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art & science continence focus

The nurses role in helping older people to use the toilet

Heath H (2009) The nurses role in helping older people to use the toilet. Nursing Standard. 24, 2, 43-47. Date of acceptance: August 5 2009.

Summary
Going to the toilet to eliminate bodily waste in private is a normal daily activity that people tend to take for granted. The inability to perform this task independently can result in an intrusive, embarrassing and stressful experience for the individual. This article outlines the nurses role in helping older people to use the toilet and the opportunities that this affords for therapeutic intervention, identification of other problems and the promotion of health and wellbeing.

Author
Hazel Heath, independent nurse consultant for older people and honorary senior research fellow, City University London. Email: hh@hazelheath.co.uk

Keywords
Continence, dignity, older people, person-centred care, urinary and faecal elimination These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords.

THE ELIMINATION OF urine and faeces from the body is a natural, essential human function. In Western societies, from childhood, individuals are taught to undertake this function in private. Influenced by cultural norms and personal beliefs, people develop their own rituals of elimination and cleansing that, for most of their lives, remain private. Individuals who are unable to eliminate bodily waste independently, as a result of illness, disability or frailty, may need to ask others for help. Those who provide assistance then enter the individuals private world with all its sights, sounds and smells. The manner in which a person is assisted can have a profound effect on their lives. If individuals are not offered maximum respect, choice, control, privacy and dignity, this can damage not only their physical elimination functions, but also their self-concept, emotional wellbeing and social confidence. NURSING STANDARD

Much still needs to be done to improve the care and facilities offered to older people who need help to use the toilet. The 2005 Royal College of Physicians National Continence Audit identified that many hospitals need to improve privacy and dignity for patients during bladder and bowel emptying (Wagg et al 2005). The Department of Health (2006) highlighted that people often have insufficient privacy when receiving care and are dissatisfied with toilet facilities in hospitals and care homes. Older people in acute care settings have little involvement in decisions regarding their personal care and limited choices in their hygiene activity. Assessment and care planning related to personal care are often limited (Hooks and Roberts 2007). Nurses neglect of personal care needs has been revealed in cases brought before the Nursing and Midwifery Council (NMC) professional conduct committee in the UK (NMC 2008). A partnership of organisations led by the British Geriatrics Society (BGS) concluded that the dignity of older people is infringed every day in many different ways. They launched a campaign called Behind Closed Doors (BGS 2006) to raise awareness that people, whatever their age and physical ability, should be given the choice to use the toilet in private in all care settings.

The nurses role

Helping people to use the toilet is commonly described as toileting and is viewed as a routine and mundane task. While such work can be unpleasant and, in contemporary practice, is rarely undertaken directly by registered nurses, helping people to use the toilet remains a core nursing function, which offers valuable opportunities for nursing to contribute towards the individuals health, functioning, dignity, wellbeing and quality of life (Box 1). Helping an individual to use the toilet offers nurses an opportunity to learn more about a persons life experiences, how he or she feels about the current situation and what his or her aspirations are for the future. Older people tend to september 16 :: vol 24 no 2 :: 2009 43

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have coexisting and interrelated health and social issues that can complicate care delivery. Using skilled observation and questioning, and working from a sound knowledge base, can help nurses to work with individuals to achieve a mutual understanding of needs, problems and priorities. By drawing on the nurses clinical judgement, care can then be planned to remedy problems, regain and maintain a persons normal elimination function and address any other needs and priorities that a person may have. Clinical BOX 1 The nurses role in helping older people to use the toilet
Helping an older person to use the toilet involves more than just doing the task. A registered nurse should bring clinical judgement in the provision of care, to enable people to improve, maintain or recover health, to cope with health problems and to achieve the best possible quality of life whatever their disease or disability (Royal College of Nursing 2003). Assessment includes seeking to understand: The individual as a person. The effects of ageing and disease on the individual. The persons normal elimination habits. Recent alterations in elimination patterns. Current problems and elimination patterns, and the nature of the urge to pass urine or faeces. Characteristics of urine and faeces passed, including noting any blood and the colour of blood. Pain associated with elimination. Self-management strategies and perceived effectiveness. Any effects of medication, including self-medication. Nutritional status and fluid intake. The persons desired outcomes for care. Other relevant aspects to assess should include: Emotional wellbeing, including mood, motivation and energy levels. Cognitive functioning. Skin condition. Mobility (ability to walk to the toilet) and dexterity (ability to manipulate clothing). Any other pain, for example pain caused by arthritis, and the effectiveness of pain management. Sleep patterns. While assisting an older person to use the toilet, the nurse can also offer support, information, education, reassurance and work towards empowering the individual and improving his or her quality of life.

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judgement also encompasses anticipating problems and working to prevent these arising, planning how care can be empowering and enabling, promoting good relationships with carers and/or relatives and optimising input from multidisciplinary professionals.

Person-centred toileting
Person-centred care encompasses a commitment on the part of staff to respect a persons values and beliefs, viewing individuals as unique human beings with feelings and the potential to change and develop (McCormack 2001). The act of helping a person to use the toilet should be approached with sensitivity, tact and patience, but it can take time to learn about the individual and establish trust. Staff should try to listen closely to what the person is saying and how language and humour are used, establishing a mutually understood vocabulary. Cultural norms and religious beliefs can influence an individuals views on the acceptability of environments in which to eliminate, for example communal facilities, and preferred body positions for voiding. Many cultures place great importance on cleanliness, in both physical and spiritual terms, with regimens that must be followed, for example purification of the perineal area with running water after using the toilet. Personal habits are important. Some people need distractions such as reading material or the sound of a running tap to help them relax, particularly in unfamiliar environments. Some individuals need to go to the toilet as soon as they recognise the urge to eliminate. Others need to go to the toilet at particular times, such as first thing in the morning, and for some this is essential as a change in routine may make it difficult for the individual to perform bowel elimination at a later time. Timeliness is an important consideration. Requests for help to go to the toilet, particularly from older individuals, must be responded to promptly. People should be given sufficient time to complete elimination, but should not be left so long that they become uncomfortable. Commodes and bedpans should be removed as soon as possible after use. Maintaining privacy and dignity are essential aspects of toileting. This can be difficult for people who are bedbound, when commodes or bedpans are used or when using equipment for moving and handling (BGS 2006). However, dignity is not merely about bodily exposure, it encompasses the ways in which the culture and social processes of care promotes personhood (Reed and McCormack 2007), for example how people are addressed, spoken to or spoken about. NURSING STANDARD

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Nurses must also assess the risks for individuals using the toilet, particularly the risk of falls. A decision aid for assessing the risk to older people of using the toilet in private is offered by the BGS (2006).

diuretics that may, in turn, cause further problems such as dehydration and urinary tract infections. The major bowel problem in later life is constipation, which can be caused by: Insufficient dietary fibre and/or fluid intake. Reduced defecation reflex complicated by postponement of defecation and long-term laxative use. Use of drugs that slow intestinal motility or increase the excretion of body water, for example opioids and anticholinergics. Organic illness such as hypothyroidism or hypocalcaemia. Tumours or strictures. Immobility. Faecal matter becoming hard and painful to pass. General debility and haemorrhoids complicate elimination.

Ageing and elimination

Older people may find it difficult to discuss bladder and bowel functioning and may be reluctant to talk about any problems. Because of views held during their formative years that bowels should open once a day and that, if not, purgation was necessary, older people can become concerned if daily bowel actions are not achieved. However, only a minority of adults experience daily bowel action and the range of normality lies between three motions per day and one every three days (Norton 2006). The majority of older people manage to maintain normal elimination function to the end of their lives. Problems are not inevitable in older age and should never be passively accepted as a consequence of ageing. There is always a cause, which can often be identified and remedied or, at least, minimised (Norton 2006). Although the ageing process in itself does not result in elimination problems, changes in the kidneys, bladder and bowels in conjunction with cardiovascular limitation, reduced mobility, lowered resistance to infection and chronic illness, particularly neurological disease, contribute to problems in later life. Common urinary problems include: Nocturia the need to urinate at night. The ability of the kidneys to concentrate urine declines so more urine is produced. The bladder is also less elastic so less urine can be stored. Urgency the need to void urgently. In early adulthood, the sensation of bladder fullness and the urge to urinate is felt when the bladder is about half full. In older age, this urge may not be felt until the bladder is nearly full. Therefore, it is essential that requests to use the toilet are responded to immediately. Urinary retention the inability to empty the bladder. This condition commonly affects older men with prostatic hypertrophy (enlargement of the prostate gland, which can inhibit the flow of urine through the urethra). Urinary tract infections the bladder may not contract effectively and some urine may remain after voiding (residual urine), which can increase the risk of bacterial growth. People may respond to urinary problems by restricting fluid intake and not taking prescribed NURSING STANDARD

Nursing assessment
Comprehensive nursing assessment, covering areas such as those listed in Box 1, will identify priorities for intervention. Aspects specifically relevant to elimination include the monitoring of fluid and food intake, elimination patterns and the analysis of specimens. Accurate monitoring is essential and can be effective if patients and/or relatives actively participate in the recording of information. Fluid balance charts record fluid intake and output. Urine frequency volume charts record how often urine is passed during the day and night, the amount passed on each occasion and any episodes of incontinence. Detecting urinary tract infection is not always straightforward as symptoms vary and can be difficult to distinguish from clinical manifestations of other conditions. Symptoms include delirium, abdominal pain, nausea, vomiting, decreased appetite, dizziness, malaise, weakness, falls, changes in mental status and strong smelling urine (Gau and Clay 2008). Incontinence can result in difficulty getting to the toilet in time, retaining the urine or manipulating clothing in adequate time. Incontinence may adversely affect the individuals self image, emotional wellbeing, dignity and quality of life (Wagg et al 2005). Literature about incontinence in men and women is available (Wagg 2008), including tools for assessment (Norton 2006). Urine should be analysed visually using a dipstick and samples such as a midstream specimen should be obtained for laboratory analysis, where appropriate. september 16 :: vol 24 no 2 :: 2009 45

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Urine ranges from a pale straw colour to amber, depending on its concentration. The more fluids ingested, the paler the colour. Urine is usually transparent at voiding. Cloudy urine may indicate the presence of bacteria or renal disease. Bacteria in urine causes an ammonia smell and a fruity odour can indicate ketones as found in diabetes mellitus. Stool charts record how often stools are passed, approximate stool quantity, stool consistency and stool characteristics such as colour or smell. Faeces varies in colour according to the food ingested. Consistency also varies, but faecal matter should not be difficult to pass. The Bristol Stool Scale is widely available (http://en.wikipedia.org/wiki/ Bristol_Stool_Scale) and can be used to determine stool consistency.

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Identifying any medications, such as analgesics, and supplements that may cause constipation. Seeking advice on laxatives (bulk forming, osmotic, stimulant laxatives) or the use of suppositories or enemas. Keeping a personal diary of bowel actions. People with dementia may experience problems with continence if they become unable to recall the location of the toilet, recognise the toilet when they reach it or identify how to remove clothing. Some people with dementia can regain continence. Effective care encompasses comprehensive assessment, diet and lifestyle advice, combined with a prompted voiding regimen in which the individual is reminded to go to the toilet at pre-determined times during the day. Environmental orientation, such as bold pictures of a toilet on the bathroom door, may improve continence in people with dementia (Spencer 2007).

Promoting health
Nurses have a leading role in promoting health. It is essential that people drink sufficient fluids to avoid dehydration, urinary problems and constipation. It is also important that individuals take sufficient dietary nourishment. Older people, in particular, should be advised to (Rush and Schofield 1999): Drink 1,500-2,000ml of fluid a day (for people with nocturia, fluid should be taken before late evening). Take regular exercise and be active to maintain mobility. Use the hands as effectively as possible to maintain dexterity. Advice to maximise an individuals potential for independent continence includes promoting normal micturition and elimination habits and positioning when using the toilet to enable complete emptying of the bladder and bowels. Nurses could also offer advice on clothing that can be removed quickly, health promotion advice, such as pelvic floor exercises, and refer patients for specialist advice or equipment (Norton 2006). Urinary catheters should only be used once all other options for preserving continence have failed (Godfrey 2008). Constipation prevention advice should include (Rush and Schofield 1999, Holman et al 2006): Eating a varied diet, including fibre in whole grain cereals, fruits and vegetables. Using the toilet after meals and sitting for at least ten minutes to allow sufficient time for the bowel to empty completely. 46 september 16 :: vol 24 no 2 :: 2009

Skin care
Prolonged contact of the skin with urine or faeces causes inflammation, which can lead to excoriation, infections such as thrush and skin breakdown. Nurses should assess the persons skin integrity regularly. It is important to minimise skin exposure to body fluids, prevent faecal matter from contaminating the urethra, and use skin barrier products to protect vulnerable skin and emollients to maintain skin hydration. After exposure to bodily fluids, the persons skin should be washed with gentle soap and water and dried by patting. Excessive use of soap can dry the skin by removing natural oils and may alter the pH (acid balance) of the skins surface, which may disrupt the normal skin flora and increase the risk of colonisation by potentially pathogenic microorganisms. The evidence base on methods of cleansing is limited (Voegeli and Voegeli 2008). Advice from a physician or pharmacist on appropriate skin products should be sought.

The toilet environment

In partnership with other professionals, nurses have a key role in influencing the design and use of toilet facilities. Toilets should: Be readily available and clearly signposted. Be free from hazards and have an emergency button or pull chord within easy reach (Swann 2005). Have a level floor with no steps (BGS 2006). Be adequately lit. Contrasting colours on walls, floors or bathroom furniture can assist people with visual impairments. NURSING STANDARD

Be of an appropriate height, with a raised toilet seat if appropriate (Swann 2005), and the flush systems should be easy to activate. Have a wash hand basin, soap dispenser and a hand dryer or towel within easy reach. Have sufficient space to accommodate wheelchairs and walking aids. Have a door that can easily be shut and locked. Have assistive equipment such as handrails. Drop down handrails to help people into a standing position should ideally be at hip level when standing (Swann 2005). Have toilet paper within reach and extractable using one hand (Swann 2005). Be clean and free from odours. The BGS (2006) recommends that all organisations should encourage a lay person to undertake an environmental audit to assess the toilet facilities.

offered handwashing facilities and assisted to use these when necessary. Toilets, commodes and bedpans must be kept clean to reduce the risk of infection. Staff are also at risk from infection when helping people to use the toilet. Handwashing is considered to be the single most important way to stop the spread of infection (Health Protection Scotland 2009, National Patient Safety Agency (NPSA) 2009). However, a survey found that only half of the staff caring for frail older people frequently encouraged patients and/or residents to wash their hands after using the toilet (Mackenzie et al 2008). Although alcohol hand rub is frequently recommended, hands should still be washed with liquid soap and water after any risk of exposure to bodily fluids (NPSA 2009).

Conclusion
Older people may experience particular challenges in using the toilet and maintaining their usual bladder and bowel elimination functions. Helping an older person to use the toilet is a core nursing function. Nurses have a key role in assessing each individual, planning care in collaboration with other members of the multidisciplinary team and delivering care that helps older individuals to maintain optimum health, functioning, dignity, wellbeing and quality of life NS

Cleanliness and infection control

Healthcare-associated infections have increased in recent years and are common among vulnerable older people (Mackenzie et al 2008). Patients and/or care home residents should be able to leave the toilet with their bodies and hands clean and dry. They should always be

References
British Geriatrics Society (2006) Behind Closed Doors www.bgs.org.uk /campaigns/dignity.htm (Last accessed: August 27 2009.) Department of Health (2006) Dignity in Care Public Survey, October 2006. Report of the Survey. The Stationery Office, London. Gau JT, Clay S (2008) Diagnostic accuracy of criteria for urinary tract infection in nursing homes. Journal of the American Geriatrics Society. 56, 3, 571. Godfrey H (2008) Older people, continence care and catheters: dilemmas and resolutions. British Journal of Nursing. 17, Suppl 9, S4-S11. Health Protection Scotland (2009) Germs. Wash Your Hands of Them. www.washyourhandsofthem.com (Last accessed: August 27 2009.) Holman C, Roberts S, Nicol M (2006) Preventing and treating constipation in later life. Nursing Older People. 20, 5, 22-24. Hooks R, Roberts J (2007) Older peoples personal care needs: an analysis of care provision: care provision and the roles of key healthcare personnel. International Journal of Older People Nursing. 2, 4, 263-269. Mackenzie L, James IA, Smith K, Barnard L, Robinson D (2008) Assessing hand hygiene in older peoples care settings. Nursing Times. 104, 32, 30-31. McCormack B (2001) Negotiating Partnerships with Older People: A Person Centred Approach. Ashgate Publishing, Aldershot. National Patient Safety Agency (2009) Clean Your Hands. www.npsa.nhs.uk/clean yourhands (Last accessed: August 27 2009.) Norton C (2006) Eliminating. In Redfern SJ, Ross FM (Eds) Nursing Older People. Fourth edition. Churchill Livingstone, Edinburgh, 315-338. Nursing and Midwifery Council (2008) Fitness to Practise Annual Report 1 April 2007 to 31 March 2008. NMC, London. Reed J, McCormack B (2007) The importance of dignity. International Journal of Older People Nursing. 2, 3, 161. Royal College of Nursing (2003) Defining Nursing. Royal College of Nursing, London. Rush S, Schofield I (1999) Biological support needs. In Heath H, Schofield I (Eds) Healthy Ageing: Nursing Older People, Mosby, London, 119-158. Spencer J (2007) Otherwise engaged. Nursing Older People. 19, 7, 24-26. Swann J (2005) Providing convenient and accessible toilet facilities. Nursing & Residential Care. 7, 8, 366-369. Voegeli D, Voegeli L (2008) Skin care and incontinence in the elderly. Nursing & Residential Care. 10, 10, 487-492. Wagg A (2008) Urinary Incontinence Management in Older People. RCN Publishing, London. Wagg A, Mian S, Lowe D, Potter J (2005) Health Care of Older People Programme. Pilot of the National Audit of Continence Care for Older People (England and Wales). Royal College of Physicians, London.

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