Urinary incontinence is described as involuntary leakage of urine in an inappropriate place (Abrams et al, 2010), and the symptoms of urinary incontinence can naturally be distressing for individuals (Alaszewski et al, 2009). Similarly, faecal incontinence can be defined as involuntary loss of liquid or solid stool which is a social and hygienic concern (Norton et al, 2010). The prevalence rates of faecal incontinence is higher in the older age population, although it is not an inevitable part of ageing (Russell et al, 2017). Another complex continence-related condition is constipation, which can be challenging to define, but is described as defecation that is unsatisfactory in clinical characteristics, with difficult passing bowel motions, seemingly incomplete bowel emptying and infrequent bowel motions (Thompson et al, 1998). Constipation is a subjective symptom based on a person's expectations of bowel frequency, volume, consistency and ease in passing bowel motions. The Rome diagnostic criteria (Table 1) can help in the diagnosis of constipation (National Institute for Health and Care Excellence (NICE), 2020). According to Werth et al (2017), the prevalence rate of self-reported constipation in Australian community-dwelling adults was 21% of the population, and 38% of residents in nursing homes in Ireland experience constipation (Neacy, 2014).
Table 1. Rome III diagnostic criteria for chronic constipation
| Must include two or more of the following: |
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The goal for all health professionals should be to reduce patient anguish and agony by promoting continence for as long as possible and effectively manage patients to prevent complications (Nazarko, 2019). For some individuals, unfortunately, incontinence must be managed rather than continence being promoted, where treatment options have been attempted, evaluated and deemed unsuccessful (Aguilar-Navarro et al, 2012). If incontinence symptoms are to be managed, some individuals may experience embarrassment, shame and humiliation (Aguilar-Navarro et al, 2012). Incontinence may present various clinical signs and symptoms from urgency, frequency, leakage when coughing to bedwetting, with implications for all cohorts of the population from childhood to end of life (Association for Continence Advice (ACA), 2017).
When communicating, consulting, collaborating, and caring for individuals with urinary incontinence, engagement should be undertaken with equity, impartiality and dignity and with the endorsement of the individual's human rights (General Medical Council (GMC), 2010). People should be given an opportunity to express their opinion on the service they receive, as this information or feedback will enhance care initiatives (Cornwell et al, 2012). Evaluating patients' experiences is essential, as research studies have identified that clinical outcomes are improved based on feedback received from individuals (Riskind et al, 2011). Ireland adheres to the principles of patient-centred care through policies, patient safety guidelines and quality procedures documents, by implementing healthcare regulations (Health Information and Quality Authority (HIQA), 2016; Health Service Executive (HSE), 2012; Gavin and Brady, 2013). The World Health Organization (WHO) (2015) outlined that patient-centred care concentrates on the conceptualisation of the individuals' wishes and wants but, most of all, distinguishing the distinctiveness of the patient beyond the presenting medical condition.
Continence assessment
A continence assessment is an essential process for an individual who experiences bladder dysfunction, as it is intended to capture critical clinical information (Ellis et al, 2017). It is considered to be crucial to conduct a holistic continence assessment before any management advice is provided or implemented to the patient for example in advance of prescribing disposable body-worn continence wear products, such as shaped and slip pads (ACA, 2017). Unfortunately, on some occasions, promotion of continence and the prevention of incontinence can be impossible for some individuals to achieve (Riemsma et al, 2017). Subsequently, if continence care is inadequate or insufficiently implemented, patients can feel degraded and psychologically distressed (Expert Group on Lower Urinary Tract Symptoms (LUTS), 2014). The prevalence of incontinence increases as people age, and it can provide a major substantial rationale for individuals being admitted into residential care settings if not effectively managed (Schluter et al, 2017).
In addition to urinary incontinence, faecal impaction and urinary retention can lead to physical complications, and these symptoms can have a major impact on psychological wellbeing, causing anxiety, agitation and apprehension (NICE, 2013). If a comprehensive continence assessment is undertaken and the patient's incontinence is subsequently managed effectively, quality of life will improve for the individual as well as caregivers (NICE, 2013). When conducting continence assessment or management, preservation of the individual's privacy and dignity are paramount principles (Alaszewski et al, 2009). When an individual develops a continence concern, they may feel stigmatised due to loss of control and invasion of their privacy (Whitehead and Wheeler, 2008). Reassessment should occur based on changes in clinical needs or planned within a periodical time span as outlined in local and national policy documents (ACA, 2017).
Continence promotion and management
Health professionals across all sectors of primary care, healthcare settings and social care environments need to be trained, educated and skilled in continence promotion and management of incontinence symptoms (Rantell et al, 2016). Incontinence that is ineffectively managed can be distressing for individuals and, therefore, can be challenging for carers (Santini et al, 2016). If effective continence products are unavailable, management of incontinence can become a strain, with the development of crisis circumstances where a person may be admitted to residential care due to bladder or bowel dysfunction (Schulter et al, 2017). Unfortunately, the availability of continence wear in some geographical areas may be based on budgetary constraints and constrictions by health service authorities, rather than on the clinical assessment needs of individuals (Harari et al, 2013). Murphy et al (2019) found that inappropriate and insufficient pad provision reduced quality of life and resulted in sleep deprivation and skin deterioration, as well as causing psychological pain to individuals. Heath professionals must be aware of and accountable for safety risks if prescribing products; where clinical complications are present; it is recommended that support be sought from the multidisciplinary team or continence service (ACA, 2017). Additionally, individuals and carers should be provided with information, training and education to be empowered on how to apply continence wear products and use them in a safe, secure manner (ACA, 2017).
Continence wear products
In many countries throughout the world, continence wear products are rationed to users, resulting in patient self-financing, which has detrimental implications for the vulnerable and disadvantaged in society (Harari et al, 2013). In a study undertaken by Murphy et al (2019), individual users and nurses reported inadequate and, inappropriate design, amount and range of pad provision. Discrepancies in the scope and choice of products can have serious consequences, such as sleep deprivation, deterioration in independence, incontinence-associated dermatitis and carer overload (Murphy et al, 2019). Nurses also reported reduced ability of individuals to self-care and independently toilet, as pull-up pants were not approved for some individuals (Murphy et al, 2019). Harari et al (2013) also reported disparity and discrepancy in the choice of continence wear products. Disposable continence wear products have an essential role to play in continence management when promotion initiatives are not successful (Trowbridge et al, 2016). The GMC (2010) outlined that it should be presumed that patients have the ability and capacity to make decisions about their care unless otherwise demonstrated, and this ought to be applied in the management of incontinence. Provision of the appropriate and acceptable type of pads in the adequate amounts can improve physical, psychosocial and emotional wellbeing for individual patients as well as their families and carers who support toileting and changing (Murphy et al, 2019).
Imamura et al (2010) identified that, by implementing low-cost community-based continence promotion interventions, a reduction in the usage of disposable continence wear can be realised. Another study found that the financial costs of introducing pelvic floor exercise programmes and bladder-retraining interventions were offset by a reduction in continence wear product usage (Demaagd and Davenport, 2012). The participation and commitment of all members of the multidisciplinary team are required to support individuals with incontinence and implement promotion interventions rather than relying on disposable incontinence wear (Spencer et al, 2017). Nationally and internationally, health services are negatively impacted by ineffective continence management strategies, which result in unnecessary, avoidable complications such as infections, pressure ulcers and falls, in turn increasing the amount of time an individual could potentially spend in acute hospital settings (Expert Group on LUTS, 2014). Consequently, successful containment of urinary and faecal leakage is vital to ensure good quality of life for patients and carers (Santini et al, 2016). The most common containment product is the disposable pad-taped, shaped and pull-up pads-the needs and wishes of users must be taken into consideration before a management recommendation is made (Murphy et al, 2019; Continence Product Advisor, 2017).
Information and communication
Health information needs to be available, accessible, and presented in diverse formats to all individuals so informed decisions can be made (National Disability Authority (NDA), 2006.) Further, information must address the needs of individuals who have visual or hearing impairment, and literacy or learning difficulties (NDA, 2006). Individuals should be involved in all decision-making strategies, and their personal preferences, apprehensions, wishes and values must be considered (HSE, 2012). If consent is provided by the individual, a family member or carer may be consulted on their choices and the care that is to be delivered (HSE, 2012). Individuals need to be given the opportunity to ask questions, discuss and query all aspects of care to ensure their active participation (HSE, 2012). Protection of individuals' privacy is essential, which will be enhanced by clear, effective communication between patient and caregivers, creating a collaborative, secure, sensitive environment for dialogue (Kadivar et al, 2018). This kind of collaborative communication is vital in the case of those with incontinence, as patient involvement in management affects quality of life.
Continence in end-of-life care
Care of the dying individual at home is a holistic process (Candy et al, 2011). Population studies have identified that over 60% of people would prefer to die at home, rather than in other settings, and these research studies even include individuals who were not terminally ill (NHS, 2014). The GMC (2010) outlined that it should be presumed that patients have the ability and capacity to make decisions about their care unless otherwise demonstrated, and this ought to be applied in the management of incontinence. Supporting the individual can range from the physical to psychological, pastoral, religious and spiritual guidance, which can be assisted by multidisciplinary team involvement (NICE, 2019). One crucial contributing factor that can cause an individual to enter a care home during the end of life is urinary incontinence (Luppa et al, 2010). For individuals at the end of life, pain can be a symptom that exacerbates feelings of fear, and the struggles experienced through the loss of body function, such as urinary and faecal incontinence, can be harrowing (Arnold et al, 2008; Clary and Lawson, 2009).
Nurses can help individuals to remain cared for in their own home setting for longer by providing effective continence care (Nazarko, 2019). Individuals who experience agitation or anxiousness require a holistic continence assessment by health professionals, as these symptoms may be due to exacerbation of urinary retention and/or bowel impaction (NICE, 2015). Conscientiousness to the caregivers' needs is essential, since this role can be demanding, due to sleep deprivation, emotional turmoil and the physical distress of providing intimate care, which may include changing a body-worn continence wear product (Candy et al, 2011). Inappropriate provision of continence wear products can increase distress to carers who may already be at breaking point (Schukter et al, 2017). It is central that each and every individual person obtain quality end-of-life care that is appropriate to their needs, preferences and wishes (Hospice Friendly Hospital, 2010). Individuals who are at the end of life ought to be offered choices in their own care (Hospice Friendly Hospital, 2010).
Person-centred care
Person-centred care is evidently reported in policy documents and safety and quality statements in addition to healthcare regulations (Gavin and Brady, 2013; HSE, 2014). The World Health Organization (WHO) (2015) defined people-centred care as ‘an approach to care that consciously adopts the perspectives of individuals, families and communities and sees them as participants as well as beneficiaries of trusted health systems that respond to their needs and preferences in a humane and holistic way’. Person-centred care requires that individuals have the education and support they need to make decisions and participate in their own care. It is organised around the health needs and expectations of people rather than diseases’. McCormack et al (2013) outlined that patient-centred care is strengthened by the carer's ability, with shared respect and understanding. As the population ages worldwide, challenges, complexities and concerns will develop to effectively deliver care with dignity, compassion and respect to all individuals (McCormack and McCance, 2017). Patient-centred care gives priority to each individual in the directing of their own care, acknowledging their distinctive wishes and with the recognition that each person is a unique individual (WHO, 2015). Patient-centred care improves quality care outcomes and patient satisfaction (Taylor and Cahill, 2018).
In the Irish context, person-centred care is described by HIQA (2012) ‘as care that is respectful and responsive to individuals' needs and values and partners with them in designing and delivering that care’. Person-centred care is a core concept in intimate continence care, where health professionals support individuals through a positive attitude, clear communication and comprehensive collaboration (HIQA, 2014).
Dignity is a central concept in incontinence management, and any negative pressures to the dignity process will adversely affect the quality of care delivered by health professionals (Zirak et al, 2017). In the practice of continence, therefore, patient-centred care is vital in all aspects from promoting, regaining or even managing incontinence (Nazarko, 2015). Identification of the individual's expectations is a fundamental process to promote patient-centred care (Nazarko, 2015). The humiliation of incontinence-where the person experiences wetting episodes-needs to be replaced with the principles of patient-centred care of compassion, empathy and proactive carefulness to encourage individuals to be self-empowered in managing their own care (Taylor and Cahill, 2018).
Collaboration
Effective leadership is central in all healthcare settings, to cultivate a collaborative approach of continuous learning and dynamic discovery, where the patient is central to planning care delivered with compassion (Timmins, 2015). Respect, dignity, kindness and consideration shown on a personal level will have an extraordinarily positive impact on the experiences of patients and carers (Ellins et al, 2012). Person-centred care combines a culture of collaboration, participation and transformational leadership to deliver quality outcomes based on individualised aspirations, anticipations and options away from the rigidity of regulations, rules and routines (Manley, 2014). Engagement and partnership with individuals, carers and families is essential to deliver coordinated care that is meaningful with quality outcomes (Health Foundation, 2014). Collaboration is essential in modern healthcare to promote altruism and prevent fragmentation (Axelsson and Axelsson, 2009). It requires interdisciplinary practice and inter-organisational and even inter-sectional collaboration (Axelsson and Axelsson, 2009). Nurses have developed codes of ethics, responsibilities and values to ensure professionalism (Zahedi et al, 2013) but they must also develop professional altruism (Axelsson and Axelsson, 2009).
In the context of incontinence management, collaboration is essential across inter- and intradisciplinary professionals, from nurses to suppliers, to ensure that a robust range of continence wear is available to individuals to promote autonomy, dignity and quality of life (Royal College of Nursing et al, 2015). A collaborative partnership consultation approach with patients ensures good patient outcomes (Manley, 2014). Furthermore, collaboration and patient-centred care are emphasised in managing urethral and supra-pubic urinary catheters, where the individual is continuously consulted regarding the physical, social, sexual and emotional implications of urinary catheter care (Adams et al, 2012).
Conclusion
In the area of continence assessment, promotion and management, health professionals should move away from the instinct of territorial behaviour and towards the concepts of collaboration, person-centred care and sharing of information, Individuals with incontinence should be supported to have their views and wishes comprehensively communicated and implemented into a care pathway. Regardless of the stage of an individual's life, health professionals should provide respect, dignity and compassion to enhance quality outcomes.
KEY POINTS
- Health professionals must provide a continence assessment, promote continence interventions and manage incontinence in all settings, thus reducing physical, psychological distress to the individual themselves, their caregivers and family
- The person is central to their own unique individual continence care, an opportunity should be offered to people to communicate, convey, their clear beliefs, views and opinions on continence care
- Dignity, respect and privacy are crucial concepts of continence care, through implication of these concepts quality continence and healthcare outcomes can be achieved
CPD REFLECTIVE QUESTIONS
- How does urinary and faecal incontinence impact on the individual, their family and caregivers?
- Drawing on your clinical experience and education, how can you promote continence and manage incontinence?
- Why is collaboration essential in the area of incontinence management?