Management and promotion of continence in rehab settings. This is an extended version of the article in Nursing Times; 104: 6, 35-36.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”
Alice Coffey, MEd, BA, RNT, RM, RGN, is research associate and college lecturer; Geraldine McCarthy, PhD, MSN, MEd, DipN, RNT, RGN,is head of school; both at School of Nursing and Midwifery, University College Cork, Republic of Ireland; Brendan McCormack, DPhil, BSc, PGCEA, RNT, RMN, RGN, is director of nursing research, University of Ulster and Royal Hospitals Trust; Jayne Wright, MSc, RGN, is research associate; Paul Slater, PhD, MSc, BSc, is research associate; both at University of Ulster.
Coffey, A. et al (2008) Management and promotion of continence in rehab settings. This is an extended version of the article in Nursing Times; 104: 6, 35-36.
BACKGROUND: Both urinary and faecal incontinence are strongly associated with institutional care and, in particular, with dependence on physical care (Durrant and Snape, 2003). Current approaches to continence care tend to focus on safety and risk reduction, rather than detailed individualised assessment and management. This study forms part of a larger study on continence care.
AIM: To explore approaches to assessment, diagnosis and management of urinary and faecal incontinence in two rehabilitation settings for older people.
METHOD: The Royal College of Physicians’ audit scheme (Brocklehurst, 1998) was used to record the assessment and management of urinary and faecal incontinence. It includes questions on resources available to enable effective continence management. Patients with incontinence (n=220) participated in two study sites in Northern Ireland and the Republic of Ireland.
RESULTS: Findings revealed a lack of specific continence assessment and rationale for treatment decisions or continuing care, even though 60% of patients had urinary incontinence, 3% had faecal incontinence and the remainder had both urinary and faecal incontinence. The focus was on continence containment rather than on management, and guidance or appropriate education for continence management was not available to staff.
CONCLUSION: Sustained incontinence has profound physical and psychosocial implications. Strategies should therefore focus on developing person-centred and evidence-based approaches to continence promotion and management.
Going to the toilet is a personal and private activity and the impact of incontinence on functional, psychological and social well-being has been widely reported (Bliss et al, 2004; Edgley, 2002). While the physiology of ageing can contribute to incontinence in older people, according to Wilson (2003), this is not inevitable.
Roe and Doll (2000) described urinary incontinence as a substantial issue following a postal survey of adults in the UK, which revealed a prevalence of 9%. Studies conducted in Europe, Australia and the US also found incontinence to be more prevalent in those over 65 (Hunskaar et al, 2004; Bogner et al, 2002; Muscatello et al, 2001).
New epidemiological studies have focused on faecal incontinence (Edwards and Jones, 2001) but research has associated it with increasing age, disability, depression and urinary incontinence (Ho et al, 2004; Edwards and Jones, 2001).
Both urinary and faecal incontinence are strongly associated with institutional care and, in particular, with dependence on physical care (Durrant and Snape, 2003). Stroke survivors are reported to be particularly affected (Brittain et al, 2006; Patel et al, 2001). In fact, Patel et al (2001) found that urinary incontinence was present for up to two years post-stroke and outcomes of stroke rehabilitation were adversely influenced by the presence of incontinence.
Although there is international research on the prevalence of incontinence, there is a paucity of research in the Republic of Ireland. Only one study, conducted by Market Research Centre Ireland (2001), reported that 33% of the Irish population over 40 suffered some form of bladder control problem, and 52% of respondents perceived bladder problems to be a natural part of ageing. However, no research has focused on continence in rehabilitation settings for older people.
Diagnosis and management of incontinence
In clinical practice the diagnostic approaches often used include a detailed history (medical diagnoses, medication and functional capacity such as activities of daily living, psychological and social function, and living environment) and a focused physical examination (Abrams et al, 2002; Thompson and Smith, 2002; Sarkar and Ritch, 2000).
According to the Royal College of Physicians (1995), urinary incontinence can be cured or alleviated in up to 70% of cases, implying that an underlying cause can be found and should be investigated. There is ample evidence (Sarkar and Ritch, 2000) that nursing measures including hygiene, diet and fluid intake and bowel care are effective in improving and restoring urinary continence for many patients. It has been suggested that simple measures such as improving toilet facilities and removing environmental barriers may resolve the problem of incontinence (Williams, 2004; Williams et al, 2002). For example, effective management of ward furniture and equipment would improve physical access to toilet facilities. Nurses can take the initiative in implementing these measures, and encourage dialogue with patients about continence.
However, there is evidence in the literature that incontinence continues to be inadequately diagnosed and managed (Coffey et al, 2007). In addition, some professionals see continence problems as an acceptable part of ageing (Irwin et al, 2001; Thomas, 2001).
In a study conducted in Northern Ireland, Irwin et al (2001) found inadequate assessment, poor record-keeping and, consequently, a limited degree of active treatment of incontinence and a reliance on incontinence pads. More recently, a national audit of continence care for older people in the UK found that inadequacies persisted in routine assessment and diagnosis, even though practitioners’ knowledge was good (Wagg et al, 2006). Underlying causes of incontinence were often not documented, especially in hospital care, and reliance on the use of pads and catheters for containment remained.
The promotion and management of continence for older people should be within person-centred models of practice (De Laine et al, 2002).
This study was conducted as part of a larger two-year case study, which aimed to identify the determinants of practice context that enable or hinder proactive approaches to the promotion of continence and treatment of incontinence. The larger study also explored the practice context in which continence care is managed using case study methodology. The methodology and findings of other aspects of this larger study are reported elsewhere (Coffey et al, 2007; Wright et al, 2006).
The objectives of this smaller study were:
To identify and describe urinary and faecal incontinence assessment, diagnosis and management in two rehabilitation settings for older people;
To examine whether resources are available for staff and patients on the unit to enable continence promotion and management.
Permission to carry out the study was granted by the hospital group ethics committees at both sites. Access to the sites was obtained through contact with the directors of nursing and heads of geriatric medicine. Written and verbal information was provided to patients and staff before written informed consent was obtained.
The research instrument used in this study was the Royal College of Physicians’ audit scheme (Brocklehurst, 1998). This included a three-part patient questionnaire; each part contained a separate record for urinary incontinence, faecal incontinence and urethral catheterisation. A second questionnaire recorded the resources available for continence promotion and management in each unit. The data was collected by researcher-administered questionnaires and a review of patient records. Resources available for continence promotion and management (such as equipment, toilet facilities, personnel, education/training and educational materials) were recorded in collaboration with clinical nurse managers in each unit.
Analysis was conducted using SPSS version 12. Descriptive statistics were used to determine the sample characteristics, the incidence of incontinence, type and frequency, assessment, treatment and follow-up. The results of both rehabilitation units were then compared.
The research was conducted simultaneously at two similar rehabilitation units for older people (a 78-bed unit in Northern Ireland and an 80-bed unit in the Republic of Ireland). All patients identified by nursing staff as incontinent and capable of providing informed consent were asked to participate. Those who were acutely ill or unable to provide informed consent were excluded.
Data was collected over a six-month period from 220 patients (130 from site 1; 90 from site 2).
Approximately 40% of participants were men and 60% women. Their mean age was 80 years. The average length of stay in the unit was 25 days in site 1 and 35 days in site 2 (range=1–150 days). Participants in both units reported similar types of incontinence – over 60% had problems of urinary incontinence only, 3% suffered from faecal incontinence only and the remainder reported both urinary and faecal incontinence.
Nursing records of urinary incontinence were maintained in both units. However, the type of record and extent of assessment varied. There were very similar findings in both units – approximately 60% of incontinence assessments were recorded as general nursing notes in care plans, with only occasional use of specific continence assessment records (in approximately 9% of assessments).
The most common investigation recorded into the cause of incontinence at site 1 was midstream specimen of urine (MSU) to rule out infection (45% in unit 1; 33% in unit 2). Residual urine measurement was also common in site 1 (24%) but not in site 2. In unit 1, 89% of patients were referred to a medical specialist and for further investigations such as blood tests for prostate specific antigen (PSA), cytology, renal ultrasound and ultrasound of abdomen, bladder or pelvis. However, in unit 2, only 2% of cases were referred to a nursing or medical specialist.
Treatment for urinary incontinence in both units mainly involved treatment for constipation (47%) and for urinary tract infection (43%). Eight per cent were treated pharmacologically (for example, anti-cholinergic medication for detrusor instability). However, over 85% of patients in both units remained incontinent following treatment.
Timed voiding was described by over 50% in both units as a continence management strategy. Incontinence pads were used for containment in just 50% of patients in unit 1, compared with 87% in unit 2.
Patients in both units reported a lack of specific communication with them regarding continence. In unit 1, for example, 62% indicated that their continence problems were not discussed with them or their carer and the percentage was even higher (97%) in unit 2. In approximately 85% of cases there was no evidence in patients’ nursing or medical records of discussion on continence issues.
According to patient and nursing records, the management of faecal incontinence took the form of advice on the use of laxatives, dietary changes and prevention of constipation. A number of patients were referred to a dietitian. However, in most cases faecal incontinence persisted despite treatment (77% in unit 1; 89% in unit 2).
Resources for the promotion and management of continence
Data was recorded on the presence or absence of policy and guidelines on continence management. It was also collected on referral procedures, staff awareness of guidelines and whether there had been a recent review of continence management guidance. Questions also included the availability and suitability of toilet facilities, the availability of specific continence personnel, education for staff on continence promotion and management and the availability of continence containment products.
Written guidance on continence management was available to staff in unit 1, with the exception of guidance on indications for referral to urodynamic assessment, medical/surgical specialists or continence nurse specialists. This was under review at the time of the study as part of the introduction of Essence of Care benchmarking. No guidance on continence care or promotion of continence was available to staff in unit 2.
Toilet facilities in both units were observed by the researchers and deemed by the clinical nurse managers to be accessible to patients, warm, private and conducive to continence promotion and management.
While a nurse-led continence advice service was available to staff in unit 2, this was not in place at the time of the study in site 1, although a regional continence adviser had been accessible in the past. However, there was no ongoing continence education and training programmes in place in either site. Health service information leaflets on continence promotion were available to staff and patients in each unit but were not displayed prominently.
The findings indicate that the focus of continence management was on containment rather than proactive management. These results are consistent with those of Irwin et al (2001), who found a lack of specific continence assessment, documentation and rationale for treatment decisions.
The results are also remarkably similar to those of a national audit of continence care in the UK, which reported that continence was under-assessed and under-treated (Wagg et al, 2006). Despite the requirement for integrated continence services under the National Service Framework for Older People (Department of Health, 2001), continence care remained a neglected area of practice.
This study was conducted in two rehabilitation units for older people, where a considerable proportion of patients are post-stroke. The findings are of particular concern as incontinence is a common problem post-stroke (Brittain et al, 2006; Patel et al, 2001). It is also known that outcomes are much more positive in patients who remain continent or regain continence quickly. There are therefore significant clinical implications of not dealing with incontinence appropriately in the rehabilitation setting. Recovery after stroke can be hampered by incontinence, leading to higher admission rates to long-term care and higher mortality.
Our study found that the diagnosis and treatment of incontinence in both units was limited and this also has major implications for nursing practice. The potential for skin breakdown and damage is maximised with continuous exposure to urine and faeces, leading to poorer patient outcomes (Ersser et al, 2005). Furthermore, patients also suffer psychosocially from incontinence, as going to the toilet is a private and personal matter over which people wish to retain control.
It is of particular concern to nursing practice that the majority of patients in this study reported that incontinence was not discussed with them. According to Williams (2004), most patients welcome a healthcare professional broaching the subject of continence with them because they may have been embarrassed about it and may not have been aware that help was available. Palmer (2000) suggested that the effects of incontinence on patients’ general well-being should be evaluated. However, in this study nothing was known about the effects of continence problems on patients’ daily lives or well-being.
Coping with incontinence can be a significant burden for carers and family, leading to increased use of hospital services and increased likelihood of admission to long-term care.
The cost of continence supplies can be considerable if the focus of management is mainly on continence containment.
To ensure a person-centred approach to continence care is taken, best practice guidance should be available as a resource for staff. A significant finding in this study was that one of the units had no guidance available. According to Thomas (2001), most nurses working with older people will see patients with continence problems every day. Sarkar and Ritch (2000) suggested that nursing interventions are effective in restoring continence for most patients. Many people in these rehabilitation units were stroke patients, and therefore more likely to be incontinent and have difficulty regaining continence. It is vital that staff in these clinical settings should be up to date in continence promotion and the evidence-based management of incontinence.
The consensus in the literature is that continence problems are common in older people but not inevitable. Incontinence is more common in older people who suffer physical disability, particularly after a stroke, and who are hospitalised.
This study recorded and compared the incidence of incontinence, and its assessment, diagnosis and management in two rehabilitation units for older people. It formed part of a larger study exploring the determinants of practice context that enable or hinder proactive and person-centred approaches to continence care for older people.
Although a high proportion of older people in both settings suffered from continence problems, there was little evidence of continence assessment, documentation or promotion. While there is evidence that incontinence can cause physical and psychosocial problems, health professionals in this study did not consult patients about their treatment or discuss concerns over continence with them.
These findings stress the importance of continuing awareness and education programmes on continence for all staff working with older people. The study also shows the need to develop person-centred and evidence-based approaches to continence promotion and management. Nurses must proactively lead change in the management of continence care and adopt a person-centred approach to working with older people with continence problems.
The research was funded by the Republic of Ireland Health Research Board and the Northern Ireland Department of Health, Social Services and Public Safety R&D office (2004-2006).
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