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Nurse-led ear care: training needs and the latest techniques

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Atie Fox, BSc (Hons) ,SRN; Paulette Bartlett, SRN DPSN.

Atie-Lecturer Practioner, Bournemouth University, Primary Ear Care Trainer; Paulette-Lecturer Practioner, Bournemouth University.

The NHS Modernisation Agency (1999) is exploring ways of improving both the quality of and patient access to audiology and ear, nose and throat (ENT) services. The development of nurse-led services through improving the skills of practice nurses could contribute significantly to both of these aims. However, adequate resources, in terms of time and equipment, will be required.

The NHS Modernisation Agency (1999) is exploring ways of improving both the quality of and patient access to audiology and ear, nose and throat (ENT) services. The development of nurse-led services through improving the skills of practice nurses could contribute significantly to both of these aims. However, adequate resources, in terms of time and equipment, will be required.

Fall et al (1996) studied the nurse-led and GP care received by patients presenting with ear problems in two similar socio-economic regions. In this study, patients demonstrated higher levels of satisfaction with trained nurse-led ear care. Patient awareness of ear-related issues were also greater in those attending the nurse-led service.

This paper will consider the psychological and legal importance of addressing communication difficulties with hearing impaired clients. It will discuss current professional practice requirements in ear-care provision, in particular detailing the contraindications to ear syringing, and the problems associated with water in the ears. The article will look at the use of aural toilet as an effective alternative to ear syringing.

When practising ear care it is important to consider the client group with which you are working. Some 18% of all adults have hearing loss and this increases to 72% of all those aged over 70. The need exists for competence in communication skills and more awareness of psychological needs when working with hearing-impaired patients. Mangan and Robins (1999) note qualitative evidence of the distress caused to hearing-impaired patients by staff with poor communication skills.

Possessing effective communication skills helps the nurse obtain a full patient history, an essential prerequisite to the ear-care process (Harkin, 2000; Grossan, 1998; Sharp et al, 1990). Without effective communication skills, the identification of contributory factors and contraindications to treatment is not possible and nurses are not able to offer appropriate advice and care. The nurse has a duty of care to patients and must be able to communicate effectively in order to achieve informed consent.

Consent - There are professional and legal issues surrounding communication difficulties related to informed consent. The DoH (2001) advise nurses that information related to consent must be 'accessible' and 'understandable' and, if not, the patient has grounds for legal action. Nurses are accountable to the patient in both public and civil law, to their employer under contract and to their professional body under The Code of Professional Conduct (UKCC, 1996) and The Scope of Professional Practice (UKCC, 1992; Dimond, 1995).

Edwards (1996) states that only mentally competent people can give informed consent and notes that limited information is a psychological barrier to competence. If you are unable to communicate sufficient information, you will not have the patient's consent.

Current nursing practice
The nurse practising ear care is advised to consider and address his or her training needs by attending a recognised course and approaching skilled practitioners for peer support. It is no longer possible to accept a doctor's referral for specified ear treatment without personally assessing the patient and being competent in the practice of that treatment, according to current guidelines (Dimond, 1995; UKCC, 1996). The UKCC (1996) requires that nurses practice within the limitations of their knowledge and competence. This would include the delivery of ear care, wax removal and related health-promotion advice.

Otitis externa
Research strongly associates swimming in recreational freshwater, such as lakes and rivers, with otitis externa (van Asperen et al, 1995). Moreover, this risk increased with the number of days swimming - a factor attributed to diminishing of the meatal lining (Senturia et al, 1980). The infecting organism was found to be Pseudomonas aeruginosa in 83% of the target group; this organism was present in all the lakes tested, all of which met European Commission standards (Van Asperen et al, 1995). Rubin (1988) also found Pseudomonas aeruginosa to be the causative organism when investigating the cause for malignant otitis externa in patients with diabetes.

British sea water has also been associated with ear infection and failed European Commission standards for Pseudomonas aeruginosa (Balarajan et al, 1991). The Environment Agency (personal communication, October 2000) confirms that British waters are not tested for Pseudomonas aeruginosa during quality testing.

Patients who are prone to ear problems must be advised to keep their ears dry when swimming and bathing; using plugs of cotton-wool coated in vaseline or ear plugs in the ears during swimming and bathing is recommended (Jobbins, 1988; Harkin, 2000).

Ear syringing
This is the traditional approach to cleaning the ear. Contraindications to ear syringing include:

- A history of any form of ear surgery

- Profound hearing loss in one ear: in the interests of protecting the hearing ear from the complications of syringing

- A history of perforated tympanic membrane: healed perforations lack the central fibrous layer and are thus weaker

- Recent or current middle ear infection

- Recent or current otitis externa.

Ear syringing will lead to a wet external auditory canal. This can harbour bacteria, macerate the canal lining and is a precipitating factor for otitis externa (Harkin, 2000; Briggs, 1995; Bojrab et al, 1996; Jobbins, 1988; Rogers, 2000). Such evidence further supports the need to dry the canal following syringing. This procedure is one part of a technique called aural toilet.

Aural toilet
In view of these considerations and the argument for drying the ear following syringing (Rogers, 2000), it would be reasonable to suggest that nurses should be trained and equipped to practise aural toilet with tools as a first-line approach to ear care. Aural toilet is the term used for manually cleaning the external auditory meatus of wax, debris or water. It is the primary treatment for otitis externa (Reilly et al, 1991). Tools required for aural toilet include the Jobson Horn probe and Henckle forceps, which must be used under a direct headlight (Reilly et al, 1991; Harkin and Rodgers, 1999). This equipment is available on a no-profit basis from the Primary Ear Care Centre in Rotherham.

Aural toilet can be performed by practice nurses following suitable training. Such skills can be taught during a single ear-care study day with subsequent clinical supervision, or a five-day course where practice on patients is supervised. Skilled practice is essential to avoid trauma to the delicate canal lining (Zivic and King, 1993). The significant expansion of new skills involved should be followed by a period of supervision in practice, before confidence and competence is achieved (UKCC, 1992; UKCC, 1996). Nurses who complete the five-day training become equipped to deliver nurse-led ear care.

The need for effective, clear communication with patients requiring ear care has been identified as it affects the psychological comfort of the patient presenting with ear problems, the issue of informed consent, patient education and health promotion delivery. The damaging effects of water in the ear have been noted and the use of aural toilet as a first-line approach to ear care discussed. It has been concluded that, with appropriate training, nurse-led services can effectively meet the need for competent, easily accessed and cost-effective ear care.

van Asperen, I.A., De Rover, C.M., Schijven, J.F. et al. (1995) Risk of otitis externa after swimming in recreational freshwater lakes containing Pseudomonas aeruginosa. British Medical Journal 311: 1407-1410.

Balarajan, R., Raleigh, V.S., Yuen, P. et al. (1991)Health risks associated with bathing in sea water. British Medical Journal 303: 1444-1445.

Briggs, R. (1995)Otitis externa: presentation and management. Australian Family Physician 24: 10, 1859-1864.

Bojrab, D., Bruderly, T., Abdulrazzak, Y. (1996)Otitis externa. Otolaryngologic Clinics of North America 29: 5, 761-781.

Dimond, B. (1995)Legal Aspects of Nursing (2nd edn). London: Prentice Hall.

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Edwards, S. (1996)Nursing Ethics. London: Macmillan.

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Jobbins, D. (1988)Otitis externa when the problem persists. Current Therapeutics 29: 5, 89-99.

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Rubin, J., Yu, V.L., Stool, S.E. (1988)Malignant otitis externa in children. Journal of Paediatrics December, 965-970.

Rogers, R. (2000)Understand the legalities of ear syringing. Practice Nurse 19: 4, 166-169.

Senturia, B., Marcus, M., Lucente, F., (1980)Diseases of the external ear. An otologic-dermatologic manual. New York: Grune and Stratton.

Sharp, J.F., Wilson, J.A., Ross, L., Barr-Hamilton, R.M. (1990)Ear wax removal: a survey of current practice. British Medical Journal 301: 1251-1253.

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UKCC. (1996)The Code of Professional Practice. London: UKCC.

Zivic, R., King, S. (1993)Cerumen-impaction: management for clients of all ages. Nurse Practitioner 18: 3, 29-39.

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