AUTHOR Gaye Kyle, MA, BA, RGN, is senior lecturer, Thames Valley University, Slough.
ABSTRACT Kyle, G. (2008) Digital removal of faeces by acute sector nurses. Nursing Times; 104: 25 , 40.
Gaye Kyle argues that nurses in the acute sector need education about the procedure for the manual removal of faeces.
The RCN’s (2006) document, Digital Rectal Examination and Manual Removal of Faeces: Guidance for Nurses, became the basis of digital rectal examination (DRE) courses throughout the UK. This publication has now been superseded by
a more comprehensive review of bowel care in adults, namely, Bowel Care, Including Digital Rectal Examination and Manual Removal of Faeces (RCN, 2008). Five key Skills for Health bowel care competencies are identified within the document, and a wide range of skills that are required for the specific bowel competency are then mapped out. Competency CC09 is particularly pertinent to bowel evacuation (RCN, 2008).
DRE courses are now organised by most continence services throughout the UK, and these will now need to reflect the five key competencies mentioned above. The aim of these courses will remain the same, however, to improve knowledge of, and increase skills in, the management of bowel dysfunction. The sensitive issue of digital removal of faeces (DRF), together with the decision-making necessary for patients who, according to the Mental Capacity Act 2007, may lack the capacity to make a decision about this intimate act, will continue to be reviewed and discussed. Particular attention will also be paid to the bowel care required by patients with spinal cord injuries and the triggers and symptoms of autonomic dysreflexia need to be identified and discussed at some length on these courses.
Those attending DRE courses are, in the main, nurses from the community – either from primary care, community hospitals or care homes. The lack of nurses from the larger general hospitals is noticeable by their absence. This in itself may not be a cause for concern, yet for those patients with a spinal cord injury, the concern is very real as DRF may be an integral part of their routine bowel management. This routine is interrupted when these patients are admitted into a general NHS hospital that does not specialise in treating spinal injuries (National Patient Safety Agency, 2004) if nurses lack sufficient knowledge and expertise to competently perform the procedure.
Nurses’ fears of DRF
The invasive nature of this procedure together with fears of litigation and accusation of abuse has led to nurses being somewhat confused with regard to their professional and legal responsibilities. It appears that nurses are actively refusing to undertake DRF for patients because either they have not been trained or, even more alarmingly, they think nurses are not allowed to perform the procedure.
In their defence, such nurses are behaving in a professional manner because the NMC (2008) states: ‘You must recognise and work within the limits of your competence.’ However, if nurses refuse to provide routine bowel care for a patient with a spinal cord injury, the end result could be catastrophic, not only for the patient but also for the nurse who, in a professional sense, has failed in her or his duty of care.
There exists a lack of national statistics for the number of people with a spinal cord injury. According to the Spinal Injury Association (2008) there are 40,000 people living with a spinal cord injury in the UK, with this number increasing by a further 1,000 new spinal cord injuries each year (www.spinal.co.uk). With this in mind, it is surely only a matter of time before someone with a spinal cord injury is admitted to the acute sector to find there is no one able to undertake their bowel care needs. To prevent this situation from occurring, more general nurses need to undertake DRE courses in order not to fail those patients that have specific bowel care needs.
No matter how many new bowel competencies are introduced, these will not help those patients who have a spinal cord injury if nurses from the acute sector are failing to take advantage of the knowledge, skills and competencies that are afforded by DRE courses.
National Patient Safety Agency (2004) Patient Briefing: Ensuring the Appropriate Provision of Manual Bowel Evacuation for Patients with an Established Spinal Cord Lesion. London: DH.
NMC (2008) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: NMC.
RCN (2008) Bowel Care, Including Digital Rectal Examination and Manual Removal of Faeces. London: RCN.
RCN (2006) Digital Rectal Examination and Manual Removal of Faeces: Guidance for Nurses. London: RCN.