveness and acceptability of an absorbent incontinence product?
- Consider the key innovations in the development of the newly redesigned MoliCare Premium Elastic product and how these could improve continence care for patients
- How can this study help users in selecting the most appropriate absorbent incontinence product?