Innovative Strategies and Ethical Considerations in the Management of Faecal Incontinence

Executive summary:

Faecal incontinence has become a matter of concern in the modern healthcare field, that poses an adverse impact on the quality of life, daily activities and social relationship of people. Uk is reported to have ever-increasing cases of faecal incontinence in which elderly people are more prevalent to this health condition. As there is limited evidence-based intervention regarding managing this health condition nursing professionals need to be highly efficient in assessing the physical health of patients and carrying out relevant therapies to improve the overall bowel movement in patients with this health condition. This report will demonstrate how rehabilitation nurses can implement innovative techniques while managing health condition in patients suffering from faecal incontinence. Here the report will present a critical discussion on how effectively rehabilitation nurses can implement ethical and legal guidelines to manage the care needs of patients suffering from faecal incontinence.

Introduction:

Faecal incontinence is the health condition which develops due to several factors such as age-related issues, chronic health condition and injuries. This health condition is associated with developing significant stigma in affected people which not only affect their quality of life but also adversely impact on their social relationship. The UK is reported to have ever-increasing cases of faecal incontinence in which elderly people are more prevalent to this health condition. There are limited research and evidence-based practices on this health condition which makes it necessary for the rehabilitation nurses to have proper knowledge on the overall symptoms, sign and associated health outcomes of this health condition while treating any patients with faecal incontinence. In this context selection of this topic is relevant which is going to provide a new insight onto the roles of rehabilitation nurses in managing the health condition, faecal incontinence by conducting well-structured health assessment and therapeutic programme.

This report is going to discuss the innovative practices that the rehabilitation nurses can implement while managing health condition in patients suffering from faecal incontinence. By using relevant evidence, the report will present a critical discussion on how effectively rehabilitation nurses can implement these innovative care processes and treatment into practices by following the ethical and legal guidelines to manage the care needs of patients suffering from faecal incontinence. Finally, the report is going to present a suitable condition in which it summarises the main aspects of the entire discussion.

Discussion on innovative care processes used by rehabilitation nurses to manage faecal incontinence:

Well-structured health assessment of patients:

While it comes to manage faecal incontinence in patients, rehabilitation nurses need to conduct an effective and well-structured assessment of patient’s overall health condition (Duelund-Jakobsen et al. 2016). Assessment is the very first stage of a care plan developed for people suffering from faecal incontinence. As mentioned by Bardsley (2018), rehabilitation nurses need to be highly skilled and efficient in conducting the assessment process that is not only concerned with presenting the current health issues of the patients but also is associated with integrating the qualitative and quantitative data. The quantitative data consists of information about patient’s physical health status such as temperature, BP, pulse rate, oxygen saturation level and metabolism. On the other hand, qualitative data consists of the premedical history of the patient, past health condition, any specific health condition such as allergies and ongoing medication. NICE (2019) has set guidelines for assessing the health condition in adults suffering from faecal incontinence [NICE, 2019]. Under these guidelines, rehabilitation nurses need to follow the following pathways in conducting a well-structured assessment of faecal incontinence.

Physical examination:

Nurses carry out the general examination of the patient having faecal incontinence, such as checking the BP, sugar level, body temperature, pulse rate and oxygen saturation level. rehabilitation nurses who carry out these primary check-ups, need to have strig professional knowledge on conducting a perfect physical assessment of patients who are suffering from this health condition (Kirss et al. 2019). For example, while checking the body temperature or using the pulse oximeter or carrying out the blood test, rehabilitation nurses need to ensure that patients are irritated or disagreed to undertake these tests.

Nurses also make a proper assessment of a patient’s ability to go to the toilet independently. Here rehabilitation nurses will check whether the patients suffering from faecal incontinence can move freely from one place to another (in case of older people), whether they can use the toilet independently without any risk of falls and also they can wear their dresses after using the bathroom.

For assessment of faecal incontinence, registered rehabilitation nurses do the anorectal examination which includes

• Conducting a visual inspection of the patient's anus
• Carrying out examination of perineal descent
• Carrying digital rectal assessment for the anal tone to check the ability of anal sphincter to make voluntary movement
• Carrying out an examination as well as the assessment of faecal loading

Medical history:

Here rehabilitation nurses assess the history of bowel movement in patients. Under section 1.3 of NICE (2019) guidelines for the management of faecal incontinence, rehabilitation nurses need to check the bowel habits of patients to examine that whether there is any sign of gastrointestinal cancer that leads to rectal bleeding as well as changed bowel movement [NICE, 2019].

Rehabilitation nurses must check and evaluate the premedical data of patients to check whether they have a history of chronic illness such as diabetes (Litta et al. 2020). Additionally, rehabilitation nurses need to check that whether the patients have constipation or diarrhoea, terminal illness, acute severe health condition and cognitive impairments.

Nurses check whether the patients have any neurological disorder such as dementia, motor neuron disease (MND) and anxiety which can contribute to the development of faecal incontinence.

Nurses would check whether the patient has any history of recurrent falls or poor pelvic floor or obstetric history that can be considered as the facilitators for faecal incontinence. Here rehabilitation nurses would check whether patients have any history of huge birth weight, complications in delivery and post-partum health issues

While assessing the health of patient which suffer from faecal rehabilitation nurses will also check whether the patient has:

• Any history of perinatal trauma of surgery
• History of the urinary incontinence
• History of the rectal prolapse
• History of Type 1 diabetes

Perform medical review of patients:

Any healthcare assessment consists of a medical review in which health and nursing professional evaluate the current medical condition, ongoing medications and current treatment as well as care plan of the patients. Under NICE (2019), guidelines, rehabilitation nurses need to carry an effective medical review of patients suffering from faecal incontinence to check that:

• Whether the medicines or drugs taken by patients can exacerbate the incontinence of faecal incontinence [NICE, 2019]
• Whether there is any alteration or modification in the overall treatment process which becomes irrelevant to the current health condition of patients
• Whether there are any issues in the metabolic and gastrointestinal; function of patients

Dietary and fluid review:

Health assessment of patients is not only carrying out a physical examination and medical history analysis but also is concerned with analysing the eating habits, solid foods and fluids intake and choice of foods.

Here rehabilitation nurses would inquire about the snacks and meals consumed by patients on regular basis. rehabilitation nurses would also review the foods selection of patients against the list the foods that are recommended by a doctor (Mizrahi et al. 2017).

Reviewing the lifestyle and quality of living:

The occurrence of faecal incontinence in patients is not only associated with the premedical condition, current health condition and dietary intake of patients but also their lifestyle as well as living standard. As mentioned by Park et al. (2016)., people who lead irregular lifestyle such as skipping of meals, irregular sleeping pattern, lack of exercise, consumption of excessive junk foods and improper sleep, are highly prevalent to poor metabolic and gastrointestinal health which leads to the occurrence of faecal incontinence in them. Under NICE (2019) guideline for the management of faecal incontinence in adults, while carrying out the well-structures assessment of patients suffering from faecal incontinence, rehabilitation nurses need to analyse the overall, quality of living of patients. Rehabilitation nurses need to review:

• Eating habits, sleeping pattern and daily routine of patients
• Family and social culture
• Social activities performance by the patients
• Food choice, tradition, cultural values of patients
• Education, employment and financial status of the family
• Any history of bereavement or loss in a past life

Therapeutic process:

In case of improving the bowel movement in patients with faecal incontinence two main therapies processes are used by the nursing and healthcare professionals which are as follows:

Sphincter exercises:

This exercise is recommended to patients suffering from faecal incontinence. Rehabilitation nursess assist patients to perform the exercise on regular basis in terms of improving the function of their sphincter muscle (Ros et al. 2016). There ser set of sphincter exercises that can assist patients to strength their sphincter muscle thereby improving their bowel movement. In this therapeutic process, special rehabilitation nurses and continence therapists assist patients to track the improvement in their bowel movement after undertaking the therapeutic process of sphincter exercise. During this exercise, rehabilitation nurses and physiotherapists guide to the patient about how to contract and release the anal sphincter muscle regularly to improve the voluntary movement of the sphincter muscle. Patients can do the exercise by sitting, lying down and standing. Throughout the process rehabilitation nurses or continence, physiotherapists guide patients with faecal incontinence about how to squeeze the anal sphincter muscle and then hold it for 10 minutes and then release the muscle. Under NICE (2019) guidelines for faecal incontinence management, rehabilitation nurses need to assure that they have proper knowledge ad expertise in assisting a well as guiding patients with faecal incontinence [NICE, 2019]. Under the NMC codes of Conducts, rehabilitation nurses must work under their level of competence as well as professional knowledge while carrying out treatment for patients with faecal incontinence in terms of assuring patients’ safety.

Biofeedback therapy [BFT]:

Biofeedback therapy or BFT is the instrument-based learning tool that uses modern equipment in terms of amplifying and recording the anorectal activity of patients thereby providing proper feedback to patients as well as a therapist (van der Wilt et al. 2017). The purpose of BFT is to strengthen the function of pelvic floor muscles, coordinate the activity of pelvic, abdominal floor of sphincter muscles throughout the evacuation process and refrain the rectal sensation in the patient.

In case of patients with faecal incontinence, CFT is used by rehabilitation nurses to carry out the anal physiotherapy and the anal manometry that enhances to overall functional strength of anal sphincter muscle thereby improving the rectal sensation. Through using BFT rehabilitation nurses and physiotherapist can measure the anorectal pressure. There is a balloon manometry probe in the rectum and in the anal canal that can record the changes in the pressure during each manoeuvre.

Analysing the impact of policies on assessment and implementation of therapeutic treatment in managing faecal incontinence:

Under NICE (2019) guidelines for managing faecal incontinence in adults, the health assessment of the patient with faecal incontinence should be carried out by special rehabilitation nurses rather than general nurses. Under the Health and Social care Act 2015, rehabilitation nurses must adhere their duties to the professional Codes of conducts set by NICE (2019) in terms of ensuring safe and quality treatment process of faecal incontinence. As argued by Young et al. (2018) sometimes legal and statutory guidelines pose some ethical obligations rehabilitation nurses that are not relevant to the current care framework. Under Care Act (2014) while managing faecal incontinence, rehabilitation nurses need to ensure that they must respect the choice of treatment, decision a dignity of patients. Under NMC Codes of Conducts set for health professionals, rehabilitation nurses while managing faecal incontinence must take informed consent from patients and their family managers before applying any therapies. In this context, Abrams et al. (2018) argued that sometimes takin informed consent poses ethical dilemmas on rehabilitation nurses as patients and their family members do not provide their consent in carrying out the therapies such as BFT or sphincter exercises which then pose big challenges on the rehabilitation nurses to manage the health condition. Under Equality Act (2010), rehabilitation nurses need to ensure that patients with faecal incontinence would be protected from any kind of humiliations, abuse, discrimination and harm. NICE (2019) guidelines for managing faecal incontinence in adults, emphasize on the fact that rehabilitation nurses need to follow the health and social care legislation while treating faecal incontinence in patients thereby ensuring that they offer systematic and highly effective care to patients.

Quality assurance:

While managing faecal rehabilitation nurses can carry out the following function to assure the quality of the overall care process:

Conducting self-assessment of nursing professionals to improve their ability to carry out the overall assessment of patients with faecal incontinence and therapeutic process effectively (Abrams et al. 2018)

Tracking the progress of the patient’s bowel movement on regular basis to analyse usefulness of the physical assessment and therapies

Setting proper risk assessment framework in the nursing practices which will enable rehabilitation nurses to overcome any work-related risk thereby ensuring the overall quality care process

Conclusion:

From the above-mentioned discussion, it can be concluded that faecal incontinence has become a matter of concern in the modern healthcare field, that poses adverse impact on the quality of life, daily activities and social relationship of people. As there is limited evidence-based intervention regarding managing this health condition nursing professionals need to be highly efficient in assessing the physical health of patients and carrying out relevant therapies to improve the overall bowel movement in patients with this health condition.

Reference list:

• Abrams, P., Andersson, K.E., Apostolidis, A., Birder, L., Bliss, D., Brubaker, L., Cardozo, L., Castro-Diaz, D., O'connell, P.R., Cottenden, A. and Cotterill, N., 2018. 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. Neurourology and urodynamics, 37(7), pp.2271-2272.
• Bardsley, A., 2018. Assessment, prevention and treatment of faecal incontinence in older people. Nursing Older People, 30(6).
• Duelund-Jakobsen, J., Worsoe, J., Lundby, L., Christensen, P. and Krogh, K., 2016. Management of patients with faecal incontinence. Therapeutic advances in gastroenterology, 9(1), pp.86-97.
• Kirss Jr, J., Pinta, T., Varpe, P., Rautio, T., Kairaluoma, M., Hyöty, M., Hurme, S., Böckelman, C., Kairaluoma, V., Salmenkylä, S. and Victorzon, M., 2019. Outcomes of treatment of faecal incontinence with sacral nerve stimulation–a Finnish multicentre study. Colorectal Disease, 21(1), pp.59-65.
• Litta, F., Parello, A., De Simone, V., Campennì, P., Orefice, R., Marra, A.A., Goglia, M., Moroni, R. and Ratto, C., 2020. Efficacy of Sphinkeeper™ implant in treating faecal incontinence. The British journal of surgery, 107(5), p.484.
• Mizrahi, I., Chadi, S.A., Haim, N., Sands, D.R., Gurland, B., Zutshi, M., Wexner, S.D. and da Silva, G., 2017. Sacral neuromodulation for the treatment of faecal incontinence following proctectomy. Colorectal Disease, 19(5), pp.O145-O152.
• Park, E.J., Kang, J. and Baik, S.H., 2016. Treatment of faecal incontinence using allogeneic-adipose-derived mesenchymal stem cells: a study protocol for a pilot randomised controlled trial. BMJ open, 6(2), p.e010450.
• Ros, E.P., Banos, P.P., Buleje, J.B., Camarena, J.M., Segade, C.E., Arenas, M.C., Valverde, F.G. and Marín-Blázquez, A.A., 2016. Short-term outcome of percutaneous posterior tibial nerve stimulation (PTNS) for the treatment of faecal incontinence. Techniques in coloproctology, 20(1), pp.19-24.
• van der Wilt, A.A., Giuliani, G., Kubis, C., van Wunnik, B.P., Ferreira, I., Breukink, S.O., Lehur, P.A., La Torre, F. and Baeten, C.G.M.I., 2017. Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence. British Journal of Surgery, 104(9), pp.1167-1176.
• Young, C.J., Zahid, A., Koh, C.E., Young, J.M., Byrne, C.M., Solomon, M.J., Rex, J. and Candido, J., 2018. A randomized controlled trial of four different regimes of biofeedback programme in the treatment of faecal incontinence. Colorectal Disease, 20(4), pp.312-320.

Appendix:

Faecal incontinence:

Therapeutic programme: