Pads are not an alternative to toileting: The aged care shortcut compromising resident dignity

Out of order toilet sign

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.

“Multiple, competing and conflicting expectations on care staff”

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 in Australia

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.

Toileting has psychological and physical benefits

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.

Toileting: Walking, sitting, dexterity

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.”

Pads increase risk of skin breakdown

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. 

Tips to help maintain toileting

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.

How can we improve continence care in aged care homes?

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.

Better training is required

Thompson provided some suggestions for managers in aged care homes to help ensure staff can deliver continence care that respects the dignity of residents.

  • Challenge ageist views and misconceptions about incontinence and bladder and bowel symptoms in old age.
  • Emphasise the human experience of being incontinent, focusing on the role of dignity and dignity-protective practices.
  • Improve residents’ choices in continence care.
  • Raise awareness about the role emotions can play in continence caregiving interactions and the associated risk of elder abuse.
  • Provide staff with education to equip them with a broad understanding of the fundamentals of care and how to enact dignity in continence care through a resident-centred approach.

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.

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  1. The reality is that incontinence “pads” have become a financially viable substitute for appropriate staffing. The normal allocation of 3 pads costs a provider $2 per resident per day. Pads are used to replace toileting activities because there simply are not enough staff to attend to everyone and its cheaper to hand out pads as a solution. Even at their very best, an aged care nursing home will have a care worker ratio of 1:6 for a period of time during the day. This blows out often to 1:25 or more as the day progresses so it is not humanly possible to assist everyone to the toilet when they may need to go. Continence care then becomes a game of Russian roulette … residents are toileted according to a loose schedule in the hope they will go when they are placed on a toilet (and they are the lucky ones who are taken at all).

    The only real solution to incontinence is appropriate individualised clinical assessment, proactive care, access to toilets and adequate numbers of staff to make it happen. Not putting everyone in jumbo pads and changing them when they are saturated.

  2. Sadly, staff are to blame again. Aged care facilities are so under staffed. Staff know the importance of getting residence to the toilet on time, trust me it is much easier to assist in adjusting clothes or helping pull up underwear than cleaning faeces that has been squashed over the lower regions. But when you have the impossible task of two or three care staff to toilet 26 residents, some with mobility issues, some residents needing two staff to assist..something is not right.
    So until the over funded private sector in aged care is properly staffed, conditions will not improve.
    You will find majority of care staff want to be able to spend more quality time with their residents, but they are forced into becoming task orientated because facilities are so poorly staffed. Toileting is just one area that is poorly managed.
    All it would take is to have at least two to three extra care staff on each shift to give residents a better basic standard quality of life.
    Care staff are so poorly paid it would not cost these large private organisations much to put on more staff. Care staff are definitely not in it for the money.
    Being a personal carer is not for every one, but it is so rewarding, and staff become very attached to their residents.
    In conclusion; yes pads are not an alternative to toileting, but they provide a bit of dignity and save embarrassment when accidents happen until the system changes this is the best alternative.

  3. This is so true. Staff need time and even if the resident feels they need to toilet every 30 minutes as staff we have to accommodate this. More education is needed, In 20 years I have done a course or three about the needs of our residents, yet when I do bring the problem forth I get told ‘you are just a carer’.

    1. Yes Rose the discrimination towards Aged Care staff needs to stop. People who are not on the floor assisting so many elderly people one after the other should actually be made as part of a contract to work as AINs 4 weeks every year. They will think twice before referring to us as “just carers” if they had to do this. God bless the highly educated. “There are none so blind as those who cannot see”. When they can fly down off of their perch 4 weeks per year it will be a humbling experience.

  4. My father suffered from prostrate problems, later diagnosed as cancer. Urinating was a slow difficult process for him with a frequent desire to go to the toilet but a slow, impeded flow. As he was a fall risk and confined to a chair for his own safety, the Nursing Home staff did not have sufficient time to take him to the bathroom and wait while he took the time needed for his toileting. They therefore encouraged him to urinate in the pad as it was easier for them. He also suffered with constipation and needed daily laxatives which would often have the opposite effect by giving him diarrhoea. Here again he was labelled as incontinent and had to use the pad even though he always knew when he needed to go to the toilet and would call out for someone to take him. If he needed to go to the toilet when I was visiting he would always tell me and I would ask a staff member to take him. My father was a proud and independent person and this severely impacted his dignity. I honestly believe this was a contributing cause to behavioural problems which were put down to dementia, but I think were often just intense frustration. Most carers do their best, but there are just not enough of them to be able to care properly for all the residents in situations like this.

  5. It’s not pads versus toileting, it’s not training or time constraints. A carer can ensure that the resident is taken to the toilet many times a day, after meals and regularly but more often than not advanced dementia residents and high care folk will wet or soil themselves minutes after being settled on returning from the bathroom.
    What’s the answer? There’s no dignity in soiling ones self or a pad?
    It’s not straight forward.

  6. ThanQ for being looking after Distinguished people. Whom built up the counties that we are enjoying nowadays,
    Looking after them or care of them it must be an honor,

    I do have an idea if you could try to create hand wishing in bathers or toilet to be able to Wash after each time they go to toilet to feel clean. I am too sure this will impact their feelings and dignity

  7. Hi I am currently working in a place that does sleepovers instead of night shift. As a support care worker I was told that I was only to write up callouts to be paid for if the care took 10 mins or longer. I am given to understand that it is desirable for there to be no call out written up and to do the care for free. With this in mind I have had to choose between not giving care or doing it for free. I have chosen giving care for free. However not even this was acceptable. I was told yesterday that if a particular resident did not get out of bed herself and use the toilet then she could just lie in a wet bed till morning. The understanding being that I was not to toilet her. I have discovered that they have CCTV in bedroom and because I just can not let anyone lie in a soaking wet bed all night so therefore have been modulating her, I fear I may be dismissed. I want to know is it legal to leave someone in a wet bed all night, o r is it a breach of duty of care. I will continue caring for residents for free overnight because that is what I believe is the right thing to do. Please give me feedback. Very stressed

  8. Could lumber spinal issues cause urine Incontinence. I get up to go to the toilet to urinate and by the time I get to the door I’m very wet. I wear a pad so I don’t get smelly. I’ve worked as hard as any man on the dairy farm for 40 years and have so much Arthritis in my spine and all my joints. At 77 I could have a few years yet. I live alone. Yvonne

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