After a redesign of Scottish school nursing services led to patchy provision of support for children and young people with nocturnal enuresis, the ‘GIRFEC’ approach offers a template for standardising services
In the past, school nurses in Scotland were trained in supporting children and young people with nocturnal enuresis (bedwetting) and would run nurse-led clinics. A recent redesign of public health and school nursing, lack of staff and the absence of appropriate training mean that, in many cases school nurses can no longer offer such support. This article describes the consequence of nocturnal enuresis on children’s health and wellbeing, highlights nurses’ role in empowering children and families to tackle bedwetting, and how the GIRFEC (Getting It Right for Every Child) approach can be used to standardise paediatric continence services across Scotland.
Citation: Rogers J, McLean H (2018) A template to standardise support for children with nocturnal enuresis. Nursing Times [online]; 114, 10: 33-35.
Authors: June Rogers is paediatric continence specialist, Bladder and Bowel UK; Helen McLean is practice development nurse, Specialist Children’s Services, NHS Greater Glasgow and Clyde.
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Nocturnal enuresis (bedwetting) is a widespread and distressing condition that can have a profound impact on the behaviour, emotional wellbeing and social life of children and young people (National Institute for Health and Care Excellence, 2014a). It can also affect their educational outcomes and be stressful for parents and carers.
For over 10 years, the GIRFEC (Getting It Right for Every Child) approach has been used in Scotland to improve the wellbeing of children and young people. This article discusses how, in the context of an ongoing redesign of school nursing services in Scotland, the GIRFEC approach can be adapted to guide the provision of nurse-led services for children and young people with nocturnal enuresis.
Burden of bedwetting
Frequent bedwetting (defined as more than three wet nights per week) has an estimated prevalence of nearly 10% in children aged seven years (Vande Walle et al, 2012). It negatively affects children’s quality of sleep (Ertan et al, 2014) and, therefore, their daytime behaviour and capacity to learn. Bedwetting has also been shown to have negative effects on health and wellbeing and to diminish the quality of life not only of children but also of their parents (Kilicoglu et al, 2014; Üçer and Gümü, 2014).
On a psychological level, nocturnal enuresis diminishes children’s self-esteem, which in turn affects their social life (Jönson Ring et al, 2017). As their age and the duration of bedwetting increase, self-esteem and quality of life worsen (Kanaheswari et al, 2012). Children and teenagers who have continence problems are more likely to lack self-esteem and feel socially excluded than those who do not (NICE, 2010). In a survey conducted by ERIC, the children’s bowel and bladder charity, young people said that their bladder or bowel problem could prevent them from taking part in school activities and that they would not feel able to discuss it with school staff (ERIC, 2013).
Role of nurses in treating bedwetting
Bedwetting is a multifactorial problem, so it is important that a comprehensive assessment is undertaken by a health professional with the appropriate expertise to ensure underlying comorbidities are identified and addressed (Vande Walle et al, 2012). The problem can be successfully treated (Van Herzeele et al, 2016; Anyanwu et al, 2015) and effective and timely treatment reduces the risk of long-term continence and psychological problems (Joinson et al, 2016).
Spending time with the family to explain treatment improves concordance and patient satisfaction. Nurse-led services are not only as effective as doctor-led services, but they can also lead to improved understanding and better adherence to treatment (Cork et al, 2003). They have been shown to be more cost-effective than doctor-led services and to improve patient outcomes (Randall et al, 2017; Williams et al, 2005).
Nurse-led clinics in primary and community services play a key role in providing information and support to help people manage their health problems. Compared with GPs, nurses allow more time (typically 45-60 minutes) to carry out assessments and discuss treatment options (Tappin et al, 2013), enabling patients to better understand their health problems, what might cause them and what treatment options are available. If they feel empowered, patients are better able to understand and take control of their health problems; with the right information, children and families can engage in meaningful discussions and make informed decisions about their care (NICE, 2014b).
Refocused school nurse role
In the past, support for children and young people experiencing nocturnal enuresis in Scotland was provided by school nurses with the appropriate training and expertise, who would run local nocturnal enuresis clinics. However, school health services in Scotland have not been standardised, which has led to variations in service provision, infrastructures and team profiles.
In 2013, as part of a redevelopment of public health nursing services, the Scottish Government asked NHS health boards to refocus the role of school nurses (Scottish Government, 2013).
Guided by the principles of the GIRFEC approach, the role was redesigned with nine identified pathways (Box 1) and a greater emphasis on:
- Assessing the health and wellbeing needs of children and young people;
- Contributing to the health assessment included in the Child’s Plan – which was introduced by the Children and Young People (Scotland) Act 2014 and is part of the GIRFEC approach;
- Providing targeted interventions for identified vulnerable school-aged groups such as those who have been affected or are at risk of adverse childhood events.
In 2015, a refocused school health service was rolled out in two early adopter sites.
Box 1. Priority areas in the new school nursing role
- Mental health and wellbeing
- Substance misuse
- Child protection
- Domestic abuse
- Looked-after children
- Homeless children and families
- Children known to, or at risk of involvement in, the youth justice system
- Young carers
- Transition points
Gaps in service provision
In June 2017, the Scottish Government published an evaluation of how this had worked in practice (Doi et al, 2017). The evaluation noted that school nurses were concerned that physical health is not included in the pathways identified for the new model.
School nurses continue to offer nocturnal enuresis services in some health board areas; evidence from the early adopter sites shows that some nurses accept referrals for bedwetting within the mental health and wellbeing pathway, revealing divided opinions on what should be included in the school nurse’s role. However, lack of staff means school nurses in many areas are no longer able to provide nocturnal enuresis clinics; teams generally lack capacity and, because training is now focused on other areas, there are fewer school nurses with the appropriate know-ledge and skills. Service provision has become unsustainable.
Barriers to accessing school nurses
Universal ‘Primary 1’ health screening is carried out on children when they start primary school. If parents have not mentioned their child’s continence issues at an earlier stage the screening appointment offers them an opportunity to do so – allowing timely provision of information, advice, support, treatment and signposting.
In the refocused school nurse role, school nursing teams are tasked with providing services only to the most vulnerable children – that is, those found to have an additional health plan indicator by health visitors at pre-school transition; school nurses assess whether individual children need to remain on their caseload. This process may eventually replace Primary 1 screening, which would create a gap in opportunities to identify children with continence problems, as well as a reliance on families raising concerns with their GPs. This could result in delays in the provision of appropriate treatment and interventions.
In the current system, children can also be referred to school nurses by support teachers. This may create a barrier as children may not want their teacher to know they have a continence problem and they may be too embarrassed to tell them. Other pathways for accessing school nurses need to be explored. The role of the wider school health team needs to be clarified. It seems that it will remain a universally accessible service that will initially include universal Primary 1 screening and Primary 7 (undertaken in the final year of primary school) health screenings, as well as weekly ‘health zones’. Whether this will provide a means for children and young people with nocturnal enuresis to access one-to-one advice and support from a health professional remains to be seen.
Lack of equity in access
Several health boards have taken steps to fill the gaps in service provision by commissioning and developing nurse-led community paediatric continence services. However, these are being agreed at a local level with no national service model directive, giving no assurance of equitable continence services for all.
The campaign group Paediatric Continence Forum proposes that all health areas in the UK should provide equitable access to an integrated, community based paediatric continence service. It challenges children’s services to develop joint plans and policies that will ensure children and young people with continence problems are appropriately supported in schools. The forum published a guide to support local service development or redesign in 2014, which was updated in 2018 (Paediatric Continence Forum, 2018).
The GIRFEC approach
The GIRFEC approach aims to offer the right help at the right time from the right people, and to foster partnership working between services and children and their families. It means the child and family:
- Understand what is happening and why;
- Have been listened to carefully, had their wishes heard, understood and taken into consideration;
- Feel confident that the support provided to them is adequate;
- Are appropriately involved in the discussions and decisions that affect them;
- Can rely on appropriate help being available as soon as possible;
- Experience a more straightforward and coordinated response from the people working with them.
The approach is illustrated in the GIRFEC Wheel (Fig 1). It provides a perfect template for how an effective community based paediatric continence service can contribute towards the health and wellbeing of children and young people affected by nocturnal enuresis.
Continence services for children and young people in Scotland remain fragmented, with service models being agreed by health boards at a local level. The roll-out of the refocused school health service, with pathways designed to meet local need, is likely to lead to more inconsistencies and wider gaps in service provision.
Adapting the GIRFEC Wheel to support children with nocturnal enuresis could help standardise service provision across Scotland, so that wherever they live, children receive the same high-quality treatment and support for nocturnal enuresis. However, the new school nursing model will require more resources to ensure school nurses have the capacity to engage with education and support staff, and with children and young people, to manage nocturnal enuresis and continence issues in schools.
- Nocturnal enuresis can have a deeply negative impact on children or young people
- A child with nocturnal enuresis needs to be comprehensively assessed by a health professional with appropriate expertise
- In Scotland, the provision of school nurse support for children with enuresis has become unsustainable
- The Getting It Right for Every Child (GIRFEC) approach is used in Scotland to improve the wellbeing of children and young people
- The approach provides a template for supporting children with nocturnal enuresis in schools
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