Promoting Continence Services

Introduction

NHS England (2018) warns that Urinary Incontinence (UI) poses the NHS significant expense, contributing to hospital admissions. With incontinence being socially and physiologically impactive on all health conditions (Eustice 2015).

Continence assessments were formerly performed by District Nurses (DN) or Community Matrons (CM). They require competence in bladder and bowel pathophysiology (Leaver 2017, Kehinde 2017). NHS England (2018) agree nurses need competency in evidence-based care in bladder and bowel health. The Long-Term Conditions service (LTC) manage patients with co-morbidities, often affecting bladder and bowel function (Drennan,2014).

NICE (2016) guidance suggests more efficient facilitation of continence services is needed. In response; the local health authority has implemented a recent change in policy whereby all continence assessments are being exclusively performed by Continence Services (Livewell,2019). The impact of services moving from generalist care to specialist services is increasingly being debated (Drennan,2014).

Search strategy

Topic: Does Continence care provision delivered to consumers, alter, according to the care provider.

• Population = Clinicians and older community-based adults
• Intervention = Continence care provision
• Comparisons = Care delivery by community staff compared to specialist services
• Outcomes = On consumers such as symptoms, quality of life or work satisfaction for clinicians.

A comprehensive literature search was conducted using databases CINAHL and MEDLINE, EBSCO. Keywords “continence” AND “district nurse” OR “community nurse” OR “community matron” were utilised. Initial results yielded 472 results. The terms “competence”, “knowledge” “confidence”, “assessment” were added to refine results, resulting in n=0. Therefore, the original search terms were reinstated with the following inclusion criteria.

The publication date was amended to 2008-2019 reducing n=233. Place of publication to the UK and Ireland n=109 results.

In hindsight this could have excluded valuable evidence. From the review abstracts were read and articles selected on their suitability and content.

2 qualitative articles and 1 quantitative Randomised Controlled Trial (RCT) were selected for review.

Systematic review and qualitative paper obtained by snowballing references of literature.

One studied assessment, 2 studied nurse perspectives, 2 studied patient perspectives. No papers fully covered question sought.

Critical review

Quantitative

This 2-arm parallel, open-label, cluster, longitudinal RCT was critiqued using CASP (2015). Authors examined how continence promotion affected older women from UK, Canada and France. Researchers were blinded to the intervention, but participants were only blinded to allocation because they either attended workshops about ageing or continence (Fritel et al,2017).

Results concerned 810 women; n=406 intervention v n=404 control. 190 participants appear unaccounted for, for reasons unknown. This could affect power calculations as 1000 participants were required to detect clinically meaningful difference in measuring outcome measures between groups (Fritel et al,2017). Dumville et al, (2006) warn that attrition rates of 5-20% can raise bias. McCrum-Gardner (2010) concur that underpowered studies decrease significance.

Sample attrition could be detrimental if lost participants unbalanced group allocation or displayed different characteristics (Dumville et al, 2006). However, as numbers remaining are balanced (n=406/404), this reduced bias.

Authors intended to include diversity. Contrarily; sampling appeared biased as it excluded housebound people who wouldn”t have been motivated or influenced by peers. They only included participants who were members of community organisations, which could have led to healthy-user bias; as Shrank et al (2011) suggests that attendees of health-related groups would more likely display positive health-related behaviours and be motivated to participate in research than frailer people. Therefore, participants are arguably more likely to report positive outcomes. Furthermore, generalisability to the frailer population is poor as their views were not represented.

The co-primary outcome was perception of improvement, measured using the Patient”s Global Impression of Improvement (PGI-I) questionnaire. This validated scale allows participants to rate symptoms from better to worse (Tannenbaum et al, 2015). Bowling (2014) stresses that assessing validity of subjective assessment tools, depends on their psychometric properties in evaluating if tools measured what they intended to. Physiopedia (2017) say the PGI-I scale is appealing due to simplicity.

Results showed statistically significant improvement by intervention compared to control 38%/19% n=154/78. p>0.0001. 95% confidence interval (CI)

Whereas questionnaires measured improvement in symptoms (Overactive Bladder (OAB) and UI) and Urinary quality of life (I-QOL), showed significant improvement in both intervention and control (p=0.80/0.34) (I-QOL-score p=0.61): rendering improvements insignificant.