LONG-TERM CONDITIONS
Promoting intermittent self-catheterisation to encourage self-care in district nursing patients Roberto Cassani
Roberto Cassani is a Community Staff Nurse in Tayside, Scotland
© 2014 MA Healthcare Ltd
M
any people in the UK live with an indwelling urinary catheter to manage urological problems (Evans et al, 2000). In the community, the nursing management of catheterised patients is normally carried out by the district nursing (DN) service (Evans et al, 2000). This author of this article is employed as a community nurse in a rural area of Scotland in which catheter management represents 30% of the total caseload. This places considerable demand on the DN team with all the associated costs. Evans et al (2000) reported that supporting one patient living in the community with a long-term indwelling catheter may cost the NHS up to £2585 over a 3-month period. The Nursing and Midwifery Council (NMC) (2008, p. 3) clearly states that ‘nurses must support people in caring for themselves’. This emphasis on self-care is a part of the ‘Modernising Nursing in the Community’ framework in Scotland (NHS Education for Scotland, 2012). An ageing population, which places great demand on the health service, has increased the need for self-management (Toward, 2008). Studies suggest that self-care can have a positive impact on people’s quality of life, clinical outcome and use of resources (Health Foundation, 2011). Within the author’s caseload, several patients with a long-term catheter are able to manage all the other aspects of their care independently, with little or no nursing input. For at least some of these patients, intermittent self-catheterisation (ISC) could be an excellent option as it would encourage self-management, improve quality of life and reduce nursing costs (Nazarko, 2012). This article will examine the district nurse’s important role in identifying those patients who would benefit from ISC and in promoting and supporting its use in order to encourage self-care in the community.
ISC in the community ISC is a procedure whereby a catheter is inserted by a person into their own bladder and removed after the bladder
British Journal of Community Nursing April 2014 Vol 19, No 4
Email: [email protected]
has been drained (Nazarko, 2012). Its use has become more common in the past 30 years, as new products have been developed to make ISC easier and more comfortable for the patient (Collis Pellatt and Woodward, 2011). There are many patients in the community who may benefit from ISC. It may be a good treatment option for both men and women of any age who have conditions causing urinary retention and/or incontinence (Woodward, 2013a). Good examples of ISC uses in the community include the management of neurogenic bladder dysfunction in patients with multiple sclerosis (MS), or to aid bladder drainage in men with benign prostatic hypertrophy (Logan, 2012).
Advantages of ISC ISC has several advantages over long-term indwelling catheterisation (Collis Pellatt and Woodward, 2011). Both catheter options effectively resolve urinary incontinence and/or retention, but ISC would allow patients to preserve their independence, intimacy, sexuality and not to have to rely on community nurses for catheter care (Nazarko,
ABSTRACT
Intermittent self-catheterisation (ISC) is deemed the preferred option for the management of urinary incontinence and/or retention in patients requiring a catheter. It also allows patients to self-care, thereby placing fewer demands on district nursing (DN) services and meeting the requirements of the current health policy agenda. Yet many patients who could benefit from ISC in the community still use a long-term urinary catheter. This may contribute to increased morbidity, poorer quality of life, and unnecessary visits from the DN team. This article analyses the role of the district nurse in promoting and supporting the use of ISC with suitable patients.
KEY WORDS
w Intermittent self-catheterisation w District nursing w Self-care w Community
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LONG-TERM CONDITIONS
Possible disadvantages of ISC ISC may also have potential disadvantages for patients who live in the community. DN teams must not presume that using ISC will improve quality of life because, in many instances, this is not the case (Colpman, 2011). Logan et al (2008) and Shaw et al (2008) are examples of published qualitative studies on the patient’s experience of living with ISC. Both studies highlight the anxieties associated with learning to adapt to self-catheterisation. For instance, some patients have reported embarrassment due to having to undertake such an intimate procedure (Logan et al, 2008).
Box 1. Benefits of ISC in the community w Allows patient to self-care w Preserves dignity w Reduces district nursing input w Can improve quality of life w Avoids traction and trauma associated with wearing leg bags w Allows the expression of sexuality w Avoids the need to wear loose clothing to conceal catheter bag w Preserves bladder tone and renal function w Reduces the risk of urinary tract infection Source: Nazarko (2009)
178
Some experienced technical difficulties while learning to self-catheterise, such as problems negotiating their own anatomical features, or simply learning to handle catheters that they often found slippery or too long (Logan et al, 2008). The fear of introducing infection was also reported as common (Colpman, 2011). At times, patients also found it difficult to perform ISC outside the home, due to difficulties finding adequate toilet facilities or simply difficulties carrying the equipment around discreetly (Shaw et al, 2008). Finally, fear of causing oneself pain was found to be common, and not all patients in the studies were happy to receive help from their partners, sometimes feeling that self-catheterisation was too personal an issue (Shaw et al, 2008). Mangnall (2013) points out that nurses’ failure to appreciate these practical and psychological disadvantages for the patients may result in poor compliance with ISC. Despite the advantages of ISC, the procedure is likely to represent a serious lifestyle change and carry huge physical and emotional implications (Mangnall, 2013). Because of this, the decision to start ISC must be taken with the informed consent of the patient (Mangnall, 2013). This not only satisfies the nursing requirement to obtain informed consent (NMC, 2008), but is also paramount if the district nurse wants to maximise the chances of patient compliance (Mangnall, 2013). A list of the most common disadvantages of ISC in the community can be found in Box 2.
DN and ISC The evidence above appears to show that ISC can be an excellent choice of continence care for those patients who can cope with its practical and psychological demands. For all the clinical and lifestyle advantages, though, there are also some disadvantages to ISC, which may cause poor compliance and its ultimate abandonment. The qualitative studies on the subject concluded that one of the most important contributing factors to a positive ISC experience is the support received from nursing services, especially while patients are learning the procedure (Logan et al, 2008; Shaw et al, 2008). Patients like to feel supported by nurses who are both technically competent and communicate with empathy (Woodward and Rew, 2003). It is not feasible to expect every patient with continence problems in the community to be closely supported by specialist urology nurses. As a result, for many people requiring catheters in the community, the DN service is the most frequent and likely avenue of support. Currently, to the best of the author’s knowledge, there is no scholarly article on ISC written with a DN focus. Nevertheless, district nurses know the patients on their caseload, as well as their personal circumstances and families. They are therefore ideally placed to identify patients whose quality of life would be enhanced by switching from long-term indwelling catheterisation to ISC. Robinson (2007) states that any nurse who undertakes urinary catheterisation would be able to teach ISC. Yet the author’s experience suggests that district nurses may not be as familiar with ISC as they are with long-term indwelling urinary
© 2014 MA Healthcare Ltd
2012). It would also preserve bladder elasticity by avoiding the loss of tone associated with long-term catheterisation (Nazarko, 2009). The advantages of ISC in the community are summarised in Box 1. According to the literature, one of the main benefits of ISC is its ability to reduce the potential for urinary tract infections (UTIs) associated with indwelling catheters (Collis Pellatt and Woodward, 2011). At present, there is no randomised controlled trial confirming that ISC causes fewer infections than long-term catheters. The few trials that have been carried out gave somewhat conflicting evidence (Jannelli et al, 2007; Hakvoort et al, 2011; Millet et al, 2012). Nevertheless, retrospective, non-randomised studies have found that intermittent catheterisation is the safest method in terms of having fewer urological complications, improving patients’ quality of life and reducing the incidence of UTIs (Weld and Dmochowski, 2000; Pilloni et al, 2005). This opinion is upheld by both the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidance Network (SIGN). Their most recent clinical guidance recommends the use of ISC as preferable to long-term catheterisation to prevent catheter-associated infections (NICE, 2012; SIGN, 2012), and also for the treatment of urinary incontinence and retention in women (NICE, 2013). The frequency of daily ISC varies from patient to patient. Depending on ability to void, bladder capacity and residual volume, ISC may be performed between one and six times per day (Nazarko, 2012).
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LONG-TERM CONDITIONS catheters, and hence less likely to initiate ISC with patients who may well benefit from it. The following three case studies provide examples of situations where district nurses may feel it appropriate to suggest ISC. In order to respect confidentiality (NMC, 2008), the patients’ names are pseudonyms and their identifiable circumstances have been changed.
w Patients must have sufficient dexterity and understanding to perform ISC w People with small bladder capacity may be required to self-catheterise too frequently
w Anxieties over causing themselves pain or urinary tract infection (UTI) may hinder compliance
Case study 1
w Carrying out ISC outside the home may require careful planning
Malcolm is a 75-year-old male with benign prostatic hypertrophy, and is currently under urology review. Malcolm has had an indwelling urinary catheter in situ for 6 months. It was originally inserted during a hospital admission, mostly due to poor mobility. The DN service became involved with Malcolm to provide catheter care. He has since been reviewed by a consultant urologist and commenced on tamslusosin. The urologist did not deem any other drug treatment appropriate in view of Malcolm’s circumstances and comorbidities. During this period, Malcolm has had two failed trials without a catheter. Despite being able to void, he maintains a significant bladder residue. Malcolm is married and lives an active life with his wife. The longterm catheter has been a source of anxiety, embarrassment and discomfort for him. He also lives in a very rural area that is difficult for nurses to reach in the winter months. Malcolm is a very capable and independent man. He would have the understanding and manual dexterity required to self-catheterise. Therefore, ISC would probably represent a very good option to promote self-care and improve quality of life, while continuing to manage Malcolm’s bladder emptying requirement.
w Self-catheterisation may still occasionally cause UTIs
Case study 2 Mary is a 58-year-old female with MS. She has had a catheter in situ for 4 years due to a neurogenic bladder. She often has problems with catheters blocking or bypassing owing to poor positioning. She has also found that wearing a catheter bag has limited her choices of clothing: she often wears large jogging trousers to hide her leg bag, which she finds unattractive. Having a catheter has reduced her desire to go out and socialise, as she finds it embarrassing and unpredictable. Mary has good understanding and dexterity, and she is also happy to let her husband help with catheter care. ISC could represent a great choice for Mary. In fact, ISC is the preferred choice of catheterisation in women with neurogenic bladder (NICE, 2013). It may also contribute to reducing Mary’s embarrassment, improve her social life and allow a wider choice of clothing.
Case study 3 © 2014 MA Healthcare Ltd
Box 2. Disadvantages of ISC in the community
Liam is a 22-year-old male who has become paraplegic following a spinal injury. Liam has had a suprapubic catheter in situ since he was treated in hospital for his spinal injury. However, now Liam is back home and working hard to regain a fulfilling social life. He finds his catheter embarrassing as he is sexually active and young. Liam’s manual dexterity is limited and he would not be able to negotiate ISC unaided. However, in recent years there have been
British Journal of Community Nursing April 2014 Vol 19, No 4
w Some patients may find the procedure uncomfortable w Some patients may find ISC socially unacceptable Source: Mangnall (2012)
several appliances developed to aid ISC for people with limited dexterity (Robinson, 2006). The community nursing team could discuss ISC with Liam and possibly assist him to explore the available aids.
ISC products If district nurses are to support patients with the choice of ISC, they need to know about different types of ISC and related aids. Both single-use and reusable catheters are available commercially, and among the single use catheters there are hydrophilic or gel-coated catheters (Robinson, 2007). Catheters can be obtained in male and female lengths (Nazarko, 2010). Recently, several manufacturers have developed new products that make it easier for people to travel carrying intermittent catheters and use them in public toilets more discreetly (Woodward, 2013b; Woodward et al, 2013). A brief summary of the types of intermittent catheters available in commerce can be found in Box 3. As yet, there is no evidence to suggest that any type of catheter is better than the others (Nazarko, 2010). Hence, prescribing should be guided by patient preference and personal circumstances. Because of this, nurses should be familiar with the various products available on their local formulary, as well as on the market as a whole, in order to facilitate appropriate choice and maximise the success of the trial with ISC.
The role of the nurse The DN team has a very important role in assessing patients for the suitability of ISC, as well as in the initial teaching and ongoing support. Firstly, ISC is not the right choice for everyone. The patient must have the ability to understand the procedure, the manual dexterity to carry it out, and the motivation required to incorporate ISC into their daily routine (Robinson, 2007). A nursing assessment is paramount in order to identify suitable candidates (Pomfret and Winder, 2007). Rew (2007) points out that ISC should be offered as a continence option only if the benefits of undertaking it outweigh the potential problems. Nevertheless, patients have reported feeling anxious about carrying out such an intimate and potentially uncomfort-
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HATTIE YOUNG/SCIENCE PHOTO LIBRARY
LONG-TERM CONDITIONS
able procedure (Rew, 2007). Because of this, the district nurse and his/her team must not work in isolation, and should try to involve the appropriate members of the multidisciplinary team (NMC, 2008). The knowledge and expertise of specialist urology nurses could indeed be called upon to suggest the most up-to-date products, or to suggest solutions when difficulties arise. The patient is central to the team and his/her opinion, dignity and views must be upheld at all times. Finally, the family and carers could be a very important part of the team too, as they may be asked to support the patient and at times even perform the procedure with the patient’s informed consent (Pomfret and Winder, 2007). Teaching ISC does not necessarily have to be carried out in a urology clinic. Logan et al (2008) found that most
Box 3. Types of intermittent catheters w Reusable catheters: can be used then washed more than once and
require to be lubricated with a local anaesthetic gel prior to insertion.
w Pre-gelled single-use catheters: can be used only once and they are prelubricated with gel.
w Hydrophillic-coated single-use catheters: their lubricant is activated by contact with water. There are several options in commerce and it is very important to follow the manufacturer’s instructions before use. Source: Robinson (2007)
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patients preferred to be taught ISC at home, putting the DN team in an ideal position to provide the initial teaching and training. In this case, the district nurse will have to be able to deliver technically competent teaching, but also use a vocabulary and a style of presentation that suits the patient (Logan et al, 2008). Again, community nurses practice these communication skills on a daily basis. Empathy should be at the centre of the process, as the nurse must recognise that patients may not feel comfortable discussing and undertaking ISC (Pomfret and Winder, 2007). The qualitative research in Logan et al (2008) and Shaw et al (2008) highlighted that the empathic attitude of the nursing team delivering ISC support is the most likely contributor to the patient’s long-term compliance. The DN team’s input must not conclude following the initial assessment and training. It must be based on ongoing support and the evaluation of the impact that ISC has on the patient’s quality of life (Rew, 2007). Hence, follow-up visits should be part of the DN input. The frequency of these visits will vary depending on the patient’s circumstances (Robinson, 2007). Despite this, once ISC is successfully established, DN visits will be required much less frequently than in cases where a long-term urinary catheter is in place.
Conclusion Many patients live in the community with a urinary catheter to manage urinary incontinence and/or retention. Catheter care is costly, especially in terms of the demands it
© 2014 MA Healthcare Ltd
A district nurse cleans the tap on a urinary incontinence bag that is strapped to an elderly woman's leg. Many patients who could benefit from intermittent self-catheterisation in the community still use a long-term urinary catheter. This may contribute to increased morbidity, poorer quality of life, and unnecessary nurse visits.
British Journal of Community Nursing April 2014 Vol 19, No 4
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LONG-TERM CONDITIONS places on the DN services. However, contemporary health care has shifted its focus from passively providing treatment to encouraging self-management where possible (Scottish Government, 2007). Failing to promote self-care would create an unsustainable situation for the NHS, given the challenges of an ageing population (Toward, 2008). ISC allows suitable patients to self-care, with support from the district nurse and the multidisciplinary team. Where applicable, ISC would not only reduce the need for DN visits, but would especially improve the patient’s quality of life, while reducing the risks associated with long-term catheterisation. The district nurse and his/her team are ideally placed to identify those patients who would benefit from ISC, and provide ongoing support to maximise its success, in order to encourage self-care and ultimately improve the patient’s quality of life. BJCN Acknowledgement: This article forms part of the author’s final project for the BA (Hons) Community Health at Robert Gordon University, Aberdeen.
© 2014 MA Healthcare Ltd
Collis Pellatt G, Woodward S (2011) The benefits of intermittent self-catheterisation. Br J Nurs 20(18): 1164–6 Colpman D (2011) Assessing and supporting men using catheters. Practice Nursing 22(8): 406–9 Evans A, Phelby D, Painter D, Feneley R (2000) The cost of long-term catheterization in the community. Br J Community Nurs 5(10): 477–88 Hakvoort RA1, Thijs SD, Bouwmeester FW et al (2011) Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for complete voiding after vaginal prolapse surgery: a multicentre randomised trial. BJOG 118(9): 1055–60 Health Foundation (2011) Evidence: Helping People Help Themselves. http://tinyurl.com/q7clajt (accessed 7 March 2014) Jannelli ML, Wu JM, Plunkett LW, Williams KS, Visco AG (2007) A randomised controlled trial of clean intermittent self-catheterisation versus suprapubic catheterisation after urogynecologic surgery. Am J Obstet Gynecol 197(1): 72. e1–4 Logan K (2012) An overview of male intermittent self-catheterisation. Br J Nurs 21(18): S18–S22 Logan K, Shaw C, Webber I, Samuel S, Broome L (2008) Patients’ experiences of learning clean intermittent self-catheterisation: a qualitative study. J Adv Nurs 62(1): 32–40 Mangnall J (2012) Key considerations of intermittent catheterisation. Br J Nurs 21(7): 392–8 Mangnall J (2013) Important considerations of intermittent catheterisation. Nursing & Residential Care 15(12): 776–81 Millet L, Shaha S, Bartholomew ML (2012) Risk of bacteriuria in labouring women with epidural analgesia: continuous versus intermittent bladder catheterisation. Am J Obstet Gynecol 206(4): 316–22 Nazarko L (2009) Managing bladder dysfunction using intermittent self-catheterisation. Br J Nurs 18(2): 110–15 Nazarko L (2010) Effective evidence-based intermittient self-catheterization: an update. Br J Nurs 19(18): S4–S6 Nazarko L (2012) Intermittent self-catheterisation: past, present and future. Br J Community Nurs 17(9): 408–12
National Institute For Health And Care Excellence (2012) Infection: Prevention and Control of Healthcare-associated Infections in Primary and Community Care. http://tinyurl.com/nubr92m (accessed 10 March 2014) National Institute for Health and Care Excellence (2013) The Management of Urinary Incontinence in Women. CG171. http://tinyurl.com/q2z3mf6 (accessed 10 March 2014) NHS Education For Scotland (2012) Modernising nursing in the community: safe, effective and person centred care. http://tinyurl.com/prqu4a2 (accessed 17 January 2014) Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. http://tinyurl.com/oc3zy2w (accessed 25 March 2014) Pilloni S, Krhut J, Mair D, Madersbacer H, Kessler T (2005) Intermittent catheterisation in older people: a valuable alternative to an indwelling catheter? Age Ageing 34(1): 57–60 Pomfret I, Winder A (2007) The management of intermittent catheterization: assessing patient benefit. Br J Neuroscience Nurs 3(6): 266–71 Rew M (2007) The use of intermittent self-catheterization in managing neurogenic bladder problems. Br J Neuroscience Nurs 3(2): 54–60 Robinson J (2006) Intermittent self-catheterisation appliances for disabled people. Br J Community Nurs 11(12): 520–3 Robinson J (2007) Intermittent self-catheterisation: teaching the skill to patients. Nurs Stand 21(29): 48–56 Scottish Government (2007) Better Health, Better Care: Action Plan. http://tinyurl. com/kq6rxe (accessed 10 March 2014) Scottish Intercollegiate Guidelines Network (SIGN) (2012) Management of suspected bacterial urinary tract infections in adults. http://tinyurl.com/pcl65g7 (accessed 10 March 2014) Shaw C, Logan K, Webber I, Broome L, Samuel S (2008) Effect of clean intermittent self-catheterisation on quality of life: a qualitative study. J Adv Nurs 61(6): 641–50. doi: 10.1111/j.1365-2648.2007.04556.x Toward S (2008) Appraising and influencing health policy and strategy. In: Porter E, Coles L, eds. Public Health Skills: A Practical Guide for Nurses and Public Health Practitioners. Blackwell, Oxford Weld KJ, Dmochowski RR (2000) Effect of bladder management on urological complications in spinal cord injured patients. J Urol 163(3): 768–72 Woodward S (2013a) Dos and don’ts of intermittent self-catheterisation. Br J Nurs 22(18): S10 Woodward S (2013b) Improving quality of life for men using intermittent selfcatheterisation. Br J Neuroscience Nurs 9(3): 114–19 Woodward S, Steggal M, Tinhunu J (2013) Clean intermittent self-catheterisation: improving quality of life. Br J Nurs 22(9): 1212–18 Woodward S, Rew M (2003) Patients’ quality of life and clean intermittent selfcatheterization. Br J Nurs 12(18): 1066–74
KEY POINTS w Many patients live in the community with a long-term indwelling urinary catheter. This is costly and at times inappropriate.
w Intermittent self-catheterisation (ISC) would be a preferred method of catheterisation for the suitable patients.
w ISC would allow patients to self-care, improve their quality of life and reduce the demands on the local district nursing service.
w The district nursing team can have an important role in identifying patients who are suitable for ISC and support them to undertake the procedure successfully.
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Promoting intermittent self-catheterisation to encourage self-care in district nursing patients Roberto Cassani
Roberto Cassani is a Community Staff Nurse in Tayside, Scotland
© 2014 MA Healthcare Ltd
M
any people in the UK live with an indwelling urinary catheter to manage urological problems (Evans et al, 2000). In the community, the nursing management of catheterised patients is normally carried out by the district nursing (DN) service (Evans et al, 2000). This author of this article is employed as a community nurse in a rural area of Scotland in which catheter management represents 30% of the total caseload. This places considerable demand on the DN team with all the associated costs. Evans et al (2000) reported that supporting one patient living in the community with a long-term indwelling catheter may cost the NHS up to £2585 over a 3-month period. The Nursing and Midwifery Council (NMC) (2008, p. 3) clearly states that ‘nurses must support people in caring for themselves’. This emphasis on self-care is a part of the ‘Modernising Nursing in the Community’ framework in Scotland (NHS Education for Scotland, 2012). An ageing population, which places great demand on the health service, has increased the need for self-management (Toward, 2008). Studies suggest that self-care can have a positive impact on people’s quality of life, clinical outcome and use of resources (Health Foundation, 2011). Within the author’s caseload, several patients with a long-term catheter are able to manage all the other aspects of their care independently, with little or no nursing input. For at least some of these patients, intermittent self-catheterisation (ISC) could be an excellent option as it would encourage self-management, improve quality of life and reduce nursing costs (Nazarko, 2012). This article will examine the district nurse’s important role in identifying those patients who would benefit from ISC and in promoting and supporting its use in order to encourage self-care in the community.
ISC in the community ISC is a procedure whereby a catheter is inserted by a person into their own bladder and removed after the bladder
British Journal of Community Nursing April 2014 Vol 19, No 4
Email: [email protected]
has been drained (Nazarko, 2012). Its use has become more common in the past 30 years, as new products have been developed to make ISC easier and more comfortable for the patient (Collis Pellatt and Woodward, 2011). There are many patients in the community who may benefit from ISC. It may be a good treatment option for both men and women of any age who have conditions causing urinary retention and/or incontinence (Woodward, 2013a). Good examples of ISC uses in the community include the management of neurogenic bladder dysfunction in patients with multiple sclerosis (MS), or to aid bladder drainage in men with benign prostatic hypertrophy (Logan, 2012).
Advantages of ISC ISC has several advantages over long-term indwelling catheterisation (Collis Pellatt and Woodward, 2011). Both catheter options effectively resolve urinary incontinence and/or retention, but ISC would allow patients to preserve their independence, intimacy, sexuality and not to have to rely on community nurses for catheter care (Nazarko,
ABSTRACT
Intermittent self-catheterisation (ISC) is deemed the preferred option for the management of urinary incontinence and/or retention in patients requiring a catheter. It also allows patients to self-care, thereby placing fewer demands on district nursing (DN) services and meeting the requirements of the current health policy agenda. Yet many patients who could benefit from ISC in the community still use a long-term urinary catheter. This may contribute to increased morbidity, poorer quality of life, and unnecessary visits from the DN team. This article analyses the role of the district nurse in promoting and supporting the use of ISC with suitable patients.
KEY WORDS
w Intermittent self-catheterisation w District nursing w Self-care w Community
177
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LONG-TERM CONDITIONS
Possible disadvantages of ISC ISC may also have potential disadvantages for patients who live in the community. DN teams must not presume that using ISC will improve quality of life because, in many instances, this is not the case (Colpman, 2011). Logan et al (2008) and Shaw et al (2008) are examples of published qualitative studies on the patient’s experience of living with ISC. Both studies highlight the anxieties associated with learning to adapt to self-catheterisation. For instance, some patients have reported embarrassment due to having to undertake such an intimate procedure (Logan et al, 2008).
Box 1. Benefits of ISC in the community w Allows patient to self-care w Preserves dignity w Reduces district nursing input w Can improve quality of life w Avoids traction and trauma associated with wearing leg bags w Allows the expression of sexuality w Avoids the need to wear loose clothing to conceal catheter bag w Preserves bladder tone and renal function w Reduces the risk of urinary tract infection Source: Nazarko (2009)
178
Some experienced technical difficulties while learning to self-catheterise, such as problems negotiating their own anatomical features, or simply learning to handle catheters that they often found slippery or too long (Logan et al, 2008). The fear of introducing infection was also reported as common (Colpman, 2011). At times, patients also found it difficult to perform ISC outside the home, due to difficulties finding adequate toilet facilities or simply difficulties carrying the equipment around discreetly (Shaw et al, 2008). Finally, fear of causing oneself pain was found to be common, and not all patients in the studies were happy to receive help from their partners, sometimes feeling that self-catheterisation was too personal an issue (Shaw et al, 2008). Mangnall (2013) points out that nurses’ failure to appreciate these practical and psychological disadvantages for the patients may result in poor compliance with ISC. Despite the advantages of ISC, the procedure is likely to represent a serious lifestyle change and carry huge physical and emotional implications (Mangnall, 2013). Because of this, the decision to start ISC must be taken with the informed consent of the patient (Mangnall, 2013). This not only satisfies the nursing requirement to obtain informed consent (NMC, 2008), but is also paramount if the district nurse wants to maximise the chances of patient compliance (Mangnall, 2013). A list of the most common disadvantages of ISC in the community can be found in Box 2.
DN and ISC The evidence above appears to show that ISC can be an excellent choice of continence care for those patients who can cope with its practical and psychological demands. For all the clinical and lifestyle advantages, though, there are also some disadvantages to ISC, which may cause poor compliance and its ultimate abandonment. The qualitative studies on the subject concluded that one of the most important contributing factors to a positive ISC experience is the support received from nursing services, especially while patients are learning the procedure (Logan et al, 2008; Shaw et al, 2008). Patients like to feel supported by nurses who are both technically competent and communicate with empathy (Woodward and Rew, 2003). It is not feasible to expect every patient with continence problems in the community to be closely supported by specialist urology nurses. As a result, for many people requiring catheters in the community, the DN service is the most frequent and likely avenue of support. Currently, to the best of the author’s knowledge, there is no scholarly article on ISC written with a DN focus. Nevertheless, district nurses know the patients on their caseload, as well as their personal circumstances and families. They are therefore ideally placed to identify patients whose quality of life would be enhanced by switching from long-term indwelling catheterisation to ISC. Robinson (2007) states that any nurse who undertakes urinary catheterisation would be able to teach ISC. Yet the author’s experience suggests that district nurses may not be as familiar with ISC as they are with long-term indwelling urinary
© 2014 MA Healthcare Ltd
2012). It would also preserve bladder elasticity by avoiding the loss of tone associated with long-term catheterisation (Nazarko, 2009). The advantages of ISC in the community are summarised in Box 1. According to the literature, one of the main benefits of ISC is its ability to reduce the potential for urinary tract infections (UTIs) associated with indwelling catheters (Collis Pellatt and Woodward, 2011). At present, there is no randomised controlled trial confirming that ISC causes fewer infections than long-term catheters. The few trials that have been carried out gave somewhat conflicting evidence (Jannelli et al, 2007; Hakvoort et al, 2011; Millet et al, 2012). Nevertheless, retrospective, non-randomised studies have found that intermittent catheterisation is the safest method in terms of having fewer urological complications, improving patients’ quality of life and reducing the incidence of UTIs (Weld and Dmochowski, 2000; Pilloni et al, 2005). This opinion is upheld by both the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidance Network (SIGN). Their most recent clinical guidance recommends the use of ISC as preferable to long-term catheterisation to prevent catheter-associated infections (NICE, 2012; SIGN, 2012), and also for the treatment of urinary incontinence and retention in women (NICE, 2013). The frequency of daily ISC varies from patient to patient. Depending on ability to void, bladder capacity and residual volume, ISC may be performed between one and six times per day (Nazarko, 2012).
British Journal of Community Nursing April 2014 Vol 19, No 4
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LONG-TERM CONDITIONS catheters, and hence less likely to initiate ISC with patients who may well benefit from it. The following three case studies provide examples of situations where district nurses may feel it appropriate to suggest ISC. In order to respect confidentiality (NMC, 2008), the patients’ names are pseudonyms and their identifiable circumstances have been changed.
w Patients must have sufficient dexterity and understanding to perform ISC w People with small bladder capacity may be required to self-catheterise too frequently
w Anxieties over causing themselves pain or urinary tract infection (UTI) may hinder compliance
Case study 1
w Carrying out ISC outside the home may require careful planning
Malcolm is a 75-year-old male with benign prostatic hypertrophy, and is currently under urology review. Malcolm has had an indwelling urinary catheter in situ for 6 months. It was originally inserted during a hospital admission, mostly due to poor mobility. The DN service became involved with Malcolm to provide catheter care. He has since been reviewed by a consultant urologist and commenced on tamslusosin. The urologist did not deem any other drug treatment appropriate in view of Malcolm’s circumstances and comorbidities. During this period, Malcolm has had two failed trials without a catheter. Despite being able to void, he maintains a significant bladder residue. Malcolm is married and lives an active life with his wife. The longterm catheter has been a source of anxiety, embarrassment and discomfort for him. He also lives in a very rural area that is difficult for nurses to reach in the winter months. Malcolm is a very capable and independent man. He would have the understanding and manual dexterity required to self-catheterise. Therefore, ISC would probably represent a very good option to promote self-care and improve quality of life, while continuing to manage Malcolm’s bladder emptying requirement.
w Self-catheterisation may still occasionally cause UTIs
Case study 2 Mary is a 58-year-old female with MS. She has had a catheter in situ for 4 years due to a neurogenic bladder. She often has problems with catheters blocking or bypassing owing to poor positioning. She has also found that wearing a catheter bag has limited her choices of clothing: she often wears large jogging trousers to hide her leg bag, which she finds unattractive. Having a catheter has reduced her desire to go out and socialise, as she finds it embarrassing and unpredictable. Mary has good understanding and dexterity, and she is also happy to let her husband help with catheter care. ISC could represent a great choice for Mary. In fact, ISC is the preferred choice of catheterisation in women with neurogenic bladder (NICE, 2013). It may also contribute to reducing Mary’s embarrassment, improve her social life and allow a wider choice of clothing.
Case study 3 © 2014 MA Healthcare Ltd
Box 2. Disadvantages of ISC in the community
Liam is a 22-year-old male who has become paraplegic following a spinal injury. Liam has had a suprapubic catheter in situ since he was treated in hospital for his spinal injury. However, now Liam is back home and working hard to regain a fulfilling social life. He finds his catheter embarrassing as he is sexually active and young. Liam’s manual dexterity is limited and he would not be able to negotiate ISC unaided. However, in recent years there have been
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w Some patients may find the procedure uncomfortable w Some patients may find ISC socially unacceptable Source: Mangnall (2012)
several appliances developed to aid ISC for people with limited dexterity (Robinson, 2006). The community nursing team could discuss ISC with Liam and possibly assist him to explore the available aids.
ISC products If district nurses are to support patients with the choice of ISC, they need to know about different types of ISC and related aids. Both single-use and reusable catheters are available commercially, and among the single use catheters there are hydrophilic or gel-coated catheters (Robinson, 2007). Catheters can be obtained in male and female lengths (Nazarko, 2010). Recently, several manufacturers have developed new products that make it easier for people to travel carrying intermittent catheters and use them in public toilets more discreetly (Woodward, 2013b; Woodward et al, 2013). A brief summary of the types of intermittent catheters available in commerce can be found in Box 3. As yet, there is no evidence to suggest that any type of catheter is better than the others (Nazarko, 2010). Hence, prescribing should be guided by patient preference and personal circumstances. Because of this, nurses should be familiar with the various products available on their local formulary, as well as on the market as a whole, in order to facilitate appropriate choice and maximise the success of the trial with ISC.
The role of the nurse The DN team has a very important role in assessing patients for the suitability of ISC, as well as in the initial teaching and ongoing support. Firstly, ISC is not the right choice for everyone. The patient must have the ability to understand the procedure, the manual dexterity to carry it out, and the motivation required to incorporate ISC into their daily routine (Robinson, 2007). A nursing assessment is paramount in order to identify suitable candidates (Pomfret and Winder, 2007). Rew (2007) points out that ISC should be offered as a continence option only if the benefits of undertaking it outweigh the potential problems. Nevertheless, patients have reported feeling anxious about carrying out such an intimate and potentially uncomfort-
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HATTIE YOUNG/SCIENCE PHOTO LIBRARY
LONG-TERM CONDITIONS
able procedure (Rew, 2007). Because of this, the district nurse and his/her team must not work in isolation, and should try to involve the appropriate members of the multidisciplinary team (NMC, 2008). The knowledge and expertise of specialist urology nurses could indeed be called upon to suggest the most up-to-date products, or to suggest solutions when difficulties arise. The patient is central to the team and his/her opinion, dignity and views must be upheld at all times. Finally, the family and carers could be a very important part of the team too, as they may be asked to support the patient and at times even perform the procedure with the patient’s informed consent (Pomfret and Winder, 2007). Teaching ISC does not necessarily have to be carried out in a urology clinic. Logan et al (2008) found that most
Box 3. Types of intermittent catheters w Reusable catheters: can be used then washed more than once and
require to be lubricated with a local anaesthetic gel prior to insertion.
w Pre-gelled single-use catheters: can be used only once and they are prelubricated with gel.
w Hydrophillic-coated single-use catheters: their lubricant is activated by contact with water. There are several options in commerce and it is very important to follow the manufacturer’s instructions before use. Source: Robinson (2007)
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patients preferred to be taught ISC at home, putting the DN team in an ideal position to provide the initial teaching and training. In this case, the district nurse will have to be able to deliver technically competent teaching, but also use a vocabulary and a style of presentation that suits the patient (Logan et al, 2008). Again, community nurses practice these communication skills on a daily basis. Empathy should be at the centre of the process, as the nurse must recognise that patients may not feel comfortable discussing and undertaking ISC (Pomfret and Winder, 2007). The qualitative research in Logan et al (2008) and Shaw et al (2008) highlighted that the empathic attitude of the nursing team delivering ISC support is the most likely contributor to the patient’s long-term compliance. The DN team’s input must not conclude following the initial assessment and training. It must be based on ongoing support and the evaluation of the impact that ISC has on the patient’s quality of life (Rew, 2007). Hence, follow-up visits should be part of the DN input. The frequency of these visits will vary depending on the patient’s circumstances (Robinson, 2007). Despite this, once ISC is successfully established, DN visits will be required much less frequently than in cases where a long-term urinary catheter is in place.
Conclusion Many patients live in the community with a urinary catheter to manage urinary incontinence and/or retention. Catheter care is costly, especially in terms of the demands it
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A district nurse cleans the tap on a urinary incontinence bag that is strapped to an elderly woman's leg. Many patients who could benefit from intermittent self-catheterisation in the community still use a long-term urinary catheter. This may contribute to increased morbidity, poorer quality of life, and unnecessary nurse visits.
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LONG-TERM CONDITIONS places on the DN services. However, contemporary health care has shifted its focus from passively providing treatment to encouraging self-management where possible (Scottish Government, 2007). Failing to promote self-care would create an unsustainable situation for the NHS, given the challenges of an ageing population (Toward, 2008). ISC allows suitable patients to self-care, with support from the district nurse and the multidisciplinary team. Where applicable, ISC would not only reduce the need for DN visits, but would especially improve the patient’s quality of life, while reducing the risks associated with long-term catheterisation. The district nurse and his/her team are ideally placed to identify those patients who would benefit from ISC, and provide ongoing support to maximise its success, in order to encourage self-care and ultimately improve the patient’s quality of life. BJCN Acknowledgement: This article forms part of the author’s final project for the BA (Hons) Community Health at Robert Gordon University, Aberdeen.
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Collis Pellatt G, Woodward S (2011) The benefits of intermittent self-catheterisation. Br J Nurs 20(18): 1164–6 Colpman D (2011) Assessing and supporting men using catheters. Practice Nursing 22(8): 406–9 Evans A, Phelby D, Painter D, Feneley R (2000) The cost of long-term catheterization in the community. Br J Community Nurs 5(10): 477–88 Hakvoort RA1, Thijs SD, Bouwmeester FW et al (2011) Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for complete voiding after vaginal prolapse surgery: a multicentre randomised trial. BJOG 118(9): 1055–60 Health Foundation (2011) Evidence: Helping People Help Themselves. http://tinyurl.com/q7clajt (accessed 7 March 2014) Jannelli ML, Wu JM, Plunkett LW, Williams KS, Visco AG (2007) A randomised controlled trial of clean intermittent self-catheterisation versus suprapubic catheterisation after urogynecologic surgery. Am J Obstet Gynecol 197(1): 72. e1–4 Logan K (2012) An overview of male intermittent self-catheterisation. Br J Nurs 21(18): S18–S22 Logan K, Shaw C, Webber I, Samuel S, Broome L (2008) Patients’ experiences of learning clean intermittent self-catheterisation: a qualitative study. J Adv Nurs 62(1): 32–40 Mangnall J (2012) Key considerations of intermittent catheterisation. Br J Nurs 21(7): 392–8 Mangnall J (2013) Important considerations of intermittent catheterisation. Nursing & Residential Care 15(12): 776–81 Millet L, Shaha S, Bartholomew ML (2012) Risk of bacteriuria in labouring women with epidural analgesia: continuous versus intermittent bladder catheterisation. Am J Obstet Gynecol 206(4): 316–22 Nazarko L (2009) Managing bladder dysfunction using intermittent self-catheterisation. Br J Nurs 18(2): 110–15 Nazarko L (2010) Effective evidence-based intermittient self-catheterization: an update. Br J Nurs 19(18): S4–S6 Nazarko L (2012) Intermittent self-catheterisation: past, present and future. Br J Community Nurs 17(9): 408–12
National Institute For Health And Care Excellence (2012) Infection: Prevention and Control of Healthcare-associated Infections in Primary and Community Care. http://tinyurl.com/nubr92m (accessed 10 March 2014) National Institute for Health and Care Excellence (2013) The Management of Urinary Incontinence in Women. CG171. http://tinyurl.com/q2z3mf6 (accessed 10 March 2014) NHS Education For Scotland (2012) Modernising nursing in the community: safe, effective and person centred care. http://tinyurl.com/prqu4a2 (accessed 17 January 2014) Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. http://tinyurl.com/oc3zy2w (accessed 25 March 2014) Pilloni S, Krhut J, Mair D, Madersbacer H, Kessler T (2005) Intermittent catheterisation in older people: a valuable alternative to an indwelling catheter? Age Ageing 34(1): 57–60 Pomfret I, Winder A (2007) The management of intermittent catheterization: assessing patient benefit. Br J Neuroscience Nurs 3(6): 266–71 Rew M (2007) The use of intermittent self-catheterization in managing neurogenic bladder problems. Br J Neuroscience Nurs 3(2): 54–60 Robinson J (2006) Intermittent self-catheterisation appliances for disabled people. Br J Community Nurs 11(12): 520–3 Robinson J (2007) Intermittent self-catheterisation: teaching the skill to patients. Nurs Stand 21(29): 48–56 Scottish Government (2007) Better Health, Better Care: Action Plan. http://tinyurl. com/kq6rxe (accessed 10 March 2014) Scottish Intercollegiate Guidelines Network (SIGN) (2012) Management of suspected bacterial urinary tract infections in adults. http://tinyurl.com/pcl65g7 (accessed 10 March 2014) Shaw C, Logan K, Webber I, Broome L, Samuel S (2008) Effect of clean intermittent self-catheterisation on quality of life: a qualitative study. J Adv Nurs 61(6): 641–50. doi: 10.1111/j.1365-2648.2007.04556.x Toward S (2008) Appraising and influencing health policy and strategy. In: Porter E, Coles L, eds. Public Health Skills: A Practical Guide for Nurses and Public Health Practitioners. Blackwell, Oxford Weld KJ, Dmochowski RR (2000) Effect of bladder management on urological complications in spinal cord injured patients. J Urol 163(3): 768–72 Woodward S (2013a) Dos and don’ts of intermittent self-catheterisation. Br J Nurs 22(18): S10 Woodward S (2013b) Improving quality of life for men using intermittent selfcatheterisation. Br J Neuroscience Nurs 9(3): 114–19 Woodward S, Steggal M, Tinhunu J (2013) Clean intermittent self-catheterisation: improving quality of life. Br J Nurs 22(9): 1212–18 Woodward S, Rew M (2003) Patients’ quality of life and clean intermittent selfcatheterization. Br J Nurs 12(18): 1066–74
KEY POINTS w Many patients live in the community with a long-term indwelling urinary catheter. This is costly and at times inappropriate.
w Intermittent self-catheterisation (ISC) would be a preferred method of catheterisation for the suitable patients.
w ISC would allow patients to self-care, improve their quality of life and reduce the demands on the local district nursing service.
w The district nursing team can have an important role in identifying patients who are suitable for ISC and support them to undertake the procedure successfully.
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