The impact of Government initiatives, The White Paper, The new NHS: modern, dependable, and the subsequent policy. documents, A first class service: quality in the new NHS and Good practice in continence services marked the introduction of a range of mechanisms to improve quality, involving setting, delivering and monitoring the standard of care patients receive (DH,NHSE, 1998; DH, 1998; DH 2000). The essence of care (DH, 2001) contains benchmarking tools relating to continence and bladder and bowel care. Clinical risk management Specialist nurses should have a clear understanding of local policies that aim to minimise and manage the risks associated with adverse incidents.
Specialist nurses should have access to relevant clinical guidelines that support appropriate decision-making and ensure good outcomes for the patient (RCN 2006). Effective action relies on an accumulating body of evidence that takes account of current clinical practices. This evidence based approach should be used to review and inform practice. All staff should demonstrate good infection control and hygiene practice.
And again it is important to stress the possibility of prevention as opposed to cure. (Health Act 2006). This idea of evidence based approaches can also be crucial in determine the efficiency of a policy or determine whether procedures need altering. For instance discussion enables one to review the success of new policies and can flag up issues which were only revealed when a theoretical solution is put into practice.
By asking the right questions nurses can provide useful insight as well as understanding the patient’s perspective. Whilst this, coupled with adherence to NHS policies would demonstrate fair and good practice there has been evidence of deviance and mal practice in all areas of healthcare regulations. A report from age concern revealed an epidemic of mal-treatment, force feeding and denial of medical treatment (1998). A survey by Age Concern (2000) found that one in 20 people aged over 65 had been refused treatment. Hodges (1997) argues that older people do not receive optimum treatment for their illness, as they are assessed with regard to their age rather than clinical need. Even hospital policies were deemed discriminatory, where 1/5 of heart units operated on age related admission.
USA studies concluded that whilst carers emphasised incontinence management rather than continence promotion. Encouraging abdominal exercise techniques have proved somewhat effective. Even with policies staff will not always comply, however acts like the Corporate Manslaughter and corporate Homicide Acts (2007) may prevent this as they enforce criminal sanction for patient death caused by clinical negligence. They clarify where serious failures in clinical management result in criminal liability. However like ‘core policies’ it is argued that such measures only force staff to act under duress in fear of punishment rather than the genuine desire to provide quality services, which may amount to poor practice management.
People who suffer from incontinence problems or who require assistance to enable to pass urine can experience social isolation, embarrassment and may isolate themselves from their family and friends. It can also impact on their quality of life including sleep disturbance, mobility problems and discomfort (Holland et al 2003). The publication of the National Service Framework (NSF 2001) for older people highlights that whilst older people are the main users of health and social care services have not always adequately addressed their needs.
This National Service Framework is the first ever comprehensive strategy to ensure fair, high quality, integrated health and social care services for older people. It is a 10 year programme of action linking services to support independence and promote good health, specialised services for key conditions, and culture change so that all older people and their carers are always treated with respect, dignity and fairness.
Older people and their carers should receive person centred care and services which respect them as individuals and which are arranged around their needs. Older people and their carers have not, however, always been treated with respect or with dignity nor have they always been enabled to make informed decisions through proper provision of information about care across care sectors. Organisational structures have acted to impede the provision of care co-ordinated around the needs of the older person.
Proper assessment of the range and complexity of older people’s needs and prompt provision of care (including community equipment and continence services) can improve their ability to function independently, reduce the need for emergency hospital admission and decrease the need for premature admission to a residential care setting. But service and system failings have undermined older people’s confidence in other aspects of care and their ability to remain independent. On the other hand policies should encourage GPs to build strong trusting relationships with members of the community and in turn would encourage people to continue to visit doctors and maintain good patient-doctor relationships and protect doctors services by opposing plans to impose impersonal polyclinics at the expense of local GP’s.
The first two standards in the NSF for Older People (DoH 2001) anti-discriminatory practice and person-centred care are inter-linked as they concern putting the older person at the centre of his or her treatment and ensuring that services are needs-led and not service-led (DoH 2001). To promote person-centred continence care, there are three principles that should underpin nursing practice: Eliminating any discrimination in continence care, to ensure staff have adequate knowledge of continence care. Contribute to the provision of a seamless continence service by providing single assessment (patientcentred, interprofessional/interagency assessment of health and social care needs). Discrimination in health care can also occur at an individual level during the client-practitioner relationship and at a wider level of service provision by organisations.
The NSF for Older People (DoH 2001) states that no patient should be declined medical diagnosis based on age. Care providers could be accused of institutionalised ageism, perhaps reflecting discrimination against older people in wider society. Nurses are part of society and it is likely that unless nurses are made aware of the impact of such attitudes, discrimination could affect personal nursing practice. It also outlines standards for each priority to be achieved across England within specified time frames. One standard relates to the provision of comprehensive integrated continence services.
By monitoring these standards, the Department of Health hopes to ensure that everyone will receive the same standard of service, regardless of their age or place of residence. You might also have identified limitations in the environment as a factor influencing poor practice in your clinical setting and this is one of the most difficult factors to change. When nurses are aware of such limitations, small steps can be taken to promote older people’s dignity in the short term, while in the long term nurses can use policy to recommend environmental changes to managers in their organisations.
Urinary incontinence can restrict employment, educational and leisure opportunities, and lead to social embarrassment and isolation, affecting both physical and mental health. It is vital that people who are incontinent are given every opportunity to regain their continence. High quality comprehensive continence services are an essential part of health care. Before treatment and management options are offered, the Royal College of Nursing (RCN) encourages the consideration of all aspects of a client’s continence problem, their lifestyle and any care needs. This RCN document looks at the key roles of nurses examining their potential influence on continence services – whether in a hospital or the community setting and the impact of the Government’s new initiatives (RCN 2006). It is a common problem in most societies for to ones intimate problems private.
However incontinence is a private matter which must be revealed and many suffers find difficulty in doing so. The problem here is that it inhibits hospital aims to tackle such issues at the earliest stage to prevent infection or critical illness. Policies may be used to address this issue by first identifying reasons for patient silence. The feminist argument that females are disadvantaged by the lack of female GPs- with whom they will feel most comfortable confiding in, may also apply to males in most societies. Not only do statistics suggest that men are less willing to discuss illnesses, but they may feel uncomfortable around carers, who are predominately women.
The legal right to privacy should be fully incorporated in home visiting policies, giving patients a right to request GP or nurse with the same sex as themselves and to avoid cases like Rodney Ledward- A gynaecologist who violated a number of patients. Religious views- notably Jehovah Witnesses may also lead people to refrain for engaging in medi-care which involve surgery and utilisation of manmade implants such as catheters. Another reason for delayed consultation may be due to deprivation.
Marxists draw upon social and economic deprivation- underclass upbringing may lead to a lesser awareness about medi-care and the heavy reliance on NHS as opposed to the interpersonal care generally offered by private hospitals. Therefore there should be increased publication about the illness to break down the embarrassing stigmas and to demonstrate the negative consequence of delayed consultations.