Analysis

How nurses can protect continence care amid intense service pressures

Nursing leaders urge staff to take action if fundamentals of nursing such as continence care are being compromised by shortage of staff and resources

Nursing leaders urge staff to take action if fundamentals of nursing such as continence care are being compromised by shortage of staff and resources

Assistance with continence needs is a patient’s right. Picture: iStock

The NHS is emerging from arguably its worst winter crisis yet, with soaring bed occupancy rates, staffing shortages and severe viruses all afflicting services.

Against this backdrop, the RCN is highlighting the importance of continence care and reminding nurses to take steps if fundamentals of nursing care are not being met in their workplace – whether the NHS or the independent care home sector.

The nurse’s duty to report poor care

RCN professional lead for older people and dementia care Dawne Garrett emphasises the nurse's duty to report substandard care to their ward leaders and managers.

 

‘It is not enough to go home and think “this is awful”. Professionally, we have to do something about it. Without understanding the scale of the problem, no one can act on it,’ she says.

400 million

The number of people worldwide thought to be affected by incontinence

Source: RCN

Ms Garrett points to the disastrous failings in care at Mid Staffordshire NHS Foundation Trust between 2005-09, in which hundreds of people are thought to have died, as an example of where unsafe staffing levels can lead. 

A public inquiry heard patients were left on soiled sheets or on commodes for hours, along with myriad other shortcomings.

‘Continence care is a matter of good care and that is what Mid Staffs showed us when staffing levels and resources started to be eroded,’ says Ms Garrett.

‘It is not a job that a robot or technology can do – it is highly skilled interpersonal work managing someone’s continence and an absolute fundamental of nursing care.’

Current pressures causing concern

Last year, the nurse brought in to manage the Mid Staffs trust in the aftermath of the scandal warned that current pressures across the health service were leading to the possibility of further care scandals. 

Sir Stephen Moss told Nursing Standard: 'We must not allow our focus on patient safety and delivering high quality, compassionate care to be diverted.

‘Increasing demand, unremitting pressures, workforce shortages and challenging financial imperatives are all too familiar, and all were prevalent when I joined Mid Staffs.’

1 in 10

people will be affected by bowel incontinence at some point, although it is more common in women and older people

Source: RCN

The situation has not improved.

The most recent figures for England show bed occupancy rates at 95%, far higher than the 85% limit considered safe, as well as the worst ever four-hour emergency care performance recorded, at 76.9% of patients.

In March, the Royal College of Emergency Medicine took the unprecedented step of appealing to patients to write to their MPs and call for action on the serious challenges facing the NHS.

An issue for any setting and patient group

But Ms Garrett is clear that continence care is not just a problem in emergency departments, or confined to the NHS.

‘There are more beds in care homes than there are in the NHS and their staffing levels are as difficult as in the NHS and the incontinence need is much higher.

‘But it is very easy for people to think this is just an older person’s issue – everybody who is unwell has the potential to become incontinent, particularly people who are delirious or confused, or who are immobile.’

Ms Garrett says people recovering from gynaecological or urological surgery are often affected by frequency or urgency problems and others need bladder retraining.

‘It is one of the most shaming experiences, to know someone is lying in urine or faeces because you have not managed to get to them in time’

Dawne Garrett

‘Many people have continence issues that they manage at home, but when ill are reliant on the nursing workforce to manage their needs.

‘Continence is such a personal dignity issue. It has an incredible knock-on effect in terms of mental well-being and discharge decisions.

‘For someone who is newly incontinent and discharged from hospital, setting up incontinence services can make a huge difference.'

Ms Garrett says that many people have to live with incontinence while waiting for a continence assessment or stock deliveries, which can take up to three months to arrive.

‘Once continence is lost, it is harder to regain,’ she adds.

‘It can be difficult going back to your own place and laundry is often the tipping point between people staying in their own home or going into care.

‘It is fine having someone with dementia at home with you, but if they are incontinent and have to be changed up to 12 times a day, what do you do with all the washing?’

Tips for discussing toilet habit

Experts advise nurses to use an empathic, matter-of-fact tone of voice to discuss patients’ continence needs. Don’t let discomfort about discussing the subject show as it can make the person uncomfortable too.

RCN professional lead for long-term conditions Amanda Cheesley says the main thing to bear in mind is ‘if you don’t ask, you won’t know’. She suggests nurses ask the following questions:

  • Do you have any difficulties getting to the toilet?
  • Do you need help to get to the toilet?
  • Do you need help in getting your pants down?
  • Are you ever wet?
  • Do you ever have a leak of wee or poo?
  • Do you need to wear a pad or special pants?
  • How often do you need to wee?
  • How often do you need to poo?
  • Have you ever had the problem investigated?

 

‘Lack of resources to help patients is soul-destroying’

Ms Garrett also points out that the number of people in mixed-sex acute facilities is rising and being in one of these facilities, with only a curtain protecting their privacy, can affect people’s ability to pass urine. 

And she says continence care that is compromised by lack of resources is highly demoralising for nurses. ‘It is one of the most shaming experiences as a nurse – to know someone has been incontinent and lying in urine or faeces because you have not managed to get to them in time.

‘Going away from a shift knowing that patients were incontinent in your care because you did not have resources to help them is soul-destroying.’

But continence difficulties are not a matter of dignity alone.

‘Urine incontinence can result in nasty tissue damage, because skin breakdown can occur,’ says Ms Garrett.

‘To be assisted to maintain your bodily functions and live with dignity is a human right, not just “nice to do”’

Amanda Cheesley

This is a particular issue if the patient is dehydrated – and they are more likely to be dehydrated if they are anxious they won’t get to the toilet in time.

RCN professional lead for long-term conditions Amanda Cheesley believes nurses are sometimes embarrassed to ask about an individual’s continence and patients often don’t want to ‘bother’ busy nurses.

‘In hospital, patients might be reluctant to press the buzzer because they can see people are busy and it is a long way to the loo.’

‘Explore all avenues before resorting to pads’

Ms Cheesley says she feels there is all too often an NHS ‘default position’ to put an incontinence pad on anyone with bladder or bowel problems. She says all avenues – including sheaths for men, pelvic floor exercises, plugs and other aids – should be explored to see if there are ways of managing the problem without the use of pads. She encourages staff to seek advice from the continence team. 

‘Continence management is not on the NMC curriculum requirements for preregistration training and therefore not identified as something that is vitally important,’ she says.

‘People need to look at the causes and ask, have they got an infection? Could this be managed in another way? There is a lack of understanding about what causes these issues and what to do about them.

‘But my anxiety is that because staff are focusing on an illness or an injury, sometimes the normal activities of day-to-day living get missed.

‘People need to get their teeth cleaned and go to the loo. To be assisted to maintain your bodily functions and live with dignity is a human right, not just “nice to do”.’

Learn how you can help

Nurses can help to tackle continence problems in a variety of ways, says Ms Cheesley.

While nurses can be reluctant to have constructive conversations about continence with patients because there is a lack of education in the area, ‘every nurse can ask small things’, she says.

40%

Up to 40% of people with urinary incontinence will seek help for their condition from a GP or nurse

Source: RCN

An online continence learning resource from the RCN and RCNi has a wealth of advice for nurses, nursing students and healthcare support workers on raising the topic of incontinence with a patient for the first time.

This advises nursing staff to:

  • Ascertain whether there is a continence difficulty
  • Discover if the individual or their carers perceive it to be a problem
  • Encourage the patient to discuss their anxieties and what support they need
  • Consider whether the person needs to be referred to someone with more specialist knowledge

‘This tool has been well evaluated and the people who have used it say it is so useful,’ adds Ms Cheesley.

‘Not to undermine the fact there are massive staffing pressures but there is also an education and training issue that this practical guide addresses.’

‘Sometimes we have to make difficult choices’

Brighton and Sussex University Hospitals NHS Trust (BSUH) emergency department (ED) senior charge nurse and practice educator Justin Walford says EDs that lack capacity are ‘intense’ environments.  

‘Sometimes there are 20 people in the corridor and if someone in the corridor needs to go to the toilet, then they need to be moved to a cubicle.’

Mr Walford says there are many different ED continence scenarios that require very individualised care. 

He says a patient involved in a road accident may need five people to help them to use a bedpan safely, while sometimes a lack of wheelchairs might mean having to give another patient a commode where a toilet visit would have been more appropriate.

Functioning above capacity

He also says the ED sees a lot of young, drunk people who are temporarily incontinent and when any ED is functioning above capacity it creates dilemmas for staff.

‘We always aspire to have the best for our patients but in the current climate we are sometimes having to make choices like “what is the least inappropriate thing to do?”

A Care Quality Commission inspection rated BSUH as inadequate in 2016, raising concerns about inadequate staffing levels and poor levels of privacy and dignity, particularly in the ‘cohort’ area of the ED.

The report highlighted an older patient who had been left on a urine-saturated sheet on a trolley for more than an hour in the ED cohort area.

Mr Walford says the trust now has a safety checklist that includes toileting.

‘All emergency nurses aim to make sure people are continent, but there are a number of issues [related to this], including logistics of toilets and capacity.’

I’m worried about a patient’s continence care – what should I do?

RCN professional lead for long-term conditions Amanda Cheesley says all nurses have a duty of care to their patients, and concerns about continence care should be tackled. If you are concerned about a patient’s care, she advises:

  • Find out why the person’s needs are not being addressed. Is the failure wilful? Are there adequate staff to support the person? Could a regimen be implemented?
  • If the concerns are not answered satisfactorily, escalate them, remembering that the key reasons for supporting people to maintain their continence apart from dignity are: skin integrity, infection risk, smell, social isolation
  • Write down your concerns, how often the problems occur and to whom
  • Keep a record and document your concerns and what you have done to address them
  • Seek advice from colleagues and managers and ask for help if you need it from: the continence nurse specialist, the patient if he or she has capacity, staff-side representatives

If no one will address your concerns then you should contact your relevant healthcare regulator:

RCNi Learning module

Promoting urinary continence in older women

Read more


Stephanie Jones-Berry is a freelance health journalist

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