The prevalence of incontinence is set to increase so it is imperative that continence education is assessed and inadequacies are addressed to improve patient care
Care for patients with continence problems is often substandard, and inadequate education is often cited as a probable cause. These factors, combined with the forecasted increase in the number of people with incontinence, prompted us to undertake a survey of all UK higher education institutions to establish how much undergraduate continence education nursing and other students receive. A mean of five hours per programme was provided (range 2.5-7). Our results indicate that the amount of undergraduate continence education has changed little over the past 17 years. Developing core competencies - which can be taught using innovative techniques in an interprofessional setting - may be a useful way to fill in the gaps that exist in continence education.
Citation: McClurg D et al (2013) Improving continence education for nurses. Nursing Times; 109: 4, 16-18.
Authors: Doreen McClurg is reader and principal investigator, Katharine Jamieson is research assistant, Suzanne Hagen is professor and programme lead, all at Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University; Francine Cheater is professor and associate dean of research at School of Life and Health Sciences, Glasgow Caledonian University; Sharon Eustice is nurse consultant for continence at NHS Cornwall and Isles of Scilly; Joanne Burke is senior university lecturer at Medical Undergraduate School, School of Medicine, Glasgow University.
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Urinary and/or faecal incontinence can affect people of any age and gender, impact on all aspects of people’s lives and on their families, and can be costly to the NHS if not proactively identified, assessed and treated (Wagg et al, 2009; Williams et al, 2005). An ageing population, with an increasing prevalence of incontinence, creates a need for continence promotion, education and training that can lead to cure and better management.
Poor standards of continence care continue to be reported (Mid Staffordshire NHS Foundation Trust Inquiry, 2010) and national audits of continence care (Royal College of Physicians, 2010; 2006) have cited inadequate professional education as a major contributory factor.
Laycock (1995) surveyed schools of nursing, schools of medicine and regional GP training units in the UK, as well as schools of physiotherapy in England. The results indicated that an average of nine hours was spent on continence education in pre-registration nurse education, four hours in physiotherapy and three hours in undergraduate medical education. These findings complement those of Norton who observed that urinary incontinence was rarely treated as a separate subject in schools of nursing in the UK (Norton, 1996). In a Nursing Times survey of 1,000 qualified nurses (Lomas, 2009), a third of respondents reported receiving no education about caring for patients with incontinence during their undergraduate nursing programme; 53% reported having no continence training after registration.
The aim of the study reported here was to identify the present structure, quantity, and content of continence education at undergraduate level in healthcare programmes by conducting a national survey of higher education institutions (HEIs).
We designed a semi-structured questionnaire following a review of the literature and consultation with experienced HEI teaching staff. Ethical approval for the study was obtained from Glasgow Caledonian University’s Research Ethics Committee.
Using the University and Colleges Admissions Service database, we identified 86 appropriate HEIs in the UK and contacted the deans or head of school to inform them of the study. The questionnaire was then sent to programme leads.
Eighty-five of the HEIs contacted agreed to take part in the study. An overall response rate of 81% (n=294) was obtained. Of the 294 respondents, 246 (83.7%) reported that there was some continence education within their programme, while 41 (13.9%) stated that there was no continence education (there were seven non-responders to this question).
All adult nursing programme leads reported some continence content. The mean estimated number of hours of such education was greatest for adult nursing (7.3 hours) and least for occupational therapy (2.5 hours) (Table 1). Of those institutions offering continence content, 5.7% (14/246) indicated that their programme included a separate continence module, which in 10 cases was in addition to content provided elsewhere in the curriculum. The remaining institutions (94.3%) offered continence content embedded within other modules.
Fifty per cent of respondents stated that over the previous five years there had been no change in the curriculum in this area (either in content or allotted time); 22% reported an increase and 30% a decrease. The main reasons reported for a decrease were pressure on curricular content (17%), and a reflection of change in curricular policy (60%). Reasons documented for an increase included a change in the curriculum, and a new member of staff with an interest in continence.
Just under half of respondents (106/237, 44.7%) indicated their programme had a member of teaching staff with specialist knowledge of the assessment and management of continence. In total, 83.3% (205/246) indicated the continence content was delivered by permanent academic staff. Only two responses - both from adult nursing - reported the sharing of education; both did so with another branch of nursing (mental health).
Across all of the professions, the main modes of delivery of continence-related training were reported to be lectures and practice-based learning. Overall slightly more time was spent on assessment and management of continence than on aetiology and prevalence.
The results demonstrate that, contrary to international recommendations (Newman et al, 2009), there is little evidence of compulsory inclusion of a specified number of hours of continence education in undergraduate programmes, or that continence is identified, planned and taught as a separate topic to approved standards within any of the UK undergraduate curricula. It would also appear that, despite repeated calls for an increase in content and emphasis in continence education, this has not occurred.
Laycock’s (1995) study identified an average of 5.6 hours of continence education over the entire undergraduate programme across medicine, nursing and physiotherapy. In comparison, we identified a mean of 4.7 hours across all educational programmes surveyed - a figure that includes the 13.9% of programmes where the leads reported no continence education provision at all. Furthermore, 50% of the programmes reported no changes over the previous five years to continence education in terms of content and allotted time. The apparent lack of change in allotted time is a concern, given that poor-quality care continues to be highlighted (Mid Staffordshire NHS Foundation Trust Inquiry, 2010; RCP, 2010; 2006) and the number of patients at risk of developing incontinence is set to increase as the population ages. If patients receive proper assessment and management, large health and social care cost savings can be made (Williams et al, 2005), as can improvements in the quality of life of patients and their carers (Cheater et al, 2008).
Developing competencies may be a way forward. Examples include core competencies in undergraduate education relating to the care of patients who are acutely ill, being developed via consensus between health professionals (Perkins et al, 2005).
Seventy-eight per cent of the programmes surveyed continued to rely heavily on lecture-based teaching. There is growing evidence to suggest that traditional “lecture-style” education is ineffective in changing physician behaviour and, ultimately, patient outcomes (Mazmanian and Davis, 2002). There is perhaps scope for online and computer-assisted learning, which can be accessed in the student’s own time and potentially reduces the amount of teacher contact time needed. One example of this is training in infection control in the King’s Healthcare Foundation Trust and Guy’s and St Thomas’ Foundation Trust (O’Brien et al, 2009).
If core competencies for undergraduate education in continence can be agreed, innovative ways of providing teaching or experience can then be developed to fit in with the time constraints of the curriculum, the conflicting needs of other topics and the limitations of facilities for clinical placements. These might be individual to each profession but could also include common interprofessional themes.
Interprofessional education was conspicuous for its absence within the results of this survey (the only shared teaching experience was between some of the nursing programmes). As such, developing core competencies in the treatment of incontinence, which can be taught using innovative training techniques in an interprofessional setting, may be the way to improve the knowledge base of undergraduate healthcare students. The harnessing of local opportunities and enthusiasm is likely to be crucial - clinical experts could offer teaching sessions, single-day visits or short, intensive placements. These may be cost- and time-effective ways of addressing some of the training gaps identified in this study.
The results of this survey of undergraduate continence education suggest that the position has changed little since Laycock’s survey more than 15 years ago.
Those involved in professional education and the promotion of professional standards - including the Royal College of Nursing - need to consider the results of this survey and address the deficiency of education that exists in this important clinical area.
- This is a summary of: McClurg D et al (2012) A multiprofessional UK wide survey of undergraduate continence education. Neurourology and Urodynamics; doi: 10.1002/nau.22284.
- This study was supported by the Dunhill Medical Trust (grant reference no: R131/0709).
- National audits of continence care have repeatedly highlighted inadequate professional education
- Nurses receive on average 7.3 hours of education on continence in undergraduate programmes
- In the past five years, the amount of continence education most students receive has either stayed the same or gone down
- Core competencies in continence could be created for nurses and other professionals
- Better use of IT-based training and expert time would help fill training gaps
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