Appropriate use of continence pads to support individuals’ dignity

Absorbent pads are commonly used in the management of incontinence but practice in this area is often poor. Including pads provision within a holistic approach to continence could help maintain patient dignity and improve outcomes

Absorbent pads have an important part to play in the everyday lives of people affected by incontinence. They should be provided according to individual patients’ needs as a part of holistic continence care. When decisions about pads are driven by cost or reflect a failure to proactively manage and treat incontinence, there can be serious negative effects on patients and carers. Careful and appropriate use of pads can maintain the person’s dignity and improve outcomes.

Citation: Agnew T (2023) Appropriate use of continence pads to support individuals’ dignity. Nursing Times [online]; 119: 4

Author: Thelma Agnew is a freelance health journalist.

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Absorbent products are worn by many people affected by incontinence and can improve quality of life when treatment options are ineffective or unacceptable (National Institute for Health and Care Excellence, 2015). Adequate provision of containment products, such as pads, can have a positive effect on the physical, psychological and social wellbeing of patients and carers (Murphy et al, 2019).

Continence pads are a significant cost to the NHS: in the UK, the NHS spends around £80m per year on pads (NHS England, 2018), a figure that does not include individuals’ expenditure on pads to supplement the limited supply provided without charge by local NHS services. The importance of continence pads in the everyday lives of people affected by incontinence has not been matched by efforts to provide them on an equitable basis or to ensure that pads are supplied according to individual patients’ needs as a part of holistic care.

On the contrary, there is evidence that pads are sometimes supplied solely on the basis of cost (Harari et al, 2012), leading to “increased burden” for patients, carers and the NHS (Orme et al, 2022). When the role of pads has become the focus of attention, it is often because of concerns that they have been used inappropriately as part of containment strategies that have little benefit for patients and can cause distress, skin damage, infection and loss of dignity (Featherstone et al, 2022; National Institute for Health and Care Research (NIHR), 2022). Pads have been viewed in isolation, or as a problem, rather than as part of holistic care; and there has been a lack of studies to demonstrate best practice in this area or to drive improvement (Orme, 2022).

To address gaps in knowledge, a recent Delphi consensus study by Orme et al (2022) asked health professionals in continence care where improvements could be made in standards of continence care alongside appropriate use of continence products. This was intended to support existing guidance by the Association for Continence Advice (ACA) on the provision of absorbent pads for adult incontinence (ACA, 2021).

The results (based on 181 responses to 50 statements drawn up by an expert steering committee) found clear support for focusing on meeting the individual needs of patients rather than budgetary concerns. This means prioritising accurate, comprehensive, continence assessment and product provision and recognising the negative impact of incontinence on patients’ mental health (Orme et al, 2022).

All 181 respondents agreed that the mental health of patients should be addressed during assessment and that provision should be tailored to their individual needs. There was also 100% agreement with the statement “Incontinence can impact a patient’s mental health (eg depression, isolation, relationship breakdowns)” (Orme et al, 2022). In addition, the steering group highlighted the need for improvement in faecal incontinence pads, to protect the mental health of patients already at risk. A philosophy of “right pad, right patient, right time” is recommended (Orme et al, 2022).

Box 1 summarises the recommendations for improvement that came out of the study.

Box 1. How to improve continence care and pad provision

Recommendations for improvement, based on continence professionals’ consensus and experience.

Individual patient needs

Falls prevention, skin health, patient assessment, accessible continence care services, education and awareness

Source: Orme et al (2022)

Outside of continence specialists, there is a general lack of awareness of continence care, and a lack of knowledge of incontinence issues by health professionals, the steering group agreed. This leads to problems in practice, such as non-specialist health professionals conducting “pad assessments” rather than continence assessments (Orme et al, 2022). The consensus statements present a strong basis of professional support for changing the approach to the education around bladder and bowel/continence care, so that all health professionals are trained in the physical and psychological factors associated with incontinence, with a focus on dignity of the individual (Orme et al, 2022). The steering group for the consensus study also recommended making patients’ clinical and holistic needs the priority for pad provision across all NHS service areas; and the development of a media campaign to inform public perceptions of pad use and design.

Self-management also emerged as a key area for improvement, with agreement that patients should be educated in the characteristics and use of their pads (Orme et al, 2022). There was strong agreement with the statement that the aim should be to provide patients with products that support their “normal” activities. The authors suggest that the right pad for the patient and the NHS, may not be the cheapest: “It is possible that any additional cost of a more ergonomic pad may result in overall savings to the NHS, as better patient self-management may result in improved outcomes (such as reduced incidence of falls and skin breakdown)” (Orme et al, 2022).

The consensus statements suggest that two-piece pads (comprising an incontinence pad and pair of fixation pants securing the pad in place), by interfering with balance, can affect a patient’s gait, which may increase the risk of falls; that the risk of falls is reduced when patients use a continence product specifically designed to be easily removed and replaced; and that “continence product design can positively impact on the risk of falls” (Orme et al, 2022). The authors point out that, in contrast to issues with medication, the possibility that ill-fitting continence pads could be a cause of falls is not routinely assessed when patients are admitted to hospital.

Improved practice around continence care and pad design and provision also has the potential to ease the pressure on health staff and carers, for example, by reducing both the risk of back injuries and the time spent changing pads (Orme et al, 2022). In care homes, it may take less time to help individuals use the toilet than it does to change their pads. A statement to this effect secured the agreement of 78% of respondents in the Delphi consensus study (Orme et al, 2022).

There is also the potential to protect important relational aspects of care, dignity, and quality of life by achieving improvements in continence care and practice around pads. “Pad cultures” on hospital wards, where staff place patients in pads as a containment strategy, instead of providing them with support to promote continence and meet their individual needs, can be highly distressing to patients and demoralising to staff (Featherstone et al, 2022). Incontinence management can also become a “battleground” for people living with dementia at home and their carers.

Inappropriate use of continence pads and excessive reliance on pads as a containment strategy often reflects a failure to proactively manage the continence of people. The backdrop to health and social care professionals’ failures, however, is a widespread lack of attention and investment in continence care, and a lack of support for staff involved in this care in people’s own homes, care homes and hospitals (NIHR, 2022). A recent NIHR (2022) review, on continence, dementia and care that preserves dignity, directed key messages for improvement in the use of continence pads at policy makers and commissioners, service providers and care regulators (Box 2).

Box 2. Key messages on continence products from the National Institute for Heath and Care Research

Policy makers and commissioners

Service providers

Care regulators

Source: National Institute for Health and Care Research (2022)

The review suggested that continence products, when selected and used appropriately, can support dignity: “Where continence cannot be maintained, sensitive management of incontinence can promote and maintain a person’s dignity. Care is needed when choosing continence products. The right product can encourage use and improve outcomes” (NIHR, 2022).

NHS England’s continence care guidance for commissioners and leaders in health and social care states that while containment products, such as absorbent pads, can maintain social continence, “treatment must always be the preferred option” (NHS England, 2018). “Containment products can offer security and comfort helping people continue with their normal daily activities. However, they are costly, can affect a person’s dignity and do not offer a long term solution unless the person has not responded to other treatments” (NHS England, 2018). There should be a review at regular intervals to:

It is important to remember that a continence or incontinence pad is a medical device with safety implications that need to be considered (Medicines and Healthcare products Regulatory Agency, 2014). The ACA’s guidance on pad provision for adult incontinence emphasises that any clinician who assesses an individual to provide an absorbent pad is “accountable for that decision, and needs to ensure that the chosen pad is fit for purpose and safe for use at the time of assessment… The patient or carer must be advised on how to apply/use the product and be given sufficient information in the safe use of the product” (ACA, 2021).

The best practice statements in the guidance also emphasise the importance of treating men and women equally in relation to available products, and offering all adults with continence problems a comprehensive assessment. There is a warning that the “custom and practice” of “automatically” providing incontinence products (including to patients with disabilities) is not appropriate and could be considered discriminatory (ACA, 2021).

Problems in the provision and use of pads may stem at least in part from a failure to recognise their importance in the daily lives of both people affected by incontinence and their carers. Used appropriately, pads can improve outcomes and support the wellbeing and dignity of patients who are often highly vulnerable. Improved practice around pads would also benefit carers, nurses and health staff who deal with some of the negative consequences when containment strategies fail.

Decisions about the provision, selection and use of pads are too often divorced from the needs and preferences of individual patients. These decisions should not be driven by cost or the failure to proactively manage incontinence. Pads should always be provided as part of holistic care.

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