There is a need for improvement in patient care on hospital wards in relation to challenging the “pad cultures” that exist in ward settings for older people and those living with dementia. This piece of work acknowledges the lack of dignity and care identified in the Featherstone et al (2022) NIHR study, but seeks to understand staff and patients perspectives and barriers to providing effective dignified continence care.

The study was underpinned by quality and improvement methodology. 
Monitoring Patient and Family Experience

•	Questionnaires  used, patient stories and case studies to capture patient and family experience 
•	Questionnaires  used to monitor staff experience

Data collected in 
Sept 23 – Dec 23
April 24 - May 24

  Activities  involved:
	A mini faculty developed with Terms of Reference for the project.
	A driver diagram established.
	Outcome measures set

Staff Survey Results 
109 substantive staff 
73% completed the survey
36% Registered staff
64% Health care support workers

Themes Identified
Training / Assessment
54% of staff had received training in toileting, bladder and bowel care for patients with dementia
40% of those questioned stated that it is common practice in their area to routinely issue pads without a continence assessment.
“Training for staff of when to use a pad, not to just put them on all patients or use really large pads on patients who are on occasionally incontinent/ an assessment that provides a key”. 

	
Equipment					       
-Staff reported that there is always-34% / often-45% enough equipment available to provide the appropriate level of care to patients. 
-83% agree that the toilets within their area of work are fit for purpose. 

Staffing / Time				       
When asked if staff had “enough time to carry out a continence assessment in a timely manner on admission?” only 15% answered Always, 28% Often with the highest percentage being 40% Sometimes.
-“Time and staffing levels go hand in hand”
-“I think if staffing levels were maintained then there would be adequate time to deal with patients need for the toilet without them having to wait unnecessarily”

Privacy					               
"It sometime feels so normal the privacy aspect is not there"
"Encourage staff to talk to patients not over them in personal care"

Processes / Communication		
"More prompts needed for patients ie note or a toileting programme" 
"Better continence assessment on admission, where we document and monitor for 24 hours" 
“Despite training changes are not implemented or supported”

Patient / Carer Experience Survey
51 responses
29 happy with care received  
Acknowledged time constraints on staff

"I'm happy with how I've been looked after , but staff are often very busy." 
"Smaller pads, like the ones I use at home" 
"More spacious toilets" 
"Having more people to help out with day to day things such as toilet as buzzer has been pressed a few times and not been taken" 
"Listen to my needs I get muddled on times so need time" 
"Respect patients dignity" 
"Encourage to go to toilet"

Interventions identified and implemented
	Continence promotion strategy via continence assessment and reassessment
	Training for staff on continence promotion, dementia care and product usage
	Establish a trial without incontinence pads.
	Rationalise procurement process, monitoring pad usage and costs.
	Enable patients to use the toilet, mobilise to toilets.
	Establish dementia friendly toilet environment.
	Encourage person centred continence care.
	Encourage effective communication of continence status

Placing someone into incontinence pads instead of toileting changes their future and adds to the progressive implications of deconditioning. It is important to understand staff and patient carers experiences in order to tackle the barriers in providing dignified continence care.

Featherston, Katie et al (2022) Continence, dementia, and care that preserves dignity, NIHR Evidence.
Aldridge Z and Dening K H (2024) Incontinence in people living with dementia., British journal of community nursing, 29(Sup5), pp. S8–S14
Boddington P and Featherstone K (2018) The canary in the coal mine: Continence care for people with dementia in acute hospital wards as a crisis of dehumanization., Bioethics, 32(4), pp. 251–260