Why nursing homes struggle with manual incontinence care

It's 6:30 AM on a Tuesday at Maplewood Senior Living, and Maria, a certified nursing assistant (CNA), is already juggling three tasks. Mrs. Gonzalez, an 87-year-old with dementia and limited mobility, needs help getting out of bed. Mr. Patel, recovering from a stroke, is requesting his morning medication. And in Room 204, Mrs. Lee has just had an accident—her third since midnight. By the time Maria reaches Mrs. Lee, the sheets are soaked, and the smell of urine hangs in the air. "I'm so sorry, sweetie," Maria murmurs, as she begins the slow, laborious process of stripping the bed, cleaning Mrs. Lee, and remaking the linens. It's a scene repeated thousands of times daily in nursing homes across the country, yet few outside the industry understand the hidden toll of manual incontinence care.

Incontinence affects up to 70% of nursing home residents, according to the American Geriatrics Society, and managing it manually—without the support of advanced tools—has become a silent crisis. It's not just about changing sheets or wiping down skin; it's about the physical strain on caregivers, the erosion of resident dignity, and the way it drains time from an already overstretched staff. To truly grasp why nursing homes struggle, we need to step into the shoes of caregivers like Maria and the residents they serve.

Let's start with the body. Caregivers like Maria spend their shifts bending, lifting, and twisting—movements that might seem small individually but add up to chronic pain. Changing a soiled bed on a standard nursing bed often requires leaning over the mattress for 15–20 minutes, shoulders hunched, back strained. "By noon, my lower back is screaming," says Jamie, a CNA with five years of experience. "I've had two herniated discs since I started. The worst part? I can't slow down—there's always someone else waiting."

Then there's the lifting. Helping a resident roll onto their side to change a pad or adjust linens can require supporting 150+ pounds of weight. Even with proper body mechanics, the repetition is brutal. The Bureau of Labor Statistics reports that nursing assistants have one of the highest rates of musculoskeletal injuries—nearly three times the national average for all occupations. Much of this is linked to manual incontinence care, where there's no "break" from physical labor.

Tools like patient lift assist devices could ease this burden, but many facilities can't afford them, or staff aren't trained to use them consistently. "We have one lift in the whole building, and it's usually tied up with transferring residents to chairs," Maria explains. "For incontinence care, we're on our own. You just grit your teeth and hope you don't tweak something."

In nursing homes, time is a finite currency. The average CNA is responsible for 8–12 residents per shift, each with unique needs: meals, medications, bathing, mobility assistance, and yes, incontinence care. Manual incontinence tasks—changing linens, cleaning skin, applying barrier creams—can take 20–30 minutes per incident. For a resident with frequent accidents (say, 3–4 times a day), that's 60–120 minutes of a caregiver's shift dedicated to one person.

"Last week, I had a resident who had five accidents in eight hours," Jamie recalls. "By the time I finished with her, I'd fallen behind on everyone else's meds. A family member got upset because their mom hadn't been taken for a walk. I wanted to explain—I just didn't have the time—but who has time to explain?"

This time drain creates a vicious cycle. Rushed care leads to mistakes: a missed skin check, a half-applied barrier cream, a resident left waiting too long for a bathroom trip, which then causes another accident. It's not that caregivers don't care—they're just drowning in tasks that could be streamlined with better tools.

For residents, the struggle is emotional as much as physical. Imagine lying in a wet bed, waiting 20 minutes for help, then having a stranger rush through cleaning you because they're late for their next task. "I used to love reading and gardening," says Mrs. Lee, the resident in Room 204. "Now I'm just… embarrassed. I hate that Maria has to do this for me, and I hate that she's always in a hurry. It makes me feel like a burden."

Rushed care strips away dignity. A 2019 study in the Journal of Gerontological Nursing found that residents who experienced hurried incontinence care reported higher rates of anxiety and depression. "They told us things like, 'I avoid drinking water so I won't have accidents' or 'I pretend to be asleep so I don't bother anyone,'" says Dr. Lisa Chen, the study's lead author. "That's not quality of life—that's survival."

The design of the nursing bed itself plays a role here. Traditional manual beds often have limited adjustability, making it hard to position residents comfortably during care. A resident lying flat can't help lift their hips, forcing the caregiver to do all the work—and extending the time the resident spends in an uncomfortable, exposed position. "If the bed could tilt or raise the head a bit, I might be able to help more," Mrs. Lee adds. "But we make do with what we have."

To understand the struggle, let's compare the tools caregivers use today with what could be possible. Take the nursing bed —the centerpiece of daily care. Most facilities still use manual beds, which require hand cranks to adjust height or angle. Upgrading to an electric nursing bed could transform incontinence care, but cost and inertia stand in the way. Below is a breakdown of how these beds stack up:

The numbers speak for themselves: electric beds save time, reduce physical strain, and improve resident comfort. But for cash-strapped nursing homes—many operating on razor-thin margins—the upfront cost is prohibitive. "We applied for a ｇｒａｎｔ to upgrade beds last year, but we were turned down," says Mark, an administrator at a mid-sized facility. "Insurance doesn't cover incontinence-specific upgrades, and Medicaid reimbursements haven't kept up with inflation. We're stuck choosing between new beds and paying staff enough to keep them from quitting."

Even when facilities do have electric beds, they're often reserved for "high-acuity" residents—those with severe mobility issues—leaving others on manual beds. "Mrs. Lee isn't in a wheelchair, so she gets a manual bed," Maria says. "But she still can't move on her own. It doesn't make sense."

In recent years, care robot technology has emerged as a potential solution. These robots can assist with lifting, turning residents, or even monitoring for incontinence (some use sensors to detect moisture and alert staff). But adoption is slow, and not just because of cost.

"We tested a moisture-sensing robot last year," Mark explains. "It worked well, but the staff hated it. They felt like it was replacing their judgment—'The robot says she's wet, but I just checked her 10 minutes ago.' Plus, residents found it intrusive. Mrs. Gonzalez would swat at it, yelling, 'Get that thing away from me!'"

Training is another hurdle. Caregivers already have to learn new protocols, document care in electronic systems, and manage resident behaviors—adding robot operation to their to-do list feels overwhelming. "I barely have time to eat lunch," Jamie says. "Now I'm supposed to learn how to program a robot? It's too much."

Even when robots are adopted, they're often seen as "add-ons" rather than integral tools. A single robot might cover a wing of 20 residents, leaving caregivers to handle the gaps. "It helps sometimes, but it's not a magic fix," Maria admits. "The robot can't comfort a resident who's upset about an accident. That's still on us."

At the end of the day, the struggle with manual incontinence care isn't just about logistics—it's about people. It's about Maria, whose back aches so badly she can't play with her kids when she gets home. It's about Mrs. Lee, who hides her face in her pillow when she has an accident, afraid of being a "nuisance." It's about facilities that want to do better but are trapped in a system that undervalues the most basic aspects of care.

So why do nursing homes struggle? Because manual incontinence care is labor-intensive, under-resourced, and overlooked. It's not glamorous enough for headlines, but it's the backbone of daily life for millions of residents and caregivers. Until we invest in better tools— electric nursing bed s, accessible patient lift assist devices, and thoughtful care robot integration—and until we prioritize the well-being of both residents and staff, the struggle will continue.

As Maria finishes Mrs. Lee's care and moves on to her next resident, she pauses for a second, rubbing her lower back. "Sometimes I wonder if this is how it has to be," she says quietly. "But Mrs. Lee deserves better. We all do."