Why Continence Care: The Importance of Including Continence Care in Your Wound Care Practice

A recent article in Ostomy Wound Management¹ emphasized the growing need for wound care nursing specialists and for ongoing education and resources for nurses specializing in wound care. Just as this need continues for practitioners of patients with a wide variety of wounds, so, too, does the need for nurses to provide their wound specialty services to persons with continence dysfunction (both bladder and bowel). We would therefore ask, Why Continence Care?

The wound care specialty nurse provides critical care and support to large segments of the population, many of whom have a wide range of complications and comorbidities, including continence issues, that require assistance from nurses with special training in order to prevent these complications from becoming worse and/or deadly. Patients with neurological diseases and injuries are living longer and need ongoing and attentive care for bladder and bowel dysfunction. Television advertisements are leading patients to believe that a simple pad will sop up their problem; this is no different than putting a bandaid on a diabetic foot ulcer or butter on a burn. An educated nurse is uniquely qualified to accurately assess patient needs and develop a patient-centered, comprehensive plan of care.

This is not a matter of adding people to our practice; they already are our patients. Persons with diabetes, multiple sclerosis (MS), Parkinson’s Disease (PD) or atypical Parkinson’s, spina bifida (SB), and spinal cord injury (SCI) not only have wounds (or risk for them), but they also have or are at risk for bladder and bowel dysfunction. In persons with diabetes, the same peripheral neuropathy that impacts the feet also affects the bladder and bowel. Patients with diabetes commonly report urinary incontinence and are at increased risk for impaired bladder sensation, impaired bladder emptying, and urinary retention. Patients with diabetes also report fecal incontinence and constipation. Medications that treat diabetes can cause diarrheal stools, which contribute to fecal incontinence and chronic skin damage, significantly altering quality of life. Urinary retention and constipation may lead to recurrent urinary tract infections, which need prompt diagnosis and treatment as well as a plan for future prevention.²

Persons with MS are at risk for skin and tissue damage related to numbness and spasms; 80% experience bladder dysfunction such as frequent urination, strong urges to urinate, inability to hold urine, or urinary retention. Less often, people with MS experience constipation, diarrhea, or loss of bowel control. These symptoms often are manageable with simple behavioral or pharmaceutical interventions.³

Patients with PD are at risk for impaired wound healing not only related to the depletion of dopamine and/or treatment,⁴ but also because they may have an overactive bladder with frequency and urgency (even at low volumes) and leakage may occur. This is particularly problematic during nocturnal hours, putting patients at risk for injury due to nighttime falls. In addition, up to 80% of patients with PD report constipation. Again, these symptoms may respond to simple behavioral or pharmaceutical interventions.

The altered sensation and altered mobility associated with SB and SCI put people at risk for pressure ulcers; the nerve damage responsible for these alterations also leaves this patient population with a myriad of irregular bladder and bowel patterns. Voiding and stooling programs need evaluation and reevaluation in order to optimize patient function and quality of life.

Thus, the wound/continence nurse specialist is in the unique position to be able to overlap care roles. As an expert in skin care, the wound care nurse appreciates the need to eliminate or at least modify underlying etiology of the skin injury, and in so many cases that is moisture or skin-damaging stool. As a continence care clinician, s/he recognizes the importance of reducing or eliminating moisture or skin irritants. The continence care nurse has expertise in treating and preventing moisture-related skin damage, providing first-line treatment for urinary and fecal incontinence (fluid management, diet counseling, toilet access, urge suppression strategies, pelvic muscle exercises, and intermittent catheterization), and selecting incontinence management products to meet patient needs.

Earning certification across practice areas. According to the Wound Ostomy Continence Nursing Society website (wocn.org), nurse certification “protects the public from unsafe and incompetent providers, provides consumers with more options when choosing health care providers, and distinguishes the health care facility and administrators by providing expertise” in a nurse’s chosen field. Recertification provides a path for ongoing education and continuing validation of those select skills.

In the United States, the Wound Ostomy Continence Nursing Certification Board (WOCNCB) is accredited by the Accreditation Board for Specialty Nursing Certification (ABNSC) for the following certifications that include continence care: CWOCN, CWCN, COCN, and CCCN. The WOCNCB certification process provides validation of specialized knowledge, skills, and expertise. The WOCNCB also adheres to strict standards of quality and is nationally certified. Their certifications meet the accreditation standards of the National Commission for Certifying Agencies and the ABNSC. If you are currently “C” certified but thinking about letting your certification lapse, we hope this will encourage you to think again. If you have never been “C” certified, we hope this will encourage you to consider it.

In addition, the WOCNCB provides Advanced Practice certification for continence as well as wound and ostomy nursing.  Certified advanced practice registered nurses (APRNs) must demonstrate proficiency as entry-level continence care nurses as well as advanced continence knowledge that incorporates the APRN role as either a Nurse Practitioner or a Clinical Nurse Specialist. Scholarships are available for those interested in pursuing this specialty training. Visit the WOCN website for details and certification exam timing.

As wound/continence nurses, we may be the only ones who initiate discussion on sensitive topics, thereby giving the patient “permission” to talk about a still taboo subject (bladder or bowel dysfunction). This also is the time for sexual counseling when bladder, bowel, and wound issues interfere with function. The Permission, Limited Information, Specific Suggestions, & Intensive Therapy model for sexual counseling, introduced in 1976,⁵ prompted the clinician to enter into discussion at the level of their knowledge/skills base and comfort level. Referrals to the next higher level would follow as necessary. This model can be applied to urological and gastrointestinal counseling as well.

Through our wound care skills and our ability to listen and diagnose, we have the potential to improve the quality of life for patients with wound care and continence conditions. We can create treatment plans, provide support and encouragement, train patients and their caregivers on how to use management devices, assist in finding other specialists and therapists as needed, and help get our patients through some very difficult and dark times. Attention to symptoms of bladder and bowel dysfunction during a wound clinic visit provides us with an opportunity for simple interventions. Clean intermittent catheterization, behavioral modification, dietary changes, fluid suggestions, or pelvic muscle exercises may be all that is needed. Wound clinic visits provide us with the opportunity to further improve the health of a patient with an already debilitating disease.

A recent 2018 roundtable meeting⁶ in the UK emphasized the importance of continence care education and its impact on the patient population we serve. June Rogers, pediatric continence specialist at the Bladder and Bowel UK, said at the meeting, “As a nurse, it’s something you can do that makes a huge difference, without having had to have surgery or see a doctor. Small things you do can make such a huge difference.”

And that is “Why Continence Care!” is important in your practice.

Acknowledgment
The authors thank Katherine F. Jeter, EdD, ET; Kathleen G. Lawrence, MSN, RN, CWOCN; and Donna L. Thompson, MSN, CRNP, FNP-BC, for their input on this article.

Dr. Faller is an ET Nurse Clinical Specialist in private practice. Ms. LaGro is Vice President of Communications and Education Services at the Simon Foundation for Continence. This article was not subject to the Ostomy Wound Management peer-review process.