To identify and address the needs of community clients with a continence problem, an appropriate clinical assessment tool would be developed to facilitate appropriate referral and clinical management.

The Broken Hill Health Service had not had a continence nurse for fifteen years. A co-ordinated process was not in place to assist people in the community with continence problems. Community clients are assessed routinely by District Nurses when admitted to our service.

Unless incontinence is the primary reason for referral, further investigation into incontinence was not undertaken. There is no existing data to account for the number of clients in the community who have a continence problem. Other community services (Home Care, Community Options, Community Aged Care Packages), also had clients who had continence problems.

The project intended to obtain basic data from these services to completely evaluate the extent of the problem in the Broken Hill region.

Without existing data, baseline information was needed. There was no way to initially gauge if people had received referral to appropriate services. In the Broken Hill region, continence products cost PADP (Program of Appliances for Disabled People) over $30,000.00 per year. These products include continence pads, urosheaths, urinary catheters, commodes and other equipment to manage incontinence.

Domiciliary Nursing Care Services at the time of investigation had 7 male clients and 17 female clients using a variety of continence aids. A Cause and Effect fishbone exercise was undertaken by the District nurses. The staff identified the barriers affecting follow and appropriate care of clients with incontinence. A Pareto Chart confirmed that patient embarrassment and access to assistance were the primary barriers affecting appropriate care and follow up for these specific issues.

Further data from PADP, Home Care, Community Options and Community Aged Care Packages highlighted the extent of continence problems in the community.

The project relates to the NSW Health State and GWAHS Strategic Direction 3, "Strengthen Primary Health and Community Care in the community". The 8th objective in this strategy is "Planning and delivering services to meet the specific needs of the population".

This project surveys the specific needs of the population with continence problems and investigates ways to provide a service to meet their individual needs. The project functions within the mission statement of the local Domiciliary Nursing Care Service and upholds the vision purpose goals and strategic directions of the GWAHS.

After consultation with clients, District Nurses, Women's Health Nurse, Physiotherapist, PADP and Specialist Clinics, a Dry as a Bone flow chart was developed to identify existing processes within the health service for clients with a continence problem. It revealed that clients within the health service with stress incontinence were managed well within the health service.

Clients in the community were left to identify and manage their own continence issues with no available support or clinical assessment. The opportunity existed for nurses already in the community to ensure that any client with even a minor continence issue was offered a clinical assessment and professional support.

By alerting other community services at weekly interagency meetings that community nurses were able to assess and care for community clients with a continence problem, a corridor for referral to the community team was established. Simultaneously, a comprehensive assessment tool was developed.

To ensure that the tool was relevant to the area and available services, consultation with the visiting Gynaecologist for identifying possible surgical interventions was essential. The assessment tool was initially named the waterworks questionnaire, but for originality (as this title had been previously used by the Continence Foundation) and pertinence to our remote environment, the Dry as a Bone questionnaire was created.

Community nursing staff and community services were informed of the strategy being undertaken for the project. Referrals for continence assessments had now started to come into the service. Co-operation between the community nursing team, PADP manager, and Community services increased for this purpose.

The Dry as a Bone clinical assessment now accompanied the necessary PADP application form and gave the PADP manager evidence to ensure that the appliances requested were appropriate to the needs of the client. The assessment tool was designed to focus on the clinical symptoms of the client. It asks not only for information from the person but provides an opportunity for the person to express their own possible ideas for a solution, providing input into their own care. With the client's permission, information can also be relayed to the client's GP for medical management if necessary. A valuable continence history is also established for the client for future reference if changes occur.

The Dry as a Bone questionnaire has become entrenched as the tool to be used by nursing staff for clinical assessment for community clients with a continence problem. It is now accepted by community services that assessment is required for effective continence management. It is expected that a continence assessment be undertaken for the supply of PADP products for clients with incontinence.

One to three referrals for assessment are received each week from community service providers for a continence assessment. The establishment of baseline statistics can now measure the ongoing needs of community clients with continence issues.

The project identified the need for education sessions for carers in the home to understand the principles of continence management. Education for community groups was another need identified as the project unfolded. Education is needed for dispelling embarrassment and assisting people who may have a simple solution to their particular problem.

The implementation of the Dry as a Bone questionnaire has become a well-established clinical service within the Domiciliary Nursing Care Service. The form has been designed to be user friendly for nurses in the community covering all aspects of continence assessment.

Maintaining the service will depend on the ongoing use of the tool and reviews of its relevance as community services, incontinence treatments and continence products evolve. It is essential that public education be maintained so the difficulties people can endure from embarrassment, discomfort, social isolation, mobility restrictions and falls risks can be reduced and a normal lifestyle within the community can be maintained.

The lessons learned from this project relate to ensuring the primary goal is kept simple and focuses on the needs of the client. The project revealed simple solutions could have a positive impact on the lives of people with continence problems. The people we encounter in the community setting are unique and the delivery of care must be adaptable to each individual, especially those with sensitive issues concerned with continence management.

An assessment tool can be adapted to suit any health care setting, providing consideration is given to the distinctive character of their own particular community, and be flexible enough to allow client input into the management of their own care.

Patient Safety & Clinical Quality Manager, Clinical Governance Unit
Greater Western Area Health Service
Ph: 02 6393 3559