Construction and validation of an instrument for the structural assessment of wards for urinary continence in older adults

Objective: to build and validate an instrument for structural assessment of wards for the preservation of urinary continence in hospitalized older adults. Method: this is a methodological study divided into two stages. The first corresponded to an integrative literature review that guided the construction of the instrument. The second consisted of the content validation stage of the instrument, by means of expert consensus, using the Delphi technique. The selected experts were recognized in the field and authors of the articles included in the integrative review. Results: six experts participated in the content validation, which resulted in the “Instrument for Structural Assessment of Wards for the Preservation of Urinary Continence in Older Adults”, composed of 27 items, distributed in three dimensions: “physical structure”, “human resources”, and “material resources”. Two Delphi rounds were carried out for validation, resulting in a final version with 83% agreement among the experts. Conclusion: the instrument reached content validity, requiring application for clinical validation. However, it can be used by researchers and health staff in hospital settings, in order to identify structural weaknesses and guide the priority of interventions for the quality and safety of this care.

In hospital spaces, at the same time the patients seek to recover health, they may suffer interference from the environment. In the case of the older adults, the influences of the environment and its possible consequences should be further monitored and prevented, since this population is in a situation of greater intrinsic vulnerability and fragility due to the process of senescence and senility (6) .
During hospitalization, older adults find it difficult to maintain urinary continence due to structural problems that directly influence the encouragement of independence for the use of bathrooms. Among these, we highlight the deficit of human resources to assist in the mobilization of the person, the deficit of material resources such as wheelchairs and commode chairs, devices such as urinals and bedpans, in addition to architectural barriers such as the beds which are high and have bars, poor lighting in the corridors and absence of support bars and anti-slip floors, which causes insecurity for mobility due to the risk of falls (3)(4) .
The unknown hospital setting, combined with situations such as decreased visual acuity or difficulty in walking, compromise the independence and autonomy of the older adults, promoting confinement in bed. Such situation often leads to the use of urinary control devices such as diapers and a permanent bladder catheter, which, in turn, may lead to cognitive decline, pointed out as one of the main risk factors for the onset or worsening of UI during hospitalization (7)(8) .
The need for the use and maintenance of these devices must be assessed by nurses in the clinical practice from admission, as the installation may discourage independence with the use of bathrooms (4,8) .
It is an important function of the health team, especially nursing, to encourage the functional independence of the older adult, making themselves available to help them with mobilization or encouraging the use of urinals and bedpans, thus keeping the most favorable environment possible for maintaining their urinary continence (4,(7)(8) . In addition, the availability of human and material resources to assist in maintaining privacy and to encourage the independence and autonomy of the older adult at the time of eliminations is extremely important in the process of this care. Therefore, the observation and measurement of aspects related to the structure of wards so that it can facilitate the maintenance of the continence of the older adult is important and necessary since, in addition to giving visibility to the theme, it alerts health professionals and managers to the necessary peculiarities in hospital architecture, in view of the aging population and the need to preserve their safety, comfort and autonomy, enabling conditions for the older adult to use the bathroom safely.
In this regard, the Brazilian Standard for Accessibility to Buildings, Furniture, Spaces and Urban Equipment brings the concept of "accessibility" as the possibility and condition of reaching, perceiving and understanding for the use with safety and autonomy of spaces by people with disabilities or reduced mobility (9) , and it is urgent and necessary to pay attention to this concept in hospital buildings. This standard highlights the importance of accessible bathrooms with the presence of support bars, adequate lighting, the presence of alarm devices with ergonomics for moving wheelchairs and ensuring safety in the individual's access to it, such as the presence of a handrail and adequate floor (9) .
Faced with this problem, the components to be observed and measured in a structural assessment of wards for the preservation of urinary continence in the older adults were considered. Validated instruments for this purpose have not been identified in the literature on the subject. Based on the above, the objective of this study was defined: to build and validate the content of an instrument for structural assessment of wards for the preservation of urinary continence of hospitalized older adults.

Method
A methodological study, comprised of two parts: construction of the instrument to assess the structure of wards for the preservation of urinary continence in the older adults, guided by an integrative literature review Góes RP, Pedreira LC, Valente CO, Mussi FC, Souza ML, Amaral JB. and content validation of the instrument constructed by the consensus of experts, applying the Delphi technique.
The construction of the instrument was guided by the "structure" pillar of the Donabedian triad and was based on three dimensions: physical structure, material resources, and human resources. In each dimension, the aspects that influence the independence and autonomy of the older adult for the use of bathrooms were considered, such as safe access to the bathroom and the necessary material and human resources.
To carry out the first stage, an integrative literature review which met the PRISMA criteria was used (10) , with the objective to identify the factors inherent to hospital care that favor the appearance of UI in older adults (4) .
Initially, in order to construct the guiding question, the PICO strategy was used, which represents an acronym for patients, intervention, comparison, and outcomes (11) .
In this case, P: older adults; I: hospitalization; C: factors inherent to the care that predispose the event, and O: onset of UI. Thus, the following research question was formulated: What are the inherent factors to hospital care that predispose the onset of UI in older adults (4) ?
For the search, three databases were selected: Subsequently, 13 studies were included, which made up the review sample. It is worth highlighting that both researchers agreed to include a study that did not coincide in their individual selections (4) .
In the content analysis of the material, the Donabedian pillars were used as theoretical framework.
Thus, a thorough reading of the articles was carried out, focusing on the corpus of studies that converged in the answer of the guiding question and associated the predisposing factors to the onset or worsening of UI during hospitalization, related to the structure, the process, and the result pillars. From that, three thematic categories were set out which are discussed in the study: (1) The unjustified and indiscriminate use of urinary control devices, such as the geriatric diaper; (2) The hospital structure adverse to the needs of the older adult; and (3) The deficit in screening, risk identification, and underreporting of the problem by the care team (4) .
The results obtained in this review revealed the impact of the "structure" pillar on the outcome of UI in The instrument for structural assessment of wards aiming at preserving the urinary continence of older adults was constructed with thirteen items distributed in the dimensions of "physical structure" (four items), "material resources" (four items) and "human resources" (five items). For the later stage, content validation, the Delphi technique was used; in which the consensus of opinions of a group of specialists is sought, through validations articulated in phases, cycles or rounds (12) .
In this study, the minimum consensus of 70% among the consulted specialists for the evaluated content was considered (13) .
As a criterion for choosing experts, consultation with all the corresponding authors of the studies included in the integrative review (4) (13 studies) was adopted, as these supported the construction of the instrument.
Considering that 11 specialists were foreigners with mastery of the English language, it was necessary to send the instrument translated into English by a specialized translator. The  Then, after accepting and receiving contributions from five of these experts, it was also decided to consult two specialists in the field, who are evaluators of the "Hospital friendly to the older adult" program, in the national territory. The program grants the "Friend of the Older Adult Seal" to the hospital that has adapted in several criteria to the needs of the hospitalized older adult, one of the evaluated criteria being structural adequacy (14) . The program was sent to the evaluators of the program via email, on September 15 th , 2018. One devolution was obtained, presenting the contributions to the instrument.
In the first Delphi round, consultants were asked The target audience chosen for the application of the pilot test was that of nursing assistants, as they assumed the management of care for hospitalized older adults, and knew the demand for care, the disposition and availability of material and human resources of these units. The instrument was presented, its purpose was explained and its clarity and feasibility of application in wards was ensured. The professionals (nine nurses) considered the instrument easy to understand and to apply, and feasible to be used for the proposed purpose, and this version was then sent to the experts, constituting the second Delphi round.

Results
The (2) The hospital structure adverse to the needs of the older adult; and (3) The deficit in screening, risk identification, and underreporting of the problem by the care team (4) .
It is worth mentioning that aspects of the three categories permeate the dimensions of human resources, material resources, and physical structure, addressed in the construction of the instrument; however, category 2 raised in this review was crucial to justify the need for visibility of this problem by measuring and evaluating these aspects in the hospital setting, as proposed in the instrument constructed.
Regarding the human resources dimension, points of the studies were considered that revealed the importance of the number of personnel to assist and encourage the hospitalized older adult to use toilets or when restricted to bed, to use urinals or bedpans instead of using geriatric diapers and a permanent bladder catheter. The latter, identified as important risk factors for the onset of UI during hospitalization (4,(7)(8)(16)(17)(18)(19) .
In addition to the number of staff, a number of studies have also highlighted the deficit in the screening and recognition of the UI problem in the older adult by these professionals, a problem that often goes unnoticed, as it is not the primary condition that led the older adult to hospitalization or the lack of validated instruments and protocols to guide this care practice (7)(8)(16)(17)(18)(19)(20) .
Therefore, for the construction of the instrument, points related to human resources were considered, both in the quantitative aspect and in the qualification of these professionals to recognize the problem.
With regard to the physical structure dimension, points mentioned in the review were considered, which highlighted adverse conditions to the safe access to the bathroom, such as bed height, floor conditions, lighting adequacy and the presence or absence of support bars (3)(4)9) .
With regard to the material resources dimension, important points addressed in the study related to the availability of materials to help care for the safe mobilization of the older adult to the bathroom, such as wheelchairs, commode chairs, or materials such as bedpans and urinals for those restricted to the bed were considered (3)(4)9) .

P2
Nurse/ Post-Doctorate Professor and researcher in the field of Gerontology, Department of Nursing, University of Haifa/Israel Agreed with 76.9% of the items and suggested reformulating three items in the "human resources" dimension. Suggested the inclusion of an item in the "physical structure" dimension on the calculation of the proportion of the size of the Unit and the size of the bathrooms and an item in the "human resources" dimension on the dimensioning of the nursing staff of the unit.

P3 Nurse/ PhD
Professor and researcher in the field of Gerontology at the Nursing Higher School of Coimbra/Portugal Agreed with 76.9% of the items, suggesting the reformulation of three items in the "human resources" dimension. Suggested the inclusion of four items in the "physical structure" dimension related to: lighting; presence of handrails in corridors or access to bathrooms; location of support bars (if present in the shower area and/or in the toilet area), and an item questioning whether the location of the bathroom is signposted or not in the hospitalization unit. Agreed with all the items and suggested adding an item in the physical structure dimension related to the type of bathroom doors, whether they were sliding or with hinges.

P5
Nurse/ Post-Doctorate Associate professor and coordinator of the Nursing Course, Department of Health, University of Udine, and researcher in the field of gerontology/Italy Agreed with 100% of the items and suggested that variables such as dementia and risk of falls should be explored in addition to urinary incontinence, but did not explain how they should be explored in the instrument.

P6
Nurse/ PhD Agreed with 84.6% of the items and suggested the inclusion of items in the "human resources" dimension on the dimensioning of nursing professionals at the unit; in the "physical structure" dimension, on adequate lighting at the headboard of beds, corridors and access to bathrooms; and in the dimension of "material resources" on the presence of stairs at the bedside for the elderly to get out of bed safely if the bed is not automatic. Rev. Latino-Am. Enfermagem 2020;28:e3374.  Figure 3, with guidance and interpretation caption of the scores in Figure 2.
Evaluation of the structural adequacy of the ward to preserve the urinary continence of the older adult: Total score* (24) Scores: 0 to 8 (low structural condition) 9 to 16 (moderate structural condition) 17 to 24 (satisfactory structural condition) *Items 1, 2 and 3 must be scored considering the nursing team's work demand in caring for the older adult using a patient classification system (25) . When scoring one of these items, after classification of the nursing team's care demand profile by the older adults hospitalized in the unit, the other two items should be disregarded.   Rev. Latino-Am. Enfermagem 2020;28:e3374.
One of the available CSPs of the resolution (22) classifies the patient's demand for care in terms of mental status, oxygenation, vital signs, motility, walking, food, body care, elimination, and therapy. Each care area is scored and the higher the score obtained by the patient, the greater the level of dependence (22) .
In order to complete the first three items of the IAEE-CUI, the older adults hospitalized in the unit must With regard to other items in the "human resources" dimension related to the use of assessment instruments for placing or maintaining the use of diapers, or to instruments that guide the nursing process in the unit, these are in line with the expanded concept of Donabedian, who considers that instruments and protocols that guide care practice are also part of the structure pillar (5) . It is noteworthy that the items included in the "human resources" dimension are not only about quantity, but also the qualification of professionals, who must be oriented to use instruments that standardize and guide a safe and systematic practice (7)(8)(17)(18)(19)(20) .
A research study carried out in Brazil on the use of diapers in hospitalized adults and older adults revealed that, of the 105 research participants, in the use of geriatric diapers, 38% had no reason to use them, that is, they did not have motor, cognitive or urinary restriction. In addition, they mentioned that the indication followed the institutional routine, supposedly revealing the unsystematic practice, the absence of evaluation criteria and the need for an instrument that would guide the decision making for the use or maintenance of this device (20) .
In iatrogenic adverse events, defined as any injury, damage or involuntary complication that results more from the management of health care than from the process underlying the disease (23) , events that demand costs from the health system and a greater number of hospitalization days.
Considering the aging population, hospital institutions will receive more and more older adults who will demand specific professional care that result in quality of life. In this sense, rehabilitation care and maintenance of functional capacity are essential. Thus, the nurse must focus attention on these scenarios both in care focused on the acute condition that determined the hospitalization of the older adult, as well as in care related to the prevention of adverse events and the rehabilitation of installed disabilities (24) .
As for the physical structure, a case study (25) that analyzed 50 hospital rooms, aiming to evaluate factors of the structure that favored the risk of falls in older adults, found problems such as: only 39% of the beds were properly locked; only 39% of the patients who needed the use of bedpans or urinals had such objects close to the beds; for patients who were able to walk, only 56% of the beds had an easy-to-view support ladder; all the routes to the bathrooms had non-slip floors; however, 56% of the bathrooms were slippery because there was water on the floor (25) . In the same study, it was also observed that 59% of the rooms did not have bells close to the bed, 49% of the environment had excess furniture, and 28% had inadequate lighting (considering the three periods of the day when the assessment was performed). In addition, isolating the night period, only 50% were properly lit (25) . Then, the importance of the structural evaluation of units to reduce damages and risks to the hospitalized older adult is emphasized, based mainly on validated instruments.
Regarding the physical structure, the Brazilian Standard for Accessibility to Buildings, Furniture, Spaces and Urban Equipment (9) is also alerted and in this sense, the construction of the instrument gives visibility to the concepts of accessibility and universal design contained Góes RP, Pedreira LC, Valente CO, Mussi FC, Souza ML, Amaral JB.
in the standard, which should be inserted in hospital architectural projects, considering the clientele demand in view of the aging population.
The concept of universal design proposes an architecture and design more centered on human beings and their diversity, establishing criteria so that internal environments, for example, meet a greater number of users, regardless of their physical characteristics, skills and age group (9) .
Regarding the item that includes aspects of the older adult's privacy as availability of materials such as curtains and screens, a study that aimed to describe the perception of patients about privacy in the hospital revealed that the bathroom was the place where some patients had their privacy invaded, especially when they occupied it (26) .
In special situations, in which walking to the bathroom becomes more difficult, the bedpan or urinal should always be within reach of the older adult, who should be guided and encouraged to use them.
Therefore, the guarantee of privacy must be seriously evaluated and ensured, since the presence of other patients in the room, as well as of health professionals and companions, can inhibit spontaneous urination, especially due to embarrassment and shame (27) .
The control of the physical space is crucial for the well-being of people, especially in the hospital setting, where public traffic is constant. It is warned that the unnecessary invasion of this space by the health team or other people is inappropriate (28) . Situations of extreme invasion of the territory, as well as the unavailability of curtains or screens that meet the demand of patients to maintain privacy may interfere in encouraging the independent use of bathrooms, urinals and bedpans, and contribute to the use of devices such as geriatric diapers and their acceptance by the older adult.
There is evidence that the hospital care setting itself must be well designed and have the potential to compensate for some deficiencies related to vision, hearing, mobility, memory, reasoning, learning, and perceptual problems, reducing the restrictions of the older adults (9,29) . The development of a favorable environment should include the review and consideration of corridors, floors, doors, furniture, bathrooms, appliances, signaling, lighting, sound, color and tone contrast, accessibility, guidance, and nursing stations (9,(29)(30) . From this consideration, it is recommended that bathroom doors should be left open whenever possible and manual continence aids such as bedpans and urinals should be left close to the patients to allow identification and subsequently, increase the likelihood of its independent use (29) .
In an aging society, it is urgent and necessary to evaluate and adapt the wards, especially in public institutions, paying attention both to human and material resources, as well as to environmental barriers and artifacts of the setting. The proposed application of the IAEE-CUI can identify the greatest structural weaknesses in this regard and, in line with the possibilities of each scenario, alert managers and professionals in the health area, especially nurses, to intervene in order to improve and ensure this care.
It is noteworthy that, when encompassing the structure pillar, in addition to only the physical structure, problems and deficits that will be above the governability of the care team and which will require investments to resolve them, will be identified in the wards studied.
However, when identifying certain weaknesses, it is possible to orient the priority of costs, alert and sensitize professionals with a view to minimizing the problem.
Thus, the validated instrument assumes an important contribution to promote the urinary continence of Rev. Latino-Am. Enfermagem 2020;28:e3374.
related to its application in the proposed scenarios and future assessments of the impact of this application on hospital units.

Conclusion
From the literature review and the experts' contribution, it was possible to build and validate the content of the IAEE-CUI, establishing components to be observed and measured in a structural evaluation of wards for the preservation of the urinary continence of hospitalized older adults.
Thus, an instrument is available to assess the physical structure, material resources, and human resources of wards, aiming at the preservation of the urinary continence of hospitalized older adults, so that based on their application, intervention measures aimed at structural weaknesses identified by the instrument are taken, minimizing the rates and impacts of this so prevalent and disabling geriatric syndrome.