This site is intended for health professionals only

Better assessment can lead to improved continence

Jayne Richardson
RN
Clinical Nurse Specialist for Continence Care
Scarborough and North East Yorkshire NHS Trust

In conversation these days many of us think nothing of discussing our family problems, talking openly about cancer and heart disease and even our sex lives. Incontinence, however, is still a no-go area, considered shameful and guaranteed to make your conversation falter. Incontinence can cause people to feel isolated from family, friends and colleagues.
Incontinence is a common condition, affecting people of all ages, from all social and cultural backgrounds. It is classified not as an illness but as a ­symptom with many causes.
While the physical effect may not be life-threatening, the symptoms can have a devastating effect on the quality of life of sufferers and their family and friends. Those with the problem and their carers frequently express feelings of anger, guilt and frustration. Embarrassment and ignorance about the subject prevent many seeking help.
Symptoms of a persistent headache or vomiting prompt people to seek medical advice, while leaking urine or faeces is surrounded by secrecy and silence.

Continence services
Continence services were originally developed to monitor usage of pads, but nowadays continence services are twofold in function, providing a product supply and a continence advisory service - both interlinked. Staffing varies across the country from lone specialist nurses to teams of nurses, with some services including dedicated physiotherapists and occupational therapists.
The role of the nurse specialist in continence is a complex one. They need to be educator, trainer and advisor and be able to manage a patient caseload via clinics and visits, perform audits and policy reviews, monitor the product supply service (while watching the budget!) and liaise with all and sundry, as continence has no boundaries to sex, age, location or other medical conditions.

[[nip04_box1_58]]

New guidelines
Good practice guidance for continence services were published by the Department of Health in April 2000.(1) The aim is to ensure that quality services are available across the UK, and the guidelines set out a model of quality continence care provision. The problem is that they are for guidance only and are not compulsory. Integration is a key message for the service.
The RCN, in association with the Continence Foundation, is conducting a review of implementation across the country. In patient-focused benchmarking the idea is that wards and departments will share good ­practice and trusts will be compared nationally.(1)
With the formation of primary care trusts (PCTs), more national frameworks and health improvement targets, it falls on continence advisors and specialist nurses in continence to keep motivation moving towards improving services and ensuring further ­integration with other services.
Provision of free nursing care in nursing homes includes provision of incontinence pads.(2) Patients should receive individual assessments, as in their own home, and equity of service. This has vast implications on time, training and financial requirements for continence ­services across the country.

New assessment tools
Care pathways have been developed in continence assessment.(3) They are evidence-based and lead the assessor through the process. A simple tool in the form of a symptom profile that the patients complete helps identify the type of incontinence. From this, correct advice and treatment can be offered, and the patient can be referred if needed.
Simple questioning about fluid intake and types of fluid, followed by adjustment of what the patient drinks, can make a big difference. For example, tea and coffee are known to irritate the bladder. Yet often elderly patients present in clinic claiming to drink six to 10 cups of tea a day. When this is reduced to three to four cups of tea and two or three drinks of another fluid, their problems reduce.
A symptom profile that I use in my practice is illustrated in Figure 1. Yellow symptoms are related to stress incontinence, pink to urge incontinence and blue to voiding dysfunction or overflow. The colour with the most ticks leads on to a colour-coordinated treatment pathway.

[[NIP04_fig1_60]]

The aim of assessment is to move away from a single visit, where pads were often issued, to three or four visits, at which through charting and reinforcing advice a true picture is gained and products are issued only where appropriate. It is important to realise that patients don't always convey a clear picture, so charting is a simple and useful tool for patients and staff. Comments from some of my patients bear this out:

  • "I'm always at the toilet" - yet the completed chart shows that the patient only makes four visits a day.
  • "I'm normal but not sure how often I go" - but a completed chart shows 25 visits a day.

Referral pathways are being developed in some areas to aid equity of service and to ensure that patients see the right person at the right time. This process is complex to set up as it involves many GPs, consultants and departments, but it does work towards a more ­integrated service.

Tackling continence problems

Prevention

  • Healthy and varied diet.
  • Adequate fluid intake.
  • Accessibility to toilets.
  • Keeping walking aids to hand.

Promotion

  • Bladder retraining.
  • Anticholinergic drug treatment.
  • Prompted voiding.
  • Timed voiding.
  • Behavioural therapies.
  • Pelvic floor exercises.
  • Physiotherapy and occupational therapy.
  • Intermittent self-catheterisation.
  • Treatment of underlying cause with medication or surgery.
  • Correct aids, urinals and commodes.

Containment

  • Sheath drainage systems.
  • Body-worn appliances.
  • Reusable sheets, pads or pants.
  • Disposable pads.
  • Catheters, urethral or suprapubic.

The future
As my colleague and I commence an audit of our pathway forms, it is becoming evident that many of those on the district nurse caseload require management in the form of containment. More work is needed to identify people earlier, and particular groups require targeting.
As part of health promotion, good bladder and bowel care should be promoted to people of all ages. School nurses are promoting drinking facilities in schools as part of a national campaign from the Enuresis Resource and Information Centre (ERIC), to promote access to fresh drinking water in schools and encourage children to drink plenty of fluids.
Women postdelivery, asthmatics, women attending well woman clinics and diabetics are groups we know who develop problems that with early intervention can be solved or improved.
The inclusion of the practice nurse in continence promotion is essential. Practice nurses give good advice but at present patients are not followed up, so improvements and statistics cannot be collated. Practice nurses need to be involved with the continence service.
The Department of Health guidelines state that:

  • All people with incontinence will be identified.
  • Will be offered an assessment.
  • Once agreed will be given a management plan.
  • Will have access to firstline treatments.
  • Will have access to specialist advice and services.
  • Carers will be given information so that they understand the condition.

It urges that primary care and community professions are identified and trained to carry out these tasks.
I hope my brief update has sparked an interest - please do get involved in your local continence service.

References

  1. Department of Health. The essence of care: patient-focused benchmarking for health care practitioners. London: HMSO; 2000.
  2. Department of Health. Free nursing care in nursing homes. London: HMSO; 2001.
  3. Bayliss V, et al. Pathways for ­continence care: background and audit. Br J Nurs 2000;9:590-2, 594, 596.
  4. Royal College of Physicians. Incontinence: causes, management and provision of services. London: Royal College of Physicians; 1995.
  5. Brocklehurst JC. Urinary incontinence in the community - analysis of a MORI poll. BMJ 1993;306:832-4.
  6. Perry S, et al. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community: the Leicestershire MRC Incontinence study. J Public Health Med 2000;22:427-34.
  7. Foldspang A, Mommsen S, Djurhuus JC. Prevalent urinary incontinence as a correlate of pregnancy, vaginal ­childbirth, and obstetric techniques. Am J Public Health 1999;89:209-12.
  8. Continence Foundation. Making the case for investment in an integrated continence service. London: Continence Foundation; 2000.
  9. Thom DH, Haan MN, Van Den Eeden SK. Medically recognised urinary incontinence and the risk of hospitalisation, nursing home ­admission and mortality. Age Ageing 1997;26:367-74.
  10. Audit Commission. First assessment: a review of district nursing services in England and Wales. London: Audit Commission; 1999.

Resources
The Association for Continence Advice
T:020 8692 4680
W:www.aca.uk.com
E:info@aca.uk.com
RCN Continence Forum
T:0171 409 3333
Enuresis Resource and Information Centre (ERIC)
T:0117 960 3060
W:www.eric.org.uk
The Continence Foundation
T:020 7404 6875
W:www.continence-foundation.org.uk
Incontact (National Action on Incontinence)
T:020 7700 7035
W:www.incontact.demon.co.uk
PromoCon
T:0161 834 2001
W:www.promocon2001.co.uk
Association of Chartered Physiotherapists in Women's Health
E:enquiries@womens physio.com
W:www.womens physio.com