Joanne is a nurse practitioner working in aged care and continence in Canberra, ACT. She has over 25 years’ experience in continence assessment and management of adults and children with bladder and bowel dysfunction. She has worked across multiple areas of practice and was recently appointed the Continence Foundation of Australia’s Clinical Lead.
What does a day in your work week look like?
I have two different types of days! My role as a nurse practitioner involves going beyond standard nursing work. I am part of a team which aims to provide complete primary health care within the person’s home – be that in residential aged care or their own home. I prescribe (or deprescribe) medications, order tests and refer to specialists. My role involves physical exams, treating minor illnesses and of course, always looking at what is happening with the person’s bladder and bowel function.
As the clinical lead with the Continence Foundation of Australia, my role covers projects like reviewing publications to make sure that information is supported by evidence, providing clinical support to National Continence Helpline staff and supporting education.
What are some of the unique challenges that come with managing continence in residential aged care?
People living in residential aged care have very complex health care needs. Often, they have multiple illnesses, are on many different medications and need a lot of help and care from other people.
Like anyone else with continence issues, people in aged care should have access to a thorough assessment and suitable management options. It should always be remembered that incontinence can be improved, or even cured, for many people.
We should focus on expecting continence rather than expecting incontinence. Sometimes there is an expectation from family, carers and the person themselves, that the only way to manage incontinence is by wearing pads. Never assume that pads are the only option.
Sometimes it can be as simple as looking at what medications may affect the bladder or bowel and making adjustments. For example, someone taking sedative medication may be drowsy and is less likely to safely walk to the toilet. This means they may be slower to recognise their need for the toilet and not be able to get there on time and without falling. All of this could increase the risk of incontinence. I’d like to note that most people’s distress can be helped in ways other than sedation.
Most people wouldn’t think falling or mobility is related to incontinence. Can you explain the relationship?
Managing the risk of falls is an important consideration in aged care. Keeping people as mobile (moving) as possible in residential care is very important. This isn’t just for their general wellbeing but also so they can fulfill basic human functions, like toileting, with independence. Evidence has shown that a lack of mobility can increase a person’s chances of incontinence in aged care.
Another issue I find often comes up is when people are given medication to help them sleep at night. Many older people still wake up at night with a full bladder and may fall trying to get to the toilet.
Why is it more difficult to manage faecal incontinence (accidental leakage from the bowel) in people in aged care?
The reasons why it happens are complex. Studies have estimated the rate can be as high as half of all residents experiencing faecal incontinence. There are many things that increase someone’s chances of developing faecal incontinence (risk factors):
- loose stools
- prior bowel surgery
- reduced mobility
- inability to toilet independently
- neurological conditions e.g. Parkinson’s disease, dementia
- chronic medical conditions e.g. diabetes, depression.
Other factors which can contribute to constipation and faecal incontinence include:
- dehydration (may occur when the person is unable to get themselves a drink)
- reduced food intake (meaning a lack of fibre which is important for normal bowel function)
- medication side-effects.
- People living in the community also experience many of these problems. However, most people living in residential aged care have a high degree of dependence on carers for help with their daily life.
If someone thinks or knows their family member or friend isn’t receiving quality continence care, what should they do?
If you have concerns about the care received it is important to speak to the staff, if you feel comfortable doing this. Often, families have a good knowledge of what helped the person to manage their toileting needs at home and can work together with staff to achieve quality care. Staff in residential aged care should include the person (or their representative) in any care planning to ensure that their personal preferences are met. If this does not resolve concerns, the facility manager or the GP would be appropriate to speak to.
There are ways to make a formal complaint if your concerns can’t be resolved. More information is available at agedcarequality.gov.au or by calling 1800 951 822.
This story was first published in Bridge magazine. Subscribe to Bridge online.