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Roundtable report in partnership with Essity

Better training is needed to improve continence care

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Claire Read reports on a roundtable event discussing continence care

Adverts for incontinence products are now a common feature on television so it may seem that the awareness of bladder and bowel control issues has increased. But when Nursing Times brought together a group of panellists to discuss continence care, it became clear that funding constraints, lack of staff resources and training, and a growth in demand are all obstacles to providing effective care.

Better training is needed to improve continence care

Better training is needed to improve continence care

Veronica Haggar

Veronica Haggar remembers hearing a colleague talk of the first-ever television advert for an incontinence product. The campaign wasn’t exactly what you’d call high profile or direct. “It was for Kanga pants,” she reports, “and it could only go out after midnight and it basically just had a kangaroo hopping across the screen.”

Today, promotion for products that help with urinary incontinence are a common feature of ad breaks across all channels at all times of day. It’s a big change, and suggests a greater willingness to acknowledge the important issues of bladder and bowel control. But, according to panellists at this roundtable discussion, there is a question over just how far that willingness extends. Are commissioners sufficiently focused on the issue? How about clinicians? The expert panel that gathered for the debate – held in association with Essity – expressed doubt on both fronts as it considered the current challenges in providing effective continence care.

June Rogers, paediatric continence specialist at Bowel and Bladder UK, was keen to stress that a consideration of the challenges shouldn’t obscure the progress that has been made. She said the products available had improved vastly, but that funding pressures sometimes limit the ability of nurses to provide appropriate options. 

“For three years, I’ve been working with clinical commissioning groups, with NHS England and the National Institute for Health and Care Excellence to support implementation of NICE guidelines and service development,” she reported. “And all the time we’re hearing: ‘We’ve got to cut the pad budget, we’ve got to reduce this, we’ve got to reduce that’.” But it was a false economy, she argued: “They’re not looking at the bigger picture … if you do a proper assessment and not just have free nappy services, you could actually save money.”

But are there enough nurses with the time and training to offer that assessment? Our panel members suggested not. “For the ward nurses, they sometimes think it’s easier to put pads on patients instead of doing continence assessments,” suggested Juliana Tinhunu, clinical nurse specialist – continence at Barts Health Trust.

She also feared sometimes there wasn’t enough education on how to use some of the products now on offer, giving the example of nurses unsure of the appropriate dilution rates for osmotic laxative Movicol.

There were concerns too about a lack of expert continence nurses able to provide advice and input on such issues. Said Jane Young, bladder and bowel lead specialist nurse at Central and North West London Foundation Trust: “We’ve had two RCP [Royal College of Physicians] audits on continence care, both recommending that all trusts should have a continence nurse, and how many are there? I think you can count on one hand the number of acute trusts that have an incontinence specialist nurse.”

Better training is needed to improve continence care

Better training is needed to improve continence care

June Rogers

Ms Rogers said staffing was a problem in other settings as well. “In the community, a lot of the experienced continence advisers have gone – some have voted with their feet and gone to work with companies, others have retired and are not being replaced. So the wealth of experience has gone.”

Ms Young said there was a “huge issue” in paediatrics, with health visitors and school nurses no longer responsible for seeing children with bed wetting and constipation. Joanne Strain, head of nursing at Four Seasons Healthcare, meanwhile, reported challenges in securing continence advice for care home residents. She suggested this was because – wrongly – loss of bowel or bladder control was sometimes seen as inevitable in these cases. “Getting someone to come in to do assessments is quite difficult, because they’re in a care home, they’ve got dementia – every ailment somebody in a care home has [tends to be attributed to] dementia.”

Ms Rogers was one of many with whom that resonated. “Because district nurses are too busy to do holistic assessments, somebody presents with a wetting or soiling problem, they’ve got dementia, that’s it – they’re put in a pull up and left. But incontinence is not a natural result of dementia.”

Ann Marie McManus, clinical nurse specialist continence services at Central London Community Healthcare Trust, argued: “[We need] more awareness with the district nurses and in care homes about continence and how important it is – and dignity and privacy too.”

But even when training is available, and experts in place, engaging nurses in an area that may not immediately attract their enthusiasm is challenging. “In our trust, we’ve got a bladder training day, a bowel day and a catheter day,” reported Caroline Knott, bladder and bowel specialist nurse at Kent Community Health Foundation Trust.

“So all of our nurses who are out in the community can attend that, get the practice with the anatomical models, and then go out and get their competencies in the workplace. But I was teaching recently and two of the nurses said: ‘I’ve been putting this off for ages because I didn’t want to do manual evacuation of patients’.”

Better training is needed to improve continence care

Better training is needed to improve continence care

Lola Kehinde

And some feared nurses felt unable to discuss the full wealth of issues that can be connected to incontinence. Lola Kehinde, lead continence nurse specialist at East London Foundation Trust, gave the example of discussions around sexuality.

“Nurses [avoid] discussing sexuality and catheters [with patients],” she reported. “When you say: ‘Did you discuss sex?’ they say no, even though we mention it when we train them to ask about their sexuality.”

This is a particular issue with male patients, many of our panellists noted. And, indeed, they felt there was much progress to made when it came to meeting the needs of this group. Reported Ms Rogers: “One of our colleagues did a big research study looking at continence issues in men, which are often neglected. [She spoke to one man], a builder who was climbing a ladder and his shirt rode up, and you could see top of his pad. He said he was so traumatised by that. He’s supposed to be a big a burly, macho workman, and he’s been seen to wear a ‘nappy’. So for men I think it is more difficult.”

Despite arguing that nurses needed a greater willingness to get involved in continence issues, our experts understood why colleagues might be reluctant to do so.“It’s not glamorous,” admitted Ms Rogers. “It’s not heart disease, it’s not cancer, it’s not mental health.”

Better training is needed to improve continence care

Better training is needed to improve continence care

Bo Yeung

And Bo Yeung, bladder and bowel clinical nurse specialist on the executive committee for the Association for Continence Advice, said she was aware some nurses’ enthusiasm was stifled by different guidance on what care they could deliver. She reported that, in some areas, district nurses were not encouraged to get fully involved in catheter care, for instance: “There’s lots of good nurses in the community out there who want to do it, but there are so many boundaries and hoops and loops, and they don’t get enough information.”

But while some may not see it as the most appealing area in which to get involved and there may be boundaries, there is no doubt that good continence support can dramatically improve lives, our panellists said. As Sharon King, national sales manager incontinence care UK and Ireland at Essity UK, put it: “Good continence care is transformational. It just makes such a difference – a hugely positive impact on wellbeing, self-esteem and dignity.”

So how can more nurses be encouraged to drive that sort of difference? For Ms Haggar, it was a case of making clear that working in continence offers an area of interesting career opportunities.

“[There are] a huge number of things I have done as a result of being a continence nurse specialist that I would never have done if I’d stayed on the ward,” she said. “Everything from editing a journal, organising a conference, working with commercial organisations, coming to a roundtable, international conferences.”

Added Ms Rogers: “As a nurse, it’s something you can do that makes a huge difference, without having had to have surgery or see a doctor. Small things you do can make such a huge difference.”

As our roundtable established, however, the key question is how – in an age of limited financial and staffing resources, and ward nurses with sometimes limited confidence on continence issues – we can ensure this important issue secures attention, deeper understanding and action that goes beyond those ubiquitous television adverts.

This event took place Wednesday 16 May 2018

The panel

Veronica Haggar, service lead, Adult Integrated Continence Service, Homerton University Hospital FT

Lola Kehinde, lead continence nurse specialist, East London FT

Sharon King, national sales manager – incontinence care UK and Ireland, Essity UK Ltd 

Caroline Knott, bladder and bowel specialist nurse, Kent Community Health FT

Ann Marie McManus, clinical nurse specialist continence services, Central London Community Healthcare Trust

Jenni Middleton, then-editor, Nursing Times (roundtable chair)

June Rogers, paediatric continence specialist, Bladder and Bowel UK

Joanne Strain, head of nursing, Four Seasons Healthcare

Juliana Tinhunu, clinical nurse specialist – continence, Barts Health Trust

Bo Yeung, bladder and bowel clinical nurse specialist, Association for Continence Advice Executive Committee

Jane Young, bladder and bowel lead specialist nurse, Central and North West London FT

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