Barriers to maintaining continence

It is estimated that more than three million people in the UK are affected by incontinence which has no anatomical cause. The person may be rendered incontinent because of physical, psychological, emotional, cognitive or environmental factors. Some of these are listed below.

Learning/cognitive disability

Learning disability or cognitive impairment needs to be taken into consideration when carrying out a continence asessment. Bowel and bladder control may take longer to develop in individuals with learning disabilities. Specialist continence support for these people can result in them becoming continent.

Mobility

If a person has the ability to know when they need to go to the toilet, but are unable to do so independently, they may experience continence issues.

For some people, accessing the toilet can be so challenging that using a pad or requesting a catheter is easier than trying to remain continent. If the person is a wheelchair user and needs support to go to the toilet, it can be particularly challenging as help is not always available in a timely manner.

A full assessment may identify toileting aids and equipment (such as urinals, handrails, commodes and removable clothing) that can support an individual to remain independent and, in some cases, major adaptations such as hoists, downstairs toilet or stairlift may be appropriate.

Ability to communicate

Many people find it difficult to communicate the need to go to the toilet. They may:

  • be unable to express need for the toilet verbally due to aphasia or dysphasia
  • lack the language skills to describe need, for example, they may speak no English or have limited vocabulary
  • may use Makaton or other sign language to express need, requiring other people to understand
  • may not be able to read, recognise or see signs to toilet facilities
  • have speech which may be difficult for others to understand if slurred or words are confused

These may be exacerbated if the person is stressed because of the difficulty in making others understand.

The assessment process should be able to identify how a person communicates. Body language is a useful tool for identifying the need in a person with learning or cognitive difficulties. Carers or relatives may easily spot when an individual wants to go to the toilet just by the change in their body language.

Some people communicate using low tech aids, such as communication books, signs, picture symbols or augmentative and alternative communication aids (electronic talkers).

However, by simply taking the time to understand how each individual communicates, (they may have unique signs) you can start to recognise when they want to go to the toilet.

Environmental factors

When people are out and about in the community, toilets can often become an issue. The location and accessibility of toilets can be a barrier to continence, and with councils closing more public toilets it makes getting to a toilet even more difficult.

In general people do not like to be heard on the toilet, or may be embarrassed when using public toilets. Often these facilities are not clean and can be unpleasant to visit. If a person does not have a choice in where they go to the toilet, it may become preferable to be incontinent than use an unsuitable bathroom or toilet.

People with Autistic Spectrum Disorders may only be able to use a toilet in the home environment or use certain toilets when they are in an unfamiliar place, so this will need to be planned before going outside of the home.

Flooring in bathroom areas need careful consideration as certain colours or shiny floors can make the floor look wet and cause problems for people with visual impairments.

Care homes and hospitals often locate toilets away from main areas and they may be poorly marked or signposted. If an individual cannot locate the toilet or it is too far away, involuntary incontinence may occur.

Often signage on toilet doors can be confusing, especially for people with dementia. Complicated or modern icons might be used, which some people may find difficult to recognise as the place where they can go to the toilet.

Other examples of where the environment can make it difficult for people to go to the toilet:

  • poor maintenance of public toilet facilities – wet, dirty floors
  • many accessible facilities need a Radar key to gain access, which can be obtained from the local council
  • poor consideration of space needed by wheelchair users or people with young children in pushchairs
  • doors are often heavy and open outwards, requiring assistance from another person to gain access
  • no hoists or changing plinths in the majority of accessible facilities
  • person has to transfer to the toilet by standing or using transfer aids
  • a limited number of cubicles in men’s toilets and lots crammed into ladies toilets, making it hard to gain privacy if they have diarrhoea or offensive smelling stools or flatulence.

Assessing an individual for the correct equipment to manage and maintain their continence is imperative. It will require input from a specialist continence professional who may be a nurse or an occupational therapist.

There is a wide variety of equipment on the market and finding the most appropriate for the individual is vital. The types of equipment may range from raised toilet seats to highly specialised toilets that may include the facility to wash the person.

Simple things that can help support people with incontinence include:

  • toilet paper is always available
  • the bathroom area is clean
  • toilet doors are able to close
  • sufficient space and access needs to be provided to allow for staff, wheelchairs and other aids

Clothing

Clothing can be a barrier to managing incontinence. If a person has poor manual dexterity they can find it difficult to undo or pull down garments. There are a number of companies which manufacture clothing that is easy to remove, pull down, etc. For example, skirts with velcro sides, trousers/pants with drop down fronts. These garments look functional and unfashionable or just unappealing and people should seek advice about where they might find clothing that meets their needs and looks nice. As an alternative, it may be possible to alter existing clothing to make dressing and living with incontinence more manageable.

"I recently spoke with a young woman (R) with muscular dystrophy. She was a wheelchair user who required support from her husband to access the toilet. She was having issues with urgency and couldn’t always manage to get her pants down before she started to pass urine. A district nurse visited to assess her needs and the solution was not to wear underwear. This left R feeling very vulnerable when at work or out in the community.

R could continue to access the toilet but remain in her wheelchair. She eventually found that crotchless knickers gave her the freedom she needed and actually required less support from her husband. She also felt young and sexy again as her underwear was pretty and not just functional."

Belinda Wolfendale

Anxiety

Many people with incontinence feel anxious about going to the toilet and this can cause them unnecessary stress. They may feel:

  • embarrassed at time and frequency when at work
  • pressure as some employers have strict monitoring of toilet breaks
  • fear and stress about availability and accessibility of toilet facilities
  • worried about being disturbed or overheard
  • scared others may notice them having frequent toilet breaks
  • fear of having accidents.

Attitudes

If a member of staff has a negative attitude it is distressing for the person who is incontinent and can prevent them from discussing their problem in an open and supportive way. No one enjoys handling other people’s urine and faeces, but as a nurse the member of staff has a responsibility not to allow personal feelings to get in the way of providing dignified and compassionate care.

"This is the fourth time I've cleaned you up today. You should really sort yourself out"

Comments like this are unacceptable and unprofessional and should be addressed under a disciplinary discussion.

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