Some students will need help with toileting procedures, and/or with managing menstruation while at school. A small number of these students may have physical and/or intellectual disabilities.

Continence is the ability to control one's bladder or bowel. A continence problem in children usually does not reflect an underlying emotional cause. The student should not be considered lazy, dirty or attention-seeking if accidents occur or if they seem indifferent to soiled or wet pants. The diagnosis of behaviour problems or neglect as a cause for incontinence problems is uncommon.

It is important that toileting problems are quickly identified. Early intervention and management by a professional multi-disciplinary team can result in an improved outcome and hence long-term social and behaviour problems can largely be avoided.

It is very important that all students have an adequate fluid intake throughout the day. Schools need to provide access to clean, palatable water and students ought to be encouraged to have the equivalent of a full cup or glass of fluid, preferably water, at recess and lunch breaks. Water fountains wet mouths only and rarely provide sufficient fluid intake. Continence problems are exacerbated by lack of fluid intake.

Teachers need to be involved in supporting therapeutic toileting programs instituted by health professionals. Education of teachers about the normal and developmental aspects of continence problems in children needs to be a high priority. This helps them to support the programs already in place and allay a lot of misunderstandings.

There are several distinct groups of students who may require assistance:

• students who have multiple and physical disabilities who are totally dependent for all toileting and hygiene needs
• students who have a medical condition which affects their bowel and/or bladder control, but otherwise function normally
• students who have a physical disability which means they are physically unable to toilet themselves
• students who have no physical disability but require a training program to learn how to manage their own toileting and hygiene needs and for whom toileting procedures are an integral part of the teaching program.
• school staff working with some of these students may be involved in:
• changing wet and soiled clothing, nappies, or sanitary pads
• bathing or showering students
• transferring and positioning students in the toilet
• cleaning students after a bladder or bowel movement
• cleaning and disinfecting toilets or change areas, and
• appropriately disposing soiled articles.

General principles

All staff involved in toileting and personal hygiene procedures and training programs should be trained in standard infection control precautions.

There should be sufficient staff available to ensure the safety of students and staff. Mechanical lifts may be required in some situations. Refer to the HR Consultant (Occupational Health and Safety) or the State Coordinator, Students with Physical Impairment for advice.

Care and thought need to be given to issues of gender and confidentiality in relation to toileting. All students should be given the courtesy and consideration of toileting procedures appropriate to their age and gender, including the right to privacy and where possible a toileting assistant of the same gender. This is particularly important for older students. Students should feel comfortable and confident with the toileting assistant provided.

All students who require assistance with toileting and personal hygiene should have a toileting plan as part of their medical action plan. This plan should be designed to meet the student's individual needs. Where possible, students should contribute to their own toileting plan with their personal preferences and needs being noted.

Staff members involved in toileting should be specifically trained to meet the needs of each individual student. Training support may need to be given by therapists, continence nurse advisers/nurses or medical practitioners.

All schools where student toileting is required should have (where appropriate) private toileting spaces, specifically designed toilets, rails and lifts, change and bathing facilities, and waste and soiled clothing disposal facilities. The advice of the State Coordinator, Students with Physical Impairment and an occupational therapist must be sought to devise plans for modifications in existing schools, for specific students. Please refer to the Circular Memorandum in relation to Minor Works for Students with Disabilities, which is forwarded to schools in August each year, for the correct procedure to follow. For further information, contact the State Coordinator, Students with Physical Impairment.

Teachers and aides involved with personal hygiene procedures need regular professional development in the areas of lifting and positioning students, back care, standard infection control precautions and procedures, and privacy and confidentiality issues.

Catheterisation

Urinary catheterisation is the insertion of a catheter via the urethra into the urinary bladder. Catheterisation is usually performed three hourly or more frequently. The frequency will vary with each child, depending on age, the severity and type of disability and gender.

Most students with spinal cord injury or spina bifida will need catheterising during school hours.

Many students can be taught to self-catheterise, from the age of five. Students may require support until the age of eight. While a student is being taught to self-catheterise, they will require assistance from an appropriately trained staff member. Self-catheterising may be seen as an important teaching task within a student's program.

By secondary school most students should be able to self-catheterise with no difficulty, depending on their physical skills, dexterity and intellectual ability. It is usual for the student to be taught to use the same procedure across all environments ie the same process should be used at school as is used at home. If self-catheterisation is unable to be achieved then a leg bag will be used and will require emptying three hourly by appropriately trained staff.

General principles

Currently the procedure recommended for catheterisation for most children is clean intermittent catheterisation. This involves precautions to ensure that basic cleanliness is achieved, but sterile conditions are not required. There may be some circumstances where sterile catheterisation is necessary.

Clean and private facilities appropriate to the procedure are necessary. Requirements may include a private space, a change table, washing and disinfecting facilities, storage cupboard for catheterisation requirements, and toilet.

There are risks involved in catheterising, such as risks of infection and trauma to the bladder. In the school setting catheterisation should performed by an appropriately trained person. Parents and children themselves are routinely taught to undertake the catheterisation procedure. The need for catheterisation should not jeopardise an educational placement or place pressure on parents to be available to catheterise the student at school.

When a non-nursing staff member is used, the following procedures must be followed:

• medical advice should be sought and the written permission of the student's medical practitioner obtained
• parents must be consulted and their permission for a staff member to undertake the procedure obtained (see Form 5)
• the aide selected for the job should feel comfortable with the role and preferably have some auxiliary nursing qualifications
• the aide must be trained to meet the needs of the individual student. Training should be undertaken by the child's parent who would normally best understand the child's individual needs. The training process should be supervised by an appropriately trained person. This could be a continence nurse adviser/nurse
• evidence of the training must be provided (see the section on Credentialling)
• after initial specific training, the aide should be observed and re-trained as necessary, but at least twice a year by the parent under the supervision of a continence nurse adviser/nurse or medical practitioner
• an aide involved in catheterisation should be trained in standard infection control procedures and should routinely follow these procedures
• issues of gender and confidentiality must be considered to ensure that the student is comfortable with the procedure.