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The nurse's role in bowel awareness

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VOL: 98, ISSUE: 14, PAGE NO: 42

Elaine Swan, BN, RGN, is advanced nurse practitioner - colorectal, Walsall Manor Hospital, West Midlands

Most people take good health for granted until illness interferes with their daily lives, but increasing numbers are becoming more health conscious. The Health of the Nation (Department of Health, 1992) sets targets for the promotion of good health and prevention of ill health, but as the UK's population ages the demand for health care will increase because older people are more likely to become ill.

Most people take good health for granted until illness interferes with their daily lives, but increasing numbers are becoming more health conscious. The Health of the Nation (Department of Health, 1992) sets targets for the promotion of good health and prevention of ill health, but as the UK's population ages the demand for health care will increase because older people are more likely to become ill.

Until recently health services focused on illness, with cure the traditionally designated responsibility of medicine and care that of nurses. However, nurses are becoming more involved with relatively healthy people, aiming to raise levels of public health through health promotion, monitoring and support.

Health education and promotion
The goal of health education is to inform people about disease prevention, motivate them to change their behaviours and equip them with the skills they need to maintain a healthy lifestyle. Nursing is changing to meet these needs, including the use of needs assessments based on a methodical framework that offers information, advice and comfort to patients and carers, while acknowledging their individuality and delivering effective care. Evaluation, effectiveness and value for money are key issues.

Health promotion recognises the need to change the way we live to foster better health. It represents a mediating strategy between people and their environments, synthesising personal choice and social responsibility in health (World Health Organization, 1984). Health education is an integral part of health promotion (Naidoo and Wills, 1994).

The colorectal nurse and bowel awareness
The colorectal nurse specialist must be aware of patients' needs, address them and constantly evaluate the effectiveness and efficiency of any planned strategy. There are about 28,000 new cases of colorectal cancer recorded in the UK every year. It is second only to cancer of the bronchus as the leading cause of cancer death and has an annual mortality rate of about 19,000 (Jones, 1999).

Some people are shocked and disgusted when told they need bowel surgery, such as an ostomy, as this type of surgery reverses the healthy body image they usually have of themselves (Salter, 1988). If surgery is performed to remove a cancer, they may also feel uncertain about the prognosis. Patients need to be allowed to explore feelings about their illness and surgery to identify any problems and help them come to terms with them.

Stoma surgery affects all ages and some people cope well, with few problems, while others need specific help and follow-up. Nurses become experts at coaching patients through illness (Banner and Wrubel, 1989).

A highly individualised approach to assessment and planning, which empowers the patient through self-awareness, self-esteem and control over decision-making, is the best way to encourage healthy living after illness (Wilson-Barnett and Macleod-Clark, 1993). This can be achieved through groupwork; practising decision-making; values clarification; training in social skills; simulation, gaming and role play; assertiveness training or counselling (Ewles and Simnett, 1992). The methods selected will depend on the patient.

The strategy outlined in this paper is based on the Tones model (Fig 1; Tones et al, 1990), a simple equation in which health promotion is represented as a process that combines public policy and education. Health education consists of two strands, education and information, which enables people to make informed choices. Empowerment, as opposed to prevention or a radical political approach, is the main aim of health promotion in the Tones model (Naidoo and Wills, 1994).

Education for health
The Tones model of health promotion is easy to adapt for use in colorectal nursing services. Health education and public policy work together to empower individuals, groups and communities, enabling them to take greater control of their lives. Education for health is aimed at patients, carers, health care workers and the community at large, the object being to raise critical consciousness of the subject and make it more acceptable.

The way nurses perform a procedure influences how patients perform it. If the nurse reacts with distaste the patient will be inclined to feel repulsed, lowering self-esteem. Enthusiasm is contagious and helps people who feel tense to channel their anxieties into more useful energy (Babcock and Miller, 1994).

Health care staff should be formally and informally educated to enable them to understand this specialist area of care. During intimate moments of care-giving or when teaching procedures, patients may divulge thoughts or feelings about their circumstances, the exploration of which should be encouraged. Other methods of exploration include role play and values clarification. Revisiting how a patient has coped with difficult situations in the past can help build self-esteem by focusing on the positive aspects.

Older people often assume that physical changes are the result of age rather than a symptom of a correctable process. Understanding enhances both the retention and recall of memory, and repetition helps people of all ages to retain information. The imaginative use of learning material also makes it easier to recall. However, older people's need for and understanding of health education differ from other age groups. The variables to take into account when planning and implementing a strategy include psychosocial development and the physiological changes associated with ageing (Babcock and Miller, 1994).

Health education empowers patients to make choices and decisions. Whether these are good or bad, patients have a right to make their own decisions after considering the information received, and nurses should act as their advocates by promoting informed choice. Blame should be avoided as this can be counterproductive and unethical. Tones (1993) emphasises that illness is not simply the individual's responsibility and that many factors contribute to it, including social and environmental circumstances.

Collaboration between the patient and the nurse is essential. Each may define health and illness differently, so they may disagree on the plan of care. The nurse should not try to change the patient's mind but should work with and involve the patient in determining the plan of care. Family members/carers must be included in the planning process where appropriate (Cookfair, 1991).

Patients' success in managing their condition depends on their personal strategies and social support, including family, friends and colleagues. Health education via the media, bowel-awareness open days and displays in local health centres help to empower patients in their daily lives.

Patients usually grieve the loss of normal elimination methods and previous body image for a long time, so it is important for colorectal nurses to work with their families and carers to help them understand the practicalities and the effect on body image of living with a stoma. Patients should be encouraged to work through their grief as this can reassure them that they will regain control of their lives and resume an active lifestyle. This means providing the family with the necessary support, for example through voluntary and self-help groups, and ensuring that they have a contact number for the colorectal nurse (Price, 1990).

Self-help groups can help people to manage such situations (Gidron and Hasenfeld, 1994). Nurses need to understand the role of experiential knowledge and its value to patients in regaining and maintaining their health status (Simpson, 1996), and should work with these groups to promote an understanding of each other's roles.

Patients may feel stigmatised by society, their families or employers, but this can be minimised by educating the public and improving public policy, for example, through lobbying, advocacy or mediation (Tones, 1993). This could involve local councillors, MPs, church officials, and voluntary and health care organisations. The issues that need to be raised include increasing public awareness of the early detection of bowel cancer, the dietary implications, research, quality-of-life issues and surgical techniques.

Referral guidelines
The recent GP referral guidelines for suspected cancer (Department of Health, 2000) aim to improve the process so that most patients with high-risk symptoms are seen within two weeks. Patients with new and persistent higher-risk symptoms (Box 1) should be referred to the fast-track system.

The health needs of any particular area need to be identified and strategies proposed to address the needs of the community, using a model and health education theory. These needs can then be met in the ways outlined in this strategy. Patients' autonomy should be enhanced, enabling them to take greater control of their lives and to regain their previous lifestyle. Health promotion using such a model may also begin to change attitudes, practice and policy.

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