What can community nurses do for older adults who experience faecal incontinence?

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).

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