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How the continence care guidelines are being implemented

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VOL: 97, ISSUE: 20, PAGE NO: 62

Jenine Willis

It has been a good year for continence care, with the issues of good practice and service provision recognised in Department of Health guidance on continence (2000), its benchmarking document, The Essence of Care (2001a) and the National Service Framework for Older People (2001b).

It has been a good year for continence care, with the issues of good practice and service provision recognised in Department of Health guidance on continence (2000), its benchmarking document, The Essence of Care (2001a) and the National Service Framework for Older People (2001b).

The downside is that nurses, who are already under pressure, may feel overwhelmed by all the information coming their way. As the guidance on continence is not mandatory, there is a danger that it may be pushed to one side as staff concentrate on seemingly more pressing priorities.

Although it is early days for the guidance, Sue Thomas, RCN policy and practice adviser, believes that it is being promoted by many specialist nurses and continence advisers. She recently began a two-year study that aims to evaluate how the guidance is being applied and identify the factors that lead to its successful implementation. 'We are looking to give people the tools to help them put the guidance into practice,' she says.

So is all the advice having any impact on the continence care patients receive? According to Judith Wardle, director of the Continence Foundation, it is too soon to tell. 'We have heard that people are using the guidance to wave at commissioners, but so far that seems to be as far as it's got in some places,' she says.

Whether the guidance is being addressed or not varies according to local circumstances and how continence services are set up. Some areas are in a better position to implement it than others, says Janet Holmes, a nurse consultant at Cannock Chase Hospital, part of the Mid Staffordshire General Hospitals NHS Trust. She compares her new role to that of a business consultant using project management skills and resources to facilitate changes in continence practice. As far as the guidance is concerned, she says: 'I am using it as a framework to sell early assessment, particularly to GPs.'

Swansea is another area where continence services are using the guidance as a basis to improve care. Lesley Simpson, continence adviser with the community continence service, has been working with the health authority and nurses to develop standards for catheter management, the promotion of continence and the management of continence problems in independent nursing homes.

One of the key aims of the guidance, to provide an integrated service, has been promoted by the incorporation of four local hospitals into the community service. 'This is already providing better services for patients on discharge and is beginning to encourage true multidisciplinary assessment,' says Ms Simpson.

'The link nurse network in Swansea means that there is now a nominated continence link nurse for every GP practice as well as secondary link nurses, who are either CPNs, paediatric nurses or learning disability nurses. All link nurses have access to our in-house training programme and regular clinical updates,' she says.

Prevention is another key part of the strategy. Local research revealed that teenage girls were not aware of the importance of pelvic-floor exercises to promote continence. As a result an education pack on pelvic-floor exercises has been developed for use by PE teachers and school nurses. Classes on pelvic-floor exercises have also proved popular with older women. 'An article in the local paper resulted in more than 40 telephone calls in two days from women of all ages interested in the classes,' says Ms Simpson.

In Southampton, the aim is to provide uniform and equitable care throughout the district, no matter where the patient is seen or who they see, be it continence adviser, physiotherapist or gynaecologist, explains Lesley Wilson, continence services manager of the primary care trust.

One initiative aims to develop a more seamless service with the urogynaecology service in the acute trust. To achieve this, GPs are helping to develop referral guidelines and treatment pathways. This should help to prevent inappropriate referrals and speed up waiting times for patients who do need to be seen by the urogynaecologist, she says.

'These initiatives are providing opportunities for us to learn from each other,' says Ms Wilson. For example, the consultant urogynaecologist has already linked up with a specialist physiotherapist to learn how to do a pelvic-floor assessment, which is quite different from the examination he would normally perform.

'We are currently concentrating on women with urinary problems, but the next logical step is to include women with bowel problems. We hope to include male patients too,' says Ms Wilson.

Funding is a problem in many areas, as Alison Bardsley, chair of the RCN continence care forum, explains. In Oxfordshire, the health authority and five primary care trusts support implementing the guidelines, but there is no funding for extra posts. 'We are looking at our existing services and trying to ensure that they are used most effectively, and using the guidelines to guide us,' she says.

Eight community physiotherapists with an interest in continence care are undergoing training and updating. 'This should improve the service we offer in the community and reduce referrals to the central hospital service, which is overloaded. It will also improve services for the patients as they will be seen nearer to home without the hassle of travelling into Oxford,' says Ms Bardsley.

The continence advisory service has six community clinics around the county and another five run by district nurse link nurses. Again, the aim is to see patients in the community for conservative treatment so that only those in need of further investigation or a consultant opinion are referred on. 'This should reduce the waiting list for urodynamics and consultant appointments and also means that patients have tried all appropriate treatments before being referred, so they do not have to be re-referred to the community or physiotherapist,' says Ms Bardsley.

Such initiatives are a testament to the goodwill and commitment of nurses and continence advisers in their efforts to implement the guidance. Only time will tell how successful they will be without additional resources or funding, which could come from making the guidance a requirement rather than a recommendation.

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