Achieving good-quality continence care: the current picture and next steps | nursing times

The NHS faces challenges to improve continence care; this last article in a series explores the current landscape and identifies what lies ahead ABSTRACT This last article in a series of

four summarises the current landscape of continence care in the UK and discusses the challenges that must be overcome to improve it. These challenges include health professionals’ education,

care costs, and variations in the care patients receive. These challenges present barriers to implementation of the incontinence care guidelines that were recently updated by the

Association for Continence Professionals and the Royal College of Nursing. CITATION: MURRAY S (2024) Achieving good-quality continence care: the current picture and next steps. _Nursing

Times_; 120: 9. AUTHOR: Sarah Murray is registered general nurse and senior clinical consultant, Essity. * This article is open access and can be freely distributed * Scroll down to read the

article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser) * Click here to see other articles in this series INTRODUCTION

At the very beginning of their consensus document, the Association for Continence Professionals (ACP) and the Royal College of Nursing (RCN) (2023) highlighted that all health professionals

are responsible for identifying and supporting people with continence issues, not only those who work in bladder and bowel care. This reinforces the need for collaboration between everyone

involved in patient care. This final article in the four-part series will revisit the areas explored in the previous three articles, touching on some of the potential obstacles to improving

continence care. > _“Although incontinence is not an inevitability of ageing, data > shows that its prevalence increases as we age”_ THE CURRENT LANDSCAPE IN CONTINENCE CARE There will

always be issues around funding and budgets when prescribing care and containment products for patients experiencing incontinence. However, this should not override the importance of

implementing research and education that support what best practice in continence care should look like. There are variations in continence care and the provision of containment products for

individuals who depend on them (NHS England, 2018); it could be suggested that a lack of guidelines is the reason for this. To improve care for all affected by incontinence, there must be a

push to embrace guidelines, such as the ACP and RCN’s (2023) recently updated guidance. However, barriers to guideline implementation remain a concern (Hunter and Wagg, 2018; Ostaszkiewicz,

2017), and innovative ways need to be found to overcome these challenges in practice. The first article in this series discussed how the ACP and RCN’s (2023) guidelines can be implemented

into practice to improve patient outcomes. Best practice statements that were amended in their updated guidelines introduced: * Wider direction around the equality of provision for men and

women; * A greater focus on the individual assessor’s interpretation of clinical need, rather than putting set restrictions in place for the style, absorbency level and number of containment

products required in a 24-hour period; * Direction to consider the patient’s circumstances when identifying any risks associated with the provision or non-provision of an interim supply of

containment products, for example, on discharge from hospital (ACP and RCN, 2023). These changes alluded to the need to consider both equity and equality, as well as the importance of

putting the person in need of containment products at the centre of considerations. Developing bladder and bowel services for the future is not only about embracing and implementing

guidelines. There needs to be a focus on new clinical topics, some of which may be viewed as taboo. The second article in this series provided an insight into continence care for individuals

following gender-affirming surgery and gender transitioning. McKechnie et al’s (2023) study showed that the number of people with a recorded transgender identity in their GP records

increased from 0.7 per 10,000 in the year 2000 to 4.7 per 10,000 in 2018. Regardless of whether an individual has undergone gender-affirming surgery, it is important to provide dignified,

gender-appropriate care and containment strategies and products. This can only be achieved through a well-educated workforce, and educational institutions may need to review content to

ensure this is achieved (Layton et al, 2023). > _“Clinicians strive to provide good-quality continence care but do > not feel equipped”_ Nurses are in an ideal position to support and

assist those affected by urinary and faecal incontinence (Hunter and Wagg, 2018). However, Agnew (2021) reported on a roundtable discussion between leading health professionals, which

concluded that health professionals often feel embarrassed about discussing incontinence issues with patients. During the discussion, both Carmel Bagness (RCN professional lead for midwifery

and women’s health) and Nikki Cotterill (associate professor in continence care, Centre for Health and Clinical Research, University of the West of England) highlighted the lack of

confidence that many nursing staff feel when confronted with conversations around continence. The gap in education is seen as the major issue: _“Healthcare professionals feel that education

has dropped off the radar.” (Nikki Cotterill)_ _“Healthcare professionals… really don’t know what to do with the answer [from patients about incontinence] when they get it.” (Carmel

Bagness)_ This is backed up by Hunter and Wagg (2018), who found that, in “postsecondary education for health professions”, the average number of teaching hours on incontinence was 4.7, and

in 14% of curricula it was not included at all. Agnew (2021) reported that clinicians strive to provide good-quality continence care but do not feel equipped to do so. This extends to

non-registered staff who, despite their key role in continence care, lack any access to education (Agnew, 2021). > _“The consequences and cost of poorly managed incontinence are > well

 evidenced”_ The common goal for all involved in patient care is to achieve the best-possible outcomes in the most cost-effective way (Lewis, 2022). Incontinence does not receive as much

attention or funding as many other conditions, and the consequences and cost of poorly managed incontinence are well evidenced (Bladder Interest Group, 2021). The third article in this

series explored how improvements in care outcomes can be reached, and provided a strong example of how value-based healthcare can be achieved in the current climate. The ethos of value-based

care might be still in its infancy, but its prominence looks set to increase rapidly over the next few years (Lewis, 2022). The opportunities it provides to rethink current bladder and

bowel services may have the potential to positively impact the future of continence care (Cairns et al, 2024). If there is a culture shift towards considering the whole system, the

opportunity may arise to look at the demands placed on bladder and bowel services. This includes considering whether these services could be improved by adopting new models of care, for

example, the model of combined tissue viability, continence and stoma care that is common in North America (Holloway and LeBlanc, 2020). Value-based care offers a potential framework to make

this a reality (Cairns et al, 2024). > _“Cure rates vary considerably between different types of > incontinence”_ THE REALITY THE NHS FACES IN IMPROVING CONTINENCE CARE Riemsma’s

(2017) review of published evidence and data concluded that cure rates vary considerably between different types of incontinence. While many patients will regain continence through accessing

bladder and bowel specialists and following evidence-based care pathways, the reality for many is an ongoing reliance on containment strategies. It is important to note that Riemsma’s

(2017) evidence was not representative of all demographics. There was a lack of data from certain groups, namely: * Disabled people; * People with neurological diseases; * Cognitively

impaired people; * Older people. Ageism in the NHS is not a new topic. The Centre for Policy on Ageing’s (2009) report found that in certain NHS services, for example cancer services, ageism

played a part in the treatments and investigations offered to patients. More recently, Jackson et al (2019) found that 25.1% of interviewees aged ≥50 in England felt they had experienced

age discrimination; of these, 41.4% “reported receiving poorer service or treatment in medical settings”. Although incontinence is not an inevitability of ageing, data shows that its

prevalence increases as we age (NHS England, 2018). Any discussions around implementing the ACP and RCN’s (2023) best-practice statements into practice must consider the realities and the

needs of the patient groups who are most reliant on containment strategies. > _“While there may be many challenges ahead, the outlook for > continence care in the UK is exciting”_

CONCLUSION While there may be many challenges ahead, the outlook for continence care in the UK is exciting. This series of articles has explored the introduction of updated guidelines,

good-quality education and value-based procurement strategies. These provide the opportunity to debate, rethink and, thereby, improve the standard of care and quality of life of everybody

affected by incontinence. KEY POINTS * Guidelines improve incontinence care but there are barriers to their implementation * Nurses lack confidence and education around discussing continence

issues with patients * Value-based care offers opportunities to improve bladder and bowel services * Cure rates vary depending on the type of incontinence * The prevalence of incontinence

increases with age ALSO IN THIS SERIES REFERENCES AGNEW T (2021) How do we talk to patients about embarrassing health problems? nursingtimes.net, 2 November (accessed 13 August 2024).

ASSOCIATION FOR CONTINENCE PROFESSIONALS, ROYAL COLLEGE OF NURSING (2023) Guidance for the Provision of Absorbent Products for Adult Incontinence. A Consensus Document 2023. ACP and RCN.

BLADDER INTEREST GROUP (2021) The Cost of Poor Bladder Management Report 2021. BLIG. CAIRNS C ET AL (2024) Incontinence products: value-based care, procurement and a pilot study in a single

acute trust. Nursing Times; 120: 9. CENTRE FOR POLICY ON AGEING (2009) Ageism and Age Discrimination in Secondary Health Care in the United Kingdom: A Review from the Literature. CPA.

HOLLOWAY S, LEBLANC K (2020) Combining wound, ostomy and continence care: is it time for a paradigm shift in the UK? Wounds UK; 16: 1, 8-10. HUNTER K, WAGG A (2018) Improving nurse

engagement in continence care. Nursing: Research and Reviews; 8: 1-7. JACKSON S ET AL (2019) Associations between age discrimination and health wellbeing: cross-sectional and prospective

analysis of the English Longitudinal Study of Ageing. Lancet Public Health; 4: 4, e200-e208. LAYTON H ET AL (2023) Supporting transgender patients with their personal hygiene. Nursing

Standard; 39: 7. LEWIS S (2022) Value-based healthcare: is it the way forward? Future Healthcare Journal; 9: 3, 211-215. MCKECHNIE DGJ ET AL (2023) Transgender identity in young people and

adults recorded in UK primary care electronic patient records: retrospective, dynamic, cohort study. BMJ Medicine; 2: 1, e000499. NHS ENGLAND (2018) Excellence in Continence Care. NHSE.

OSTASZKIEWICZ J (2017) Reframing continence care in care-dependence. Geriatric Nursing; 38: 6, 520-526. RIEMSMA R ET AL (2017) Can incontinence be cured? A systematic review of cure rates.

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