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Jana Lognon is a Nurse Continence Advisor (NCA) in the pelvic floor clinic at Foothills Medical Centre Woman’s Health Ambulatory Clinics in Calgary, Alberta. To compliment this speciality, Jana became an NCA in 2015 to add to her knowledge base and learn new approaches for her work with women struggling with incontinence of varying kinds.
The women referred to the clinic have pelvic floor dysfunction that can have consequences for bladder and bowel symptoms including incontinence (urinary and fecal), urinary retention, outlet constipation, discomfort, pain, and chronic urinary tract infections. The clinic believes that women need a proper understanding of their condition so that they can make the right treatment choices. In light of this, Jana works as part of a team to care for clients. The nurses focus on providing assessments, teaching (either in group sessions or one on one with clients) and pessary fitting and care. Some of the nurses will also assist with cystoscopies or perform urodynamic tests. The physicians focus more on medical and surgical interventions while the physiotherapists focus on the musculoskeletal rehab patients may need.
A typical day for Jana will include 2-4 one hour initial assessments and about 3-5 follow up patients. Some days she may teach group educational sessions to new incoming patients so they have some baseline knowledge before their first appointment with a clinician. She is often assigned to help teach medical residents who will take this training into their medical career. However, the one on one time she has with her patients is the most valuable part of her job because she can see how her thorough assessments can help find simple strategies to overcome continence issues, and her motivational interviewing techniques often help patients take behavioural steps to help themselves. Patients come in with a lot of fear, anxiety, or embarrassment because of the private nature of their health issues. There are often tears on the first visit as patients disclose their symptoms to someone who cares and can help them. The tears turn to smiles and laughter as patients understand how they can be helped and that they are not alone. Daily she hears comments like, “you made me feel so comfortable talking about this” or “I can’t believe I have my life back!”
“I have been a nurse for 30 years and have loved all my jobs, but working as an NCA is probably the most fulfilling because I feel that I make such a huge difference in the lives of whole families. Women are central to their families and communities, so when I help them feel better about themselves it affects their entire outlook on life.”
Brenda Callahan is a Nurse Continence Advisor (NCA) with Eastern Health* in St. John’s, NL. Brenda finished her NCA program in 2012 and joined the team of 5 NCAs working at the Women’s Health Clinic, Health Sciences Center (HSC).
Brenda and the other NCAs provide a NCA clinic at the HSC, provincial tertiary care center. Both men and women are referred to the NCA clinic if they are experiencing bladder and / or bowel incontinence. In this role, NCA completes comprehensive assessments and physical examination of clients/patients; establishes a diagnosis (stress, urge, stress/urge, overflow, functional, iatrogenic); collaborates with the physician, patient/client, family and other health care providers as required in developing treatment objectives; provides teaching and education to client/family; implements a treatment plan that works toward a better quality of life.
After caring for many women who require a pessary as part of their treatment plan, Brenda noted some women needed extra support or education with pessary care. She attended a Pelvic Floor clinic in Calgary to train in NCA pessary. She came back to NL and brought back that learning to the clinic so the other NCAs could also better care for these patients. Now in addition to the option of physician visits for pessary care, patient can also attend the NCA pessary clinic or be trained to provide self-care at home.
Brenda and NCAs also collaborate with the urologists and urogynecologists to play an integral role in the operation of a complete urodynamics testing service at the Women’s Health Clinic.
The NL NCAs work collaboratively with physicians in clinic in the Women’s Health Clinic to assess and manage incontinence issues for the residents of Newfoundland and Labrador. In looking to the future - They look forward to expanding the program with biofeedback technology and clinic.
*Eastern Health is the largest integrated health organization in Newfoundland and Labrador. We provide the full continuum of health services to a regional population of more than 300,000 and are responsible for a number of unique provincial programs. Our over 13,000 health care and support services professionals believe in providing the best quality of care and health service delivery in our region and in the province. Eastern Health extends west from St. John's to Port Blandford and includes all communities on the Avalon, Burin and Bonavista Peninsulas.
Grace Neustaedter is a Nurse Continence Advisor (NCA) at the Pelvic Floor Clinic in Calgary, Alberta. She became an NCA to build her knowledge base and credibility for her work with Urogynecologists assessing patients, providing counselling about behavioural methods, and fitting women with pessaries.
Today she works with women aged 16-100 with pelvic floor dysfunction – bladder, bowel and prolapse issues primarily. As an NCA she provides educational workshops to new patients three times a week and spends the rest of her time in clinic assessing new patients, helping them with behavioural training, fitting and following up with pessaries, as well as self-catheterization teaching, help with cystoscopies, and urodynamic testing. Grace enjoys working with patients “who are so grateful for the help that is provided for them.”
Grace works on a multidisciplinary team in an ambulatory clinic that includes nurses, Urogynecologists, a family physician and a team of physiotherapists. They also have access to a dietitian for nutrition counselling and soon a nurse practitioner will join the team. The physicians focus on surgical and medical interventions, the nurses the assessments, behavioral training and pessary fitting and care. Services are provided by referral and are covered by provincial health insurance coverage. Supplies such as pessaries are usually covered by private health insurance.
Grace’s role as a Clinical Nurse Specialist includes education, clinical practice and assorted administrative responsibilities. Most days are spent assessing and triaging new patient referrals as well as follow up appointments and phone calls. She sees patients at the Pelvic Floor Clinic but may also be called to see patients at the main hospital. Grace also teaches a patient half-day workshop several times a month as well as educational presentations to healthcare providers and students.
“Working in this area has been the most interesting and fulfilling role in my nursing career…women, men and children who are dealing with pelvic floor issues… are amazed to find out how common these problems actually are and how some simple strategies can make such a huge difference.”
Nadine is an NCA, who is currently working as a Geriatric Nurse Clinician in an outpatient’s clinic in Sudbury. She sees patients for the completion of comprehensive geriatric assessments, as well as patients who are referred for continence issues. Her continence referrals are generated mainly from physicians working at the clinic.
Through the course of the pandemic, Nadine’s role changed to accommodate the volume of patients referred to the clinic. With a plan in place, the clinic offered virtual assessments. Although virtual assessments became more popular as a way to provide care during the COVID-19 pandemic, the staff found their geriatric clients did not adjust well to technology and preferred seeing health professionals in-person. As a result, the referrals to specialized geriatrics in-person increased. This resulted in limited availability to see continence patients.
As an NCA, Nadine ensured that the continence clients’ needs were addressed. She incorporated more of the in-depth continence assessment into the geriatric assessment completed by clinicians. Continence is one of the “Geriatric Syndromes” that are assessed by each clinician at a basic level. When Nadine had the opportunity, she used the NCA assessment tool to gather data, so that at the end of the Geriatric assessment, a thorough review of continence was completed, and recommendations were included in the patient’s plan of care.
For Nadine, some of the biggest hurdles/challenges over the past two years have definitely been the impact of the pandemic itself. The community was in outbreak, as well as the rest of the province (hospital, long term care homes, retirement homes, group homes, work places, and schools). This made it very difficult to maintain the face-to-face interaction because of the multiple changes in personal protective equipment (PPE). Many patients decided to cancel their appointments in fear of leaving their home and contracting COVID-19 and just “deal with” their continence issues instead. This then snowballed into a long waitlist for the clinic, a challenge that is still ongoing. Now in the middle of 2022, the clinicians are seeing somewhat of a reprieve in COVID-19 stats. However, fall has arrived, which means it is influenza time. They are hopeful that many patients with continence will have concerns addressed.
Jackie recently graduated from the Nursing Concepts in Continence Care Certificate program earlier this year, and currently works at an outpatient geriatric continence clinic. The majority of her clients are 65 years of age and older, as well as adult women 18 and over, those with spina bifida and spinal cord injuries. Jackie currently addresses a wide variety of issues including, but not limited to stress, functional, urge and mixed incontinence. She also provides pessary fitting and management, she sees men post prostate surgery. Jackie is also able to perform urodynamic testing at her clinic. Since the pandemic started, Jackie has noticed a new client population that has emerged in the clinic; those experiencing stress incontinence due to post- COVID cough.
The pandemic has opened up the opportunity for Jackie to see clients virtually. She states that this is particularly important, as she works at a clinic that serves clients who live up to 6 hours away. Since the pandemic started, Jackie reports that clients in general are presenting sicker, with more severe bowel and urinary symptoms. Jackie also shares that due to limited access to primary care for many clients, NCAs are now going beyond their roles to assist their clients in addressing general health issues. For example, she has now been completing more comprehensive assessments and reviews diagnostic tests outside of what NCA would focus on. She has also seen improvements in people accessing the clinic services due to virtual appointments being offered. This clinic has also seen a growth in their wait list for continence services going from a few months to 9 months.
Shauna is an NCA who currently works at an outpatient Multiple Sclerosis (MS) clinic where she is a part of an interprofessional team. She mainly sees clients that experience MS-related complications with incontinence including neurogenic bladder, Urinary Tract Infections (UTIs), urinary retention, require self catheterization teaching, sexual dysfunction and other bowel and bladder issues. Shauna provides care to adults 18 years of age and older. The majority of clients are mobile, however some experience challenges in attending the clinic in-person due to the progressive nature of MS.
During the pandemic, the clinic offered virtual visits through ZOOM and telephone. Shauna states that a lot of clients have expressed great appreciation for virtual appointments, as they help to decrease barriers to attending clinic including driving and finding a support person to accompany them. Virtual visits have also provided a cost savings to many clients, as they no longer have to factor in gas and parking costs. Finally, clients highlight how convenient a phone call or a ZOOM call is for them. Shauna believes that these virtual visits are also safer for clients who experience significant mobility issues and generally reduce health care costs.
As an NCA, Shauna also states that the pandemic has allowed her to learn to connect with clients in a different way, when face-to-face is not possible. It was challenging at first, however, learning to connect with technology has now become the norm and Shauna believes that the benefits of virtual visits greatly outweigh the barriers. The pandemic enabled many NCAs such as Shauna to become more innovative in how they provide education. An example of a practice change: Shauna sends urinary catheters in the mail and provides education over the telephone once the client has received the equipment.
Mary Kjorven is a Clinical Nurse Specialist (CNS) in Geriatrics and a Nurse Continence Advisor (NCA) in the Interior Health Region of British Columbia. She has a small continence clinic in the Central Okanagan Seniors’ Health and Wellness Centre in Kelowna, B.C. Mary obtained her NCA certification in 2012 when she recognized the great need for services specific to bowel and bladder health for the older adult population. She incorporated the NCA role into her already existing CNS role and has been advocating for a more robust inter-professional continence clinic for her region, one that serves all populations.
Mary’s current clinic is a component of an out-patient inter-professional specialized assessment clinic for older adults. Other members of the team include a Physiotherapist, Social Worker, RN with a specialty in geriatrics, Dietician, Occupational therapist, Respiratory Therapist, Speech and Language Pathologist, Primary Care Physician and Geriatrician. Because Mary’s clinic is relatively small the wait list is high. As a result she is not able to provide the full spectrum of NCA services. Mainly she provides a comprehensive continence assessment, offers behavior modification interventions and consults to other professional services. These services include both public services within the Seniors’ Health and Wellness Centre and community private partners such as Physiotherapists with postgraduate certification in pelvic floor function.
Mary has been fortunate and continues to be grateful to have excellent CNCA mentors from other regions and provinces who continue to provide guidance for her practice. Without this collegial support it would not have been possible to build and maintain her clinic. Everything from sharing business plans of existing clinics, clinical decision support tools and the evidence behind them, education and learning modules have proven invaluable.
In her words: “Even though I was the only NCA in the region I didn’t feel like I was alone. I had enough knowledge and support to get started. We need to focus more on possibilities and opportunities, in other words, look for ways we can instead of can’t. If we have the evidence to support our practice we are better prepared when those opportunities present themselves. For example, organizations have come to appreciate that incontinence is a major risk factor for residential care placement. Often NCAs can make a difference and that provides possibilities for improving outcomes for everyone”.