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Nurses' hidden work

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VOL: 98, ISSUE: 04, PAGE NO: 53

Marlene Powell, BSc, RGN, DipN, FEATC, is continence adviser, St Martins Hospital, Bath

Many nurses in clinical practice today view the management of personal hygiene as low-status work. It may be regarded as being on the fringe of respectability (Lawler, 1991) and undertaken as a soft option (Doyal, 1995).

Many nurses in clinical practice today view the management of personal hygiene as low-status work. It may be regarded as being on the fringe of respectability (Lawler, 1991) and undertaken as a soft option (Doyal, 1995).

Embarrassment may cause people with bowel problems to suffer in silence for many years. Yet if both nurses and patients could overcome these deep-rooted emotional and cultural barriers the quality of life for people with bowel dysfunction could be greatly improved. Embarrassment can be a two-way experience. Nurses are not taught formally how to manage embarrassment (Lawler, 1991), although this inability may improve with experience.

The best nursing practitioners seek to understand the meaning of the illness in order to facilitate treatment and cure. Nurses will only be able to improve care to people with bowel problems if they are given the opportunity to develop their assessment skills. This will give nurses a better understanding of not only the physiological aspects but also the social and psychological problems associated with bowel dysfunction. Helping patients to understand how their bodies work should lead to better compliance with management options, in turn leading to improved quality of life.

Psychological implications
The psychological implications of bowel dysfunction are many. It can lead to feelings of remorse, guilt, uncleanliness and a misconception of what is normal. It is still common for sufferers to hide their bowel problems for many years while they develop complicated coping mechanisms. This results in chronic constipation, obsessive purging and cleanliness. For example, Mary Burke was an elderly but very fit retired midwife who got up every morning at five to allow the previous night's laxatives to clear her bowel in time for the day's activities. After assessment by her local continence adviser we were able to give her other options for managing her bowel routine: she needed to re-learn pelvic floor exercises and benefited from neuromuscular stimulation to improve pelvic floor strength. It would have been easy for us to assume that as a midwife she was practising the exercises correctly, and we may have given her up as a lost cause.

Coping strategies
It is important to understand the origins of long-standing coping strategies. For example, a well-meaning doctor advised one mother who was suffering postnatally with horrendous piles to ease the passage of the stools using Vaseline. Thirty-five years later she can now only have a bowel action twice weekly using the same procedure, plus digital stimulation and suppositories. After several visits to the local continence advisory clinic we initiated a management strategy when the woman herself stated that she would like to be able to go to the toilet normally. Childbirth is a significant factor in faecal incontinence and health promotion strategies should include early identification of those at risk.

Presentation of faecal incontinence
Faecal incontinence has a number of different presentations. Passive loss of stool may happen when voiding with no apparent sensation of stool in the rectum. The only signal may have been a dampness around the anus or, even worse, just noticing the smell. A very embarrassing problem for both men and women is the inability to control flatus. Bowel incontinence, in particular, can have a devastating effect on personal and sexual relationships. Sufferers keep their secret to themselves for many years, although they may be in a loving and stable relationship.

Fear of embarrassing accidents in public may make the sufferer retreat from normal life and, due to lack of understanding of the problem by both health professionals and the general public alike, they may never seek help. It is possible to break down these barriers that have been built up over the years. Nurses in most clinical areas talk to patients about their bowel problems and need to use all their nursing skills, intuition, empathy, communication and knowledge of how the body works in the assessment of bowel function.

Assessment
The longer a person has had a bowel problem the more difficult it is to regain control. For example, a pre-school child may react to the arrival of a new baby by soiling to gain attention. If the soiling continues the bowel is allowed to develop irregular habits. Combine this with today's busy stressful lifestyle for parents, the use of convenience foods and often erratic meal times and the situation is compounded.

Children who soil may experience bullying because of the smell and this can affect school work. However, with multidisciplinary working it is possible to give psychological as well as practical advice in order to restore self-esteem and, eventually, normal bowel routines. Failure to address the problem of bowel dysfunction in childhood means that young adults may develop complicated routines to hide faecal incontinence, and sometimes their closest family are unaware of their problem.

Seeking help is difficult. Many people live in a nightmare world ruled both physically and mentally by their bowel problems. Fear of having accidents, using public toilets, making a noise or a smell can keep people prisoner in their own home. Planning a trip away from home may involve coping mechanisms such as starving the previous day, to remove the possibility of needing to use a toilet while away.

Counselling and psychotherapy can play a big part in helping sufferers deal with their problem, but this is not available in many areas. There is much more that can be done to help those with bowel problems. With improved nursing skills, in many cases it is possible to affect a complete cure. All nurses, midwives and health visitors should develop these skills.

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