Continence care rounds were introduced to provide education to staff and patients at the bedside. The initiative has promoted toileting and reduced disposable pant use
The introduction of continence care “back to the floor” (BTTF) rounds at Queen Elizabeth Hospital, Birmingham has resulted in improved patient care, along with increased knowledge and skills for nurses in the management of incontinence. During the BTTF rounds, patient and staff education is delivered direct at the bedside by specialist nurses. This has improved patients’ understanding of these issues, and built nurses’ confidence and ability to provide dignified and individualised care. The rounds have also helped to reduce unnecessary expenditure on continence products. This initiative won the Continence Promotion and Care category of the 2012 Nursing Times Awards.
Citation: Roberts F, Thompson L (2013) Back to the floor for continence care. Nursing Times; 109: 4, 12-14.
Author: Fran Roberts is urology continence nurse specialist; Liesel Thompson is practice development nurse; both at University Hospitals Birmingham Foundation Trust.
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In the UK, 14 million people are affected by some form of bladder problem, and 6.5 million by some form of bowel problem (Bladder and Bowel Foundation, 2012). This means there are more people affected by these problems than by asthma, diabetes and epilepsy combined. Incontinence can impact upon an individual’s life hugely, causing role limitation and social exclusion, and can significantly affect physical and psychological wellbeing. Incontinence in older adults is often the factor prompting a move into a residential care setting (Pearson et al, 2002).
Since incontinence impacts on many conditions, good continence care can contribute to many NHS priorities. Failure to manage incontinence adequately could lead to patient injury or other adverse consequences. For example:
- It could result in damage to the skin, leading to infection or increased risk of pressure ulceration;
- Urinary catheterisation places patients at significant risk of acquiring a urinary tract infection;
- Unmet “toileting needs” may lead to falls;
- Inadequate assessment of incontinence with an emphasis on containment rather than cure is expensive, from both a health and financial perspective.
Continence care BTTF rounds facilitate bedside continence education, empowering ward nurses to offer high-quality continence assessment and care. Ward visit observations and experiences are now influencing development of more appropriate training strategies while championing changes in practice. The visits also provide opportunities to speak to patients who have continence difficulties and their families, allowing them time to comment on their perception of their care.
The project has reinforced what we already know about the challenges of managing time to access staff education and training. As a result we have tried to be creative in how we deliver education and training, by taking it to clinical areas.
What we do
Our aims are to:
- Improve the patient experience;
- Prevent hospital-acquired incontinence;
- Reduce incontinence-related pressure ulcers, infection and falls;
- Promote patient independence while in hospital;
- Improve nurses’ knowledge and skills in continence care;
- Encourage dignified and individualised care.
Getting the right message across as to what you are hoping to achieve is key to being welcomed into a clinical area. We demonstrated our intentions were non-threatening and that we were there to support, not to judge. We listened to the needs of the patients and staff and addressed these, without making assumptions.
We devised a BTTF template to ensure continuity, and to give structure to the visits. The template focuses on areas of practice and care that have been identified as requiring improvement following incidents, from local and national recommendations and from trust standards.
We currently spend one to two afternoons per week, depending on workload commitments, in areas where clinical care is given. We review the standard of care delivered, and check that it is reflected in the patient’s documentation. We identify patients to review in each clinical area in collaboration with the nurse in charge and/or department manager. This ensures we prioritise the needs of patients and the ward during the allocated time. As a result we can support and educate nurses and patients at the bedside, addressing any care issues that may arise.
Improving assessment and care
Staff benefit from the visits by accessing our skills and knowledge in the assessment and management of this group of patients. This also allows us to identify education and training needs and any gaps in resources. As a result staff feel confident to undertake accurate assessments that identify individual care needs, and empowered to deliver care to a high standard.
We review continence products stored on the ward to see if the range is appropriate to patient need, and address economic efficiency to prevent wastage. We also promote the use of visual product guides to assist staff in selecting the product that best meets the needs of their patient.
The BTTF round is used as an opportunity to promote trust guidance on all aspects of continence and urinary catheter management, along with other related guidance such as skin and pressure area care. Given that preventing and reducing pressure ulcers and falls is a high priority, our visits give us the perfect opportunity to raise awareness on how incontinence can impact on both of these issues.
Our findings are uploaded onto the clinical dashboard where the ward staff, matrons and managers can access them. This ensures our findings and recommendations are shared, promoting a learning experience. We also ensure our BTTF visits are catalogued by the risk management department, so we can provide evidence to visiting governing bodies when required.
Benefits of the initiative
We have found the continence care round:
- Improves the support and reassurance offered to patients and carers, while promoting dignity and independence during their hospital stay;
- Raises the profile of continence assessment and care, which in turn will improve the care delivered to patients;
- Improves staff confidence, knowledge and skills in caring for patients with continence problems;
- Increases staff awareness of when and how to refer to specialist services;
- Helps to reduce the incidence of infection, pressure damage, moist tissue lesions and hospital-acquired incontinence;
- Helps to minimise the impact of continence problems.
We believe the benefits from the rounds, and the positive effect they have had on ward staff, suggest they could be replicated by other specialties and even throughout all healthcare settings. The positive effects of the rounds were immediate, which has been demonstrated by the number of requests we have received to visit and support staff in other clinical areas.
The case study in Box 1 gives an example of how our rounds are having a positive impact on patient care. This demonstrates how useful an assessment document is, and how important it is to get the content right to encourage nurses to consider other options for patients. It is also vital to ensure the content is appropriate for the environment, which is something we can assess on our rounds.
A recent audit has demonstrated that since March 2012, a previously increasing trend towards pad and pant use for patients is now changing. There has been a 23% reduction in the use of adult pull-up disposable pants and an increase in use of the lowest absorbency pads. There has also been a reduction in the use of all-in-one belted incontinence pads, which we feel could be reduced further. We will continue to work in partnership with other specialist teams to promote this good practice on our continence care BTTF rounds, while encouraging staff to use care rounds to promote toileting.
After implementing the rounds, we have received an increasing number of requests to visit clinical areas and provide education on continence care issues. This highlighted a bigger need for these rounds than anticipated, and demonstrated that there had been a lack of easily accessible education in continence care.
We have considered the cost and time implications of setting up these rounds. They are not only proving valuable to ward staff and patients, but also an aspect of our own roles is being fulfilled because we are promoting best practice across the trust.
By undertaking this project we are promoting cost-effective care. We are reducing stock of inappropriate products and helping to reduce the cost implications associated with infection, pressure ulcers, falls and increased length of hospital stay due to unresolved continence issues.
We are also proud to have won the Continence Promotion and Care category in the 2012 Nursing Times Awards. We hope this will raise the profile of the continence care BTTF rounds, and other trusts will be inspired by the project.
- 14 million people in the UK are affected by a bladder problem
- Incontinence in older people may prompt a move to residential care
- Poor continence care can lead to pressure ulcers and falls
- Hospital staff welcome ward-based continence training
- Better continence care saves money and benefits patients
Bladder and Bowel Foundation (2012) About Us.
Pearson J et al (2002) Incidence of Incontinence as a Factor in Admission to Aged Care Homes. Report prepared for the Australian Government Department of Health and Ageing.