Children with bladder problems may need help with catheterisation at school. Health professionals must know local and national policies to deliver this safely
Joanne Searles, MmedSci, RGN, RSCN, is urology nurse specialist, Sheffield Children’s Hospital.
Searle J (2010) Enabling school staff to provide clean intermittent catheterisation during the school day. Nursing Times; 106: 47, early online publication.
Successful clean intermittent catheterisation depends on the ability of the child, parents and carers to undertake the procedure and to effectively integrate it into both home and school life. Paediatric continence nurses need to support this process by addressing the concerns and anxieties of school staff. Inconsistencies in practice and absence of local policy can exacerbate concerns and anxiety. This article highlights the main issues surrounding use of CIC in schools and discusses them in the light of current legislation and guidance.
Key words Catheterisation, Procedures, Schoolchildren, Training
- This article has been double-blind peer reviewed
Implications for practice
Health professionals involved in the care of children with bladder problems should be appropriately qualified and competent to teach clean intermittent catheterisation. Their role and responsibilities include:
- Providing education and information regarding the individual child, the medical condition and the procedure;
- Considering anxieties and concerns of staff before identifying volunteer staff to carry out the procedure (several introductory/planning meetings may be necessary);
- Negotiating, planning and delivering evidence based training which is child and carer specific;
- Ensuring there is comprehensive and robust documented evidence of training and competency of competency staff;
- Providing ongoing support for child, parents ,carers and school staff;
- Facilitating individualised school health care plans;
- Making sure they are familiar with local, national policy and available literature to help address the questions and concerns of school staff.
Clean intermittent catheterisation (CIC) is a simple, quick and effective procedure for the management of children with neuropathic bladder, intractable urinary incontinence, urinary retention or incomplete bladder emptying.
Legislation in the UK over the past twenty years has promoted inclusive education so that children with special needs, including those with disabilities or complex health needs, have the right to be educated in mainstream schools (Department of Education, 2001). Government policies including Managing Medicines in Schools (Department for Education and Skills and Department of Health, 2005) and Including me (Carlin, 2005) offer guidance for schools about roles, responsibilities, entitlement and provision of support for those with complex healthcare needs.
I have found that where there are no local policies for CIC, school staff, parents and health professionals can experience heightened feelings of inadequacy, anxiety and concern, which can lead to conflict. This can also prevent children from participating fully in school activities and affect attendance, achievement and socialisation (Fishwick and Gormley, 2004).
School staff do not understand bladder problems as well as other long term conditions such as diabetes, asthma and epilepsy and this lack of knowledge and understanding is a major reason for anxiety and concern (Fishwick and Gormley, 2004). The intimate and perceived medical nature of CIC can raise issues about child protection, the risk of harm to the child and debate about who should be responsible for it. Head teachers may be concerned about the provision of appropriate facilities and adequate funding to support the child.
Developing a local policy for CIC is essential to decrease anxiety and confusion for parents, school staff and health professionals and will ensure commitment and promote shared governance and ownership (Carlin, 2005; Fishwick and Gormley, 2004). The guiding principle throughout all negotiation, planning and training must be to safeguard the child and the employees who agree to undertake the procedure.
Protection and preventing harm
Health professionals need to reassure carers that CIC is a normal everyday procedure which, if painful, would be unacceptable to the child and would result in non compliance. Extensive research has demonstrated the efficacy of the procedure and shown that carers performing CIC pose no more risk than an individual performing self catheterisation (Moore et al, 2007).
CIC ensures complete bladder emptying, thereby preventing infection, preserving renal function and promoting continence. This in turn increases self esteem, self worth, positive body image and the confidence to enjoy and participate in normal everyday activities. This helps to secure the child’s physical, psychological, emotional and social wellbeing (DfES and DH, 2004; DH 2003). Failing to carry out CIC in school puts children with continence problems at significant risk of harm and is detrimental to their overall health and safety.
The Children Act (2004) requires organisations employing staff in child care positions to ensure that these staff have regular checks by the criminal investigations bureau. This allows them to provide intimate care without needing a second person present (Carlin, 2005). Written consent from parents and head teacher is essential to protect everyone involved in CIC (Carlin, 2005; DH, 2001).
Who can perform CIC?
There is no contractual obligation for teachers and non teaching staff to manage pupils’ medical needs, and staff do so voluntarily.
To ensure safety and protection, CIC must be delivered reliably and consistently during the school day by someone familiar and acceptable to the child. Privacy and dignity dictates that the number of people present during the procedure should be kept to a minimum and there must be cover for absence and sickness.
It is practical for CIC to be undertaken by school staff (DH, 2000) as they have a common law duty of care to behave as a responsible, careful parent would do to promote the welfare, health and safety of children (DoE, 2001; The Royal College of Nursing, Carlin, 2005) suggest that CIC can be safely taught to unqualified personnel and in school the classroom assistant is the logical choice. Office staff, dinner ladies and other school staff may also be considered as suitable carers. In the absence of any volunteers it may be necessary for schools to advertise and employ someone specifically for this purpose.
In some areas parents are expected to come into school to perform CIC or to change a continence product. This does not foster independence or promote social normality for the child and contravenes the Equality Act 2010. It is also inappropriate to leave a child in soiled or wet clothes until a parent is able to attend (Carlin, 2005)
Facilities and equipment
The Local Education Authority (LEA) has a responsibility to provide an appropriate room for medical treatment with suitable hand washing and toilet facilities (DoE,1999). Funds are available for schools via the LEA annual school action initiative fund to improve the physical environment so that children with disabilities can access mainstream education. Facilities must take account of the need for privacy and dignity.
Staff must be taught effective hand washing techniques and schools should ensure adequate provision of soap and water. Care staff should use protective non sterile gloves (NICE, 2010) and it is the employer’s responsibility to provide protective equipment (Health and Safety Executive, 1999) and waste disposal facilities (DH, 2002). Hygiene disposal units are a cost effective way for the school to dispose of catheters. Further information regarding facilities or equipment in schools for CIC is outlined in GoodPractice Guidelines for Continence Services (DH, 2000). Catheter manufacturers also provide information and booklets on catheterisation in schools.
A robust governance framework is essential for training and preparation of carers. Training must be undertaken by PCT or NHS trusts and carried out by suitably qualified health professionals who are experienced and competent in catheterising children (Carlin, 2005). Health professionals are legally accountable for the tasks they delegate, even if they are not present when it is undertaken (NMC, 2008).
It is vital the procedure taught follows evidence based guidelines and the competency of the carer is assessed and documented. Staff who follow documented procedures given by the health professional will have full support of the LEA and are fully covered by their employers liability insurance in the event of a complaint (DfES/DH, 2005) The head teacher has a contractual duty to ensure staff receive training and the PCT has discretion to make resources available for training. While parents may play an important part in the training process it is not appropriate for parents to be responsible for organising and delivering training to schools as this will affect liability insurance.
To validate insurance, education authority risk assessors will require written evidence of comprehensive training undertaken by a suitably qualified health professional and written evidence of competency in addition to consent of all relevant parties. It is also necessary to ensure staff have regular updates and reassessment of competency (Carlin, 2005). Individual authorities may require additional information.
Catheterisation should be included in carers’ job descriptions and in the child’s school health care plan. Individual healthcare plans should be drawn up by the school nurse and the person teaching CIC in collaboration with parents, school staff and the child where appropriate. Including Me (Carlin, 2005) offers in-depth guidance on compiling health care plans.
Comprehensive and legally robust documentation is essential to minimise the risk of litigation and to ensure employee safety is not compromised. Examples of documentation are available in Including Me (Carlin, 2005) and Managing Bladder and Bowels in Schools and Early Years Setting (Promocon, 2006).
Funding of support
CIC generally requires less than three full hours support per week (approximately 15 minutes per catheterisation) and this is usually funded from within the school special needs budget. Some children who require CIC have additional needs such as hydrocephalus and may require assessment for an educational statement.
Schools with a number of children requiring CIC may choose to approach the LEA for additional support. Clarification of local funding arrangements is invaluable and may be obtained from the LEA.
Providing CIC in school is fundamental to the overall safety and wellbeing of the child who requires it. Effective communication, negotiation and collaboration between health and education services are vital to ensure that it is performed safely and effectively.
Many of the issues and concerns around CIC also apply to other aspects of continence care in schools such as changing continence products and implementing toileting programmes for children. Much of the guidance discussed in this article is relevant to other areas of continence care.
Health professionals involved in paediatric continence care should seek to influence the development of local policies to include the specific needs of children with continence issues for the benefit of children, parents, and health and education services.
Carlin J (2005) Including Me; Managing Complex Health Needs in Schools and Early Years Settings. London: DfES/CDC.
Department of Education and Skills (2001) Special Educational Needs and Disability Act. Code of Practice. London: DoE.
Department of Education (1999) Education School Premises Regulations.
Department for Education and Skills, Department of Health (2005) Managing Medicines in Schools andEarly Years Settings. London: DfES/DH.
Department for Education and Skills and Department of Health (2004). National Service Framework for Children, Young People and Maternity Services. London: DfES/DH.
Department of Health (2003) Every Child Matters. Change for children in health services. London: DH.
Department of Health (2002) Control of Substances Hazardous to Health. London: DH.
Department of Health (2001) Reference guide to consent for examination and treatment. London: DH.
Department of Health (2000) Good Practice in Continence Services. London: DH.
Fishwick J, Gormley A (2004)Intermittent Catheterisation in School: A collaborative agreement. ProfessionalNurse; 19: 9, 519-522.
Health and Safety Executive (1999) Management of Health and Safety at Work Regulations. London: HSE.
Moore KN et al (2007) Long-term bladder management by intermittent catheterisation in adults and children. Cochrane systematic review. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD006008. DOI: 10.1002/14651858
National Institute for Health and Clinical Excellence (2010) Infection Control. Prevention of healthcare associated infection in primary and community care. London: NICE.
Nursing and Midwifery Council (2008) The code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC.
PromoCon (2006) Managing bladder and bowels in schools and Early Years Settings: Guidelines for Good Practice. Manchester: PromoCon, Disabled Living.
Enabling school staff to undertake clean intermittent catheterisation