Rachel Gilbert, RN, DipN.
Continence Nurse Specialist, Kingston Primary Care Trust, Tolworth Hospital, SurreyThe NHS now has responsibility to provide a continence service, free of charge, for residents living in nursing homes (DH, 2003).
The NHS now has responsibility to provide a continence service, free of charge, for residents living in nursing homes (DH, 2003).
To date, primary care trusts (PCTs) have contributed financially towards the purchase of incontinence pads but the new guidelines (DH, 2003) dictate that they should now be responsible for the purchase of all products for continence, and for delivering them to nursing homes. Product delivery must be on a named resident basis only and according to clinical need, and there should be no payment offered as an alternative (DH, 2000; DH, 2003).
It was expected that the objective would have been met by April 2003, but progress nationally has been slow. This may be owing in part to financial implications, workload pressure and to the traditional segregation between the NHS and the independent sector.
This article discusses how the service was successfully implemented in one primary care trust, and how we as the continence nurse specialist and nursing home co-ordinator collaborated with nursing home staff in the area to promote an effective partnership and teamwork.
Implementing the service
The first stage involved looking at the structure already in place for continence care and the processes that would be required to meet the desired outcomes. Richardson and Droogan (1999) suggest that any attempt to introduce change should be preceded by a diagnostic analysis to identify factors that may help or hinder progress.
We ascertained that the extra workload that would be generated to change practice would overload the service. We therefore needed to forge very close partnerships; the Modernisation Agency (2004) highlights how collaborative working is critical. Lafasto and Larson (2001) emphasise how effective teamwork can provide huge benefits. Our discussions centred on ways of training the nursing home staff to undertake the continence assessments and how we would support, monitor and evaluate the process in partnership with them.
From the mapping exercise we knew that sharing office space and databases would be beneficial, and would provide a nucleus for service activity. Indeed, this is helping us with internal and external communications, teamwork and access to information and resources.
An administrator was appointed to assist with the development and implementation of the service, and a new electronic database was established, along with a well-maintained paper system. Systems were put in place to track new admissions, individual assessments, reassessments, product requests and provision.
Networking is a useful way of sharing good practice and improving services (Ward, 2001) and was certainly an important part of the process. We networked externally, in particular with a continence adviser who had already implemented a similar service in another part of the country.
All the relevant stakeholders were invited to attend a meeting to discuss the DH guidance and the proposed service. These included nursing home managers, service users, product suppliers and service leads. All nursing home residents were informed in writing of the change and invited to make contact and become involved in service planning accord-ing to the guidance (DH, 2000, 2001b, c; Modernisation Agency, 2003a). Only one resident replied, who was visited by the continence nurse specialist. Following the stakeholder meeting an action plan was developed.
We identified a level two continence assessment in keeping with Department of Health guidelines (DH, 2002) - an overview assessment. The tool contains elements of continence assessment identified by the DH in 2000 (see box, page 37). In conjunction with our product supplier we designed a continence product prescription form that allows the assessing nurse to choose the most appropriate product for a resident.
Both of these documents must be completed fully and accurately by the assessing nurse and submitted to the continence nurse specialist. This is a prerequisite for product delivery. The assessing nurse is encouraged to keep a copy of the documentation in the resident's care plan.
A comprehensive programme of training was devised for nursing home staff and was delivered in the local nursing homes. The following topics were covered:
- Continence assessment
- Continence promotion
- Incontinence management
- Service delivery
- Product education.
The initial training was well attended and positively evaluated. Staff are now encouraged to access other NHS training to develop further their knowledge and competences. All the training is provided free of charge, but it is often difficult for the nurses to leave the homes for this training. In response, we have recently purchased training models and equipment to provide on-site courses if required.
To combat the high staff turnover within the care home sector, the training programme will continue, both for the induction of new staff and as refresher courses so as to sustain practice development and motivation.
Link nurse groups
A continence link nurse group was established. Roberts and Casey (2004) discuss the potential value of link groups in nursing homes. The trust's link group is promoting and maintaining communication channels, therefore enhancing the partnerships and relationships we have developed. The group currently meets every six weeks, and each home is encouraged to host the meeting in rotation. The agenda was initially set according to the needs of the service, but is now beginning to meet the educational and professional needs of the individual members. The group was facilitated in identifying and agreeing their role (see box below).
Changing the culture
All residents in a local nursing home with a continence problem now have a continence assessment completed by means of an endorsed tool. Completion of the assessment is mandatory before product delivery can start and is in keeping with guidelines (DH, 2000; Modernisation Agency, 2003a). Emphasis is placed on identifying treatable and transient causes of incontinence, or causes that can be managed better.
The standard of continence care provided in nursing homes should continue to improve now that the culture of care has begun to change. During implementation of the service and our ongoing discussions, widespread inappropriate use of products was identified. This included 'double-padding', incorrect fitting and the use of large quantities of barrier creams. The general ethos among nursing home staff was that 'one pad fits all for day, and one pad fits all for night'. This practice is now changing, and residents are receiving more individualised and evidence-based care.
After starting up the new service, complaints from stakeholders about delivery and products were fewer than we had anticipated. In keeping with PCT policy, complainants were encouraged to put issues in writing to us. We acknowledged their complaints, then forwarded them to our product supplier. We have made it clear that we value the feedback from our partners and that we will use it to make any changes needed. An example of this in practice was ensuring that alterations were made to the product delivery note to meet the needs of the nursing homes.
The databases we developed enable us to track and monitor the service from the time an individual is admitted to a nursing home to delivery of that person's continence products. We often found that continence documents were being received for residents not known to the nursing home co-ordinator. Furthermore, it was noticed that some nursing homes were not notifying us of the death of residents, or of transfers or admissions to hospital. This was causing unnecessary cost.
These issues were addressed by introducing a form detailing any resident admission, transfer and discharge. The idea has been extended to facilitate continuity of care between the community hospitals, residential care homes and the patient's own home. The community continence service and the hospital ward staff now notify us of any admissions to local nursing homes. We are then able to compare the new resident's previous continence assessment and product prescription with those we receive from the home. We can also divert or suspend product delivery accordingly.
In addition to ensuring seamless care, this system means that we can address potential overspend and evaluate the outcome of staff education. It also allows us to target homes for training and additional support.
During the assessment of residents for fully-funded continence care, some concerns over the provision of pressure-relieving equipment and pressure ulcer risk assessment became evident. The issue of skin integrity was also raised: nursing home staff felt that it was related to the different brand of continence products being supplied. Further exploration found that the issue was much wider and, as a consequence, the nursing home co-ordinator has developed a pressure ulcer group that is an extension of the continence link group, so enhancing practice development. Joint working has also started with the trust's tissue viability and infection control nurse specialists.
The continence link group is progressing well and attendance each quarter is high. Education in small sections is proving popular, with guest speakers suggested and chosen by the members. We have also begun compiling continence care resource folders for staff and residents to access. Additionally, we anticipate working as a group to develop a policy and guidelines for the promotion of continence and the management of incontinence in the local nursing homes.
New concepts have been introduced to the staff, such as Essence of Care benchmarking (Modernisation Agency, 2003a,b), and we have begun to look at this within the context of care delivery within the nursing homes.
Providing a quality service
A continence care programme was developed for use in nursing care homes in response to DH guidance on the provision of fully funded continence care in nursing homes. The approach we adopted has worked well and is continuing to evolve.
The current cost to the PCT of introducing fully funded continence products has fallen within budget and indeed has been favourable when compared to the experience of other PCTs that have implemented the direct product service. By analysing costs and client needs the PCT is able to provide a quality, cost-effective continence service based on clinical need and without rationing of the product range.
We have begun to enhance care in other related areas of practice such as skin care and pressure ulcer prevention.
We are currently measuring the outcome of the service we have provided since it began 13 months ago. An initial satisfaction survey has recently been issued and we await feedback from our partners. Early feedback is very encouraging.
An evaluation of the link group will be carried out to assess its impact upon practice, and an audit of our current systems and processes has recently been completed. Results indicate the suitability of the current service, but have highlighted the need for staff in some homes to receive extra training and support. An action plan has been finalised in response.
The effectiveness of our work has been demonstrated by the audit and the satisfaction survey results received so far, and therefore on reflection we have found an effective approach to implementing a new service, particularly one that needs to cross care boundaries. The working partnerships are just evolving at this stage, but we expect these to go from strength to strength. In turn, this will ensure that the residents in our local nursing homes receive high-quality continence care, based on their individual and clinical needs.
Author's contact details
Rachel Gilbert, Nurse Specialist, Kingston Primary Care Trust, Tolworth Hospital, Tolworth, Surrey. Email: email@example.com
Improving continence services in nursing homes
- Good Practice in Continence Services (GPICS) (DH, 2000) was issued to help achieve equitable and effective continence services
- The funded nursing care agenda was previously known as 'free nursing care' (DH, 2001a). The NHS is now responsible for paying for the registered nursing care all residents of nursing homes require. Following a nursing assessment completed by NHS staff, payment is made according to a nationally agreed low, medium or high banding (DH, 2001a; 2003)
- The National Service Framework (NSF) for Older People (DH, 2001b) sets national standards and service models of care across health and social services with the aim of improving care whatever the setting. It promotes integrated policy, services and practice development
- Standard Two (Person-centred care) of the NSF for Older People (DH, 2001b) makes explicit reference to integrated continence services, as does GPICS (DH, 2000). Integrated continence services should involve all local stakeholders (including nursing homes) working together to provide seamless, equitable and accessible continence care to people wherever they live or are being cared for.
Key elements of a continence assessment
- Review of symptoms and effect on quality of life
- Desire for treatment
- Physical examination, which may include abdomen, perianal region and rectum
- Assessment of manual dexterity
- Assessment of environmental influences, for example toilet accessibility
- Use of an 'Activities of daily living' diary
- Identification of exacerbating conditions, for example chronic cough
The Department of Health notes that this assessment is in addition to the general assessment of a patient in respect to mental health and underlying medical conditions. Also, it notes that it may not be conducted at a single point and that it should be ongoing.
Source: DH, 2000
Department of Health. (2000)Good Practice in Continence Services. London: DH.
Department of Health. (2001a)Guidance on Free Nursing Care in Nursing Homes. HSC 2001/17: LAC (2001) 26. London: DH.
Department of Health. (2001b)National Service Framework for Older People. London: DH.
Department of Health. (2001c)The Expert Patient: A new approach to chronic disease management for the 21st century. London: DH.
Department of Health. (2002)Guidance on the SIngle Assessment Process for Older People. HSC 2002/001: LAC (2002). London: DH.
Department of Health. (2003)Guidance on NHS-Funded Care. Health Service Circular 2003/006: LAC(2003)7. Available at www.dh.gov.uk/ publications/coinh.html (Accessed June 9, 2004).
Lafasto, F., Larson, C. (2001)When Teams Work Best. London: Sage Publications.
Modernisation Agency (2003a)Benchmarks for Continence and Bladder and Bowel Care. London: DH.
Modernisation Agency (2003b)Benchmarks for Pressure Ulcers. London: DH.
Modernisation Agency (2004)Collaborative Working. London: Modernisation Agency Leadership Centre. Available at: www.executive.modern.nhs.uk/framework/deliveringtheservice/collaborative.aspx (Accessed September 30, 2004).
Richardson, R., Droogan, J. (1999)Implementing evidence-based practice. Professional Nurse 15: 2, 101-104.
Roberts, C., Casey, D. (2004)An infection control link nurse network in the care home setting. British Journal of Nursing 13: 3, 166-170.
Ward, M. (2001)Ten ways to improve your practice. Nursing Times 97: 23, 24-26.