A review of continence services around the world revealed that a key element in improving care would be the use of trained nurse specialists at the first assessment
Global demographic trends suggest the incidence of both urinary and faecal incontinence will rise in the coming years, with significant health and economic costs for patients and healthcare services. Healthcare providers across the globe lack guidance on how to deliver the most efficient, patient-focused care. The key finding of a report drawn up to address this was that specialist nurses have an important role in initial assessment and treatment, supplanting doctor-led provision models. This can be achieved through accredited training.
Citation: Wagg AS (2015) Improving continence care around the world. Nursing Times; 111: 22, 22-23.
Author: Adrian Wagg is professor of healthy ageing, Department of Medicine, University of Alberta, Canada.
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The World Health Organization says incontinence is a group of diseases that affects 4-8% of the world’s population (Milsom et al, 2009) - at least 400 million people. Despite this high prevalence and a rising incidence, incontinence has a low priority with health professionals and policy makers.
Continence is a significant issue with ageing populations. Incontinence is often associated with long-term conditions such as dementia, diabetes and heart disease, all of which have an overwhelming effect on the quality of life of those affected, as well as their families and caregivers. Aside from embarrassment and social stigma, incontinence can lead to depression and social isolation. It is also the most common reason for a move into supported accommodation.
Incontinence is associated with significant morbidity, which increases use of health and social care resources. This in turn increases the burden on healthcare systems beyond the treatment of the condition itself. A significant economic effect results from indirect costs due to lost productivity from working older adults and caregivers. There are also associated intangible costs, including those associated with the financial burden of the disease.
Continence care therefore needs to be as efficient and effective as possible.
Developing an evidence base
The Developing an internationally-applicable service specification for continence care report (Wagg et al, 2014a) was drawn up to provide an evidence base for providers and health professionals on how best to procure, organise and deliver continence care services.
Evidence for the report was obtained from a systematic and grey literature review of randomised controlled trials reporting on the efficacy of continence service design at the level of the community-dwelling patient with bladder and/or bowel incontinence. We also looked at governmental reports and policy, and used data from 47 semi-structured interviews with clinicians, patient representatives and policy experts to broadly represent healthcare systems around the world.
The report examines in some detail the provision of continence care in the very different healthcare systems of the UK, the US, India and the Netherlands. It also makes recommendations regarding measures that could enable people with incontinence to enjoy a better quality of life, be encouraged to manage their own care, remain in the community for longer and have less need for acute services.
Continence care in the UK
For the UK, the report emphasises the importance of patients being seen at the most appropriate time by the most appropriate professional. Evidence suggests that care delivered by trained or specialist nurses, rather than doctors, during initial assessment and treatment should lead to improved outcomes. Conservative treatment options, individually tailored, should be considered first as they are often as effective as more invasive measures.
This approach is supported by data from the Leicestershire MRC incontinence study (Williams et al, 2005), which suggests that, where trained specialist nurses lead the provision of continence services and provide conservative treatment, the short- and medium-term outcomes are good. Such nurses may also be well suited to act as case coordinators for patients with continence problems. Patients in the study were more satisfied with their overall level of care than those receiving existing approaches, which provides further evidence that in the UK continence nurse specialists are well suited to performing the role of case coordinators.
Where fully trained continence specialist nurses are unavailable or resources are constrained, employing extended practice nurses in continence care would seem logical. These practitioners could provide the initial assessment and management. Better training for GPs would improve referrals to specialist physicians and physiotherapists for assessment and treatment.
The UK is also well placed to exploit technology to enable and support self-management and information-sharing between patients and practitioners, and potentially to reduce geographical inequality in access to care.
To enable appropriate nurse training, case coordination and better patient management, investment is needed in local services. Growing pressures on the NHS may prompt this. Greater collaboration with patient-advocacy and third-sector organisations dedicated to incontinence, women’s health issues or care for older people has a significant role to play; such partnerships may improve the accessibility of care. Financial and performance incentives, perhaps through Commissioning for Quality and Innovation incentive payments, could be agreed locally between commissioners and providers.
While continence care is unlikely to be included in the Quality and Outcomes Framework for general practice in the near future, the report proposes that linking the achievement of continence-related quality outcomes to payment could dramatically improve how continence care is regarded among GPs in the UK. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) also need to carry more weight when service quality is assessed, and performance incentives could be linked to these measures.
Greater use of nurses is also central to improving continence care in the US, particularly where advanced practice nurses are able to act in an advisory role in addition to providing initial assessment and management. Improvements to continence care would require significant reforms in the US healthcare economy to integrate health and social care, as well as to improve multidisciplinary working and define pathways between primary, secondary and tertiary care providers.
In the Netherlands, there was compelling evidence for the greater involvement of continence care nurse practitioners; a greater shift of resources to primary care also appeared important to allow earlier and more effective assessment and implementation of conservative treatment, which would be more efficient than immediate referral to secondary care. Moreover, Dutch higher professional education (HBO-level) nurses required further training so they could practise in primary care; this would extend their scope of practice to include initial assessment and treatment and prescribing products and medicines.
In India, there is a general shortage of nurses and those that do exist typically work under the supervision of doctors, with little autonomy. The report advocates training a new group of staff, regardless of background, to improve access to continence care. This would include better education for doctors as well as for community healthcare workers, who could be trained to deliver the initial assessment and management.
Regardless of nation, there is a clear need to produce a cohort of appropriately trained nursing staff to deliver care, from basic continence care provision through to highly educated clinical nurse specialists with higher degrees.
The role of the specialist nurse in its widest sense is essential in providing high-quality care that is compliant with guidelines to patients with incontinence around the world. In particular, these nurses have an important role to play in initial assessment and treatment, supplanting physician-led models of provision. This can be achieved by establishing accredited training programmes for nurses wanting to become continence specialists. The role of these nurses is an important aspect of the report’s recommendations, particularly given that incontinence is not widely seen as a priority condition by many GPs.
The Summary of Optimum Continence Service Specification (Wagg et al, 2014b) - a summary of the main report - discusses how health systems could review the way in which continence care is organised and how they could use resources in the most effective and efficient way to improve patients’ quality of life.
The summary report advocates a holistic and collaborative approach to continence care, which will deliver benefits regardless of the healthcare system in operation. However, if its recommendations are to be successfully implemented, there is a pressing need for policymakers everywhere to place greater focus on continence as a health and social care issue and devote adequate funding and resources to it.
- Incontinence affects 4-8% of the world’s population - at least 400 million people
- It causes significant morbidity, leading to a greater burden on healthcare systems
- Incontinence is not seen as a priority condition by many GPs
- Patients need to be seen at the most appropriate time by the most appropriate professional
- Trained specialist nurses are best placed to make the first assessment of patients
Milsom I et al (2009) Epidemiology of Urinary (UI) and Faecal (FI) Incontinence and Pelvic Organ Prolapse (POP). Bristol: International Continence Society.
Wagg AS et al (2014a) Developing an internationally-applicable service specification for continence care: systematic review, evidence synthesis and expert consensus. PLoS ONE; 9: 8, e104129.
Wagg AS et al (2014b) Summary of Optimum Continence Service Specification: the Ideal Organisation of Care for People with Incontinence. Gothenburg, Sweden: SCA.
Williams K et al (2005) Clinical and cost-effectiveness of a new nurse-led continence service: a randomised controlled trial. British Journal of General Practice; 55: 696-703.