Impact of applying the theory of human becoming and self-care deficit theory of nursing on insomnia in after stroke urinary incontinence patients

One of the problems that arise in post-stroke urinary incontinence (UI) is insomnia. Insomnia is a sleep disorder that occurs in around 23% due to UI in post-stroke patients.¹ This disorder is 3 times more than 10% of the general population who experience insomnia disorders.² Insomnia often co-occurs with nocturia, where there is a sensation of the full bladder that leads to the need to wake up to urinate at night (nocturia).³ Nocturia is the most commonly reported reason for disturbed sleep at night, more often than pain.⁴

Insomnia can exacerbate problems related to brain damage and can complicate the recovery process.² Insomnia also has consequences for functional disorders, immune function, impaired concentration and memory, increased risk of falling, and psychological disorders.⁵ Post-stroke insomnia can worsen post-stroke depression.⁶ Several studies have stated that UI and insomnia affect the quality of life of patients, causing social isolation, financial problems, and physical and psychological fatigue in both patients and caregivers.⁷

Until now, the management of insomnia is still focused on pharmacological agents.⁸ However, these pharmacological agents can cause sedation, tolerance, and dependence.⁸ Several studies recommend cognitive behavioral therapy-insomnia (CBT-i). To date, no trials have specifically investigated the effect of CBT-i on sleep disturbances after stroke.⁹

Management of insomnia in post-stroke UI patients requires comprehensive nursing care. A person living with post-stroke UI will develop skills in dealing with their own condition by trying various ways to cope with the situation (UI) and achieve quality of life.¹⁰ Parse in her theory (human becoming) recommends that individual experiences can be used as a focus in public health nursing.¹¹ The theory of human becoming provides a continuous way of dealing with the realities of life, especially the reality of people experiencing change.¹²

In our previous qualitative study, we found that patients need information about post-stroke UI so that patients can take steps to deal with their post-stroke UI.¹⁰ In addition, patients also exercised self-control, remained enthusiastic in doing the recommended exercises, and continued to carry out daily activities independently according to their abilities, as well as received family support and attention from friends.¹⁰

Several studies have applied Parse’s theory to improve the quality of life of patients and the quality of health nursing services.^12,13 Human becoming theory emphasizes person-centered care and coherence with chronic disease management.¹⁴ However, there has been no research on its application to post-stroke UI patients until now. Considering the physical limitations (paresis and hemiparesis) experienced by after-stroke UI patients, the application of Orem’s theory also needs to be used in this study. According to the theory of Orem, barriers to self-care are related to limited knowledge, lack of social support, lack of access to care, or high costs. Physical limitations and fatigue in stroke patients also contribute to sleep disturbances.¹⁵

The innovation of this research is the emphasis on the application of a combination of human becoming theory and Orem theory in the nursing care of post-stroke UI patients who experience insomnia. The nursing interventions provided are based on these two theories which include health education, skills training to overcome health problems experienced, encouraging patients to remain enthusiastic and think positively, and carrying out daily activities according to ability. This research intended to determine the impact of applying the theory of human becoming and self-care deficit theory in overcoming insomnia on patients of UI after stroke.

In this study, the majority of participants were women (57.1%). The mean age of participants was 55.80 years (standard deviation [SD] = 11.79, range = 35–75 years old). Participants in the experimental group were 56.46 years (SD = 12.06, range = 35–75 years old) and 55.14 years in the control group (SD = 11.71, range = 35–73 years old). All participants had ischemic stroke (100.0%). The majority of participants had leftsided hemiparesis (55.4%), had a history of hypertension (41.1%), had mixed incontinence (53.6%), with a very severe level of incontinence (50.0%), and the most experienced moderate insomnia with an average insomnia severity score of 16.34 (SD = 4.20, range = 8–21). Data in the intervention group and control group were homogeneous (P > 0.05) (Table 1).

Statistical analysis revealed that the mean score of insomnia increased in both groups on the first and third measures. There were significant differences in the second and third measurements (P < 0.001). There were interactions between the measurements (first, second, and third measurements) and the groups (experimental and control) based on the results of the repeated measures ANOVA (P < 0.001). The intervention was effective in overcoming insomnia by 4.11 times in the second measurement and 5.82 times in the third measurement according to the results of pairwise comparisons (Table 2).

The mean score of all insomnia assessment items decreased in the third measurement in the intervention group. Of the 7 insomnia assessment items in the intervention group, the biggest decrease was sleep efficiency (decreased mean score 2.29 with a SD of 0.21). There was a significant difference between the first and third measurements on all items measuring insomnia in the intervention group. However, in the control group, not all assessment items experienced a decrease in insomnia score in the third measurement. The assessment item that did not experience a decrease in score was the use of sleep medication (the mean score increased by 0.07 with a SD of 0.26). The statistical test results obtained a P-value of 0.326 (on the sleep quality item) and 0.161 (on the use of the sleep medication item) so it can be concluded that there was no significant difference in the sleep quality and use of sleep medication items between the first and third measurements in the control group (Table 3).

The state of insomnia is more associated with physiological and psychological changes experienced by patients and these changes are prone to triggering sleep disturbances in the early phase of stroke recovery.¹⁸ Thirtyeight to 50% of patients with subacute stroke report poor sleep quality.¹⁹ Major characteristics of insomnia include dissatisfaction with the quantity and quality of sleep, and a person would indicate one or more of the following symptoms: difficulty initiating sleep, difficulty maintaining sleep (frequent or prolonged awakening), difficulty back to sleep again, and waking up earlier than desired after a full sleep of only 3–5 h.²⁰

The measurement of insomnia after the intervention (2nd measurement) and 4 weeks after the intervention (3rd measurement) showed a significant difference. The results of this study were in line with other studies showing that sleep structure undergoes the most changes for several days after stroke, indicating a trend toward normalization/recovery.¹⁹ In this study, the average decrease in insomnia scores in the intervention group was greater than the control group, namely 4.11 at the 2nd measurement and 4.43 at the 3rd measurement, while in the control group, it was 1.00 at the 2nd measurement and 2.10 at the 3rd measurement.

Although there were not many studies have investigated the association between post-stroke sleep changes and neurological recovery, however, sleep deprivation/after stroke insomnia and better sleep recovery over time appear to be associated with better neurological and cognitive recovery.¹⁹ A higher score on the Insomnia Severity Index in the first 2 weeks of stroke is associated with lower extremity motor function.¹⁹ This makes it clear that this model includes not only interventions related to insomnia but also nursing interventions related to improving the patient’s functional abilities such as joint movement exercises. Management of UI after stroke is focused on improving functional ability, both functional ability to urinate and functional ability to walk.²¹

Sleep disturbances are more common in patients who are unable to walk for a month after stroke.²² At 1 month after stroke, patients who were unable to walk experienced more sleep problems than patients who were able to walk.²³ Several observational studies have shown that sleep disturbance was also a predictor of poor functional outcome in post-stroke patients, increasing the risk of short-term neurological damage, and experiencing long-term dependence.²⁴ This strengthens the findings of this study that the decrease in insomnia scores in the control group was not as large as the decrease in the intervention group. The results of the researcher’s observation that respondents in the control group in the fourth week (post-test) have not shown maximum improvement in the ability to walk and the ability to resist the urge to urinate so functional incontinence still occurs.

In this study, before the respondents were taught the necessary skills training in overcoming post-stroke insomnia, the respondents were given health education. Sleep hygiene education is effective in improving sleep quality and is an approach that can be taken to help insomnia patients improve their sleep.²⁵ Sleep hygiene interventions such as avoiding caffeine before bed and reducing light at night.

Health education provided can increase the knowledge of respondents. The patient’s knowledge and desire to recover becomes the basis for the patient to transfer or transform his/her health pattern.¹⁰ In human becoming theory, it is stated that the transformation of health patterns can occur through several things, namely when individuals find insights relating to themselves that were beforehand unclear and when they find ways to achieve the hopes and dreams, they cherish.^26,27 The hope of recovery makes respondents always carry out recommended interventions to overcome post-stroke insomnia and this becomes a strength for respondents when dealing with their illness. In the human being theory, it is also stated that health is a personal commitment in which individuals participate in creating their health. UI management requires patients to be motivated to actively participate.²⁸ This is influenced by imaging, valuing, revealing—concealing, enabling—limiting, and powering the individual.^27,29

Individual powering relates to acts of self-control. Self-control describes how a person selects and finds ways to face the situations they find themselves in.¹⁶ The ways that are carried out are related to the values of beliefs they hold. In Parse’s theory, it is stated that beliefs reflect what is important in a person’s life, in this case, related to his/her health, which becomes a reference for a person to make choices about how to think, act, and feel.³⁰

One of the self-control measures is to use distraction techniques. Distraction techniques can inhibit the transmission of impulses from the thalamus to cortical structures by activating the limbic system at the front of the brain.³¹ Coordination between the brainstem and the cortex helps to ensure that urination occurs at an appropriate time, voluntary micturition control needs input from the forebrain.³² Distraction techniques can distract the brain to eliminate things that can interfere with sleep, including the urge to urinate. When the bladder sends a signal to the brain to urinate, the brain can focus on other things, reducing the need to urinate. Thinking too much about urinating can create an impulse to urinate.³³

In Orem’s theory (self-care deficit theory of nursing), Orem believes that individuals have the ability to care for themselves and others. If these abilities are distorted, so nurses help them to retrieve their abilities by providing direct care.³⁴ The supportive-educational system in Orem’s theory states that individuals can do or can learn to take necessary actions externally or through therapeutic self-care but cannot do so without help.²⁷ Supportive educative is a form of assistance given to patients in the form of educational support so that patients are able to carry out nursing intervention independently.³⁵ For this reason, guidance from health workers and families is needed. In this study, the family is involved as caregiver in carrying out the recommended nursing intervention. However, in carrying out self-care activities, emphasis is placed on the active role of the patient rather than the passive role.

Family, spouse, friend, or health professional support is often recommended as a source of emotional, instrumental, informational, and affirmative support for people with chronic disease conditions.³⁶ Family support programs are an effective way to meet patient needs. Social support plays an important role in improving the quality of life of post-stroke UI patient.³⁷ Orem believes that the lack of social support in patient care can lead to limitations in self-care behaviors.²⁷ Family and other social support work together and collaborate to give a sense of safety and compassion for chronically ill family members in dealing with their illness.³⁸

The limitation of this study was the number of samples, so it needed more numbers to generalize the findings. The first measurement was carried out in the hospital, while the second and third measurements were carried out in the patient’s home. This research plays a role in improving the quality of nursing care, especially the quality of nursing care in post-stroke UI patients who experience insomnia. For this reason, the results of this study need to be disseminated to nurses who care for UI patients experiencing insomnia after the stroke so that nurses can increase their knowledge about this model of nursing care and thus make it easier to apply it to improve the patient’s quality of life.

The application of the human becoming theory and the self-care deficit theory of nursing in nursing care in this study could significantly reduce the insomnia score of post-stroke UI patients. This study can be used as a guide for nurses, patients, and families in managing insomnia. The use of nursing theory in nursing practice can systematize nursing care plans and organize professional knowledge into a conceptual framework, as well as provide effective guidance for nurses on what to do. This study can also be used to improve the care of post-stroke UI patients.