VOL: 98, ISSUE: 04, PAGE NO: 48
Ian Pomfret, RGN, NDNCert, PWT, is district continence adviser, Chorley and South Ribble Primary Care TrustThe review of continence services took place at our trust in June 1999, prompted by a local study into the practice of vaginal examination during continence assessments and pelvic floor muscle re-education. As a male continence adviser I did not perform vaginal examinations when assessing female patients - relying on examinations performed by female colleagues or medical staff.
The review of continence services took place at our trust in June 1999, prompted by a local study into the practice of vaginal examination during continence assessments and pelvic floor muscle re-education. As a male continence adviser I did not perform vaginal examinations when assessing female patients - relying on examinations performed by female colleagues or medical staff.
While I was teaching pelvic floor exercises as part of interventions to promote continence, there is evidence that teaching pelvic floor exercises in the absence of vaginal examination may be ineffective or, more seriously, may cause additional physical harm (Bump et al, 1991).
A clinical audit of current practice with the aim of assessing whether female patients would consent to vaginal examination/perineometry being performed by male nurses and physiotherapists was carried out. Audit findings showed that vaginal examination by male nurses or physios was more acceptable to female patients when performed in a clinical setting and less so in their own or residential homes. This raised the question as to the most appropriate and effective members of staff to teach pelvic floor exercises in the community and formed the basis of a subsequent service review.
A multidisciplinary link group for continence care comprising of nurses, physiotherapists and occupational therapists from both hospital and community had been established locally in 1989.
The aims of the group were:
- To promote awareness of the role of the bladder and bowel in maintaining health;
- To disseminate information that will enable professionals and the public to make informed choices in matters relating to continence;
- To develop, as a group, a resource for the promotion of continence within the district.
In 1999 the continence nurse for residential homes resigned and responsibility for assessments and continence care was returned to community nurses. This meant that I was the sole provider of the trust continence service. Although liaison and collaboration with other health and social care professionals had been developed, the continence service had been nurse-oriented.
These reductions in service provision and the findings of the vaginal examination audit provided the opportunity to plan a reconfiguration of the trust continence advisory service with the aim of establishing a fully integrated, multidisciplinary continence team. Following discussion with nursing, occupational therapy (OT) and physiotherapy managers, a plan to reconfigure the service was submitted and accepted.
Our community OT began work in June 2000 one day a week for the continence advisory service. Research by Masterson et al (1980) showed that 17% of people in residential care experienced some form of urinary incontinence, with a third of these needing help with toileting. A local study of the prevalence of incontinence in residential homes showed that between 15-20% of residents were experiencing some form of incontinence. Management varied from the use of toileting programmes, pads, catheters and sheaths to doing nothing.
Maintenance or restoration of independent function for clients with a disability is the major focus of the OT. Her holistic approach to assessment and treatment often identifies clients who are experiencing problems with incontinence. Many of our OT's colleagues have welcomed the opportunity to access the specialist skills she is developing and have arranged joint visits to clients with her.
Our physiotherapist completed the continence team in September 2000. Before our service review access to continence physiotherapy was via consultant referral only, with lengthy waits to see both a consultant and then a specialist physiotherapist. The physiotherapist established three community physiotherapy clinics in health centres within the trust, held three afternoons a week, situated in the areas of major population to promote easy access for patients.
Referrals are taken from all sources: 62% GP, 14% continence adviser, 6% district nurse, 6% practice nurse, 6% health visitor, 6% consultant. It is pleasing to see that the major source of referrals is from GPs; In addition to the clinic work, the physiotherapist has seen patients in their own homes, both on her own and as a joint visit with other members of the team.
Positive outcomes in the first year have resulted in the OT and physiotherapy posts being made permanent. We are putting together an end-of-year report, which will include the findings of the clinical audits. It is hoped that this will demonstrate and support the need for additional occupational and physiotherapy input. Irrespective of additional funding available for development, the team is committed to providing the best quality, integrated continence care.