Routine assessment and monitoring

While incontinence was rarely the over-riding reason for a patient’s admission, it was said by most of our interviewees to be an issue that featured prominently in their everyday practice, as suggested by its description a consultant physician as ‘one of the geriatric giants’ (B46). Incoming patients’ incontinence was often said to accompany multimorbidity: mobility problems, frailty, prolapse consequences, diarrhoea, mental illness or a degenerative condition, such as Parkinson’s. Practitioners were equally aware that a patient’s incontinence may have been aggravated by the condition’s poor management prior to admission.

Notwithstanding this backdrop, the commonly used pro-forma hospital admission assessment procedures were said to insufficiently capture continence care needs, due to ‘variable’ or sometimes ‘incomplete’ detail. As a result, staff strove to gather detailed understanding in their ongoing work on the wards, through routine checks of skin condition, temperature and urine/faecal output, and when possible, in discussion with patients and family members:

If I am doing an assessment of someone and their dementia, I would be asking questions around their continence and how they are managing to get to the bathroom…Are they normally continent at home, do they wear pads?… so it’s trying to make sure that full assessment is done in hospital… so we don’t make things worse for that person while they are an inpatient. (C26, dementia specialist practitioner)

Routine investigation also helped practitioners establish when incontinence pads could be dispensed with in favour of regular toileting, as well as the need for, and potential problems of, catheter use.

Forward planning

Participants told us the hospital environment could inhibit patients talking about their incontinence because they were embarrassed and feared drawing attention to themselves in this semipublic space. A nursing assistant emphasised the value of being proactive through paying close attention to patients who also have difficulty articulating their continence care needs:

Those patients [with dementia] you need to be a lot more proactive with… encouraging them to use the bathroom at those key times when they get out of bed first thing in the morning, before they go to bed, before lunches, before dinners. I think they feel more comfortable and happy in the hospital if they are not having to ask to go to the toilet. (B47, nursing assistant)

Planning ahead was also important to a physiotherapist (B44), who commented that in the course of her work with catheterised patients who had restricted mobility, she strove to get a trial without catheter (TWOC) procedure (commonly referred to as ‘TWOC’d’) undertaken ‘early’, as this could help motivate patients to increase mobility as well as offset the risk of patients returning home still catheterised.

Person-centred care

According to one participant, nursing staff should aim to be fully aware of continence care issues ‘because we are taught to look at the patient holistically’ (A06, staff nurse). Examples of person-centred care include a staff nurse (B42), who told of her work with catheterised patients with dementia whose psychological need to use the toilet was respected, and a nursing assistant (C22), who interpreted a patient’s change in behaviour as a ‘communication tool’ alerting her to his urine retention. A physiotherapist, describing her role in helping a patient recover balance and mobility skills, said she used toileting as a motivational strategy because this goal was the patient’s own mental ‘priority’.

Underpinning these approaches to continence care was a commitment to building a rapport with patients, so that patients could confidently communicate their needs, in itself confirmation of good continence care practice:

If your patient…can ask you to use the toilet, I feel like you are being a very good nurse. And [if] they feel like they can tell you if they need changing, I feel like you are being a very good nurse. (C21, ward sister)

Encouragement of independence

On all hospital wards included in the study, the ambition to help older patients with incontinence ‘get back’ to their original ‘baseline’ or ‘as independent as possible’ was commonly reported by participants to be a primary objective in caregiving. An important strategy in this respect was enabling less mobile to transfer more readily to the toilet, activity that appealed to notions of normality and was motivational, physically strengthening and positively impacted patients’ mental health. In addition, such practice was said to be time-efficient:

If their continence improves by emptying their bladder and bowel [on the toilet rather than commode] and they feel a lot better because they have sat up [in privacy] in a good position, then they are going to have less interventions for their incontinence. (C25, physiotherapist)

Lack of oversight

Participants pointed out that information gained from monitoring patients’ continence care was only useful if accurately and routinely recorded and, as this was not always the case, such information could not be relied on:

This morning a lady was TWOC'd…she is mobile, gone to the toilet a couple of times last night but nobody has documented to see if she has passed urine or not or how much. (A04, senior nursing assistant)

Interviewees also speculated that this laxity arose because of a tendency not to notice, or take stock of, the commonplace:

Continence care is an important area and the only thing I find is because it’s such basic care, it gets overlooked and forgotten about at times… some [staff] think there is nothing to worry about. But I think they should do. (B41, staff nurse)

A ward sister concurred that continence care is ‘forgotten about’, claiming because other procedures and tasks are seen as more important, with the result that patients are ‘kept in pads’ by unquestioning staff or are sent home with catheters that are not necessary. A dilatory attitude could also preclude consideration of proactive continence care strategies. In this respect a dementia specialist practitioner described how when she advised staff to engage in regular 2-hour toileting routines, to keep patients dry and stop them becoming agitated, she was sometimes viewed ‘as though I have got snakes coming out of my head. It’s an old fashioned concept but it works’ (C26).

Over-reliance on incontinence products

The use of pads, without due regard to the possible health implications, led one nursing assistant to worry that this could ‘encourage incontinence and becomes an obstacle to keeping people continent’ (B47). A ward sister echoed this point when she drew the conclusion, ‘We cause incontinence a bit’ (C21). In addition to the question of staff inattention, discussed above, participants suggested a number of intrinsic reasons for over-reliance on products: custom and practice, expediency and patient acceptance.

Custom and practice in respect of pad over-reliance was implied by many interviewees when speaking of pads being provided as a matter of course, without first determining need, suitability, benefit or risk. This convention was summed up by one staff nurse when admitting, ‘we tend to get pad happy’ (C23). A nursing assistant added weight to this concern by pointing out that ‘registered nurses should prescribe continence products [but] it’s very rare that I have seen that done’ (B47), leaving her and her peers to make these clinical decisions.

Expediency, given staffing levels and pressures on time, was another reason for over-reliance on pads. A physiotherapist spoke of nurse colleagues being ‘always up against the clock [so] it’s easier just to stick a pad on someone [and] not allow them to walk to the toilet’ (C25). Although expediency was most often talked about in relation to over-reliance on pads, it was also said to contribute to overuse of catheters. Unnecessary provision of catheters was said to occur as a service convenience or because staff were too busy to review their use. A junior doctor noted that over-reliance on catheters and delay in their removal ‘can be a very common situation’ (C29).

Patients themselves were said to be, on occasion, complicit in the routine use of products such as incontinence pads, by accepting pads in order to reduce the burden on obviously overstretched staff. As one staff nurse put it, ‘they don’t want to bother the nurse’. Another reason for patients’ assent in the regular use of pads was said to be anxiety and embarrassment about their incontinence, which could lead to dependency on pads as a method of masking their incontinence in a semipublic environment. An important consequence of product over-reliance was reported to be the weakening of patient independence and fostering of dependency.

Staffing pressures

A senior staff nurse (A01) referred to the benefit of having secured an extra nursing assistant to help patients with toileting but added that with the heavy workload on the ward, ‘we are still struggling’. The general pressure that hospital staff were under led one consultant geriatrician to reflect how older patients’ incontinence needs could be missed if they were not highlighted by the patient, adding ‘the pressures on hospital are to treat the primary condition and get them out… we don’t pick up [continence needs] as much as we could do because it’s not the thing that’s flagged up in front of you’ (C24). Other staff agreed that key indicators of continence need could easily be overlooked, with one staff nurse saying by way of example, ‘this patient might not have wee’d for an hour or two and urine output might have tailed off [which] might be missed’ (A06).

These concerns were often reinforced by reference to low staff to patient ratios, especially problematic on wards where many patients were bedbound or recovering from surgery, requiring two members of staff to support them with their needs.

Participatory care

Interviewees talked of wishing to enable greater patient independence and management of their continence, thereby helping mitigate ‘institutionalised’ and ‘dependent’ behaviour. This, they said, would best be achieved through a facilitative approach based on participatory care, both in respect of product use and mobilising to use the toilet:

I think we are all very well meaning as a profession but I do think we put an onus on people being dependant on us. You know, “it’s OK, I will come and wash you my lovely”. No! Put a bowl there, let them do it themselves! Get them walking out to the toilet, get a commode by the side of them, do what it takes… we need to look at that and say, “right, we are managing your care but I need you to be participating in your care and increase your independence so we can [better] meet your needs”. (A09, senior staff nurse)

Opening up communication

Participants put forward the likely benefit of opening up, or broadening, their communication with, or about, patients with incontinence. A consultant geriatrician, admitting that faecal incontinence is ‘a bit under-recognised’, observed that ‘we only uncover things when we ask about them [and] we are less good asking about bowel problems than we are about bladder problems’ (C24). More generally, interviewees suggested that talking in a matter-of-fact way with older patients about incontinence would help overcome patients’ reluctance to do so. Furthermore, attentive listening and opening up a dialogue so that patients, and where appropriate, family members, were better able to express their views would also allow staff to fine tune interventions to meet the individual’s needs:

Some feedback from patients about how we can make them feel a bit more comfortable being incontinent would be good. Because sometimes you can go over to somebody and say its fine, don’t worry. It would maybe nice to know how they would want us to approach it as opposed to [us] just batting it off. (A08, senior staff nurse)

Robust planning

Participants told us that continence care plans, where they existed, provided a useful guide ‘so that everyone knows what the situation is and how it should be managed’ (C25, physiotherapist). Interviewees added that to be effective, however, continence care planning had to be robust in terms of routine updating and forward thinking. Routine consideration of continence care needs would more likely take place, according to one consultant geriatrician, within an integrated appraisal system:

The thing that we have lost is proper old fashioned MDTs [multidisciplinary teams]… now you have a daily ward round where you catch up with everyone but continence [is missed] when you are nipping round quite quickly, whereas in the past I would do MDTs where we would routinely talk about skin care, continence, nutrition. We don’t do that now. So having something where it was routinely discussed for everyone, that would help. (C24, consultant geriatrician)

A consultant physician also advocated a higher profile for continence care within ‘intentional rounding’ (B46). This sharper focus on continence care would, according to a staff nurse, facilitate forward planning and preventative work, with the corollary ‘I think we can then avoid the need for catheters’ (A09, senior staff nurse).

Participants also wished to see more proactive planning in regard to patient discharge and associated community liaison. Particular emphasis was put on improving referral procedures for district nursing regarding catheter care, in order to mitigate delays that were said to arise when discharge letters to general practitioners were not promptly acted on and to enable a better ‘flow’ of information to district nurses (B49).

Staff training

The majority of participants told us they had received no ‘specific’, ‘formal’ training in continence care but had learnt about it ‘on the job’, ‘talking to colleagues’ or ‘just doing it’. This was a particular concern in regard to nursing and healthcare assistants, given that they often worked with ‘high continence needs but haven’t really had much training in it’ and so may be unaware, for example, of ‘the link between skin [integrity] and continence’ (C23). Doctors also conceded ‘we get very little [continence care] training… it’s not high enough on our curriculum’ (C24), and, ‘if we did have [continence care] training we might be able to stop these situations when we have forgotten to TWOC the patient’ (C29).

Participants believed continence care education would potentially have a pivotal impact on practice, improving staff awareness of relevant information, advice and best practice guidelines. Most importantly in the opinion of many participants, improved recourse to relevant education would help ensure proper, safe use of continence care products. Specific updates on incontinence pads would help provide ‘awareness of why we are putting a pad on’ (C27) as well as guidance on ‘how to make sure [staff] have got the right size pad’ (C29) and ‘how often you change pads… we don’t know’ (B42). As regards catheters, a therapy technician suggested staff would benefit from ‘teaching around… weighing up the effects of long-term catheter and short-term catheter [use]’ (A03). Education would also help staff ‘get rid of’ incontinence sheets, which were in some cases still used inappropriately with incontinent patients and sometimes ‘causes their skin to break down’ (A01).