The problem of incontinence is still with us

Abstract

It is tempting to think that continence nursing has come a long way since James P. Smith's editorial in 1982. And indeed, in the UK, in many ways we have made considerable progress. There are over 400 clinical nurse specialists devoted to continence in the UK; the Royal College of Nursing has an active continence care forum; and several major texts on continence nursing have been published in the UK. The Medical Research Council has spent well over £5million on research relating to incontinence; the UK government has issued a major report recommending integrated continence services and targets arising from this are included in The National Service Framework for Older People (Department of Health 2001). The UK National Institute for Clinical Excellence has recognized the importance of the subject and is currently developing guidelines on both urinary and faecal incontinence. Incontinence is included in many other major policy initiatives, including being one of the topics for the Department of Health's quality initiative (benchmarking), the NHS information authority's datasets project, and the Royal College of Physicians’ audit programme. There are similar developments in other healthcare systems around the world. Thirty-six countries now have a national continence organization of some kind. The Cochrane Collaboration has reviewed the effectiveness of all major interventions for incontinence and other authoritative reviews have suggested efficacy for many different treatment modalities (Abrams et al. 2005). Public awareness of the subject is growing, and a Google search on ‘incontinence’ produces over 2 million hits! Yet we have to question whether all of this activity has really changed everyday nursing practice. Anecdotally, it seems still to be common in clinical practice to routinely use a pad, rather than assess the individual and implement appropriate care. The employment of all the continence nurse specialists may have improved care for the minority of patients who gain access to their services, but it seems that the wider educational role of continence nurse specialists, and their potential influence as role models, have been less effective. And many continence nurses are so overwhelmed by the imperative of trying to keep their budget for pads and other equipment under control that clinical care does not always take first priority. The focus of James P. Smith's 1982 editorial was entirely on urinary incontinence, and mostly on practical management, rather than on assessment and the possible resolution of symptoms. Now practitioners would agree that nurses do have a therapeutic role, and that the situation of many people with both urinary and faecal incontinence can be improved by nursing interventions (Getliffe & Dolman 2003, Norton & Chelvanayagam 2004). However, in reality, many continence-promoting interventions are difficult to implement and to sustain. Pelvic muscle exercises certainly help, when delivered within the context of a closely-monitored research protocol, but it is notoriously difficult to teach patients the correct technique and to keep up their motivation for long enough to make a long-lasting difference. We still have, with a few exceptions, almost no evidence about successful interventions in the nursing home environment (where the largest burden of incontinence falls), and in neuro-disability (where the highest proportion of patients have problems). And faecal incontinence remains neglected, even amongst continence specialists. Recipients of specialist nursing continence advice have reported that an informal friendly approach by nurses with good communication skills relieves embarrassment and anxiety, thus facilitating information exchange and the effectiveness of care. Both the interpersonal and technical skills of the nurse are important and, together, they lead to effective treatment (Shaw et al. 2000). Are most nurses too busy to take this approach or learn continence-specific technical skills? Maybe we have information overload, and nurses are overwhelmed with the volume of literature on incontinence and do not have the time to sort out what is actually meaningful. Maybe this will never be a popular topic and it is unrealistic to expect more. Whatever the reason, there is little doubt that in 2006 ‘the problem of incontinence’ is still with us, and still with the millions of people worldwide, who all too often still get little or no help with this distressing symptom.