Neurourology and Urodynamics 35:400–406 (2016)
Minimum Standards for Continence Care in the UK Angie Rantell,1* Lucia Dolan,2 Liz Bonner,3 Stephanie Knight,4 Carmel Ramage,5 and Philip Toozs-Hobson6 1 Lead Nurse Urogynaecology, King’s College Hospital, London, UK Consultant Gynaecologist and Subspecialist in Urogynaecology, Belfast City Hospital, Belfast, UK 3 Lead Nurse Bladder and Bowel service, Haringey, Whittington Health, London, UK 4 Principal Physiotherapist, Women’s Health/Urodynamics, Airedale General Hospital, West Yorkshire, UK 5 Consultant Urogynaecologist, Bradford Royal Infirmary, West Yorkshire, UK 6 Consultant Urogynaecologist, Birmingham Women’s Hospital, West Midlands, UK 2
Aim: This paper reports on the publication of a joint statement on minimum standards for continence care in the UK. Methods: A multidisciplinary working party were tasked with creating standards for both training and education in continence care, as well as explicit standards for a framework of service delivery. This was done through a process of extensive consultation with relevant professional bodies. Results: The standards suggest a modular structure to continence training, including basic, male, female, catheter care etc. Discussions on service provision cover primary care through to expert tertiary centres. Conclusions: This is the first attempt to standardise continence care and training for all health care professionals nationally. The document is available on the United Kingdom Continence Society website www.ukcs.uk.net. Neurourol. Urodynam. 35:400–406, 2016. # 2015 Wiley Periodicals, Inc. Key words: continence care; joint statement; national guidelines; service delivery; training and education
INTRODUCTION
METHODS
Several multi-professional groups have sought to promote awareness and the delivery of high quality continence care across health sectors in the UK. The National Service Framework for Older People1 and Good Practice in Continence services2 laid the foundation for organisation of continence services in the last decade. Despite the many quality improvement initiatives which emanated from these publications, an audit on continence commissioned by the Royal College of Physicians (RCP) in 2010 found that that the quality of care remains variable and sometimes poor.3 The RCP Audit would suggest that there is a deficiency in structured continence training for health care professionals (HCPs) across hospital and mental health care Trusts. Restructuring of the National Health Service (NHS) in England could potentiate existing weaknesses through movement of trained personnel from clinical to managerial posts; tendering of continence under ‘‘Any Qualified Provider’’ might lead to fragmentation of training and services.4 There are early indications that NHS restructuring is having a detrimental impact on professional skill mix and on the priority given to local teaching.5 In response to these signs and concerns raised by the membership regarding the downgrading of continence posts, a UKCS Working Party (2014) was convened to develop minimum standards for delivery of continence care across health service sectors. The objectives were firstly to set minimum standards for education and training of all health care professionals (HCPs) such that patients could access appropriate continence care at point of entry to the health service; secondly to set explicit standards for training such that all HCPs would have attained the training requirements to work within their designated role. The intention is that these standards are adopted by health service managers, providers and commissioners, as a blueprint to ensure that HCPs are working to an agreed minimum standard for continence care commensurate with their role.
A UKCS working party was established. The UK Continence Society (UKCS) is a multidisciplinary multi-professional society comprising members with a clinical and/or scientific research interest in continence. The UKCS Working Party for minimum standards of continence care comprised representatives from community continence nursing, secondary care nursing, physiotherapy, urology, urogynecology, and commissioning. The Working Party communicated by teleconference, email and roundtable discussion. The group met initially over a period of two days to scope the extent of the proposed document and work collaboratively on initial drafts. A systematic literature search under the direction of Derrick Yates (Librarian at Birmingham Women’s NHSFT) was performed during the initial scoping exercise. Several MEDLINE searches performed using multiple key words (including service, delivery, commissioning, continence, urinary incontinence, fecal incontinence, community, secondary care, etc) yielded no useful information. The search strategy was refined to include health policy and organisational models in addition to the previous key words however yielded few relevant articles. Evidence was searched
#
2015 Wiley Periodicals, Inc.
Christopher Chapple led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Dr. Rantell reports personal fees from Astellas, Allergan, Uroplasty, Pfizer, Mediplus, and Braun, outside the submitted work. Dr. Dolan reports a grant from the Physiotherapy Research Foundation outside the submitted work. Dr. Knight reports personal fees from Pfizer outside the submitted work, as well as membership of the NICE guideline development group for the update of management of female urinary incontinence, and membership of the NICE quality standard committee for that guideline. Dr. ToozsHobson reports grants and personal fees from Astellas, and personal fees from Allergan, outside the submitted work. *Correspondence to: Angie Rantell, Lead Nurse Urogynaecology, Kings College Hospital, London, UK. E-mail: [email protected] Received 19 October 2014; Accepted 5 November 2014 Published online 16 January 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22717
Minimum Standards for Continence Care through TRIP (Turning Research Into Practice) which is a simple text based search engine style interface. A total of 842 documents were found using the keywords Health AND (policy OR policies) AND incontinence. Guideline filters were applied for each of the results sets, the abstracts were read systematically and a set of saved guidelines relevant to the project was created. The minimum standards have been written as a set of modules and the full publication will be available electronically. Module 1 gives an overview of organisation of services within the healthcare sector, modules 2–6, continence care training standards for HCPs according to role within the NHS, module 7, standards for catheterization and module 8 guidance on application of assessment tools. The Working Party recommendation is that all HCPs should be trained to a basic level defined in module 2 with more advanced training requirements with higher role described in other modules. The formatting used in the UKCS minimum standards document on training in urodynamics was adopted; links to Skills for Health competencies developed by the DoH have been included.6 The document was concluded following an interactive process of editing, a period of open review on the UKCS website and selected external peer review. The document in set to be launched in the UK in November 2014 and will be available to download from the UKCS website (www.ukcs.uk.net).
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(3) Setting—suggestions on whether these services should be provided in primary, secondary or tertiary care. (4) Patients—advises on suitable patient groups for each service and at which part of their pathway they should be offered these services. (5) Information—guidance on all forms of information both written and verbal that should be available to all patients within the service. (6) Equipment/facilities—proposes what clinical space and medical equipment should be available in the service to perform appropriate assessment while maintaining privacy and dignity. (7) Supporting services—considers other services that should be available in the locality, e.g., radiology, physiotherapy etc. and prompts to understand referral pathways. (8) Workload—where applicable minimum workloads to maintain competency are discussed. (9) Performance monitoring—recommendations for appropriate outcome measures to assess performance both locally and nationally. Care delivery has been subdivided into four levels: (1) (2) (3) (4)
Community based staff (including those in nursing homes). Specialist continence teams. Local multidisciplinary teams. Regional expert multidisciplinary teams.
Description of Modules
(1) Structure of continence services. (2) Basic assessment and conservative management of bladder and bowel symptoms. (3) Specialist assessment and conservative management of the female lower urinary tract. (4) Specialist assessment and conservative management of the male lower urinary tract. (5) Specialist assessment and conservative management of patients with a neuropathic bladder. (6) Specialist assessment and conservative management of constipation and fecal incontinence. (7) Urinary catheterization. (8) Assessment Tools. Module 1: Structure of continence services. The first module within this document aims to provide an ideal structure of a continence service, not only in relation to staffing and training but also in relation to the settings of services, available resource and minimum workload to maintain expertise in specialist services. Within this part of the document, continence care was divided into five services.
(1) (2) (3) (4) (5)
Basic assessment. Specialist assessment. Behavioural and physical therapies. Surgical interventions for uncomplicated incontinence. Complex surgical interventions.
Each of these modalities has been discussed under the following subheadings: (1) Staff—recommendations were made as to which health care professionals were most suitable to providing this service. (2) Training—links to the other modules in relation to levels of knowledge and training recommendations. Neurourology and Urodynamics DOI 10.1002/nau
Modules 2–8: Training standards. These are recommendations for a minimum standard of training across the UK. Each training module is intended to give a simple overview of the curriculum and minimum standards required to perform an appropriate assessment or implement conservative management at that level. These are presented in a tabular format with explanatory text. Each comprises a component on required knowledge, clinical, and professional skills to be acquired, guidance on the educational environment in which the training should be received and the proposed methods of assessment.
Modules 2–6 have been divided in to six steps: (1) (2) (3) (4) (5) (6)
Knowledge base. Assessment of the patient. Basic investigations. Initiating treatment. Reviewing the outcome of treatment. Supervision and training.
Summary of Modules Module 1: Structure of continence services. The following recommendations are just a few examples from the document in relation to service structure and available resources:
Healthcare professionals should receive a multi-disciplinary education to promote continence awareness,
It should not be necessary to refer a patient to a specialist service in order for a basic assessment of continence to take place and therefore most services should have a basic level of continence awareness and training, Simple assessment tools such as bladder and bowel questions on a holistic nursing assessment, screening questionnaires, symptom questionnaires, frequency volume
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charts or bladder diaries, and knowledge of the application of a bladder scanner should be available for basic assessments, Written information on a full range of normal bladder/bowel function, abnormal function, and treatment options should be readily available, Good practice should be shared among those undertaking assessments through the development of a wider Continence Specialist team to whom those working apart from the specialist team will link, and have ready access for advice and support and educational resources, MDTs should be incorporated into job plans of the individual participants and have appropriate administrative support to facilitate record keeping and audit.
prolapse and prostatism have been included in module 4; basic investigations for patients with LUTS aligned to NICE guidance are defined (CG171, DOH 2013) (Table II).7 Many of the conservative treatments that may be initiated at this level of care are the same for both these modules (Table III). However, the skills to be assessed are the HCPs ability to individualise care for each patient based on their needs and wishes. The HCPs in this level of care may often be autonomous in practice and because of this, more stringent methods of training and supervision have been suggested to ensure appropriate knowledge and skills are gained to guarantee safe practice. Box 1 lists the training and supervision requirements proposed.
Module 2: Basic assessment and conservative management of bladder and bowel symptoms. This module was designed for any
Training and supervision.
HCP at care level 1 (care of men and women with bladder and/ or bowel symptoms in the community). This module is most relevant to health care assistants and nursing staff in residential and care home settings, however, also relevant to nursing staff in the acute secondary care setting. The main training goals are for the HCP to be competent in identification and recording of symptoms, performing an assessment of skin integrity, and in identifying barriers to effective toileting such as reduced mobility and cognitive impairment (Table I). Although it would be ideal for all HCPs to attend a training course in continence, that was considered unrealistic and the recommendation would be for all HCPs to observe a continence assessment performed by a competent HCP and to undergo clinical supervision until competence attained.
(1) Training must initially be given under the supervision of an identified preceptor. (2) Access to national training courses and continence modules. (3) Written evidence of observations of clinical practice must be undertaken and completed to satisfaction of preceptor before trainee is deemed competent. (4) Access to an MDT to discuss case management.
Module 3: Specialist assessment and conservative management of the female lower urinary tract and Module 4: Specialist assessment and conservative management of the male lower urinary tract. These modules are standards for a HCP who
provides a specialist continence service for men and women with lower urinary tract symptoms (LUTS); these are most likely to relate to a level 2 role within the care structure, however, they will form the core competences for staff working in level 3 and 4 roles. These modules have been divided into gender specific modules, which would be attained depending on specialty e.g., module 3 is applicable to urogynaecology nurses, modules 3 and 4 would both be applicable to urology nurses who work with male and female patients. Male and female specific issues that impact upon continence status for example, pregnancy,
Module 5: Specialist assessment and conservative management of patients with a neuropathic bladder. This module is designed
to supplement modules 3 and 4 to highlight the additional knowledge and skills required to assess and manage patients with a neuropathic bladder. HCPs caring for patients with neurogenic bladder dysfunction should have appropriate knowledge of, neurological conditions, relevant national guidance, and risks and barriers associated with assessment, investigations and treatment specific to this patient group for example, risk of autonomic dysreflexia, impaired renal function. It has been recommended that given due to the complexity of patients with a neurogenic bladder that care should be provided within experienced units (level 3 and 4) with adequate resources and a multidisciplinary team. This module (in line with 2, 3, and 4) could also be used by HCPs working within the field of neurology / neurosurgery. Module 6: Specialist assessment and conservative management of constipation and fecal incontinence. This module is aimed at
continence specialists in level 2, however, it describes the basic
TABLE I. Module 2—Assessment of the Patient
Knowledge criteria Knowledge of types of incontinence, basic anatomy and pathophysiology in relation to continence status Knowledge of red flag signs and symptoms (NICE Guideline CG171 and CG97) Awareness of the impact of mobility, manual dexterity and the patients environment on their continence status
Clinical competence and professional skills Ability to take a basic history about continence status from the patient and assess symptom bother and desire for treatment Examination of the perineum to identify excoriation Ability to undertake a functional assessment of mobility, manual dexterity and environment
Training support Observation of continence assessment performed by a competent health care professional Clinical supervision as required
Assessment
References
Direct observation
ICS/IUGA
Competences
CHS168
CC01
SCDHSC0219 NICE CG40 NICE CG171 NICE CG97 QOL SF (ref ICI)
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Minimum Standards for Continence Care TABLE II. Basic Investigation of LUTS in Women
Knowledge criteria Understand the implications of urine testing Knowledge of ‘‘red flags’’
Understand the use and interpretation of bladder diaries Knowledge of bladder scanners and when to measure post-void residual
Clinical competence and Professional skills Be able to perform and interpret dipstix testing of urine and know when to send MSU Know when to refer into other pathways such as haematuria pathway Be aware of appropriate and inappropriate antibiotic prescribing Be able to administer, explain and interpret bladder diaries
Training support
Assessment
References
Supervised learning with appropriately trained clinician
Training record
CC01
Training days
Direct observation
CC10
Continence module
CG40
Clinical Supervision
CG171
Competent use of bladder scanner to measure postvoid residual and act upon findings including onward referral when appropriate
competences for staff within care level 3 and 4 in specialist services such as colorectal departments. There are separate specialist modules for bowel symptoms and LUTS as many HCPs in care level 3 and 4 may focus on either bladder or bowels and not necessarily both. (Table IV) As for other modules, skills and treatments for example, anal irrigation and digital rectal stimulation are listed in addition to knowledge and sources of help and advice for patients and carers.
Module 7: Urinary catheterization. The Working Party considered that a minimum standard document for continence care should contain recommendations for catheterization although national guidance on catheterization is already available.8 Catheter care is a key priority for many health care organisations with explicit national targets for rate of hospital acquired infections and when commissioning for example, reducing health care acquired infections (ref. CQUINs).
TABLE III. Initiating Treatment for Male LUTS Knowledge criteria Knowledge of conditions causing LUTS in men
Knowledge of available treatment options
Awareness of co-morbidities and their effect on LUTS Knowledge of pharmacotherapy and the effect of drugs on the lower urinary tract Knowledge of lifestyle interventions
Clinical competence Development of treatment plans and agree this with the patient based on initial assessment and basic investigations including explanation of bladder diary findings to patient and giving advice based on findings To demonstrate knowledge of impact of lifestyle modifications e.g., fluid intake, bowel management, caffeine reduction, weight reduction, smoking cessation Initiate bladder training programme and/or pelvic floor muscle training and allow 6–12 weeks for optimal treatment Understanding of effects of medication on the lower urinary tract
Demonstrate knowledge of available and suitable products and counsel patient about their correct use
Knowledge of bladder training programmes Knowledge of when onward referral is appropriate Knowledge of washable or absorbent products, collecting devices and toileting aids Knowledge of available resources
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Training support Direct supervision
University based Continence module
Direct observation of colleagues, observation by preceptor
Assessment
References
Direct observation
CHS 41
Case log
Bladder and Bowel Foundation
PromoCon
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TABLE IV. Initial Treatments Recommended in Module 6 Knowledge criteria
Clinical competence and professional skills
Training support
Knowledge of anatomy of anal sphincters and pelvic floor muscles and their role in maintaining continence
Development of treatment plan and agree this with the patient/carer based on initial assessment and basic investigations including explanation of bowel diaries and giving advice based on findings To demonstrate knowledge of impact of lifestyle modifications eg regular eating and improved diet and fluids Initiate bowel management training and or pelvic floor exercises. Perform vaginal and rectal examination where appropriate
Direct clinical supervision
Knowledge of conditions causing fecal incontinence and constipation and their treatments Knowledge of lifestyle interventions and appropriate onward referral
Knowledge of available treatment options and skills of occupational therapist, dietician, pharmacist, specialist colorectal nurse, colorectal surgeon and gastroenterologist Knowledge of autonomic dysreflexia
Knowledge of bowel management training
Knowledge of oral and rectal laxatives Knowledge of digital anal stimulation Knowledge of digital rectal evacuation of stool
Understanding of the effects of medication on the gastro intestinal tract including the use of oral and rectal medications to treat symptoms Ability to initiate, perform and teach digital rectal evacuation, rectal stimulation and rectal irrigation Demonstrate knowledge of available and suitable products and counsel patients about their correct use Ability to initiate and teach transanal irrigation to evacuate stool Explanation of different products available to manage incontinence Demonstrate knowledge of the voluntary/charity organisations and help provided
Knowledge of trans anal irrigation Knowledge of disposable incontinence products , anal plugs Knowledge of available information resources for patient
University based continence module Direct observation of colleagues, observation by preceptor Clinical supervision
Assessment
References
Direct observation
CC01
Case log
CC08
CCO9
CC11
CC12
CHS40
CHS41 CHS46 CHS47
CHS52 CHS53 CHS93 PE4 GEN14 GEN 40 GEN 44 GEN 47 MASCIP2012 NPSA 2004 Norton 2011 CHS210 COO9
The format of module 7 was modified to accommodate the broad nature of catheter care. The module was subdivided into 8 sections. (1) (2) (3) (4) (5) (6) (7) (8)
Knowledge base. Risk assessment. Catheter care. Infection control. Intermittent self-catheterization. Education. Training and supervision. References.
The module should be tailored accordingly to the level of catheter care undertaken by the HCP with the most basic level being ability to change drainage bags, however, all HCPs would Neurourology and Urodynamics DOI 10.1002/nau
be taught the principles of good catheter care and infection control policy (Table V). Module 8: Assessment tools. Many national guidelines contain recommendations for assessment tools in clinical practice. In practice they are often not utilised due to poor accessibility and poor understanding of the right tool for a particular clinical application. Module 8 comprises a list of the assessment tools and equipment included in Modules 1–7. These tools should be accessible through the electronic links or citations provided in Module 8; these will direct the user to the most relevant resource to acquire background information for the tool including any national and or international guidance on application to clinical practice. The module has been subdivided into a section on tools for the assessment of symptoms and treatment efficacy, and a section on tools for service evaluation. It is hoped that by including this information in the
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TABLE V. Catheter Care Knowledge criteria Knowledge of catheter care procedures
Clinical competence and professional skills In all care settings clinicians will have the necessary knowledge and skill to care for a patient with an indwelling urethral catheter or SPC as follows: Assessing individual patients to ensure catheterization is required and regularly re-evaluated Obtaining a catheter specimen of urine (CSU) Changing urinary drainage bags and valves, ensuring appropriate positioning and support Emptying a urine bag or catheter valve Meatal cleansing both prior to catheterization and as part of daily care Catheter insertion both urethral and supra-pubic (NB initial supra-pubic catheter insertion should be performed in secondary or tertiary care but subsequent changes can be undertaken in the community) Catheter removal, both urethral and supra-pubic Trial without catheter Management of catheter associated complications e.g., blockages/encrustation
document it will facilitate implementation of the recommendations of the Working Party. DISCUSSION
Many guidelines for practice focus on the clinical pathways for patients. This document seeks to establish an educational framework for service provision in management of bladder and bowel incontinence. The focus of the UKCS Working Party was to establish standards for training at all levels of care and for any HCP who might encounter patients with bladder and/or bowel symptoms. The principles underpinning good practice in continence care are that all patients should be offered initial assessment by a suitably trained provider and that care should be delivered by those appropriately trained to meet the complexity of the given condition.1,2 Many patients with urinary and/or fecal incontinence will only require a basic assessment undertaken by a HCP with basic assessment skills. Even at an ‘‘entry’’ level, 20% of assessments in acute and primary care are conducted by a provider without basic continence training and the number is likely to be higher in the care home sector (RCP, 2010). Implementation of the educational standards established in this document should help to reduce variation in quality of care and improve outcomes for patients through better identification of their symptoms and access to the most appropriately trained individual to meet their individual needs. The new NHS Health Care Bill in England and Wales (DoH, 2013) has necessitated a review of structures for training and education in incontinence. (Royal College of Physicians, 2010). The APPG survey of continence services in England (2013) would suggest the need for explicit standards for training in incontinence at each level of care provision within the NHS. The guiding philosophy of all HCPs should be ‘‘a duty to ensure that all patients benefit from the highest standards of clinical care’’9 and an agreed UKCS minimum standards for training of HCPs should help to achieve this in practice. These standards will be launched in the UK to raise awareness among HCPs, commissioners and service managers who are responsible for setting Neurourology and Urodynamics DOI 10.1002/nau
Training support
Assessment
References
Attendance at national or local catheterization education events
Professional portfolio
GEN6
Direct observation
CC02
RCN 2012 EPIC 2013
up services and in the recruitment and training of staff. They should guide service audit to ensure that all continence services are compliant with agreed standards and provide a benchmark for service improvement projects. HCPs working in the field of incontinence should ensure that they have acquired the appropriate knowledge and skills to perform their role. This document will provide a framework of knowledge and skills to inform the appraisal process and to facilitate access to training sessions and clinical supervision as part of their continuing professional development (CPD). Iteration of clear training standards for all HCPs might encourage service leads and educators to guide and develop accessible and appropriate training materials (e.g., e-learning packages), to improve continence assessment skills through vocational training courses (e.g., current nursing training in the UK) or ultimately for continence care to become a mandatory part of the syllabus. CONCLUSIONS
Patients with incontinence should feel confident that their needs will be met through access to appropriately trained individuals working within a Regional Clinical Network. HCPs should feel confident that they have access to appropriate training and that they are practicing to an agreed standard. Service leads and commissioners should have a benchmark by which they can measure the quality of the educational framework for continence care within their service. This is first document to set minimum standards for training in continence across the health care sectors in the UK. Implementation of these minimum standards would ensure that HCPs have attained the knowledge and skills to assess patients with incontinence and for patients to have access to dedicated continence services. REFERENCES 1. Department of Health (2001), National Service Framework: Older People. London. DH. 2. Department of Health (2003), Good Practice in Continence Services. London: DH.
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3. National Audit of Continence Care (2010) conducted Royal College of Physicians,commissioned by the Healthcare Quality Improvement Partnership (http://www.rcplondon.ac.uk/resources/national-auditcontinence-care). 4. Department of Health (2012), Health and Social Care act accessed http:// www.legislation.gov.uk/ukpga/2012/7/contents/enacted 5. All Party Parliamentary group, (2013), Continence Care Services England 2013, Survey Report, www.appgcontinence.org.uk
Neurourology and Urodynamics DOI 10.1002/nau
6. Skills for Health - http://www.skillsforhealth.org.uk/ 7. National Institute for Health and Care Excellence (2013) Urinary Incontinence: The Management of Urinary Incontinence in Women. Clinical guideline 171. September. NICE, London. 8. Royal College of Nursing, 2012, Catheter Care – a guide for nurses. RCN, London. 9. Singh G, Lucas M, Dolan L, et al. Minimum standards for urodynamic practice in the UK. Neurourol Urodyn 2010;29:1365–72.
Minimum Standards for Continence Care in the UK Angie Rantell,1* Lucia Dolan,2 Liz Bonner,3 Stephanie Knight,4 Carmel Ramage,5 and Philip Toozs-Hobson6 1 Lead Nurse Urogynaecology, King’s College Hospital, London, UK Consultant Gynaecologist and Subspecialist in Urogynaecology, Belfast City Hospital, Belfast, UK 3 Lead Nurse Bladder and Bowel service, Haringey, Whittington Health, London, UK 4 Principal Physiotherapist, Women’s Health/Urodynamics, Airedale General Hospital, West Yorkshire, UK 5 Consultant Urogynaecologist, Bradford Royal Infirmary, West Yorkshire, UK 6 Consultant Urogynaecologist, Birmingham Women’s Hospital, West Midlands, UK 2
Aim: This paper reports on the publication of a joint statement on minimum standards for continence care in the UK. Methods: A multidisciplinary working party were tasked with creating standards for both training and education in continence care, as well as explicit standards for a framework of service delivery. This was done through a process of extensive consultation with relevant professional bodies. Results: The standards suggest a modular structure to continence training, including basic, male, female, catheter care etc. Discussions on service provision cover primary care through to expert tertiary centres. Conclusions: This is the first attempt to standardise continence care and training for all health care professionals nationally. The document is available on the United Kingdom Continence Society website www.ukcs.uk.net. Neurourol. Urodynam. 35:400–406, 2016. # 2015 Wiley Periodicals, Inc. Key words: continence care; joint statement; national guidelines; service delivery; training and education
INTRODUCTION
METHODS
Several multi-professional groups have sought to promote awareness and the delivery of high quality continence care across health sectors in the UK. The National Service Framework for Older People1 and Good Practice in Continence services2 laid the foundation for organisation of continence services in the last decade. Despite the many quality improvement initiatives which emanated from these publications, an audit on continence commissioned by the Royal College of Physicians (RCP) in 2010 found that that the quality of care remains variable and sometimes poor.3 The RCP Audit would suggest that there is a deficiency in structured continence training for health care professionals (HCPs) across hospital and mental health care Trusts. Restructuring of the National Health Service (NHS) in England could potentiate existing weaknesses through movement of trained personnel from clinical to managerial posts; tendering of continence under ‘‘Any Qualified Provider’’ might lead to fragmentation of training and services.4 There are early indications that NHS restructuring is having a detrimental impact on professional skill mix and on the priority given to local teaching.5 In response to these signs and concerns raised by the membership regarding the downgrading of continence posts, a UKCS Working Party (2014) was convened to develop minimum standards for delivery of continence care across health service sectors. The objectives were firstly to set minimum standards for education and training of all health care professionals (HCPs) such that patients could access appropriate continence care at point of entry to the health service; secondly to set explicit standards for training such that all HCPs would have attained the training requirements to work within their designated role. The intention is that these standards are adopted by health service managers, providers and commissioners, as a blueprint to ensure that HCPs are working to an agreed minimum standard for continence care commensurate with their role.
A UKCS working party was established. The UK Continence Society (UKCS) is a multidisciplinary multi-professional society comprising members with a clinical and/or scientific research interest in continence. The UKCS Working Party for minimum standards of continence care comprised representatives from community continence nursing, secondary care nursing, physiotherapy, urology, urogynecology, and commissioning. The Working Party communicated by teleconference, email and roundtable discussion. The group met initially over a period of two days to scope the extent of the proposed document and work collaboratively on initial drafts. A systematic literature search under the direction of Derrick Yates (Librarian at Birmingham Women’s NHSFT) was performed during the initial scoping exercise. Several MEDLINE searches performed using multiple key words (including service, delivery, commissioning, continence, urinary incontinence, fecal incontinence, community, secondary care, etc) yielded no useful information. The search strategy was refined to include health policy and organisational models in addition to the previous key words however yielded few relevant articles. Evidence was searched
#
2015 Wiley Periodicals, Inc.
Christopher Chapple led the peer-review process as the Associate Editor responsible for the paper. Potential conflicts of interest: Dr. Rantell reports personal fees from Astellas, Allergan, Uroplasty, Pfizer, Mediplus, and Braun, outside the submitted work. Dr. Dolan reports a grant from the Physiotherapy Research Foundation outside the submitted work. Dr. Knight reports personal fees from Pfizer outside the submitted work, as well as membership of the NICE guideline development group for the update of management of female urinary incontinence, and membership of the NICE quality standard committee for that guideline. Dr. ToozsHobson reports grants and personal fees from Astellas, and personal fees from Allergan, outside the submitted work. *Correspondence to: Angie Rantell, Lead Nurse Urogynaecology, Kings College Hospital, London, UK. E-mail: [email protected] Received 19 October 2014; Accepted 5 November 2014 Published online 16 January 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22717
Minimum Standards for Continence Care through TRIP (Turning Research Into Practice) which is a simple text based search engine style interface. A total of 842 documents were found using the keywords Health AND (policy OR policies) AND incontinence. Guideline filters were applied for each of the results sets, the abstracts were read systematically and a set of saved guidelines relevant to the project was created. The minimum standards have been written as a set of modules and the full publication will be available electronically. Module 1 gives an overview of organisation of services within the healthcare sector, modules 2–6, continence care training standards for HCPs according to role within the NHS, module 7, standards for catheterization and module 8 guidance on application of assessment tools. The Working Party recommendation is that all HCPs should be trained to a basic level defined in module 2 with more advanced training requirements with higher role described in other modules. The formatting used in the UKCS minimum standards document on training in urodynamics was adopted; links to Skills for Health competencies developed by the DoH have been included.6 The document was concluded following an interactive process of editing, a period of open review on the UKCS website and selected external peer review. The document in set to be launched in the UK in November 2014 and will be available to download from the UKCS website (www.ukcs.uk.net).
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(3) Setting—suggestions on whether these services should be provided in primary, secondary or tertiary care. (4) Patients—advises on suitable patient groups for each service and at which part of their pathway they should be offered these services. (5) Information—guidance on all forms of information both written and verbal that should be available to all patients within the service. (6) Equipment/facilities—proposes what clinical space and medical equipment should be available in the service to perform appropriate assessment while maintaining privacy and dignity. (7) Supporting services—considers other services that should be available in the locality, e.g., radiology, physiotherapy etc. and prompts to understand referral pathways. (8) Workload—where applicable minimum workloads to maintain competency are discussed. (9) Performance monitoring—recommendations for appropriate outcome measures to assess performance both locally and nationally. Care delivery has been subdivided into four levels: (1) (2) (3) (4)
Community based staff (including those in nursing homes). Specialist continence teams. Local multidisciplinary teams. Regional expert multidisciplinary teams.
Description of Modules
(1) Structure of continence services. (2) Basic assessment and conservative management of bladder and bowel symptoms. (3) Specialist assessment and conservative management of the female lower urinary tract. (4) Specialist assessment and conservative management of the male lower urinary tract. (5) Specialist assessment and conservative management of patients with a neuropathic bladder. (6) Specialist assessment and conservative management of constipation and fecal incontinence. (7) Urinary catheterization. (8) Assessment Tools. Module 1: Structure of continence services. The first module within this document aims to provide an ideal structure of a continence service, not only in relation to staffing and training but also in relation to the settings of services, available resource and minimum workload to maintain expertise in specialist services. Within this part of the document, continence care was divided into five services.
(1) (2) (3) (4) (5)
Basic assessment. Specialist assessment. Behavioural and physical therapies. Surgical interventions for uncomplicated incontinence. Complex surgical interventions.
Each of these modalities has been discussed under the following subheadings: (1) Staff—recommendations were made as to which health care professionals were most suitable to providing this service. (2) Training—links to the other modules in relation to levels of knowledge and training recommendations. Neurourology and Urodynamics DOI 10.1002/nau
Modules 2–8: Training standards. These are recommendations for a minimum standard of training across the UK. Each training module is intended to give a simple overview of the curriculum and minimum standards required to perform an appropriate assessment or implement conservative management at that level. These are presented in a tabular format with explanatory text. Each comprises a component on required knowledge, clinical, and professional skills to be acquired, guidance on the educational environment in which the training should be received and the proposed methods of assessment.
Modules 2–6 have been divided in to six steps: (1) (2) (3) (4) (5) (6)
Knowledge base. Assessment of the patient. Basic investigations. Initiating treatment. Reviewing the outcome of treatment. Supervision and training.
Summary of Modules Module 1: Structure of continence services. The following recommendations are just a few examples from the document in relation to service structure and available resources:
Healthcare professionals should receive a multi-disciplinary education to promote continence awareness,
It should not be necessary to refer a patient to a specialist service in order for a basic assessment of continence to take place and therefore most services should have a basic level of continence awareness and training, Simple assessment tools such as bladder and bowel questions on a holistic nursing assessment, screening questionnaires, symptom questionnaires, frequency volume
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charts or bladder diaries, and knowledge of the application of a bladder scanner should be available for basic assessments, Written information on a full range of normal bladder/bowel function, abnormal function, and treatment options should be readily available, Good practice should be shared among those undertaking assessments through the development of a wider Continence Specialist team to whom those working apart from the specialist team will link, and have ready access for advice and support and educational resources, MDTs should be incorporated into job plans of the individual participants and have appropriate administrative support to facilitate record keeping and audit.
prolapse and prostatism have been included in module 4; basic investigations for patients with LUTS aligned to NICE guidance are defined (CG171, DOH 2013) (Table II).7 Many of the conservative treatments that may be initiated at this level of care are the same for both these modules (Table III). However, the skills to be assessed are the HCPs ability to individualise care for each patient based on their needs and wishes. The HCPs in this level of care may often be autonomous in practice and because of this, more stringent methods of training and supervision have been suggested to ensure appropriate knowledge and skills are gained to guarantee safe practice. Box 1 lists the training and supervision requirements proposed.
Module 2: Basic assessment and conservative management of bladder and bowel symptoms. This module was designed for any
Training and supervision.
HCP at care level 1 (care of men and women with bladder and/ or bowel symptoms in the community). This module is most relevant to health care assistants and nursing staff in residential and care home settings, however, also relevant to nursing staff in the acute secondary care setting. The main training goals are for the HCP to be competent in identification and recording of symptoms, performing an assessment of skin integrity, and in identifying barriers to effective toileting such as reduced mobility and cognitive impairment (Table I). Although it would be ideal for all HCPs to attend a training course in continence, that was considered unrealistic and the recommendation would be for all HCPs to observe a continence assessment performed by a competent HCP and to undergo clinical supervision until competence attained.
(1) Training must initially be given under the supervision of an identified preceptor. (2) Access to national training courses and continence modules. (3) Written evidence of observations of clinical practice must be undertaken and completed to satisfaction of preceptor before trainee is deemed competent. (4) Access to an MDT to discuss case management.
Module 3: Specialist assessment and conservative management of the female lower urinary tract and Module 4: Specialist assessment and conservative management of the male lower urinary tract. These modules are standards for a HCP who
provides a specialist continence service for men and women with lower urinary tract symptoms (LUTS); these are most likely to relate to a level 2 role within the care structure, however, they will form the core competences for staff working in level 3 and 4 roles. These modules have been divided into gender specific modules, which would be attained depending on specialty e.g., module 3 is applicable to urogynaecology nurses, modules 3 and 4 would both be applicable to urology nurses who work with male and female patients. Male and female specific issues that impact upon continence status for example, pregnancy,
Module 5: Specialist assessment and conservative management of patients with a neuropathic bladder. This module is designed
to supplement modules 3 and 4 to highlight the additional knowledge and skills required to assess and manage patients with a neuropathic bladder. HCPs caring for patients with neurogenic bladder dysfunction should have appropriate knowledge of, neurological conditions, relevant national guidance, and risks and barriers associated with assessment, investigations and treatment specific to this patient group for example, risk of autonomic dysreflexia, impaired renal function. It has been recommended that given due to the complexity of patients with a neurogenic bladder that care should be provided within experienced units (level 3 and 4) with adequate resources and a multidisciplinary team. This module (in line with 2, 3, and 4) could also be used by HCPs working within the field of neurology / neurosurgery. Module 6: Specialist assessment and conservative management of constipation and fecal incontinence. This module is aimed at
continence specialists in level 2, however, it describes the basic
TABLE I. Module 2—Assessment of the Patient
Knowledge criteria Knowledge of types of incontinence, basic anatomy and pathophysiology in relation to continence status Knowledge of red flag signs and symptoms (NICE Guideline CG171 and CG97) Awareness of the impact of mobility, manual dexterity and the patients environment on their continence status
Clinical competence and professional skills Ability to take a basic history about continence status from the patient and assess symptom bother and desire for treatment Examination of the perineum to identify excoriation Ability to undertake a functional assessment of mobility, manual dexterity and environment
Training support Observation of continence assessment performed by a competent health care professional Clinical supervision as required
Assessment
References
Direct observation
ICS/IUGA
Competences
CHS168
CC01
SCDHSC0219 NICE CG40 NICE CG171 NICE CG97 QOL SF (ref ICI)
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Minimum Standards for Continence Care TABLE II. Basic Investigation of LUTS in Women
Knowledge criteria Understand the implications of urine testing Knowledge of ‘‘red flags’’
Understand the use and interpretation of bladder diaries Knowledge of bladder scanners and when to measure post-void residual
Clinical competence and Professional skills Be able to perform and interpret dipstix testing of urine and know when to send MSU Know when to refer into other pathways such as haematuria pathway Be aware of appropriate and inappropriate antibiotic prescribing Be able to administer, explain and interpret bladder diaries
Training support
Assessment
References
Supervised learning with appropriately trained clinician
Training record
CC01
Training days
Direct observation
CC10
Continence module
CG40
Clinical Supervision
CG171
Competent use of bladder scanner to measure postvoid residual and act upon findings including onward referral when appropriate
competences for staff within care level 3 and 4 in specialist services such as colorectal departments. There are separate specialist modules for bowel symptoms and LUTS as many HCPs in care level 3 and 4 may focus on either bladder or bowels and not necessarily both. (Table IV) As for other modules, skills and treatments for example, anal irrigation and digital rectal stimulation are listed in addition to knowledge and sources of help and advice for patients and carers.
Module 7: Urinary catheterization. The Working Party considered that a minimum standard document for continence care should contain recommendations for catheterization although national guidance on catheterization is already available.8 Catheter care is a key priority for many health care organisations with explicit national targets for rate of hospital acquired infections and when commissioning for example, reducing health care acquired infections (ref. CQUINs).
TABLE III. Initiating Treatment for Male LUTS Knowledge criteria Knowledge of conditions causing LUTS in men
Knowledge of available treatment options
Awareness of co-morbidities and their effect on LUTS Knowledge of pharmacotherapy and the effect of drugs on the lower urinary tract Knowledge of lifestyle interventions
Clinical competence Development of treatment plans and agree this with the patient based on initial assessment and basic investigations including explanation of bladder diary findings to patient and giving advice based on findings To demonstrate knowledge of impact of lifestyle modifications e.g., fluid intake, bowel management, caffeine reduction, weight reduction, smoking cessation Initiate bladder training programme and/or pelvic floor muscle training and allow 6–12 weeks for optimal treatment Understanding of effects of medication on the lower urinary tract
Demonstrate knowledge of available and suitable products and counsel patient about their correct use
Knowledge of bladder training programmes Knowledge of when onward referral is appropriate Knowledge of washable or absorbent products, collecting devices and toileting aids Knowledge of available resources
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Training support Direct supervision
University based Continence module
Direct observation of colleagues, observation by preceptor
Assessment
References
Direct observation
CHS 41
Case log
Bladder and Bowel Foundation
PromoCon
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TABLE IV. Initial Treatments Recommended in Module 6 Knowledge criteria
Clinical competence and professional skills
Training support
Knowledge of anatomy of anal sphincters and pelvic floor muscles and their role in maintaining continence
Development of treatment plan and agree this with the patient/carer based on initial assessment and basic investigations including explanation of bowel diaries and giving advice based on findings To demonstrate knowledge of impact of lifestyle modifications eg regular eating and improved diet and fluids Initiate bowel management training and or pelvic floor exercises. Perform vaginal and rectal examination where appropriate
Direct clinical supervision
Knowledge of conditions causing fecal incontinence and constipation and their treatments Knowledge of lifestyle interventions and appropriate onward referral
Knowledge of available treatment options and skills of occupational therapist, dietician, pharmacist, specialist colorectal nurse, colorectal surgeon and gastroenterologist Knowledge of autonomic dysreflexia
Knowledge of bowel management training
Knowledge of oral and rectal laxatives Knowledge of digital anal stimulation Knowledge of digital rectal evacuation of stool
Understanding of the effects of medication on the gastro intestinal tract including the use of oral and rectal medications to treat symptoms Ability to initiate, perform and teach digital rectal evacuation, rectal stimulation and rectal irrigation Demonstrate knowledge of available and suitable products and counsel patients about their correct use Ability to initiate and teach transanal irrigation to evacuate stool Explanation of different products available to manage incontinence Demonstrate knowledge of the voluntary/charity organisations and help provided
Knowledge of trans anal irrigation Knowledge of disposable incontinence products , anal plugs Knowledge of available information resources for patient
University based continence module Direct observation of colleagues, observation by preceptor Clinical supervision
Assessment
References
Direct observation
CC01
Case log
CC08
CCO9
CC11
CC12
CHS40
CHS41 CHS46 CHS47
CHS52 CHS53 CHS93 PE4 GEN14 GEN 40 GEN 44 GEN 47 MASCIP2012 NPSA 2004 Norton 2011 CHS210 COO9
The format of module 7 was modified to accommodate the broad nature of catheter care. The module was subdivided into 8 sections. (1) (2) (3) (4) (5) (6) (7) (8)
Knowledge base. Risk assessment. Catheter care. Infection control. Intermittent self-catheterization. Education. Training and supervision. References.
The module should be tailored accordingly to the level of catheter care undertaken by the HCP with the most basic level being ability to change drainage bags, however, all HCPs would Neurourology and Urodynamics DOI 10.1002/nau
be taught the principles of good catheter care and infection control policy (Table V). Module 8: Assessment tools. Many national guidelines contain recommendations for assessment tools in clinical practice. In practice they are often not utilised due to poor accessibility and poor understanding of the right tool for a particular clinical application. Module 8 comprises a list of the assessment tools and equipment included in Modules 1–7. These tools should be accessible through the electronic links or citations provided in Module 8; these will direct the user to the most relevant resource to acquire background information for the tool including any national and or international guidance on application to clinical practice. The module has been subdivided into a section on tools for the assessment of symptoms and treatment efficacy, and a section on tools for service evaluation. It is hoped that by including this information in the
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TABLE V. Catheter Care Knowledge criteria Knowledge of catheter care procedures
Clinical competence and professional skills In all care settings clinicians will have the necessary knowledge and skill to care for a patient with an indwelling urethral catheter or SPC as follows: Assessing individual patients to ensure catheterization is required and regularly re-evaluated Obtaining a catheter specimen of urine (CSU) Changing urinary drainage bags and valves, ensuring appropriate positioning and support Emptying a urine bag or catheter valve Meatal cleansing both prior to catheterization and as part of daily care Catheter insertion both urethral and supra-pubic (NB initial supra-pubic catheter insertion should be performed in secondary or tertiary care but subsequent changes can be undertaken in the community) Catheter removal, both urethral and supra-pubic Trial without catheter Management of catheter associated complications e.g., blockages/encrustation
document it will facilitate implementation of the recommendations of the Working Party. DISCUSSION
Many guidelines for practice focus on the clinical pathways for patients. This document seeks to establish an educational framework for service provision in management of bladder and bowel incontinence. The focus of the UKCS Working Party was to establish standards for training at all levels of care and for any HCP who might encounter patients with bladder and/or bowel symptoms. The principles underpinning good practice in continence care are that all patients should be offered initial assessment by a suitably trained provider and that care should be delivered by those appropriately trained to meet the complexity of the given condition.1,2 Many patients with urinary and/or fecal incontinence will only require a basic assessment undertaken by a HCP with basic assessment skills. Even at an ‘‘entry’’ level, 20% of assessments in acute and primary care are conducted by a provider without basic continence training and the number is likely to be higher in the care home sector (RCP, 2010). Implementation of the educational standards established in this document should help to reduce variation in quality of care and improve outcomes for patients through better identification of their symptoms and access to the most appropriately trained individual to meet their individual needs. The new NHS Health Care Bill in England and Wales (DoH, 2013) has necessitated a review of structures for training and education in incontinence. (Royal College of Physicians, 2010). The APPG survey of continence services in England (2013) would suggest the need for explicit standards for training in incontinence at each level of care provision within the NHS. The guiding philosophy of all HCPs should be ‘‘a duty to ensure that all patients benefit from the highest standards of clinical care’’9 and an agreed UKCS minimum standards for training of HCPs should help to achieve this in practice. These standards will be launched in the UK to raise awareness among HCPs, commissioners and service managers who are responsible for setting Neurourology and Urodynamics DOI 10.1002/nau
Training support
Assessment
References
Attendance at national or local catheterization education events
Professional portfolio
GEN6
Direct observation
CC02
RCN 2012 EPIC 2013
up services and in the recruitment and training of staff. They should guide service audit to ensure that all continence services are compliant with agreed standards and provide a benchmark for service improvement projects. HCPs working in the field of incontinence should ensure that they have acquired the appropriate knowledge and skills to perform their role. This document will provide a framework of knowledge and skills to inform the appraisal process and to facilitate access to training sessions and clinical supervision as part of their continuing professional development (CPD). Iteration of clear training standards for all HCPs might encourage service leads and educators to guide and develop accessible and appropriate training materials (e.g., e-learning packages), to improve continence assessment skills through vocational training courses (e.g., current nursing training in the UK) or ultimately for continence care to become a mandatory part of the syllabus. CONCLUSIONS
Patients with incontinence should feel confident that their needs will be met through access to appropriately trained individuals working within a Regional Clinical Network. HCPs should feel confident that they have access to appropriate training and that they are practicing to an agreed standard. Service leads and commissioners should have a benchmark by which they can measure the quality of the educational framework for continence care within their service. This is first document to set minimum standards for training in continence across the health care sectors in the UK. Implementation of these minimum standards would ensure that HCPs have attained the knowledge and skills to assess patients with incontinence and for patients to have access to dedicated continence services. REFERENCES 1. Department of Health (2001), National Service Framework: Older People. London. DH. 2. Department of Health (2003), Good Practice in Continence Services. London: DH.
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3. National Audit of Continence Care (2010) conducted Royal College of Physicians,commissioned by the Healthcare Quality Improvement Partnership (http://www.rcplondon.ac.uk/resources/national-auditcontinence-care). 4. Department of Health (2012), Health and Social Care act accessed http:// www.legislation.gov.uk/ukpga/2012/7/contents/enacted 5. All Party Parliamentary group, (2013), Continence Care Services England 2013, Survey Report, www.appgcontinence.org.uk
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6. Skills for Health - http://www.skillsforhealth.org.uk/ 7. National Institute for Health and Care Excellence (2013) Urinary Incontinence: The Management of Urinary Incontinence in Women. Clinical guideline 171. September. NICE, London. 8. Royal College of Nursing, 2012, Catheter Care – a guide for nurses. RCN, London. 9. Singh G, Lucas M, Dolan L, et al. Minimum standards for urodynamic practice in the UK. Neurourol Urodyn 2010;29:1365–72.
