Continence Promotion and Care

Bowel and bladder problems can have a devastating effect on quality of life and dignity, both for patients who are dependent on others due to physical or mental disability, and for those who are otherwise independent. This category rewards initiatives and innovations that promote continence, increase the effectiveness of care and improve the quality of life of people who have continence problems, whether temporarily or permanently. This award is open to individual nurses or teams working in any setting in the NHS or independent sector – including nursing and residential homes – and those working in specialist continence services.

Central Cheshire Integrated Care Partnership
Bladder and bowel promotion

It was recognised that CCICP Adult Bladder and Bowel service was under significant pressure due to increased patients and increased complexity. This triggered the team to think differently about how they were working. As a community service the nurses work in a variety of ways to ensure that their service is accessible, they offer telephone appointments, clinic appointment and domiciliary visits whilst also supporting care facilities and wider services using their expertise to provide holistic care. What did we do? Our clinical lead worked with the wider service to develop and launch a e-learning training module to spread basic knowledge and awareness of bladder and bowel conditions, this was launched across community services as well as in the acute trust. Promotion week, the service divided into groups and hosted an engagement table at each community base and in the hospital. Engaging with staff and the public about conditions and signs to be aware of. Visited wards to share knowledge of conditions, signs and symptoms but also spoke about referring into the Bladder and Bowel service and what they do as a specialist service. Clinical lead was interviewed on Radio Northwich sharing information about the service and how they work to improved the quality of lives of the general population breaking the stigma of bladder and bowel conditions. The team attended nursing homes to educate staff on basic care and ensure that they feel confident in caring for patients with incontinence. Clinical lead presented to the GP engagement group to ensure that symptoms are captured early and the correct treatment was put in place. Trust communications about the team was disseminated and the team gave out promotional merchandise.

City Health Care Partnership CIC
Bladder and bowel service

As an established provider of community services across Hull and the East Riding of Yorkshire, City Health Care Partnerships CIC (CHCP) recognised that the care of people with continence problems needed addressing. Concerns included: An increased burden being experienced by Community Nurses in providing continence care. Care home and housebound patients were often in receipt of inadequate provision. Inappropriate product usage which increased financial pressures. A substantial number of patients with diverse needs who were receiving standardised care which did not address their individual requirements or reflect their specific circumstances. In response to these challenges, CHCP began a comprehensive transformation programme. This included, as part of the first phase of activity, a presentation to CHCP’s Executive Board on the proposal for change and the development of a business case to secure funding from the Integrated Care Board.Key drivers for change included: A necessity to enhance quality care. Reduce burden on community nursing. Improve resource utilisation. Provide patient-centred care. The initiative initially faced several challenges including: A surge in referrals overwhelmed capacity. Sickness absences and migrated patients exacerbated existing workforce pressures. A backlog of patients awaiting assessment and treatment due to the influx of referrals. Positive outcomes includedReduced waiting times for continence assessments. Reduced use of continence products through patients being supported to regain/maintain their continence. Improved referral rates. Improved patient satisfaction. Reduce delayed discharges from hospital. CHCP future plans are centred on sustaining a Bladder and Bowel treatment service which remains patient-centred and available for all adults (irrespective of where they live/their functional abilities/cognitive abilities/disabilities/social circumstances). Furthermore, future intentions include an expansion of the service to include annual reviews and improving the alignment of continence product providers to yield greater efficiencies.

East Suffolk and North Essex NHS Foundation Trust
Don’t just grab a pad – developing an effective continence service in an acute hospital setting

In 2021, East Suffolk and North Essex NHS Foundation Trust launched a quality improvement project to introduce a continence service to the acute setting, with a continence assessment, training, and education plan, which aimed to raise awareness of the importance and impact that good continence care has on patients and their outcomes. (T Woollerton 2023) (Fig 1). We wanted to, stop, or reduce the following. Stop over reliance on continence products for in-patients. Reduce moisture associated skin damage (MASD) linked with poor continence care. Reduce falls associated with incontinence. Reduce deconditioning. Reduce costs and the impact on the environment from continence products. We wanted to achieve the following. Promote continence for inpatients in the acute setting.Educate both staff and patients in good continence care. Introduce a continence assessment and care plan focused on giving evidenced based and patient centred continence care. The initial QI project was a pilot on 4 wards in one of the trust’s acute hospitals proved successful in achieving the 3 points above, and also reducing costs and the impact on the environment. Since the initial pilot, the continence assessment and care plan were rolled out to all wards in the trust. Education and support were provided in many different formats, E-learning, lecture theatres and ward based. The main challenge was overcoming ward culture and attitudes of the ward staff. However, in the past 36 months through auditing and monitoring. There have been some significant improvements.Reduction in MASD. Reduction in use of continence products. Increase in use of continence assessment and care plans.In future we plan to monitor and try and decrease falls associated with incontinence. The continence assessment and care plan has been updated to be more concise and user friendly.

Hampshire Hospitals NHS Foundation Trust
Continence care – leaving the one size fits all approach behind

Continence care across the trust was poorly executed with no real focus was given to it. As a result within our umbrella service team, those with continence backgrounds created a new service which would address: the amount of incidents resulting in harm linked to continence i.e MASD, Falls and PU the idea that one size pad or plan fits all approach to continence was the best way to support those with dysfunction of the bladder and or bowel, the availability of products to promote, manage or contain procured by non-clinical staff rather than clinical specialists, key patient cohorts where wider guidance advocates continence care as part of their hospital based care were not receiving access to specialist nurses and or appropriate continence plans, wait times for community assessments for high risk patients meant many were at risk of harm, deterioration or financial burden following a referral from the trust on discharge, the lack of education and knowledge relating to the topic held by clinical staff. At the start of 2023, we developed an inpatient continence referral service, which ensured all had access to a continence management plan, key groups were visited on twice weekly ward rounds, formularies became clinically owned, mirroring the community formularies, and prescriptions for management aids (pads etc) were made at point of discharge by ourselves and then taken over by community teams after 12wks, and all staff had access to a continence programme which raised awareness of its value Along the way we have met with multiple challenges, such as letting go of the reigns, gaining stakeholder buy-in or encouraging staff to value our vision, but with good relationship building and working in partnership value can now be seen as we now explore clinics and new pathways.

Nottinghamshire Healthcare NHS Foundation Trust
Level one continence clinic in Rushcliffe

Following the pandemic, we had a 2-year 6 month waiting list for level 1 continence clinics, with 333 people waiting for an assessment. Having reviewed the waiting lists it became evident that we needed a robust plan, whilst managing the increased referrals coming through due to the post pandemic surge and most importantly return to delivering a quality continence service to the patients across Rushcliffe. We identified a gap in workforce engagement with continence as well as observing a difference in the quality of assessments, received in a clinic setting and within a patient’s own home creating a 2-tiered system. We decided that we had two different issues but initially needed to priorities the clinic waiting list and then move onto phase 2 of my plan, which would be to increase continence education of the workforce. Phase 1; we sought senior approval to recruit a full-time level one continence nurse to increase our continence clinic offer from 1 clinic a week to a daily continence clinic across Rushcliffe to reduce the waiting list requirements with 6-7 months. To streamline, the clinic process was reviewed, a standard operating procedure was developed, we sought administrative support to help facilitate the process. In 9 months, the waiting list is now zero weeks, this is an outstanding achievement but not only due to the waiting list reduction but from the feedback received continuously for the care delivered by our level 1 continence nurse Kay. She has worked tirelessly over the last few months, building her own knowledge, skills and expertise, developing a close network with the wider MDT, specialist continence, community nursing teams and administrative teams. Phase 2; is to focus on staff training to deliver quality care regardless of setting. This will be achieved by equipping staff with the correct education and training.

Royal Wolverhampton NHS Trust
Catheter Project

The focus of the idea came from reoccurring problematic catheters and patients not getting the support that they required. In addition to this patients that required a trial without a catheter in the community, (TWOC) were not receiving consistent patient centered care, which unfortunately also resulted in many failed TWOC's and an increase in catheters within the community. This lead to increased volumes of call out visits from patients with issues. The aim of the project was to resolve some of these issues and reduce call out numbers, also to ensure patients with catheters were receiving a specialized service with good quality care. We centralized patient referrals requiring a TWOC and problematic catheters and had a focused problem solving approach to resolve issues for these patients. Challenges faced were that there were a large number of referrals for one nurse to manage and although I had a long extensive knowledge of catheters, I did not have any specialist urology experience. To overcome this I acquired an extra member of staff and I also arranged to spend time with urology. I would also participate in extra learning events within my own time to further develop my knowledge as I was so passionate to make a difference for this cohort of patients. Outcomes of the service have been fantastic, patients have a one stop point of contact, professional relationships have developed, the number of calls outs have reduced and I have developed my wider knowledge. Patient feedback has been really positive. Future plans for the initiative are to grow the team wider to help more patients within the community live a greater quality of life with their catheter and ensure all education is provided.

Sanctuary Care
Nurturing skin health through simplified incontinence associated dermatitis care

The primary issue we aimed to resolve was the management of incontinence-associated dermatitis (IAD) within the long-term care setting. Our goal was to address this issue by introducing a novel one step solution in the form of 3-in-1 pre-impregnated cloths and moving away from the standard method of washing with soap and water and the adding barrier protection. we also focused on enhancing residents' skin health and improving operational efficiency. To address this issue, we conducted an observational intervention study that included two key components. Firstly, we thoroughly trained staff to ensure adept use of the new product. Secondly, we implemented an assessment strategy, including a skin assessment score and a time & motion study, to compare the one step process with the standard care on both skin health and operational efficiency. Throughout the study, we encountered several challenges, including staff training and adaptation to the new product, as well as logistical hurdles in implementing the assessment protocols. However, through proactive measures such as training sessions and monitoring, we were able to overcome these challenges effectively. The outcomes of our initiative were highly promising. We observed a significant improvement in skin integrity, as indicated by a notable reduction in skin assessment scores and a decrease in the prevalence of skin issues among residents. Moreover, the adoption of 3-in-1 pre-impregnated cloths led to substantial improvements in operational efficiency, with reductions in the number of products used per care episode, cost savings, and significant time savings in the care process.

Stow Healthcare, University Hospitals of Leicester NHS Trust and Care England
The Decaf Project

Could introducing decaffeinated drinks reduce falls associated with toileting? This was the question first explored by University Hospitals Leicester in 2021 and taken up in social care by trade association Care England and elderly care provider Stow Healthcare in 2023. Caffeine has a diuretic effect, impacting the bladder and bowel and increasing the urgency of using the toilet. This may be a contributing factor to falls, particularly among elderly or infirm people who often have limited mobility and a higher prevalence of incontinence than the general population. In this innovative cross-sector learning opportunity, the three organisations operationalised a unique trial focused on a low/no cost innovation to improve lives and potentially reduce the significant cost to the NHS associated with fractures caused by falls (£4.4bn per annum). UHL and Stow Healthcare engaged staff and participants with both blind taste testing and health information around the potential health benefits of reducing caffeine intake. This resulted in a high take up of decaffeinated products – 89% of Stow Healthcare’s 350 elderly residents chose to take part in the trial. In both settings, caffeinated products always remained available upon request, with decaf becoming the default option. UHL’s trial saw an initial reduction of 30% in falls occurring on the way to the toilet, eventually dropping by 61% compared to pre-trial by Autumn 2023. In Stow Healthcare’s care homes, toileting-falls reduced by 35% compared to pre-trial data. Both organisations are now recommending decaf as the default option. Challenges have included accurately identifying falls associated with toileting, which can be more complex in those unable to vocalise reasons for their fall, and sharing information effectively to engage participants and staff. Enthused by the excellent results, Care England, UHL and Stow Healthcare are promoting their work nationally to engage ICBs, acute settings and social care providers.

Sussex Community NHS Foundation Trust
Development of a children and young people's continence physical assessment module

The NICE guidance (2017) clearly identified it is best practice to undertake a physical assessment to confirm the diagnosis of constipation prior to treatment. Most academic physical assessment modules available cover all body systems which due to the specialist nature of the the CYP Continence nurse role is not required. On scoping there were no available modules nationally to support the specific physical assessment needs for CYP continence nurses. Therefore due to the gaps in available and appropriate training, the service decided to establish a bespoke module for their CYP continence staff. The Practice development nurse undertook building the curriculum and teaching . To ensure the training was of an high standard, and provided quality assurance, module endorsement from the University of Chichester was applied for and successful . Level 6 module endorsement obtained. To support the wider CYP continence nurse community we promoted the module via social media. We had national interest and sign up from children's continence nurses from across the country. The overwhelming challenges are the time required to build a specific curriculum and ensure that it met the required standards. The process has taken nearly 2 years from the concept, organisational support, building the curriculum, endorsement process and delivery. The feedback for the module has been incredibly positive and requests are coming in for the next cohort. We aim for the module to run biannually . With physical assessment, many of the taught elements of the module are carried out in a classroom- this potentially limits people accessing due to he costs of travel and overnight stays - Our module could be adopted by another health organisation in a different geographical area - this will increase specialist continence nurse knowledge and development - improving assessment and quality care for children and young people with dysfunctional

University of Bristol
URApp – a smartphone app to support young people's adherence to bladder training

Our research with young people with urinary incontinence (UI) led us to recognise that they need more support to self-manage their bladder symptoms. Despite the prevalence and adverse impacts of UI on quality of life, educational attainment, and mental health, many young people with UI feel they are not adequately supported by current services. Bladder training can be effective, but success depends on adherence and self-motivation. Young people with UI told us that they find it challenging to adhere to bladder training because ongoing support is lacking. They reported poor treatment experiences including a lack of continuity in care and high rates of relapse, which lead to feelings of hopelessness about their prognosis. Paediatric continence nurses told us that young people require more bespoke understanding, management and care and that the current method (bladder diary) for collecting data on fluid intake and urine output is not optimal for young people. We developed a smartphone app- URApp (https://urapp.org.uk/) to aid adherence to bladder training. We co-designed URApp with young people with UI and a multidisciplinary team including paediatric continence nurses. We conducted real-life testing of URApp with young people, and gathered feedback from clinicians, to refine and optimise URApp prior to its launch in October 2020. Key challenges included (i) identifying and securing funding to develop the initial URApp prototype and subsequent funding for updates and maintenance of URApp, and (ii) getting funders to recognise that incontinence is common in adolescence and is not just a problem that affects the very young and old. URApp is already being recommended by clinicians in some paediatric continence clinics in the UK and our future plans are for URApp to be adopted into clinics across the UK to and offered to young people to help them to adhere to bladder training.