Abstract
Aims
Certain occupations may predispose individuals to develop lower urinary tract symptoms presumably through the adoption of unhealthy toileting behaviors. This study aimed to pilot the feasibility of recording healthcare workers’ perceptions of daily, work-related interference with toilet use using a cellular, text-based survey tool.
Methods
A cohort study of adult healthcare professionals completed a baseline questionnaire, a daily survey for fourteen consecutive days regarding their restroom use for the current workday, and a posttest survey providing feedback on study design and participation. Contributors to daily toilet use was analyzed in a linear mixed effects model that allowed for modeling effects within a given day. A backward stepwise regression was performed to assess for the presence of the effect of toilet use among control variables.
Results
Increased work burden (i.e. increased inconvenience for using the restroom at work) was provisionally found to be associated with fewer voids per day. The number of voids at work was also associated with the number of breaks, urinary urgency, and limiting fluids. Subjects reported that participation in the study was easy, did not interfere with work, and that they would be willing to participate again in a similar study.
Conclusions
The utilization of a daily text message survey is a feasible way to study healthcareworkers and their toileting behaviors at work. A larger similarly designed study could potentially confirm that limitations to restroom use may result in toileting behaviors that could predispose healthcare workers to develop bothersome urinary symptoms. Further investigation is warranted.
Introduction
Approximately 1 in 5 U.S. men and women have moderate to severe lower urinary tract symptoms (LUTS)1 and for most individuals the etiology remains unknown. It has long been proposed that certain occupations predispose individuals to develop LUTS, presumably through the adoption of unhealthy bladder behaviors, such as urine holding or delayed voiding, in response to restrictions on toilet access2–8. Medical practitioners, particularly nurses, are proposed to be at particular risk9–11 giving rise to the term “Nurse’s Bladder,” oftentimes postponing micturition due to workplace demands12. Several studies have examined the associations between LUTS, bladder behaviors, and occupations; however, the evidence that occupational toilet restriction impacts bladder habits and contributes to LUT conditions remains somewhat limited. Authors from the Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium recently reviewed this body of literature and noted that the published data support the hypothesis that occupation group plays a role in LUTS, even though they found limited evidence that specifically supported the hypothesis that infrequent voiding contributes to the development of LUTS7. While several limitations were noted, the review identified only one study that evaluated the toilet environment and access in the workplace based on subject perceptions13. A more recent study also examined associations between restroom use in the workplace, toileting behaviors, and LUTS in a survey-based study of 3,000 full-time working women14–16. In this study, women who limited restroom use at work more often listed poor quality, limited availability and restricted access as reasons why their use was limited. These women also reported a greater degree of unhealthy bladder habits and behaviors as well as more LUTS than those who did not limit restroom use at work.
Our goal is to better understand what determines whether the workplace environment, as it relates to toilet access, impacts the risks of unhealthy bladder behaviors and LUTS in men and women. Because recall bias may play an important role in a subject’s perception of the degree of toilet environment restriction risk, developing a method to record real-time perceptions is an important tool for future studies. Therefore, the aim of this study was to pilot the feasibility of recording healthcare workers’ perceptions of daily, work-related interference with toilet use using a cellular, text-based survey tool. We hypothesized that those who perceived higher occupational interference to restroom use would report fewer daily voids.
Methods
After institutional IRB approval, a cohort of healthcare professionals was recruited from four different occupational settings at our academic institution: outpatient clinic, inpatient floor unit, operating room (OR), and physician providers. Eligible subjects were adult men and women 18 years or older who were employed full time (40 hours or more per week), able to complete the tasks, able to read and write in English, and had the availability of personal cell phone use. Subjects were excluded if they worked part time or pro re nata at our academic institution or were not working during the study period (i.e. on vacation, work travel, etc.). Subjects were invited to participate in the study by word of mouth and were not randomized. Participation was voluntary and participants were reimbursed $50 for completion of the study.
Once enrolled in the study, subjects completed a baseline electronic questionnaire collecting information about demographics, job specifics, and baseline perceptions of the work restroom environment (Figure 1). Participants also received detailed instructions in the use of the survey text message platform. Research Electronic Data Capture (REDCap) is a software toolset and workflow methodology for electronic collection and management of research and clinical trial data. In addition to storing data, REDCap has the capability to send SMS text messages to survey respondents by using a third-party web service, Twilio (www.twilio.com)17,18. Using this method, participants can receive a survey link by SMS message in which the data is then collected in REDCap directly from their phone. This platform allows for customizable distribution of SMS survey invitations. In our study, participants received a daily SMS message every day at the end of the work day for a test period of 14 days prompting them to complete the REDCap survey. Participants also received an hourly SMS notification reminder to complete the daily survey until it had been submitted or for a total of 3 reminders.
Figure 1.
Study design consisting of enrollment with baseline questionnaire followed by a 14-day test period, and finally a post test-period questionnaire.
If they worked that day, participants completed items related to their restroom use from the current workday, including 11-point numeric rating scale (0 – 10) for work interference with restroom use (“Rate how much your work interfered with your restroom needs today”); reasons for limiting restroom use during work (“Which of the following were reasons you limited your restroom use during work? Check all that apply: none or did not limit, poor quality or unclean, limited availability, too busy with work, restricted access by supervisor/company, restroom not private enough”); 11-point numeric rating scale (0–10) for inconvenience to use restroom at work (“How convenient was it for you to use the restroom at work today when you wanted or needed to”); number of voids at work; 5-point Likert scale (never, occasionally, sometimes, most of the time, or all of the time) questions on urinary urgency, pain, and holding derived from the ICIQ-LUTS questionnaire; incontinence (“How much urine did you leak? None, a small amount, a moderate amount, or a large amount”), fluids consumed (reported as both ounces and cups); whether they restricted fluid consumption (“How much did you limit drinking fluids to help manage restroom use at work? Not at all, a little, somewhat, much, or a great deal”); hours worked; number of breaks including for meals; and number of bowel movements at work. Completion of the survey took 2–3 minutes. At the end of the test period, subjects were asked to complete a survey providing feedback on the experience, such as the feasibility, ease of use, or inconvenience, and any suggestions for improvement.
Our primary outcome was number of voids during work hours and our primary exposures were work interference with toilet use (NRS 0 – 10) and work inconvenience to use restroom (NRS 0 – 10), which defined as the primary measures of occupational environmental burden on restroom use. Additional independent control variables included: number of breaks, how much they limited fluid intake, urgency score, number of hours worked, fluid consumption, urinary urgency, bladder pain, occupational status (MD provider or other occupational setting), and number of bowel movements. To analyze the daily responses, we first examined contributors to daily toilet use in a linear mixed effects model that allowed us to model the effects within a given day, accounting for variation between respondents and trends across days. Following, we performed a backward stepwise regression to assess for the presence of the effect of toilet use among control variables, including those with positive effects in our final model. This approach allowed for an examination of the relative importance of primary exposure variables when considered along with other plausible predictors of times voided.
Results
We recruited a total of 21 healthcare professionals (70% female, 90% Caucasian) at our academic center from 4 different occupational settings: outpatient clinic (n = 5); inpatient floor unit (n = 5); operating room (OR) (n = 5); and physician providers (n = 6) (Table 1). Ages were similar in each group (median years [IQR]): outpatient (50 [35–57]); inpatient (23 [25–28]); OR (36 [27–49]); and MDs (34 [33–37]). Overall, 15 participants completed all daily surveys, while 6 completed a median of 12 of the 14 test-period surveys. Of the completed surveys (n = 280) 55% represented workdays for the respondents. Typical workday hours ranged between 8 and 12 for all groups. Across all occupational settings, the outpatient clinic nurses were the only group to more often “agree” or “strongly agree” that they “go to the restroom whenever anytime [they] want while at work” (Table 1). The majority of inpatient floor nurses (3), MDs (4) and all operating room nurses and technicians (5) responded “disagree” or “strongly disagree” to this question. Outpatient clinic nurses, compared to all other occupational setting groups, had higher median satisfaction for some restroom characteristics including accessibility, availability, cleanliness, and odor. Overall, participants from all occupational settings were satisfied with the safety and privacy of restrooms.
Table 1.
Characteristics of study participants, including baseline perceptions of restroom infrastructure in respective occupational settings.
| Outpatient Clinic | Inpatient Floor | Operating Room | MDs | |
|---|---|---|---|---|
| N | 5 | 5 | 5 | 6 |
| Age, years, Median (IQR) | 50 (35 – 57) | 25 (25 – 28) | 36 (27 – 49) | 34 (33 – 37) |
| Female gender | 4 (80%) | 5 (100%) | 3 (60%) | 3 (50%) |
| Years at current job, Median (IQR) | 2 (2 – 12) | 3 (2 – 3) | 8 (3 – 10) | 2 (2 – 2) |
| Years at work, Median (IQR) | 12 (10 – 20) | 3 (3 – 3) | 12 (3 – 15) | 7 (6 – 7) |
| Typical workday, hours, Median (IQR) | 9 (8 – 9) | 12 (12 – 12) | 10 (10 – 12) | 10 (10 – 11) |
| “I go to the restroom whenever anytime I want while at work…”(N) | ||||
| Strongly agree | 2 | 0 | 0 | 1 |
| Agree | 2 | 1 | 0 | 0 |
| Neutral | 0 | 1 | 0 | 1 |
| Disagree | 1 | 3 | 4 | 4 |
| Strongly disagree | 0 | 0 | 1 | 0 |
| “How often do you use opposite gender restroom?” (N) | ||||
| Never | 5 | 5 | 1 | 3 |
| Occasionally | 0 | 0 | 2 | 1 |
| Sometimes | 0 | 0 | 2 | 2 |
| Restroom characteristics [Visual Analog Scale 1 (Extremely Dissatisfied) – 10 (Extremely Satisfied)], median (IQR) | ||||
| Accessibility (e.g. nearby, physically accessible) | 10 (8 – 10) | 7 (6 – 8) | 5 (2 – 6) | 5 (5 – 6) |
| Availability (e.g. occupancy, wait in line) | 8 (5 – 9) | 4 (4 – 6) | 2 (1 – 6) | 5 (3 – 5) |
| Cleanliness | 9 (5 – 9) | 5 (4 – 6) | 4 (2 – 7) | 5 (5 – 7) |
| Odor | 9 (5 – 9) | 4 (2 – 5) | 6 (2 – 7) | 5 (5 – 6) |
| Availability of Toiletries | 7 (5 – 9) | 5 (3 – 8) | 4 (4 – 6) | 6 (4 – 7) |
| Safety | 10 (9 – 10) | 9 (8 – 10) | 9 (8 – 10) | 8 (7 – 10) |
| Overall Privacy | 9 (9 – 10) | 8 (7 – 8) | 9 (8 – 10) | 7 (6 – 8) |
| Privacy – sound (e.g. noisy, sound-proof) | 6 (5 – 8) | 7 (5 – 7) | 8 (6 – 9) | 6 (5 – 7) |
| Privacy – sight (e.g. exposure, can be seen using) | 6 (5 – 8) | 8 (7 – 10) | 4 (1 – 8) | 6 (5 – 7) |
A model of both primary exposure variables (i.e. work interference and inconvenience) together significantly predicted times voided over and above respondent-level random effects over time, X2(2) = 8.44, p = .01 (Table 2, Primary exposure only model). Daily experiences of work inconvenience on restroom use more strongly predicted number of voids than experiences of work interference in the model. Next, we explored for an optimal stepwise regression model for the fixed effects using several variables in addition to our primary exposure variables (Table 2, Optimal stepwise model). The optimal model kept work inconvenience, fluid restrictions, urgency, and number of breaks as most related to times voided during the day over and above respondent-level random effects (Figure 2). Crucially, work inconvenience emerged as a key predictor of times voided amidst other plausible variables, providing additional evidence of its unique importance in predicting daily voiding.
Table 2.
Predicting daily times voided (fixed effects) beyond the variability of individual participants over time (random effects).
| Times voided Primary exposure only model |
Times voided Optimal stepwise model |
|||||
|---|---|---|---|---|---|---|
| Fixed Effects | Estimates | CI | p | Estimates | CI | p |
| (Intercept) | 4.25 | 3.69 – 4.82 | <0.001 | 3.28 | 2.50 – 4.06 | <0.001 |
| Primary exposure variables | ||||||
| Work inconvenience | −0.09 | −0.18 – 0.00 | 0.06 | −0.06 | −0.12 – −0.00 | 0.04 |
| Work interference | −0.00 | −0.08 – 0.08 | 0.97 | |||
| Control variables | ||||||
| Breaks | 0.29 | 0.16 – 0.42 | <0.001 | |||
| Limiting fluids | −0.27 | −0.52 – −0.01 | 0.04 | |||
| Urgency | 0.24 | 0.04 – 0.44 | 0.02 | |||
|
Random Effects | ||||||
| σ2 | 0.50 | 0.42 | ||||
| τ00 | 1.49record_id | 1.63record_id | ||||
| τ11 | 0.01record_id.day | 0.01record_id.day | ||||
| ρ01 | −0.35record_id | −0.47record_id | ||||
| ICC | 0.75 | 0.79 | ||||
| N | 21record_id | 21record_id | ||||
| Observations | 152 | 152 | ||||
| Marginal R2/ Conditional R2 | 0.039 / 0.760 | 0.103 / 0.816 | ||||
Figure 2.
Point estimates (95% confidence intervals) from linear mixed regression analyses for variables predicting times voided at work
A total of 16 participants completed the posttest-period survey. 81% reported that completing the daily survey was “as easy as possible,” while 88% reported that participation in the study did not interfere at all with work. Regarding the length of the test period, 81% of participants felt that a 14-day test period was “about right” while 19% believed the test period was “too short.” There were no participants that reported the test-period was “too long.” When asked about the use of technology in this study, 100% reported that they “liked” or “strongly liked” the daily text messages, links to daily surveys, and reminders. Similarly, 100% of participants reported that they were willing to participate in a study like this again.
Discussion
In this pilot study we demonstrated the feasibility of using a daily text message survey about restroom use at work in a group of healthcare workers from different occupational settings. This was overall well-received by the study participants. Additionally, we provisionally confirmed our hypothesis that increased work burden (i.e. increased inconvenience for using the restroom at work) would be associated with fewer voids per day. In addition to inconvenience, we also determined that the number of voids at work was associated with the number of breaks, urinary urgency, and limiting fluids.
Our findings are consistent with those of previously reported studies. In a previous survey-based study investigating internal and external influences on a woman’s toileting experience in public and in the workplace, women identified that workplace time constraints, rules and obligations, and accessibility as situational influences used to decide when to use the restroom16. This same study also identified restricting fluids as one of many behavioral strategies women employ to manage their toileting behaviors when in public and at work16.
Another study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium conducted 44 focus groups with a total of 360 female participants to identify factors influencing perceptions, beliefs, and behaviors around women’s toilet access19. Investigators identified “gatekeepers,” defined as individuals who control access to toilets, as a prominent force in limiting toilet access for participants in the workplace. Women described “gatekeepers” in their workplace limiting toilet use to certain designated break times throughout the day or monitoring how many restroom breaks women take while at work. Investigators also identified “self-restricting toilet use” (deciding not to use the toilet despite the biologic need to urinate, often in response to the internalization of external norms) as another prominent theme that played a role in toilet access and use at work. Many participants described the inability to leave their work responsibilities, for example when caring for children or patients, in order to use the toilet19. Both of these themes, gatekeepers and self-restricting toilet use, were also found in our cohort of medical providers as was demonstrated by the association of increased toilet burden with number of breaks and limiting fluids.
In particular, the influence of the workplace on healthcare workers’ toileting behaviors has been suspected for several decades. In 1991, Bendtsen et al.12 reported results of their study examining the “Nurse’s Bladder,” the habitual suppression of the desire to void over a long period of time, among 72 participating nursing staff in a busy surgical hospital. They found 57%−80% of respondents reported suppressing the desire to void during working hours due to “business at work.” Previous research performed by Xu et al10 found that nurses were likely to wait too long to urinate while at work with 42.0% reporting that they often or always waited too long to empty their bladders at work and 53.6% delayed emptying their bladder when they were busy. However, the study by Xu et al. did not investigate why the nurses perceived that they were too busy to empty their bladder.
Other investigators have sought to examine toileting behaviors among healthcare workers and the association with LUTS. An online study of 113 female advanced practice providers (APPs) in a large urban healthcare system, found that 40.2% of participants reported “often/always” waiting too long to urinate at work9. When compared to women without urinary incontinence (UI), women with UI were more like to report delaying voiding at work until the last minute (26.9% without UI vs. 52.7% with UI; p=0.006). Another online study of 182 female employees of a large academic medical center found that women who waiting too long to urinate at work and work panty liners for urinary leakage had a greater odd of urinary urgency than women who did neither11. Although these studies cannot determine a direct causation for the development of LUTS from healthcare professionals’ workplace toileting behaviors, they do emphasize the importance of considering the context of women’s lives, including their workplace behaviors and habits, in their overall bladder health and the presence of LUTS.
In the current study, we were able to gather and report near real-time measures of the subject’s interaction with their workplace toileting environment as well as contextual factors that govern the restroom use such as number of breaks, convenience of restroom use, and LUTS experienced while at work. While the generalization of these results are limited, it is worth noting that the number of breaks and inconvenience of restroom use identified are potentially modifiable workplace factors that, with appropriate adjustments to the workplace environment, could help to improve workers’ toileting experience and potentially lead to overall improvement in bladder health.
The present study employed methods used in ecological momentary assessment (EMA) studies to survey the daily restroom experience of participants in their work environment. EMA, the repeated sampling of subjects’ current behaviors and experiences in real time20, has grown with the expansion and widespread use of mobile technology and has been used to study a range of health conditions including psychiatric disorders, physical activity, substance use, eating disorders, self-harm, and bowel function with good compliance21,22. Particularly in the study of irritable bowel syndrome, the use of EMA to study pain and stool frequency was more accurate compared to bowel diary cards23,24. The advantage of this approach is that participants reply to a daily survey reporting their behaviors for that day’s events, thus minimizing recall bias. This also allows evaluation of microprocesses that influence behavior and maximizes ecological validity.
To our knowledge, EMA has not been used previously for the study of urinary restroom use in the context of occupational settings. The majority of participants found the prompts unobtrusive and easy to complete and the length of the study appropriate, which supports the feasibility of conducting future studies with a similar design. Unanimous agreement among participants that they liked the technology used for daily text messages, links to daily surveys, and reminders and subjects’ willingness to participate in further studies with a similar design further supports our aim to show the feasibility of recording daily toilet burden in healthcare workers using a cellular, text-based survey tool.
This study is limited by the small number of participants, albeit within the constraints of a pilot study. The ability to compare perceived limitations of restroom use between different occupational settings of healthcare workers was also limited by the small numbers of participants in each subgroup. This study sample was composed of 70% female participants limiting its applicability to both genders; however, prior research has almost exclusively examined female workers, and little is known about men’s needs or perceptions of toilet environments. Therefore this study has shown that reproducing a similar design in a larger subject population of both genders is feasible. Our study was also conducted at a single academic institution and 90% of participants are Caucasian further limiting the applicability of findings to larger populations. Finally, extending this study design to other populations could be limited by the ability of participants to have access and understanding of the technology necessary to complete a study of this design. Elderly or illiterate populations may have difficulty completed a daily survey sent by SMS text message on a cellular phone and some participants may not have access to a personal cellular phone at all.
Despite these limitations, this pilot study has shown the feasibility of a new methodology by which to objectively measure a subject’s interaction with their workplace toileting environment and contextual factors that govern their restroom using EMA technology. A larger study using similar methodology will hopefully be able to further investigate how workplace toileting environments impose limitations that put workers at risk for developing unhealthy bladder outcomes long term.
Conclusion
Utilization of a daily text message survey is a feasible way to study healthcare workers and their restroom use at work. Our hypothesis that increased inconvenience for using the restroom at work results in fewer voids per day was provisionally confirmed. While this study had a small number of participants and is primarily a feasibility study, a larger study with similar methods could potentially confirm that interference with using the restroom at work may result in toileting behaviors and habits that could predispose healthcare workers to develop urinary symptoms and conditions in the future. Further investigation is warranted to confirm and expand upon these preliminary results.
Acknowledgments
Disclosures:
Funding K23DK103910; UL1 TR002243
Footnotes
Conflicts of Interest: The authors have no conflicts.
Contributor Information
Hartigan Siobhan, Hunterdon Urological Associates, Flemington, NJ, U.S.A..
Finn Michael, Vanderbilt University Medical Center, Nashville, TN, U.S.A..
Dmochowski Roger, Vanderbilt University Medical Center, Nashville, TN, U.S.A..
Reynolds W. Stuart, Vanderbilt University Medical Center, Nashville, TN, U.S.A.
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