Faecal incontinence has multiple clinical signs and symptoms, and it has a catastropihc impact on an individual's quality of life. The signs and symptoms of faecal incontinence may vary from persistent protraction to rapid presentation (RCN, 2012). The prevalence of faecal incontinence is higher in the older population; however, health professionals must not accept that bowel dysfunction is an inevitable part of the aging process. Faecal incontinence is multidimensional with various comorbidities from fragility, urinary incontinence, faecal loading, structural abnormalities, cognitive impairment, functional disabilities, neurological disorders and depression (Goodman et al, 2017; Russell et al, 2017). It can negatively alter an individuals' lifestyle, causing social isolation, embarrassment, despair and even physiological discomfort, distress and pain (Markland, 2010; Razjouyan et al, 2015).
Faecal incontinence can be defined as involuntary loss of liquid or solid stool, which is a social and hygienic concern (Norton et al, 2010). Some individuals clinically experience a strong urgency and desire to defecate, which is classified as urge faecal incontinence; in contrast, others may be unaware of the need to defecate, which results in passage of liquid or solid stool and is classified as passive faecal incontinence (RCN, 2012). Community nurses are central figures within the heart of the multidisciplinary team of professions to clinically recognise and respond to individuals' continence needs and provide physiological, psychological and spiritual support to patients with the distressing, disturbing and difficult symptoms of faecal incontinence (Smith, 2010; Saldana Ruiz and Kaiser, 2017; Barrie, 2018).
Communication, engagement, education and empowerment
The incidence of faecal incontinence in the older population can vary dramatically depending on the definition used and the setting in which the people live. Individuals in a residential setting present with higher statistical rates of faecal incontinence, with appropriately 12-22% of this population displaying symptoms, compared to older people living in the community, for whom the recorded figures are as low as 1-10% (Macmillian et al, 2004; NICE, 2007; Harari et al, 2014). Older people may apprehensively conceal faecal incontinence symptoms because of anxiety, fear and embarrassment; however, nurses must invite open dialogue and engage in active listening to encourage patients to willingly express their symptoms. Edwards and Jones (2001) identified that over 50% of older people with faecal incontinence symptoms did not discuss their symptoms with any health professionals. Mcalearney (2006) identified the importance of communication as a core competency for the nursing profession, which accordingly stimulates trust, transparency, accountability and empowerment in the entire healthcare structure. Communication is fundamental for developing the nurse-patient relationship and provision of high-quality, patient-centered care (Quality Improvement Division, Health Service Executive, 2015). A paradigm of continence promotion approaches in the community setting will improve the health and wellbeing outcomes for individuals as they progress into old age (Perry et al, 2002).
In addition to communication, consultation and collaboration with patients and their families, nurses must develop interpersonal skills that can be utilised with peers and colleagues in multidisciplinary teams. Effective multidisciplinary teamwork has been shown to improve patient outcomes, shorten patients' length of stay if hospitalised and increase patient satisfaction, in addition to providing job satisfaction and improved job performance among all staff involved (Epstein, 2014).
Assessment, planning, implementation and evaluation
A holistic faecal incontinence assessment will clinically feature a comprehensive history taking, which objectively involves recording dietary intake and bowel pattern and noting the size, consistency and frequency of stool with reference to the Bristol Stool Scale (NICE, 2007; Gage et al, 2010). Other factors that should be assessed include past medical and surgical history, obstetrical injury, food consumed, fluid intake, dose and duration of prescription and over-the-counter medications and the current management plan (Vaizey, 2014). Objective measurable analysis can be applied to the assessment process for individuals with incontinence, although subjective holistic assessment incorporating psychosocial, sexual and spiritual wellbeing is also vital in the area of continence promotion (Thompson and Smith, 2002). The timeframe when symptoms were initially experienced should be recorded, as the onset of menopause may trigger symptomatic faecal incontinence years after an obstetrical injury has occurred (Saldana Ruiz and Kaiser, 2017). Perry et al (2002) identified that once they were initially assessed, individuals with symptoms of faecal incontinence positively embraced and engaged with health professionals to improve their quality of life and reduce the stigma of incontinence.
The engagement of the multidisciplinary team-general practitioner, gastro enterologist and physiotherapist is essential to enhance quality health outcomes for individuals with faecal incontinence (Smith, 2010). Community nurses face challenges in supporting, sustaining, guiding, assessing, examining and implementing treatment interventions. Nurses are crucial health professionals in the community setting to undertake assessment, establish evidence-based treatment interventions and conduct clinical evaluation with emphases on patient-centered care principles adhering to patient satisfaction, values, belief and eminence of wellbeing (Brown Wilson, 2009). There is a need for privacy, respect and dignity with collaborative engagement and enthusiastic involvement of all stakeholders to initially assess and subsequently implement quality treatment interventions (Walsh and Kowanko, 2002), rather than recommending passive management plans, such as prescribing disposable containment products. Conservative treatment strategies to improve faecal incontinence will enhance patient dignity, respectability and bowel control, thus improving patients' physical and psychological wellbeing and reducing feelings of vulnerability (Walsh and Kowanko, 2002). The implementation of treatment interventions may be challenging and complex, although constructive, for community nurses, as knowledge of causative factors, results of examinations, investigations, patient preferences and analysis of assessment process is required (Saldana Ruiz and Kaiser, 2017). Individualised treatment plans should be based on the objective findings of continence assessment in accordance with local, national and international guidelines (Smith, 2010). Conservative interventions should include lifestyle advice, which can vary from establishing a toileting routine encouraging evacuation of bowels after meals by utilising the gastrocolic reflex to the regulation of diet, fluid intake and referral to the multidisciplinary team of professionals (also see Box 1 and Box 2) (Norton et al, 2007).
| Type of product | Indications and contraindications | Examples |
|---|---|---|
| Barrier creams with dimethicone, a silicone-based polymer that moisturises skin and repels water | Safe to use on damaged skin, moisturises skin and provides a long-lasting barrier to protect skin |
|
| Barrier films. These liquid barrier films are alcohol free and dry to form a breathable transparent cover, lasting up to 72 hours | Safe to use on damaged skin, provides a long lasting barrier to protect skin |
|
| Barrier creams with cetrimide, a compound of different quaternary ammonium salts. It has antiseptic properties | It is thought that the antibacterial qualities of cetrimide reduce the risk of skin damage when incontinence occurs |
|
| Barrier creams with honey. Medihoney has antibacterial and moisturising properties | Used to prevent skin damage, to treat candidas and intertrigo. Can be applied to damaged skin |
|
| Barrier creams with local anaesthetics | Used to sooth sore skin, require frequent, 3–4 times daily application If used too thickly, may impair absorption of urine in incontinence pads |
|
source: Van Olsen, 2018
| Category | Example of indications | Example of products available |
|---|---|---|
| Low-volume device | Faceal incontinence |
Qufora® IrriSedo Mini system |
| Cone devices | Slow transit constipation | IryPump® |
| Catheter/balloon devices | Faecal incontinence |
Peristeen |
| Bed systems | Neurogenic bowel dysfunction in bed-bound individuals | Qufora® IrriSedo Bed system |
Adapted from Figure 1, Lancashire Medicine Management Group, 2009; Emmanuel et al, 2013
Following the assessment process, immediate referral to specialist gastroentrology services for investigations should occur if critical red flag symptoms are identified, such as weight loss, blood in stool, rectal bleeding, abdominal cramping, pain, the presence of mucus, nausea and vomiting (NICE, 2007). Additionally, if conservative strategies are not successful, appropriate specialist referral no matter what the age profile of the patient should be recommended (Orrell et al, 2013).
Professional development
An effective and efficient education programme on continence promotion among nurses will improve attitudes, viewpoints, values and knowledge of incontinence in older adults through the implementation of evidence-based policies, procedures and standards (Orrell et al, 2013). There is a need for continuous competence training of community nurses on continence promotion strategies, thus encouraging and enhancing interaction, communication and consultation with all stakeholders (family members, physiotherapists, occupational therapists and general practitioners) to ultimately empower patients with faecal incontinence to self-manage (Gillibrand, 2012). Continence education for community nurses will enhance quality health outcomes for patients (Perry et al, 2002). Additionally, Thyer (2003) proposes the role of nurses as philosophers who participate in continuous learning and thus transform their clinical practice and adopt advocacy approaches for the patients they care for.
Community nurses are pivotally positioned within their clinical practice, culture and society to communicate with, assess, care for, educate and empower patients, their families or caregivers and allied health professionals to promote quality continence and health outcomes (Kelly and Jordan, 2015). They must be expertly equipped with evidence-based skills, knowledge and quality-assured education to follow the essential principles of encouragement and empowerment of patients in developing the competence of self-efficacy, duly preventing progression of conditions into chronic complications (Smith, 2010). Advanced practice and clinical specialist continence nurses who have expertise in continence promotion should educate community nurses, caregivers, family members and patients to overcome the challenges of faecal incontinence. This education evolution will happen when engagement, interaction, collaboration and cooperation occur, with nurses being cognizant of patients' personal beliefs, values and community or cultural preferences (Schonwetter et al, 2002).
Conclusion
Faecal incontinence sign and symptoms can be common in older people, with various clinical presentations. Through their diverse and dynamic role, community nurses can act as advocates to improve care for community-dwelling older adults with faecal incontinence. Community nurses should undertake individualised standardised continence assessment, implement proactive treatment interventions and decisively evaluate the service provided (Harari et al, 2014). Once the community nurse completes the faecal incontinence assessment, comprehensive evident-based treatment interventions on continence promotion should follow, rather than passively providing disposable products to manage faecal incontinence (Orrell et al, 2013). Proactive interventions that are rooted in evidence-based treatment stimulate health professionals to critically think and develop analytical skills to enhance quality health outcomes for affected individuals (Brookfield and Preskill, 2005). Local, national and international evidence-based guidelines assist community nurses in the area of continence promotion by highlighting the importance of assessment, identifying active treatment interventions and constant evaluation and providing knowledge to promote quality health outcomes for patients with faecal incontinence (NICE 2007; Norton et al, 2010).