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Best practice - Exploring Continence care provision in nursing homes

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VOL: 102, ISSUE: 47, PAGE NO: 46

Joanne Mangnall, BSc, RN, is continence adviser, Rotherham PCT

Julie Vickerman, DipCO, SROT, is clinical specialist/research occupational therapist, Chorley and South Ribble PCT/Promocon, Disabled Living, Manchester; Phyll Taylor, MSc, RN, is an independent continence adviser

Accessing toilet facilities is a daily problem for some people, leading to misery, frustration and even social isolation. Older people are more likely to experience physical problems that can make it difficult for them to get to the toilet. Problems include (Thomas, 2001):

Accessing toilet facilities is a daily problem for some people, leading to misery, frustration and even social isolation. Older people are more likely to experience physical problems that can make it difficult for them to get to the toilet. Problems include (Thomas, 2001):

- Failing eyesight;

- Arthritis;

- Long toenails that they can have difficulty cutting, or poorly fitting footwear, both of which can impair mobility;

- Clothing that is difficult to unfasten;

- Toilet facilities that are difficult to reach, for example, up or downstairs or outside.

Many older people living in their own homes may adjust their daily routine or adapt their clothing to enable them to maintain continence. Problems occur when they are no longer in their home environment, for example if they are admitted to a care home. They may not be able to adapt to the environment and have to rely on the input of others to maintain continence.

Many care home staff view incontinence as an inevitable part of the ageing process (Nazarko, 2001), while continence assessments by district nurses and those working in care homes often focus on selecting the appropriate absorbent pad rather than on treating the condition (Nazarko, 2003). This means opportunities to identify problems that can be cured or improved are missed (Brandeis et al, 1997).

Audit of continence care
The independent sector has approximately 411,500 beds in care homes across the UK (Laing and Buisson, 2004). National prevalence figures suggest that two out of every three people who live in care homes have continence problems (Department of Health, 2000). In order to explore continence care provision and try to gain a greater understanding of some of the issues involved, the RCN Continence Care Forum, in conjunction with the RCN Institute, carried out an audit in care homes. Data collection took place between December 2004 and August 2005, and used the Royal College of Physicians' Continence Care in Older People audit tool with supplementary questions that were specific to care homes.

Six care homes from various NHS regions took part in the audit, which explored how continence problems were assessed and treated, the attitudes of care home staff to continence problems and the educational support available to them.

Toileting difficulties
Care Homes for Older People: National Minimum Standards (DH, 2003) specifies that all service users should have a toilet within close proximity of their private accommodation and that there should also be accessible, clearly marked toilets close to lounge and dining areas. But no matter how close toilets are situated, clients will be at risk of incontinence if they are reliant on staff to help them get to these facilities.

Care home staff participating in our audit highlighted problems they experienced when assisting clients to use the toilet. A common problem arose when they needed to use a hoist. They felt that no matter how quickly they responded to requests to be taken to the toilet, clients needing hoists would almost certainly be wet before they got to the toilet because of the lengthy process involved in using the device.

Hoists can also cause other problems. For example, pain associated with conditions such as arthritis may be aggravated during the hoisting procedure and may make clients reluctant to ask for the toilet. This may lead to many serious problems. In an attempt to reduce visits to the toilet clients may reduce their fluid intake to dangerously low levels, putting themselves at risk of dehydration, constipation, confusion and urinary tract infection (Bissett, 2004).

Replacing toileting with incontinence pads can lead to skin rashes and ulceration, especially in frail older patients, and is expensive to manage (Le Lievre, 2000).

Changing practice
The audit included a three-hour training session for staff. This addressed issues relating to functional incontinence (difficulty reaching the toilet in time due to physical problems), and equipment and adaptations that were currently available. Female hand-held urinals were perceived to be particularly useful as clients could maintain a level of independence and toilet themselves overnight, while daytime use of the urinal could potentially reduce or eliminate the need for hoisting.

Maintaining clients' dignity while hoisting them was a concern for many staff and a range of adaptations to clothing, such as drop-front pants, trousers and skirts, were displayed and discussed. Staff identified the benefits for clients and themselves in making the process much easier.

Care Homes for Older People: National Minimum Standards (DH, 2003) recommends that service users are provided with the specialist equipment they require to maximise their independence. However, the staff who participated in our audit were unaware of the range of specialist toileting equipment that was available and none of the homes had requested input from an occupational therapist to assist them in assessing their toileting facilities. When individual clients have continence problems, a detailed assessment should be requested from an occupational therapist (Vickerman, 2002) (see case study).

Continence care in care homes takes time, energy and dedication. When successfully achieved it brings dignity and peace of mind to residents and a sense of achievement to staff. Simple measures can sometimes bring about the most effective results but staff need to be aware of the range of equipment and resources that are available.

Case study
Mr Emery (not his real name), aged 72, had lived in a care home for four years. Staff members were unsure of the reasons for his admission.

During an informal discussion with the staff group in the dining room about general continence issues in the home, they mentioned that they were having problems with Mr Emery: he was passing urine in inappropriate places. At that moment, Mr Emery walked into the room and to the far corner and passed urine into a large, empty plant pot and walked out again.

The staff said he was aware of when he needed to go to the toilet and used the toilet in his room in the early morning and during the night.

During a continence assessment we identified that Mr Emery was from Poland and his spoken English was poor. He also commented that his eyesight had deteriorated greatly over the past few months.

When asked why he went into the dining room to void he was horrified. He said that he did not remember the exact location of the toilet nearest to the lounge. He thought it was the first left turn when in fact it was first right.

Mr Emery also appeared to have undiagnosed short-term memory problems but care home staff had attributed his forgetfulness to his poor English. An eye test also revealed advanced cataracts on both eyes. He said that he could not focus very well and that while the dining room did not really look like a bathroom he could not be sure.

The environment of the home was very modern and the owners had decided not to have signs on doors or corridors in an attempt to retain a homely feeling.

However, we discovered that several of the other residents became disorientated at times and opened incorrect doors in an attempt to find their bedroom, the lounge or the toilet.

The care home manager arranged to have digital photographs taken of the residents to put on their bedroom doors, photos of the dining table set with a meal for the door of the dining room, and the TV and chairs for the door of the lounge. Most importantly, pictures were taken of all the toilets and bathrooms and enlarged for the appropriate doors.

Each resident, regardless of how long they had lived in the home, was taken through a 'reorientation' process and shown where all the facilities were. Staff continue to monitor residents' orientation and reinforce information if this is required.

Mr Emery is now able to use the toilet appropriately during both day and night.

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see

This project was funded by an unrestricted grant from Pfizer Ltd.

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