In 2021/2022, the Newcastle Specialist Continence Service embarked on a quality improvement (QI) project, the Bladder and Bowel Assessment Project (BBAP). The project's underpinning aim was to improve and increase the assessment and treatment of bladder and bowel dysfunction, while reducing reliance on containment products. National guidance tells us that we must attempt curative treatment for bladder and/or bowel dysfunction, before offering containment to patients (NHS England, 2018). Historically, some patients had not received a full holistic assessment, a diagnosis or a treatment plan for their bladder and bowel dysfunction. Instead, they received a containment product, which can then lead to psychological dependence (Department of Health, 2018)
The Newcastle Specialist Continence Service consisted of a small team of one community specialist nurse and one acute nurse consultant. To enable the project, a second nurse specialist was appointed to the service on secondment in 2020. The QI project began amid the COVID-19 pandemic. This came with some challenges. Backhouse and Ogunlayi (2020) stated that leading and embedding QI changes can be a challenging, complex process, requiring a multifaceted approach. At this time, staff at the Newcastle upon Tyne NHS Foundation Trust were under tremendous pressure, often working with reduced staffing due to colleagues having to isolate, a shift in priorities of work and little opportunity to engage with training. Despite the challenges, the project has still been extremely successful.
A pre-project audit showed:
- Only 5% of patients presenting with bladder or bowel dysfunction to the district nursing service received appropriate treatment within the trust
- Staff were not confident in implementing treatment plans
- Containment prescribing was increasing year on year with no increase to budgets.
The aims of the QI project were to engage community staff across the trust to improve their knowledge of the assessment and treatment of bladder and bowel dysfunction; and to empower them to have the confidence to implement level 1 treatment plans for patients and reduce initial reliance on containment products. These plans are the basics of good continence care and consist of advice on fluid consumption, lifestyle changes, toileting schedules, aids or equipment or basic bladder retraining. District nursing was the group receiving the majority of requests for first-line continence assessments, which gave the team the focus area for the project.
Training
Already established training was increased. Bespoke and accessible training sessions across the city were offered, along with continuing daily support offered to staff across the directorate at their bases. The Newcastle Specialist Continence Service team provided classroom-based training at a variety of locations; plus desk side training on request of staff or through regular district nursing base ‘walkarounds’ where educational needs were identified. The team also advocated an ‘open door policy’ where ad hoc support, advice or education could be sought face to face in the office area, by telephone or email 5 days a week. The idea was to make the training and support as easily accessible as possible for staff.
Project outcomes
The results of the project were as follows:
- The percentage of patients receiving an active level 1 treatment plan rose to 40%
- All product requests are now triaged and this ensures that patients receiving containment products have had other options explored first
- Prescribing of some products has fallen by 35% compared to pre-project data
- Staff knowledge of the assessment and treatment of bladder and bowel dysfunction has increased from pre-project 62% to 96% after training.
In order to embed these changes into practice for the future, the service secured another year for the secondee to continue providing support to staff in the form of community-based walkarounds, education and support drop-in sessions, joint visits to patients to support staff with the assessment process and continuing telephone and online support.
The project has highlighted that with varied education, support and engagement for staff, continence care and patient outcomes can be improved. However, there are still challenges and staff continue to need support and advice on the assessment and treatment process. Ongoing plans include continuing with regular training and engagement through ‘you said we did’ methods and capturing new or newly qualified staff to ensure they receive the training they require on entry to the department. Although continence training is not mandatory across the trust, we do strongly recommend staff to come along to the sessions, to ensure that their patients are receiving best practice care and hopefully contributing to improving the quality of life for patients with bladder and bowel dysfunction.
Receiving an award for the BBAP project in the BJN Awards 2023 was an honour. To have the hard work and dedication of the team recognised in such a way has encouraged us to continue to strive for better patient outcomes and improvements in care.