“The Big Five”: Why is Toileting Last?

As an occupational therapist, it has always been my role to help maximize clients’ safety and independence with their occupations or activities of daily living (ADL). “The Big Five”, as I like to call it, are eating, grooming, bathing, dressing and toileting. In the early part of my career I noticed something very interesting about this list and it always puzzled me. On the progress charts and in practice, toileting was always last. Even though toileting occurs more frequently than any other ADL, it always seemed to be put at the end of the list. After many years of working in various clinical settings and interviewing hundreds of patients and therapists, I want to share why this is and how we can put toileting where it belongs – at the top!

It comes to no surprise that the role of each discipline in a hospital or clinic can vary from setting to setting. Some facilities may have a lot of overlap in practice where both OT and nursing work on bladder management while others leave the responsibility to a sole discipline. The common themes I’ve noticed over the years that cause toileting to fall between the cracks include everything from OTs assuming the nurses will do it and vice versa, lack of knowledge, lack of communication, time constraints and lack of resources. While there are very real and legitimate reasons that make delivering high quality care difficult, even small changes in practice can lead to significantly better outcomes for patients.

I can’t tell you how many times over the years I have seen documented “patient missed therapy session secondary to bladder/bowel accident.” When I see this, I can’t help but think that the therapist missed out on the perfect opportunity to address toileting and bladder/bowel management. Now to be fair, there are definitely times when it is not possible to continue a therapy session after a patient has an incontinent episode. And getting your hands dirty (pun intended) isn’t exactly what many health care professionals look forward to in their day. But, whether or not it’s a topic you are passionate about, every attempt should be made to help your clients by educating them and problem solving to find solutions. While there is nothing wrong with calling the nurse, it was obvious to me that more education was needed. In creating a comprehensive course on bowel, bladder and ostomy management, my hope is to change the way health care practitioners think about toileting and ultimately increase the quality of life of the clients under their care.

Jeffrey Despommier, OTR, OMS, CUA, ATP


About the author – Jeffrey is an occupational therapist with over 12 years of rehabilitation experience. He is board certified as a urologic associate and ostomy management specialist.  He also specializes in complex rehab technology and is board certified as an assistive technology professional.

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