Name: Charlotte Porter
Job title: Specialist Practitioner School Nurse
Specialty: School Nursing
Organisation: Walsall Healthcare NHS Trust - School Nursing Service
What is the initiative and or project you are involved in?
The school nursing service has provided support for children and young people with nocturnal enuresis for several years. More recently the service took over a contract to manage continence in children and young people and in response developed a robust pathway with the aim of promoting continence and supporting children and young people for whom continence cannot achieved.
What prompted you to do this work?
Over 900,000 children and young people within the United Kingdom have a medical condition affecting their bladder and bowel, the most problems are delayed toilet training, bedwetting, daytime bladder problems, constipation and faecal soiling all of which can impact negatively on quality of life (Perez, 2014, Rinald and Mirenda, 2012, Rogers, 2016). The promotion of continence therefore, where appropriate, supports children and young people to maximise their ability and to reach their full potential (DH, 2004).
It had been custom and practice to provide children with continence containment products at a young age which then continued to be issued throughout their childhood with no further assessment being undertaken. However, it is essential for children and young people to have an appropriate continence assessment and that the issuing of continence containment products should be the exception rather that the rule (NHS England 2018).
How did you initiate the work?
A review of the delivery of continence and enuresis support was reviewed drawing on national guidance and good practice. A pathway which promoted continence including appropriate assessment and prescribing of continence containment products was developed.
What have the challenges to implementing the service/intervention been? And what has enabled the implementation of the service/intervention?
A pathway was implemented which included a robust initial assessment incorporating a toilet training readiness tool to identify children and young people who are showing signs that they could be toilet trained. Families are encouraged to attend either a toilet training for school aged children workshop, a toilet training for children with additional needs workshop or a bedwetting workshop (dependent upon need). If children are assessed and issued with continence products, then reassessment is planned every 12 months (ERIC and the Paediatric Continence Forum (2017).
It was important to ensure that staff were up to date with the assessment and management of continence and supported to deliver the pathway. A competency framework and training packages have been put in place to support this process.
The biggest challenge in implementing this intervention has been changing practice that has been left unchallenged for several years. This has taken courageous leadership to set a standard for the assessment and promotion of continence and the issuing of containment products which is consistent across the organisation. The lead School Nurse for continence has met with the community nursing teams to discuss why the need for change is essential. It has been important to work with parents to gain their trust and improve their understanding of the pathway and reassure them that we are working with them to achieve the best care for their children. Further work is required in this area.
Has the initiative or project made a difference to patients/service users and or staff?
Children and young people referred into our service with bladder and bowel problems now have a pathway of support. New referrals receive a continence assessment and when appropriate attend a toilet training workshop. The pathway has been in place for over 6 months and long term this approach can effectively supports children and young people to achieve continence, promote their independence, raise self-esteem and reduce the risk of social exclusion (Perez, 2014, Whale, 2016). The organisation will benefit, in the long term by ensuring that resources are used in the most cost-effective way whilst delivering high quality, safe care.
What are the long-term aims for the work?
The focus of our work has been on promoting toilet training and appropriate, evidence based prescribing of continence containment products based on needs of the child. A wider paediatric continence pathway is still in development. Although progress is starting to be made, adequate referral pathways to specialist services, as necessary, is still required and School Nursing are part of a task and finish group to scope and develop this pathway.
Alpaslan, A.H., Kocak, U., Avci, K. and Guzel, H.I. (2016) Association between elimination disorders and abusive maternal attitudes. Journal of Forensic and Legal Medicine. 40(2016), pp.22-27
Department of Health (DH) (2004) National Service Framework for Children, Young People and Maternity Services: Disabled Children and Young People and those with Complex Health Needs. London: Crown Copyright
NHS England (2018) Excellence in Continence Care. Leeds: NHS England
Nursing and Midwifery Council (NMC) (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. London: NMC
Paediatric Continence Forum. (2017) An Examination of Paediatric Continence Services Across the UK. London: Paediatric Continence Forum
Perez, J. (2014) Early intervention for childhood continence problems. Community Practitioner. 87(7), pp. 44-46
Rinald, K. and Mirenda, P. (2012) Effectiveness of a modified rapid toilet training workshop for parent of children with developmental disabilities. Research in Developmental Disabilities. 33(2012), pp. 933-943
Rogers, J. (2010) One step at a time: how to toilet train children with learning difficulties. Nursing Times [online]. 106(47), [Accessed on 2nd April 2018]. Available at: https//:www.nursingtimes.net
Stenson, A. and Danaher, T. (2005) Continence issues for people with learning disabilities. Learning Disability Practice. 8(9), pp.10-14
Whale, K. (2016) Effects of continence problems on children. Nursing Times. 112(36/37), pp. 8-10.