VOL: 97, ISSUE: 30, PAGE NO: 52
Linda Nazarko, MSc, RN, is director of nursing, Nightingale House, Wandsworth, LondonContinence problems can affect an older person's physical and mental well-being and make people feel that life is not worth living. When older people move to a nursing home they, their family and staff often feel that nothing can be done to treat such problems. Often the onset of urinary incontinence leads health care professionals and relatives to seek continuing care (Thom et al, 1997).
Continence problems can affect an older person's physical and mental well-being and make people feel that life is not worth living. When older people move to a nursing home they, their family and staff often feel that nothing can be done to treat such problems. Often the onset of urinary incontinence leads health care professionals and relatives to seek continuing care (Thom et al, 1997).
Yet incontinence is a symptom that merits investigation and, with appropriate treatment, many older adults can regain continence.
Why continence care matters
Continence care that enables older adults to regain or retain continence and effectively manage incontinence is a key indicator of quality of care. Nursing and residential homes are increasingly giving it more attention, as incontinence rates are high in both settings. Government guidance (Department of Health, 2000a) recommends that homes develop a systematic approach to continence management (Box 1).
The Care Standards Act (Department of Health, 2000b) is due to be implemented next year when homes will be required to meet national required standards. The consultation document, Fit for the Future, (Department of Health, 1999) outlined a range of standards, including outcome measures. The final document, Care Homes for Older People: National Minimum Standards, has just been published (Department of Health, 2001).
Our care complex cares for over 300 people in sheltered flats, four residential and three nursing units. Despite an overall urinary incontinence rate of 76% among residents, staff did not consider urinary incontinence to be a problem. This view is not unusual: US research suggests that nurses in nursing homes tend to accept urinary continence problems as normal. Palmer et al (1991) discovered that despite high rates of urinary incontinence less than 3% of nurses identified it as a problem on their care plans.
The rate of incontinence pointed to the need to change the culture in our care complex through cooperation and collaboration with other professionals and education.
Continence adviser involvement
I began by contacting the continence advisers employed by the local health authority: one community and two hospital-based advisers. We discussed the scale of the problem and strategies to manage continence within the complex (Box 2).
The continence advisers had taught staff in local homes about assessment and continence promotion strategies, but little had changed. We decided that I would begin by setting up a continence clinic within the complex. The continence advisory service offered support, advice and access to their portable bladder scanner if I required it. They also offered to help with teaching programmes.
The care complex has five GPs, each of which cares for their own patients and provides the complex with emergency cover. The cooperation of the GPs was crucial to developing high-quality continence services, as some of the patients to be assessed were expected to require a review of their current medication and a referral to a urologist or gynaecologist.
The doctors, whom I met individually, were enthusiastic about developing a continence service. They had been referring some of their patients with problems directly to hospital specialists. They recognised that in-house continence services would reduce referrals and improve continence care.
We agreed that I would write up notes following assessments and meet the GPs to discuss treatment plans, medication reviews and specialist referrals.
Staff involvement was vital if we were to move from a culture where incontinence was viewed as normal to one where it was viewed as a distressing symptom that merited investigation and treatment.
I discussed the issue with the managers of the eight units within the care complex who in turn discussed it at unit level. We also discussed the issue with representatives of the health care assistants from each of the eight units. Staff suggested changing the documentation to enable us to plan and manage care more effectively.
We are now introducing better assessment and care planning documentation. Staff felt they needed to update both their practical and academic knowledge to enable them to provide better quality continence care so, as a result of this feedback, we developed an education programme.
It was important to consult residents to ensure the services we developed were capable of meeting their needs. We asked them for their views, both individually and at resident meetings, about how they would like to see the service developed.
Some were worried that, if continence assessments were carried out in their rooms, they might feel embarrassed if friends or relatives called. They felt that being seen in our clinic would be more discrete and professional. Many female residents said that they would like a drop-in service, as they felt uncomfortable about discussing continence problems with our male GPs.
We decided to set up a continence clinic one afternoon a week and publicise it at residents' meetings and in the home's newsletter. When the clinic opened residents who had concealed continence problems from staff because of embarrassment dropped in for help.
We also consulted relatives about our intention to offer the residents continence services. This was done as part of care reviews, at relatives' meetings and through the relative's newsletter.
Aims of the clinic
The clinic has two aims: to assess and treat residents and educate staff to enable them to provide high-quality continence care.
When a resident visits the clinic, I review the medical and nursing notes and check whether any medication might be contributing to continence problems. I take the patient's continence history and obtain a urine sample. The specimen is tested for infection and if this is positive it is sent for culture and sensitivity.
The examination and history may indicate why continence problems have developed. More usually, the resident or relevant staff are asked to complete a frequency volume chart for one week to help pinpoint the type of incontinence the person has. The resident is usually seen in the clinic a week or two after the initial visit, when a plan of care is developed, which indicates how the person will be followed up. If it is necessary to check a residual urine, this will be carried out in the clinic.
Staff attend the clinic to learn how to carry out continence assessments and to acquire skills such as male catheterisation and changing suprapubic catheters.
The way forward
We plan to hold a number of ongoing study days to enable nurses working in the care complex to assess residents and develop management strategies. The nurses will eventually assess most residents with continence problems. This will enable the continence clinic to concentrate on helping residents with more complex continence problems.