An evidence-based procedure for the digital removal of faeces

Digital removal of faeces is viewed as a last resort in the management of severe constipation and is only practised when all other methods of bowel evacuation have failed. A systematic assessment and a stepped approach to the management of the patient's constipation (Bayliss et al, 2000) can prevent the need for this procedure (Royal College of Nursing, 2000). Digital removal of faeces is often identified as the only viable method of bowel evacuation for people with neurological impairment (Fader, 1997).

However, all patients should have received appropriate bowel management by dietary manipulation, adequate fluids, abdominal massage and adjustment of their medication before the digital removal of faeces is considered.

Controversy continues to surround the subject. Rigby (2003) states that although the procedure continues to be used, it is seldom taught formally. The invasive nature of the procedure, together with fears of litigation and accusations of abuse, have led to confusion among nurses about their professional and legal responsibilities.

The document Digital Rectal Examination and Manual Removal of Faeces - Guidance for Nurses (RCN, 2000) addresses many of these issues. This document has become the mainstay for courses on digital rectal examination (DRE) that are currently run throughout the country by continence advisers, specialist continence nurses and lecturers.

Need for education and training

The authors of this article are all involved in facilitating DRE courses, which enable nurses to undertake DRE confidently and competently. However, evaluation of courses facilitated by the authors showed that nurses still required additional learning on a more practical level on, for example, a clinical procedure for how to perform a digital removal of faeces. This is an area not fully explained in the RCN's document. A further survey was therefore conducted to ascertain the proportion of all nurses that felt a need for clinical guidelines.

Survey of training needs

The survey consisted of a questionnaire that was piloted by nurses undertaking the 'Promotion of Continence and Management of Incontinence' course at Thames Valley University in Berkshire. The questionnaires were then sent to registered nurses working in three acute regional hospitals, two community trusts and senior nurses/matrons of nursing homes local to the three areas where the authors work.

The response rate of the survey was positive. All those who responded requested clinical guidelines. The only areas where the guidelines were reported to be unnecessary were outpatient departments and paediatric units.

Despite the advances of pharmacological approaches to the management of constipation, the survey showed that there are still many patients who require digital removal of faeces either as part of long-term bowel care (patients with neurological conditions and older people) or for relief of acute impacted faeces (after orthopaedic surgery, and for patients receiving palliative/terminal care, and also older people).

The procedure

The priority for the authors was to produce definitive guidelines. It was not the intention to endorse the digital removal of faeces as a regular form of bowel intervention, but to give nurses a reliable, evidence-based procedure.

A literature search revealed a paucity of such evidence-based research. However, empirical evidence suggests that the digital removal of faeces continues to be practised in an ad hoc fashion.

The procedure that was developed relies, therefore, on current research and a panel of clinical experts, who were consulted to ensure best practice where published research was unavailable.

The procedure has been reviewed and endorsed by the Association for Continence Advice (ACA) as an example of best practice. It has also been endorsed by the RCN Continence Forum.

The Code of Professional Conduct (NMC, 2002) and the Reference Guide to Consent for Examination or Treatment (Department of Health, 2001) are both fundamental to the procedure.

It is recommended that the procedure should be used in conjunction with the document Digital Rectal Examination and Manual Removal of Faeces - Guidance for Nurses (RCN, 2000) and should become a part of all DRE courses.

Only a competent practitioner should undertake this procedure. To ensure the required level of competence, the nurse should have successfully completed a DRE course based on the RCN (2000) document. Also, nurses should familiarise themselves with trust/organisational policies and protocols before undertaking it.

Conclusion

Each patient's care should be considered on an individual basis and, accordingly, the procedure of digital removal of faeces should only be undertaken when clinically justified. Each individual's bowel-management strategy must be regularly reviewed.

FURTHER INFORMATION

This procedure document was sponsored by Norgine Ltd. Free copies can be obtained from: Norgine Ltd (DRF), FREEPOST (HA4696), Uxbridge, Middlesex UB9 6BR. Or e-mail your details to: mss@norgine.com

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