Nurses must receive sufficient continence education and training

When a 2008 Healthcare Commission report found that patients at Mid Staffordshire NHS Foundation Trust had been left in ‘wet or soiled’ sheets it caused a public outcry.

Yet this is not the first time an NHS trust has hit the headlines for poor continence management. In 2007, the Healthcare Commission’s report on Maidstone and Tunbridge Wells NHS Trust highlighted significant failings, with some nurses telling patients with diarrhoea to ‘go in their beds’ rather than assisting them to a toilet or commode.

As one of the initial nine Essence of Care benchmarks - set by the Department of Health in 2001 - continence is an essential part of basic nursing care, so these high-profile reports made shocking reading.

However, a recent Nursing Times survey revealed significant gaps in nurses’ training and education in continence management, suggesting staff were not receiving sufficient support to assess and care for people with continence problems.

More than one-third of over 1,000 respondents had not received any education about caring for incontinent patients in their nurse training, and 53% had had no training in this after registration.

‘I don’t recall being taught anything relating to incontinence in general nurse training,’ said one respondent. Another said: ‘We were never taught to do a full formal continence assessment or how to give guidance on methods such as pelvic floor training.’ A third said: ‘Training courses were provided by the PCT but, due to reorganisation and lack of funding, these have been discontinued.’

These are just a few of the hundreds of comments received. The survey showed that, while most nurses believe continence care is their responsibility, they are not getting enough training to be able to deliver effective treatment.

‘Continence is a fundamental aspect of nursing care, but it is not always seen as a priority,’ said Kath Wilkinson, nurse consultant and continence service manager at Bradford and Airedale PCT, and chair of the RCN continence forum.

‘There needs to be a more uniform approach to continence training and education because, at present, it varies enormously across the country. Universities need to ensure that continence is adequately covered, and student nurses should be actively encouraged to spend time with continence nurse specialists.’

Student nurses often miss out on continence education because it is not part of the national curriculum for pre-registration training, said Alison Harris, senior lecturer in the primary healthcare department at Middlesex University, and executive member of the Association for Continence Advice (ACA).

‘Continence education may be threaded through into other areas of care, but it is not seen as a specialty in its own right so does not have a stand-alone slot,’ she said. ‘Not all universities have the funding to bring in specialist practitioners to teach students about continence, so education is of varying quality.

‘It can take a long time and a lot of practice to develop the skills to perform a continence assessment effectively, and this needs to be embedded in education and training as early as possible.’

According to Good Practice in Continence Services - published by the DH in 2000 - performing an initial assessment is essential in identifying people who may have problems.

‘Assessment is the cornerstone of identifying bladder and bowel problems because you can’t initiate a care plan or treatment until you have identified what the continence problem is,’ said Sharon Eustice, nurse consultant in continence at Cornwall and Isles of Scilly PCT, and chair of the ACA.

Although 84% of the nurses surveyed said they did ask patients about their bladder and bowel function, more than 40% said they do not always complete a continence assessment.

Additionally, the 44% who had received post-registration training did not feel it equipped them fully to carry out a continence assessment.

‘I try to complete a continence assessment for those with major problems, but it takes time and my workload is often too great,’ said one respondent. ‘I do not have the specific skills or knowledge to do a comprehensive functional assessment,’ said another.

‘Some patients don’t feel able to discuss continence issues freely, so nurses need support in clinical practice and user-friendly tools to enable them to ask the right questions at first contact,’ said Ms Eustice.

‘Patients can be assessed opportunistically during the hospital admission process or, if a nurse sees a patient who has problems with their diabetes, for example, a continence assessment may reveal problems that could be related.

‘Assessing the patient and identifying the problem will enable nurses to know if the patient needs to be referred to specialist continence services.’

Knowing when to refer a patient to a continence nurse specialist is a core part of continence care. Yet the Nursing Times survey also revealed that 43% of nurses have never referred a patient to a continence adviser, and 42% do not even know who their local adviser is.

‘Using an assessment form to gather information is only part of the process,’ said Ms Wilkinson. ‘Continence services need to have pathways and easy referral processes in place to encourage health professionals to refer patients to them, or contact them for advice.

‘It is also up to the continence services to raise awareness of the service, and make sure people know they are there.’

When the DH published the NHS Next Stage Review in June last year, it said that patients should be treated with ‘compassion, dignity and respect’. The RCN’s Dignity campaign, launched in the same month, pledged to ‘champion patient dignity by giving nurses practical tools to ensure compassionate care and challenge poor practice where it exists’.

Effective continence care is at the heart of patient dignity, says Ms Harris, and it has to be given the attention it deserves.

‘Research has shown that incontinence is significantly related to falls, and it can be a precursor to residential care,’ she said. ‘But it is not a problem that just affects the elderly. We need to move the viewpoint on this so that the people who hold the purse strings recognise it as a serious health issue.’

The ACA has asked the Care Quality Commission to conduct a specialist review of continence services - including nurse training - and it is also pushing for continence care to be included in GPs’ quality and outcome frameworks.

‘Incontinence is a massive public health problem that costs the NHS billions every year,’ said Ms Eustice. ‘There needs to be an attitude change so that it is not seen just as an isolated problem that somebody else will deal with.

‘If we are going to improve the quality of care, education needs to be embedded in pre-registration training so that post-registration nurses are hungry to access training and ready to help change practice.’

Have your say

You must sign in to make a comment.