Toileting aged care residents is both time consuming and costly, a fact that often results in staff adopting passive methods of continence management in aged care homes, such as using pads, rather than more active assistance with taking residents to the toilet.
In the royal commission’s final report, the commissioners wrote, “Staff members do not have the time needed to assist residents to go to the toilet in a timely manner.
“Too often there is a routine use of incontinence pads to manage workload,” leading to them becoming “reliant on incontinence aids”.
In other words, in order to get through all the work they need to do, aged care staff are using pads as an alternative to toileting, a process not considered best practice, that compromises the physical and psychological wellbeing of residents and is an affront to their dignity.
Poor continence management was one of the main quality and safety failings identified by the royal commission.
“Many aged care residences don’t encourage toilet use or strictly ration continence pads, often leaving distressed residents sitting or lying in urine or faeces,” they wrote.
Janie Thompson has more than 27 years of experience in continence care, primarily in aged care rehabilitation and community care. She is clinical services manager with the Continence Foundation of Australia, and leads their National Continence Helpline.
Thompson says research has shown that when staff are “inadequately resourced” to provide aged care residents with toileting assistance, particularly overnight, they are forced to adopt “pragmatic decisions”.
Furthermore, Thompson’s observations have been borne out by research. A 2014 study that followed 18 nurses and personal care assistants in aged care homes in Western Australia found staff “struggled to enable residents to exercise choice and autonomy” when it came to continence care.
In other words, staff were too busy to properly attend to continence care.
“This situation was compounded by workforce constraints, inadequate information about residents’ care needs, and an unpredictable work environment,” the researchers concluded, recommending that “structural factors that hinder high quality continence care” be “urgently addressed”.
Incontinence is one of the biggest factors contributing to older people having to move into residential aged care.
In Australia, a 2011 report by Deloitte estimated that in 2010, 71% of aged care residents had urinary or faecal incontinence – or both.
The cost of bowel and bladder management and help with toileting is said to be $1.3 billion annually, or 32% of the aged care subsidy.
A study in the US found that one staff member is required for every five residents to optimise continence management in an aged care home. As HelloCare readers will know, this ratio would be present in very few aged care homes in Australia, if any.
Thompson says helping older people continue toileting is important for both their psychological and physical wellbeing.
“Independent toileting is important for an older person’s self-esteem,” Thompson told HelloCare.
“We are toilet trained from a young age, so using the toilet is considered a normal part of life. To lose that ability can have a negative impact on how a person perceives themselves.”
Maintaining the ability to use the toilet as people grow older is also important to maintaining dignity, Thompson explained.
While going to the toilet is something many of us take for granted, the act uses a range of important physical skills that are beneficial to maintain as we grow older.
“There are a number of steps involved in going to the toilet, including walking, sitting, standing and hand function/dexterity with clothing adjustment and personal hygiene,” Thompson said.
“Being active, even with using the toilet, can have a positive impact on a person’s strength and dexterity.”
Using pads as an alternative to going to the toilet increases the risk a person’s skin can become irritated or begin to break down, especially the skin of an older person, which can be more fragile.
Pressure wounds can form, and if urine or faeces is left against the skin, there is a risk that incontinence associated dermatitis can develop.
So, what can be done to make it easier to toilet residents in aged care homes?
Encouraging older people to maintain or enhance their strength and functioning is an important way to help them continue using the toilet.
“It is important to exercise as they are able,” Thompson suggests. “Do they have an appropriate gait aid? Consider a physiotherapy assessment to look at an exercise program and review their gait and gait aid.”
Easy access to the toilet is also important.
“Look at the toilet itself. Does it have appropriate equipment to suit the person such as handrails, elevated seat and so on?” Thompson advised.
“Look at the person. Can they adjust their clothing easily? Consider elasticated pants and skirts. Is their footwear supportive?
“Would a toilet alternative be helpful, such as a male or female urinal bottle or commode?” Thompson proposed.
An occupational therapy assessment can also be useful in determining if the set up is appropriate for the person.
In their final report, the commissioners recommended that by July next year, less than 18 months after the report’s release, the government should ensure best practice continence care is implemented in aged care homes across the country.
We will be watching closely to see if the government implements this recommendation.
Thompson provided some suggestions for managers in aged care homes to help ensure staff can deliver continence care that respects the dignity of residents.
If you have questions or concerns about continence management, you can call the National Continence Helpline on 1800 33 00 66 or access the Continence Foundation’s Continence Support Now web app, which aged care staff can use as a quick reference while they are at work.