Bowel problem management among nursing home residents: a mixed methods study

Faecal incontinence (FI) and constipation are prevalent conditions among nursing home residents [1],[2]. The conditions cause difficulty with hygiene, skin problems, pain and discomfort, as well as having serious implications for residents' dignity [3]. Bowel problems are a professional challenge for nursing home staff. In addition, FI is associated with high costs related to pad use, time spent by staff to wash and change patients, laundry expenses, skin damage and infections. A nursing home is a place of residence for people with health problems and significant deficiencies in activities of daily living (ADL), requiring medical or nursing care. Nursing home residents could be described as "frail older persons who have impaired physical activity, mobility, muscle strength, cognition, nutrition, and endurance" [2]. Nursing home residents are a particularly vulnerable population as they have lost the independence to live in the community through illness, disability and frailty. At the same time, recognition of the unique skill of nursing home staff is low [4]. Life expectancy will increase in the in the coming decades, however often with accompanying morbidities [5]. These demographic changes will constitute a significant challenge for the health care systems involved, particularly nursing homes. RNs spend a lot of time managing residents' bowel problems in nursing homes and they have a key role in the assessment, prevention and management of bowel problems. However, there is little evidence on how RNs actually manage bowel problems and the quality of the interventions performed.

In order to obtain information about how RNs manage bowel problems among nursing home residents, cross-sectional data were collected. RNs filled in a questionnaire regarding bowel interventions for all nursing home residents in one Norwegian municipality. In addition, in order to shed some light on the quantitative data, a qualitative focus group interview with RNs was used. A focus group interview is a technique used to obtain dynamic and interactive discussion to clarify the informants' perceptions and experiences and is especially useful to reveal shared understanding and practice [28]. Using a mixed method approach, descriptive data from the population based cross-sectional study, was combined with rich qualitative data from a focus group interview to offer a more comprehensive picture of RNs' bowel management practices in nursing homes [29]. This study was carried out in accordance with Declaration of Helsinki and The Regional Committee for Medical and Health research Ethics, REC South East, approved the study (2009/1225). No consent from residents or their next of kin was required by the ethical committee because all the resident information gathered was de-identified and anonymous to the researcher. The participants in the focus group interview gave their written informed consent to participate in the study.

The quantitative data demonstrated that the use of pads and fixed toilet schedules were the most commonly used interventions for FI (Table 1). Additionally, the qualitative data showed that controlled emptying of the bowels (using laxatives and/or enemas) was used (Table 3). These findings are in accordance with results from the few studies existing on this topic; namely that toileting and pads were commonly used by the nursing home staff [26]. In the questionnaire used in this study, the RNs answered questions regarding what kinds of remedies/interventions were used for incontinence, thereby including both urinary and FI. However, in the focus group interview we did not focus on urinary incontinence. Pads were used for both urinary and FI and it is not likely that the RNs would be able to differentiate pad usage between the two. In addition, it seems likely that the RNs did not only have defecation in mind when the residents were toileted at fixed schedules, but also bladder emptying. This reveals that nursing is complex to measure and that it is not always easy to isolate specific nursing actions.

Regarding constipation, the quantitative data demonstrated that laxative use and enemas were common measures, as well as dietary interventions and manual emptying of faeces. In addition, the qualitative data showed that the RNs also used fixed toilet schedules to prevent constipation. Regarding diarrhoea, the quantitative data demonstrated that the RNs mainly managed the residents' diarrhoea with Loperamide and dietary interventions. The qualitative data demonstrated the RNs' reflections and considerations that were a part of their daily life regarding residents' bowel problems; the importance of assessing probable causes of constipation and diarrhoea and the recording of bowel movements in residents with constipation. In addition, the RNs described bowel care management as challenging due to a challenging resident group, the impact of residents' and families' experience, physical and organizational working conditions and a professional challenge to nurses (Table 2). Over 60% of the residents with diarrhoea or loose stool had no reported interventions directed towards this problem. FI was mainly treated passively with pad use. The qualitative data revealed that the RNs did not consider diarrhoea or FI to be significant problems, despite the high prevalence of both as shown in the quantitative data. However, constipation was considered to be a great problem and both the quantitative and qualitative data showed that most of the RNs' effort was directed towards solving this problem. There seemed to be a shared understanding that emptying resident's bowels to prevent constipation was the main concern of the RNs. How this was done was less important, consequently leading to compromises in nursing ethical standards such as maintaining residents' dignity.

The staff identified a challenging resident group and did not feel that they had enough time, resources and the physical and organizational conditions necessary to meet all the residents' different needs. The RNs were doing their best to manage the resident's needs within limited time and resources. Nevertheless, all nursing activities are performed within a physical and organizational framework and to have a personalized care approach requires that this is founded in the institutional leadership [34]. The management of bowel problems and FI will therefore require an institutional commitment. The care quality is dependent on the competence of the staff and the standards they set. RNs are in charge of the nursing care given in nursing homes through guidance of other skilled and unskilled staff, including bowel care. In the setting for this study, only 25% of caring staff were RNs and this may pose a limitation for the quality of the care. In the meanwhile, pads are the most widely used intervention for FI; a very passive solution which may enhance the resident's experience of being infantilized, and compromise their feeling of well-being. Not being able to control one's bowel will likely undermine self-esteem and sense of dignity. The RNs in our study were also concerned about not being able to help residents to the toilet in time would make residents incontinent. Even if the residents felt the need and asked for help from the staff, they did not necessarily get help when they needed it. Robinson found in a qualitative study of nursing home residents that fear of being alienated by caregivers because of extra care required by toileting led to residents preferring or accepting the use of pads [35]. According to the RNs in our study, pads were considered a safety mechanism by both RNs and the residents who would ask for them. This dissonance causes stress because it leads to an ethical dilemma between what you think you should do and what you actually do.

This situation demonstrates that there is a great potential for improvement in continent emptying of bowels among nursing home residents. Given the fact that the RNs are responsible for the care given, and thereby quality of care in the nursing homes, RNs unique contribution is that they set the standard of care by their priorities, decisions and standards. It is their mandate to provide professional guidance to both skilled and unskilled staff. FI is a costly and debilitating condition, it is therefore important to prolong and maintain such an important function as continent emptying of bowels, which should be the RNs' aim for good bowel care. In order to achieve this, an individual assessment is important. RNs should identify treatable causes of constipation, diarrhoea and FI, such as modifying stool consistency [16]. Although clear clinical guidelines are missing, it is of great importance that RNs implement existing evidence-based practice [1],[16]-[18],[20]-[25]. It is also important that RNs prioritize care needs differently, recognising the value of residents' continence and providing toilet assistance in a timely manner. Education of health care workers should embed both a sense of value in identifying bowel problems, as well as a confidence that the conditions are treatable. This in turn depends upon institutional leadership that recognizes the importance of continence and bowel health. Toileting is time-consuming and requires resources. More importantly, continence and bowel care requires clinical competence in this specific field. Educational institutions for nurses should take responsibility for providing future nurses with sound knowledge of relevant care practices.

Although there is a need to establish new reliable knowledge regarding the management of FI among nursing home residents, there are few published trials of treatment of FI among nursing home residents, and no trials on prevention. The existing studies have small numbers, problematic methodology, and are all non-blinded [1]. This evidence on how RNs' are actually managing FI in nursing homes will be an important contribution in the planning of future studies of interventions regarding FI or other bowel problems in nursing home.

In this mixed methods study of RNs' management of bowel problems and FI in nursing home residents, we found that FI and diarrhoea were not considered to be significant problems, despite the high prevalence of both. Due to too many tasks and too few resources, the RNs were not able to complete tasks effectively. In this situation, constipation and emptying the resident's bowels became the most important aim of preventive tasks and nursing interventions. Although some preventive measures were taken, FI was mainly treated passively with pads. No interventions were used for most of the residents with diarrhoea or loose stool. The RNs performed repetitive, but not often successful tasks in managing the residents' bowels. This calls for a new approach for bowel management for older residents in nursing homes. In the context of an increasing ageing population in western countries, investing in the professional development of registered nurses and physicians within the field of incontinence and bowel management may yield significant improvements in dignified and effective care practices. This however requires an awareness of the problem, as well as a commitment to improvement in care practices amongst institutional authorities.