My work in continence nursing: raising issues and disseminating knowledge
My first ever placement as a student nurse, in 2001, was on urology. Since then I’ve nursed in neurological rehabilitation, working with neurogenic bladders after spinal cord injury, and in neurosurgery where I have strictly monitored urine production after pituitary surgery to monitor for diabetes insipidus. Currently I work in the nursing home setting where poor fluid intake, decreasing renal function and advancing dementia provide new challenges to catheter care.
It soon became clear to me that there were many unknowns in continence nursing. How often should a catheter be changed? What are the benefits and harms of catheter washouts? Do silicone or silver coated catheters help reduce infection? By writing for nursing and medical journals to make these unknowns known, my aim was to expose evidence gaps and make clear where research is urgently needed. I hoped to encourage discussion which would lead to better outcomes for patients. I also wrote for the public, in magazines, in order to address common concerns and increase understanding around continence.
To this end, I wrote on catheters for Evidently Cochrane, with a piece entitled “Urinary catheter care: what does the evidence say?” (Cowan, 2017). The article was read more than 10,000 times and was awarded “Top Blog” for 2017; it was also republished by the Spinal Injuries Association (Cowan, 2017a). In December 2019, I wrote a piece entitled “Bridging the evidence gap in the care of indwelling urethral catheters” for the Nursing Times (Cowan, 2019).
As carer for my husband with spinal cord injury, I had also become aware of autonomic dysreflexia, a medical emergency that can occur after spinal cord injury. Being triggered most commonly by a stimulus such as a blocked catheter, it can result in hypertension, stroke, convulsions, cardiac arrest and death. In order to raise awareness, I wrote on this condition for the Nursing Times (Cowan 2015) (reprinted by the Spinal Injuries Association (Cowan, 2016)) and for a medical history website (charting the discovery of the condition during the 20th century) (Cowan, 2017b). I accessed a wide range of articles, including even the 1947 writings of Sir Ludwig “Poppa” Guttman, neurologist and founder of the Paralympic Games, on sets of symptoms that he observed after spinal cord injuries inflicted during World War 2. His observations led him to conclude, correctly, that “distension of a visceral organ, such as the bladder, situated in the paralysed part of the body, had set up a response of autonomic mechanisms, which had induced profound effects on the cardiovascular activity in parts of the body above the level of the spinal lesion.” (Guttmann and Whitteridge, 1947).
I also blogged about my husband’s experience of misdiagnosis of autonomic dysreflexia for the Hippocratic Post, a medical blogging site, highlighting the sobering fact that in one survey, emergency department staff scored an average of two out of twenty-nine points on a questionnaire to test their knowledge of this condition (Cowan, 2016a). A piece on autonomic dysreflexia, co-authored by myself, is currently awaiting publication in a medical journal.
I am also a columnist for the Reader’s Digest, and have written a well-received piece for the public on topics of concern or interest that I had encountered when caring for patients with catheters as a nurse (Cowan, 2018). These included “dealing with blockages”, “dealing with leaks”, “being discreet”, “going on holiday” and when to call for help. Patients have commented that my articles are easy to read and answer questions that they may have felt embarrassed to ask in the clinical setting. One patient said that he gained confidence in catheter care from my article in Readers Digest. For the same publication, I also wrote on urine tests, reflecting that something so apparently simple can be used to act as a “window into the workings of your body” (Cowan, 2018a). “Three particular proteins in urine perhaps show promise in the detection of pancreatic cancer,” I wrote, referring to current scientific studies. “Other molecules may predict whether epileptic seizures develop after head injury. Whether a baby will be born pre-term or a foetus will suffer stunted growth may also be revealed by tiny particles in the mother’s urine”.
Nurses have reported feeling empowered to question practice, since the evidence gaps are made clear. One nurse felt confident to question the need for catheterisation and her patient’s catheter was removed; another questioned the decision to administer antibiotics in the absence of urinary symptoms. My article on autonomic dysreflexia was instrumental in one nurse identifying the condition, caused by a blocked catheter, and she was able to deal with the life-threatening emergency quickly and efficiently.
I remember feeling, as a student nurse, that “you just did what has always been done when it comes to catheters – no questions asked”. Through my articles I have made clear that many questions do not yet have answers and that it is important to ask the questions, and to listen to your patient.
In a piece for the British Journal of Cardiac Nursing (where I am also a columnist and Board Member), I have written on the importance of embracing the expertise of patients with long-term conditions, focussing again on autonomic dysreflexia as an example (Cowan, 2020). I finished with these words, “Miles Sibley (Director for the Patient Experience Library) calls for a change in culture that treats patient feedback as a valued resource for learning and for patient experience to be embedded in professional training, clinical guidelines and practice protocols, just as medical evidence is.” I hope that my writing will encourage nurses to view their patients as expert partners in care: a subject that I have also written on, from a personal viewpoint, in the British Medical Journal (Cowan, 2018b).
I would like to thank the British Journal of Nursing for recognising the importance, in their own journal and in those that I have written for, of nurses asking questions and writing and reflecting on what the evidence says, or where gaps remain.
Cowan H. Autonomic dysreflexia in spinal cord injury. Nursing Times. 2015.
Cowan H. Autonomic dysreflexia in SCI. Forward. 2016. https://www.helencowan.co.uk/sites/default/files/articles-uploaded/autonomic-dysreflexia-web.pdf
Cowan H. Misdiagnosis: a personal story. Hippocratic Post. 2016a. https://www.hippocraticpost.com/muscular-skeletal/misdiagnosis-personal-story/
Cowan H. Urinary catheter care: what does the evidence say? Evidently Cochrane. 2017.
http://www.evidentlycochrane.net/urinary-catheter-care-evidence/
Cowan H. Urinary catheter care: what does the evidence say? Forward. 2017a.
https://www.helencowan.co.uk/sites/default/files/articles-uploaded/Urinary%20catheter%20care.pdf
Cowan H. Medical lessons from the battlefield. Past Medical History. 2017b.
https://www.pastmedicalhistory.co.uk/medical-lessons-from-the-battlefield/
Cowan H. Top ten tips for living with a catheter. Readers Digest. 2018.
https://www.readersdigest.co.uk/health/health-conditions/top-10-tips-for-living-with-a-catheter
Cowan H. What can a urine test tell you about your body? Readers Digest 2018a.
https://www.readersdigest.co.uk/health/wellbeing/what-can-a-urine-test-reveal-about-your-body
Cowan H. Why carers matter. BMJ 2018b;361:k2385
Cowan H. Bridging the evidence gap in the care of indwelling urethral catheters. Nursing Times. 2019.
Cowan H. Caring for and listening to the well-informed patient in cardiology. British Journal of Cardiac Nursing. 2020 15 (1) 1-2. https://doi. org/10.12968/bjca.2019.0132
Guttmann L, Whitteridge D Effects of bladder distension and autonomic mechanisms after spinal cord injuries. Brain. 1947. 70: 361-404