Improving faecal incontinence in Care Homes: developing an intervention and conducting a feasibility study

Faecal incontinence (FI) is inability to control the bowels. FI is much more likely in older people in Care Homes (CHs) than those who live at home, affecting about half of all residents in many surveys around the world. Faecal incontinence is associated with shame, social isolation and reduced quality of life, as well as physical discomfort and risk to skin health. The causes of FI among older people are complex and what works for younger people may not be as effective for people living with dementia in a CH. The use of incontinence pads is the most common management of FI (and urinary incontinence) in CHs. This does little to protect the dignity or skin health of the resident and does not disguise odour or make life much easier for staff. A recent review of the evidence indicates that it is unlikely that addressing just one aspect of care, such as staff training and education will lead to improved outcomes. We need to develop complex multi-faceted interventions that enable staff and Residents to work together to develop bowel care which is appropriate for each individual and their circumstances. We have conducted a Norwegian pilot study and then trial of an education intervention for FI in CHs which was both feasible and has shown significant improvements in FI. We will adapt this for UK CHs.

Phase 1. Scoping of literature on collaboration between clinicians and residents or carers working together to design service delivery in care home settings.

Phase 2. Stakeholder consultation. To test the assumptions of the proposed intervention, hear alternative suggestions and involve those who understand the daily experience and challenges of providing personal care to care home residents. We will convene separate face to face discussion meetings of different stakeholders (care staff; residents and their family and friends; care home managers; commissioners) and present to them the results of our review and the findings from Norway. We will seek their suggestions for adaptations needed for a successful FI programme in UK CHs as well as what outcome measures are the most relevant.

We will follow up these meetings with individual interviews and electronic communications until we have a clear picture of what is likely to be feasible and acceptable.

Phase 3. Feasibility study. Conduct of a feasibility study of the programme on FI in 5 varied CH units (approximately 70-100 Residents).

Feasibility outcome measures will include: characteristics of Residents with FI, screening findings, recruitment rates, drop-out rates, number of log-ins to online training materials and guidance, time online, completion of outcome measures, acceptability of intervention (questionnaire to all plus interviews of participants and care staff). Number of staff support sessions and content analysis of those sessions. Staff, Resident and relatives’ views on the intervention (qualitative data). This will include a Process Evaluation.

Clinical outcome measures at baseline and 6 months (to be refined and confirmed in Phase 1):
Primary clinical outcome: episodes of FI, continent bowel motions and episodes of dependent continence (assisted to use the appropriate receptacle).

Secondary outcome measures: episodes of continence-related skin damage, pad use, laundry use (bed linen and clothes), other bowel symptoms (e.g. constipation), laxative use, rates of urinary incontinence, Quality of Life, a general health questionnaire. Exploration of the results will enable a robust sample size calculation for a subsequent trial. Any episodes of primary care team call-out and hospitalisation for bowel-related issues will also be recorded.

Phase 4. Presentation of results to stakeholder and planning of a definitive study and grant application.