Management of Urinary Incontinence in Primary Care

Introduction

Incontinence is a condition that affects 1.4% of the general population aged over 40 years old and in 1998, the World Health Organisation (WHO) reported that bladder control problems affected more than 200 million people worldwide. Prevalence of urinary incontinence in women that are not institutionalised is 10-40% while for those living in institutions the prevalence is as high as 50%. It is estimated that 46% of women and 34% of men over 80 years suffer from urinary incontinence (NICE 2006). There is a huge financial impact of incontinence on primary care organisations in the UK in excess of £750 000 per year. This is indicative of a total expenditure of the UK of more than £420 million (approximately 1/20th of the total cost of the NHS). This means that the costs of incontinence are high to both individuals and health services (Euromonitor 1999).

Since incontinence is an aspect that affects the mental well being of service users, research into this area helps to make comparisons and hopefully help health care professionals, carers and service users to better manage the problem. While there is evidence that incontinence can cause physical and psychosocial problems, evidence shows that patients are rarely consulted about their treatment or management of their continence. There is therefore a need to develop person-centred and evidence-based approaches to continence promotion and management.

Incontinence is one of the oldest medically recorded complaints in the history of mankind with the first known cure being recorded in 1500 BC. Traditional remedies such as juniper berries, cyprus and beer were used to cure incontinence of urine (Smith 1987). Gradually in the 19th century, diet became associated with maintenance of continence and in 1974, the first national incontinence advisory service was established. The 1980s saw the setting up of continence services and appointment of continence advisors which comprised of representatives from health and social care professions who were charged with reviewing the provision of continence services and the training of professionals.

Incontinence in older adults is consistently associated with adverse effects on the quality of life for service users. Some of the effects include social isolation, loneliness, depression, stigmatisation, embarrassment that affects the activities of daily living and disturbed sleep.

The author chose this area of practice following negative encounters while on placement on an over 65 psychiatric ward. During this time the author was exposed to negative attitudes and bad practice where incontinence was concerned. For the purpose of confidentiality, the exact location and any names used in this piece of writing have been changed in accordance to the NMC Code (2008). Research can be defined as the search for knowledge or any systematic investigation to establish facts and may be either qualitative or quantitative in nature. Qualitative research can be defined as a form of social inquiry that focuses on the way people make sense of their experiences and the world in which they live (Holloway et al 2010) while quantitative research involves the use of data collection methods such as questionnaires, structured observations, interviews and other measuring tools (Parahoo 2006). Research is useful in the sense that healthcare professionals have to demonstrate effective integration of evidence including research findings into their clinical decision making (Fitzpatrick et al, 2007). The Department of Health (DoH 2000) introduced a clinical governance which was designed to ensure efficient and effective healthcare and this required practitioners to demonstrate that they are using evidence-based practice to support service developments, besides, the Nursing and Midwifery Council (NMC 2008) demands that nurses base their practice on the best available evidence.

Objectives of the Study

To review a research paper on urinary incontinence in older people in the community (see appendix 1)

To assess the impact of urinary incontinence on quality of life and evaluate user and carer perspectives on the subject.

To discuss and develop an effective clinical intervention and management strategy while involving the service user in the process.

To draw conclusions and make recommendations for future practice.

Literature Review

Paper I: Stoddart H et al (2001) “Urinary Incontinence in Older People in the Community: a neglected problem?” British Journal of General Practice, Vol 51 pp 548-554.

The study was carried out in an unspecified British city in 11 general practices where a stratified random sample of 2000 men and women aged 65 to 74 was used. The aim of the study was to investigate the unmet need in relation to urinary incontinence and its impact on everyday life in adults aged 65 years and over. This was done using a quantitative analysis where a postal questionnaire about incontinence was sent to a random sample of 2000 elderly people stratified by age and sex in order to yield equal numbers of men and women. 79% of the people completed and returned the questionnaires and the findings indicated that incontinence was more prevalent in women than in men at all ages. The key findings in this study were as below:

Plan for Implementation of Best Practice

Devise an effective assessment procedure for incontinence

Involve service users and carers in decision making

Assess staff skills and provide training where there are deficiencies

Ensure an effective multi-agency working environment

Ensure adherence to policies and procedures by staff and service users.

THE CHANGE PROCESS

In implementing best practice in management of continence in the care setting, the author plans to use Kurt Lewin’s change management model (1947). Lewin, who is recognised as the ‘founder of psychology’ proposed in his model that in order to influence people to change, it takes 3 stages namely;

Unfreezing – getting ready for change and moving away from the comfort zone.

Change – the process of transition.

Freeze (refreeze) – establishing stability after change has taken place.

The promotion and management of continence for older people should be within person-centred models of practice (De Laine et al, 2002). During the freezing stage, the author intends to ensure that there is improved communication between service users and health care professionals and seek to change attitudes especially staff attitudes towards management of incontinence. This would be important as it would help service users and carers to make informed decisions and according to Straus et al(2005), evidence based practice requires healthcare practitioners to use it together with clinical skills including assessment and communication. Straus also suggests the need for healthcare professionals to consider the dynamic interaction of belief and value systems affecting the patients’ experiences of healthcare. It will also be necessary to create some awareness to the public and service users regarding the subject since it has for a long time remained a taboo or something that is embarrassing and not nice to talk about. The most important nursing intervention is educating the service users about treatment options and facilitating their decision making in relation to the available choices. Education should therefore address the impact of dietary factors such as caffeine and fluid intake on bladder and bowel function i.e. bladder training and pelvic muscle exercise. Rankin et al (1996) stresses the fact about consideration being given to the information that is provided to service users and the use of strategies that are sensitive to the learning needs of seniors. Health care professionals need to appreciate the fact that patients have a right to know and be taught and be enlightened about issues regarding their health. The author proposes to use an assessment tool which fully involves the service user in terms of what should and should not be done. A complete physical assessment will be performed by a nurse practitioner and aided by someone familiar with the service user and this will hopefully provide accurate predictions concerning the level of care accorded. Staff will have to undergo proper training which will emphasise the importance of communication with service users and also the impact of attitude on the recovery process of patients.

Some of the important points to note while carrying out an assessment will be the frequency of incontinence, if its urinary or faecal, length of time that it has been occurring, changes in behaviour and any medication being taken. While looking after incontinent service users, it would help to ensure that the person has a good fluid intake, observe the patients toileting patterns and suggest that they use the toilet at regular times, try and toilet the patient before and after meals and before bed. A lot of reassurance would need to be accorded to the service users where short and simple words and ones that are familiar to the patient are used. In regards to the environment, distance from the bed area to the toilet would have to be looked at. In some cases, a commode would be considered. Toilets would have to be clearly marked and lighting constantly checked to ensure that it was just right. If the patient requires help to mobilise then the nurses and the healthcare assistants would be required to assist. It is important to respect privacy and dignity. Losing control can be humiliating and embarrassing and caregivers need to be sensitive to these feelings. There are bound to be accidents and in such cases, a lot of assurance needs to be given and help in managing the problem given. Privacy would given to the patients in accordance to the regulations set out in the NMC Code (2008).

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It is important to note that sometimes clothing may be a cause of patients becoming incontinent. The healthcare professionals would need to educate patients about the importance of wearing flexible, easy to remove clothing. Things like elastic waist banded clothing would be advisable. Protective garments and disposable pads may also be useful. Skin care is very important. Advice and help would be given to wash the skin after an accident to keep it clean and dry and to prevent rashes. Soiled beddings would need to be changed regularly to ensure that the patients do not suffer from bedsores. Where a patient is bedbound, the caregivers would need to ensure that the patient is turned on a regular basis to ensure that there is no occurrence of bedsores.

After all the above is in place, the author then proposes to move to Kurt Lewin’s second stage which is change or transition. Lewin was aware that change is a process, not an event, hence he considered this stage as being the transition. This is usually a very difficult stage as people are learning about changes and the need to be given time to understand and work with them. Support is important and this can take the form of training and coaching, a lot of mistakes are bound to be made during this stage but that is considered as part of change taking place. At this stage the author proposes that staff be well trained and refresher courses given to those who already have the skill. Better communication with patients and carers will have to be improved in order that psycho education may take place as this would ensure that change is effective. Staff, service users and carers would need to be educated about the products that are used for incontinence and thorough assessment and better observational skills would be required of staff. Service users would be educated about their incontinence and how to manage it. Use of charts (food & fluid and urine input and output) would be used so that proper follow up is done. Henderson (2002) denotes that effective documentation provides a record which demonstrates that individualised nursing care has been given and the patient’s response to that care (outcome). Documentation also provides improved quality of care due to increased communication between patient and caregivers. Multi-agency working which is teamwork will also be emphasised so that there is consistency in the provision of care. This will also be useful as it will keep communicating a clear picture of the desired change and the benefits to people so they do not lose sight of where they are heading.

The final stage in Kurt Lewin’s model of change is the freezing or refreezing. This stage is about establishing stability once the changes have been made and have been accepted as the new norm. The author is aware that it may take a long time before people settle into comfortable routines. It is however important that health workers move away from clinical practice based on ritual and unsubstantiated practice and head towards making considered and informed judgements about the range of evidence available and include careful consideration of experience and expert opinion in making clinical decisions, Appleby et al (1995). At this stage the author proposes that new policies will have to be written to replace the old ones to ensure that any new staff members adhere to the up to date guidelines. Regular seminars on management of change will be held to ensure that staff are up to date with the current policies. Communication at all levels will be stressed in order that proper care may be delivered to the patients. The author also anticipates rigidity of freezing which may not fit with modern thinking about change being a continuous chaotic process in which great flexibility is demanded.

FACTORS THAT WOULD ASSIST IN THE IMPLEMENTATION OF EVIDENCE BASED PRACTICE

In implementing the above practice, the author anticipates that the factors that would assist would include:

Safe environment with proper equipment for example proper lighting, commodes, etc.

Well trained staff that would need to have positive attitudes as this would make communication with service users easier and hence creating awareness about the impact and management of incontinence would be much better handled.

Teamwork in this area would be essential. Collaboration among healthcare professionals, the service users and their carers would be required in order that the implementation is effective.

FACTORS THAT WOULD HINDER THE IMPLENTATION OF EVIDENCE BASED PRACTICE

Service users state of mind, especially in cases where there is dementia and in which case it would be quite difficult to communicate with them or get them to make any sense about their condition.

Lack of knowledge and access to service and resources.

Resistance to change from healthcare professionals.

Strain on healthcare professionals which would be as a result of long working hours and poor staffing levels.

Pressure and negative attitudes from the service users’ relatives may also cause a problem while trying to deliver good service.

Lack of finances to purchase the proper equipment to be used in delivery of care. This would be as a result of poor allocation of resources or even low budgets from the Department of Health.

CONCLUSION

The involvement of users perceptions and experiences is important as it creates avenues for research on elderly incontinence. It is also of utmost importance that service users and their carers to be involved in care planning procedures and reviews of policies when they happen. Healthcare professions may be