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Providing integrated services for people with continence problems

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VOL: 99, ISSUE: 19, PAGE NO: 63

Sue Brown, RGN, DN Cert, is senior continence adviser, Nottingham City Primary Care Trust

Standard 2 of the National Service Framework for Older People (Department of Health, 2002) recommends that by April 2004 all local health and social care systems should have established an integrated continence service. This recommendation is supported by the document Good Practice in Continence Services (DoH, 2000).

Standard 2 of the National Service Framework for Older People (Department of Health, 2002) recommends that by April 2004 all local health and social care systems should have established an integrated continence service. This recommendation is supported by the document Good Practice in Continence Services (DoH, 2000).

In 1998 the Continence Advisory Service in Nottingham identified an increase in the number of older people with continence problems in day care centres. Some service users with continence problems were not able to access day care facilities and many staff had negative attitudes towards those who did.

This was the catalyst for a pilot project which aimed to improve the services provided to people with continence problems in a social services day care centre for older people with mental health problems.

Pilot project in a day care centre

Initially we met with day care centre managers and staff to explain the project. We then gave questionnaires to staff to identify their views on incontinence and identify training needs. As a result of the responses given, we provided a training course consisting of nine, one-hour sessions.

Also, an environmental audit of the facilities available to people with continence problems was carried out and an action plan devised and reviewed. Staff were involved in advancing continence promotion.

The results of this pilot demonstrated that:

- After the pilot, staff were able to deal with incontinence more effectively;

- The continence status of many clients was greatly improved, enabling them to continue attending the day care centre and avoid admission to residential care or hospital;

- No client was refused attendance at the day care centre because of incontinence;

- Recommendations from the environmental audit had been implemented, improving cleanliness and access to toilets;

- Incontinence was discussed with day care centre users, leading to referral to the continence service.

Additional continence adviser posts

In January 2000, funding was secured for two continence advisers via a social services prevention grant. Evidence used to support the funding included:

- The projected increase in the older population;

- 70 per cent of referrals to social services in Nottingham are for older people;

- Incontinence is often the precipitating factor in admission to residential or nursing homes;

- Incontinence is a major factor in creating social isolation and places a huge burden on family and carers;

- Social workers in assessment teams are required to enhance their assessment skills with increased knowledge of continence issues.

Extending the project

With two additional continence adviser posts, it was possible to extend the project to all Nottingham social services care settings and service users.

The aims of the project were redefined to:

- Provide continence adviser support to Nottingham social services staff and service users;

- Improve the quality of continence care for individuals in all social services care settings, in order to promote and maximise personal independence;

- Minimise the risk of clients developing incontinence;

- Prevent or delay admission to a residential care setting;

- Improve staff development and motivation;

- Provide specialist continence advice in the assessment of patients/clients being considered for rehabilitation placement in the community or in intermediate care;

- Aid the implementation of action plans set by staff.

Role of continence advisers

The two advisers provide training and support to social care staff on the identification and management of continence problems (Box 1). This training is mandatory and staff are supported by working in partnership with advisers to assess and plan care with patients.

The advisers are also responsible for environmental audits, writing guidelines, running link worker schemes and providing input into the design of new buildings.

Continence clinics have also been set up in day, residential and intermediate care centres and in an Indian day care centre. This has helped to raise continence awareness with clients and carers through information and support sessions.

Outcomes of the project

Continence advisers have carried out many activities in social services care settings (Table 1), and the project has led to many outcomes.

Education and training

All staff in social services care settings have undertaken training, including managers, team leaders, social workers and occupational therapists (Table 2). Talks with independent home care providers have led to their staff undertaking the same training.

The development of comprehensive continence guidelines, including sections on pressure sore prevention and infection control, have set standards of care expected for people with continence problems.

NVQ coordinators have said the quality of the training, support given to staff, and the continence guidelines, have helped staff achieve NVQ competencies. A link worker scheme now has 35 members, and four study sessions a year are run on continence-related topics.

Direct care

Day care centre clinics have shown an increase in service users reporting continence problems. Clients know the continence advisers and feel less embarrassed about discussing their problems.

An assessment tool has been developed to enable staff to gather information about their clients for referral to either the continence adviser or community nurse. This ensures more efficient management of the patient's problem. The advantage for day care clinic clients is that they have a key worker to support and reinforce advice.

A clinic led by a continence adviser was organised in a learning disability day care centre, in conjunction with community learning disability nurses.

An Asian co-worker was employed with the aid of a short-term grant to provide interpretation and cultural support for the continence advisers. Community nurses have better relationships with residential home staff and receive more relevant referrals and contact from them.

Decaffeinated tea and coffee, and cranberry and prune juice are served in most day care centres and residential homes. Pelvic floor exercises are part of exercise programmes in some day care centres.

The future

Although much has been achieved over the past three years, there is scope for continued development of the service. The present service provision for older people is to be rolled out to learning disabilities services and an audit is being designed to seek the views of all staff groups and service users.

The environmental audit tool is being reviewed to enable continence advisers to benchmark day care centres and local authority homes (DoH, 2001).

Funding has been sought for an Asian co-worker to take forward the work begun with the short-term funding. Work is underway to introduce more advanced continence trigger questions into the single assessment process - a new care pathway will enhance this process.


In Nottingham, the provision of two continence adviser posts has demonstrated that investment by social services in health care can have enormous benefits for staff and service users alike. This success has resulted from the enthusiasm and work of the continence advisory service and the support of all staff in social services from senior managers to those working at the frontline.

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