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Bowel care

Updated RCN guidance on digital rectal examination

Bowel care is an essential nursing skill but nurses need up-to-date guidance to ensure their practice is safe

In this article…

  • Why digital rectal examination guidelines are necessary
  • The revised guidance from the Royal College of Nursing

Bowel care is a fundamental part of patient care that is frequently overlooked, yet it is of paramount importance for the quality of life of our patients - many of whom are hesitant to admit to bowel problems or to discuss such issues (Ness et al, 2012).

However, the competencies for digital rectal examination (DRE) and the digital removal of faeces (DRF) have not been a nursing priority. The intimate nature of DRE, together with fears of litigation and accusations of abuse, have caused nurses confusion regarding their professional and legal responsibilities (Kyle, 2010).

In 1999, following a survey to establish nurses’ views on DRE and DRF, the Royal College of Nursing published Digital Rectal Examination and Manual Removal of Faeces (Addison et al, 1999). This was updated in 2008 following publication of the Skills for Health (SfH) National Occupational Standards (NOS) relating to continence care.

The RCN guidance has been revised again this year to incorporate the most recent developments in bowel care (Ness et al, 2012). It is designed to be used primarily by nurses but can be used by any health professional as it provides a resource and framework for practice. It will support nurses in a range of activities related to lower bowel dysfunction.

The guidance expands on the SfH continence-care competencies relating to lower bowel dysfunction by starting each chapter with an NOS statement, then expanding on it. At the end of each chapter there are further SfH competencies relating to this area of care to encourage readers to expand their knowledge.

The document describes normal anatomy and physiology, defines bowel dysfunction such as constipation and faecal incontinence, then discusses the importance of assessment, including DRE, to establish a differential diagnosis. It explains in depth when DRE and DRF should be carried out, as well as the legal and professional implications surrounding these procedures.

The document then looks at the simple and complex interventions to improve and maintain bowel function alongside consent, chaperoning, legal aspects, delegation and risk assessment. The guidance also includes procedures for DRE, DRF and digital stimulation, which are now new additions.

As well as enabling nurses to deliver evidenced-based patient care, the guidance can be used to:

  • Support competency frameworks;
  • Benchmark services;
  • Produce protocols, guidelines and procedures at local level on lower bowel care;
  • Stimulate nursing audit and research activity in lower bowel care.

It should also be used as a point of reference to support academic work related to bowel care for nurses.

Conclusion

I took part in a recent Nursing Times clinical webchat on constipation, many of the questions were around the aspect of who could carry out a DRE and what training is required. It is hoped this document will provide a useful resource that can be used as a basis for training. This will enable more nurses to be competent to carry out evidenced-based care including DRE. It also confirms that DRE and DRF are nursing roles.

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Wendy Ness is colorectal nurse specialist at Croydon University Hospital

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