A safety alert was released in 2018 about the importance of providing the correct bowel care for people with a spinal cord injury. Five years on, the issue still hasn’t been addressed.
Now the RCN Bladder and Bowel Forum is endorsing a campaign by the Spinal Injuries Association (SIA) to raise awareness among nursing staff about how crucial appropriate bowel care is.
Bowel management is a basic nursing skill which all nursing staff can learn. Without this, the quality of life and care for many patients is severely compromised,” says Fiona Le Ber from the forum.
Guidance from the NMC (Nursing and Midwifery Council) says registered nurses must be competent in bowel care and the expectation is that student nurses will be educated about this.
Knowing you're confident and competent to carry out bowel care could have a life-changing impact on many patients
However, Fiona says the issue is often about competency and more training is needed.
“If you don’t use the skill, nursing staff may not feel confident or competent. They may not undertake bowel care for years but then find themselves in a situation where they have to do it.
Regular, annual mandatory training should be required so nursing staff, whatever field they work in, feel they are competent and confident to do the role. But resources are stretched everywhere, and this seems to be bottom of the pile.
“I sympathise with how my colleagues feel. I didn’t have any additional training until I became a specialist nurse. Knowing you're confident and competent to carry out bowel care could have a life-changing impact on many patients.
“It can be a delegated task too, so all nursing staff can do this, but competency is key. It can’t be delegated if the nurse isn’t competent in the first place, but many health care assistants do crucial bowel care in the community. We must not be embarrassed to ask about it.”
We must not be embarrassed to ask about it
A patient’s dignity must also be considered alongside their clinical needs. Fiona has seen first-hand the impact of inappropriate care on rehabilitation wards.
“Nursing staff were giving suppositories to patients before they started their physio. Their bowels would open, and they would miss essential rehab which alongside causing considerable embarrassment, delays them getting home.”
Bowel care: what you need to know
What are the risks to patients?
If bowel care isn’t performed when it’s needed, patients may have faecal incontinence and constipation. Patients could also be at risk of autonomic dysreflexia, especially those with a spinal cord injury.
What is autonomic dysreflexia?
It’s a dangerous syndrome involving an overreaction of the autonomic nervous system. Symptoms include a sudden and severe rise in blood pressure and patients are at risk of having a stroke. It’s considered a medical emergency requiring immediate treatment due to the extra pressure in the body.
How often is bowel care required for people with a spinal cord injury?
It depends on where the injury is. If higher up, care may be needed several times a week. If lower down, daily or even 2-3 times a day.
Is digital removal of faeces illegal?
No. But it should only be done when it’s clinically required. (See below).
Can patients’ carers carry out bowel care when patients are admitted to hospital?
Not always. Some trusts don’t recognise training completed in a different workplace and say carers aren’t insured to carry out bowel care in hospital. However, a nurse should always discuss the care with the patient.
If no one is available to give bowel care on the ward and the patient is happy for their carer to give the care, a care or personal assistant should be able to do this.
Where can you access training on bowel care?
What’s the RCN doing?
Digital removal of faeces
Fiona says that in her experience, most nursing staff seem to be OK with inserting suppositories or helping people use commodes, but many are concerned about digital removal of faeces or carrying out rectal stimulation.
“In nursing homes years ago, this used to be done routinely, whether it was required or not. Thankfully, it’s now “banned” as a routine task but communications around this have become confused,” Fiona explains.
“Some nursing staff believe digital removal of faeces is now illegal. It’s not – but it should only be done when it’s clinically required.”
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The RCN Bowel and Bladder Forum asked nursing staff about their experience and some of the comments made on our Facebook page demonstrated that nursing staff were not being given the correct information.
One said: “I have been trained but my trust won’t allow me to do it.” Another commented: “It’s illegal and we are not allowed to do it.”
There’s been a change in the language used with the wording being changed from “manual evacuation” to “digital removal”.
Fiona explains: “This was to try to prevent confusion, but people still seem scared they will hurt patients by doing this, but you do more damage by ignoring the situation.”
Not being able to receive proper bowel care can affect someone's entire health and wellbeing. It's life threatening and it’s really scary and people with a spinal cord injury really don’t deserve that
What can you do?
While nursing staff don’t want to do harm, giving no care could do just that.
“We’re focused on being competency based, but this mustn’t hold people back to the point they’re frightened to care,” says Fiona. “Registered nurses fear being reported to the NMC but that can happen if you don’t provide care too. So, raise the issue – don’t ignore it and take positive action.
“As well as accessing elearning, you need to get practical experience. Get in touch with the bladder and bowel service or the education department if you have one in your workplace. There aren’t always quick answers, but they might be able to point you in the right direction.
“We need to consider patient choice and not be too scared of something going wrong if it’s in the patient’s best interests. If my arguments haven’t persuaded you of the importance of this issue, please take some time to look at this powerful Spinal Injuries Association film.”