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Practice comment

''We must invest in diarrhoea assessment skills for staff''


Bowel care lies at the heart of person-centred care

Like urine output, it gives a unique indication of patients’ condition, body functioning and how they are responding to treatment. However, the varied spectrum of “normal” bowel function can present nurses with a challenge - namely, assessing what is normal for a particular individual and when an indication exists that shows something is not right.

Diarrhoea receives much attention, mainly as a result of its association with infections such as C difficile and norovirus. Both infections are clinically important and can cause significant day-to-day operational challenges for inpatient settings.

C difficile is also politically sensitive as significant exposure following large outbreaks in the UK has been linked to poor cohesive infection prevention management and, in some cases, poor organisational management. This political sensitivity has led to targets being introduced to cut the number of C difficile cases in the NHS year on year, which have been successful to date.

This focus on C difficile reduction has unintentionally heightened sensitivity to the presence of diarrhoea and loose stools. At times, this has become an almost automatic suspicion of infection, despite transmission of C difficile rarely being seen in healthcare settings today.

Nurses are quietly expressing a loss of confidence and knowledge in fundamental nursing assessments as a first intervention for patients with diarrhoea. They know diarrhoea is important and react to exclude infection but, at the same time, some say they are not allowed to take faecal specimens unless approved by medical staff. Such scenarios are likely driven by anxiety over financial penalties, as well as ongoing debate over testing methods and what constitutes C difficile infection. This diverts focus away from the patient and the fundamental implications of diarrhoea as a symptom of underlying pathology or the body’s reaction to disease, treatment or hospitalisation.

Energy must be applied to investing in assessment skills for staff and the proactive care and management of patients. Infection prevention and control should not be used to justify avoiding or delaying testing to suit methodological contentions. Nurses must take a step back and regain confidence in assessing diarrhoea. Improving practice will improve patient outcomes and help the profession avoid criticism for reacting to the first episode of loose stool or diarrhoea, or aperient (laxative effect) overdose.

Nurses can make a real difference to individuals’ experiences of care if nurses are supported to recognise and avoid constipation and overflow (frequently mistaken for diarrhoea) and understand the complexity of diarrhoea, particularly during end-of-life care. Prioritising improvements in knowledge and assessment skills can only enhance the holistic care of patients. Focus and energy must always remain with individual patients and their symptoms, not political sensitivities. Prioritise this and the rest will follow.

Rose Gallagher is nurse adviser infection prevention and control, Royal College of Nursing.

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Readers' comments (3)

  • An unfortunate first sentence. Good article otherwise.

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  • tinkerbell

    bowels now have a new location.

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  • I think bowels are hugely neglected in the elderly these days. Years ago patients bowels were closely monitored and if they hadn't been for three days they were given a mild enema and boy did they feel better for it. These days due to consent issues it is overlooked and I've seen patients with overflow being mistaken for diarrhoea and needless samples being taken etc. No one seems to want to do that job anymore and yet in my day we just got on with it.

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