Bowel management is a key concern for individuals with spinal cord injury (SCI) and can commonly be associated with symptoms of autonomic dysreflexia (AD) (Inskip et al, 2018). Improving bowel function has been identified by patients with SCI as a key factor in enhancing quality of life (Inskip et al, 2018). Poor bowel care can not only trigger AD in those prone, but also faecal urgency, faecal leakage, constipation, haemorrhoids and abdominal distention (Inskip et al, 2018).
The NHS Improvement (NHSI) patient safety alert (NHSI, 2018) for England triggered a similar patient safety notice in Wales (Patient Safety Wales, 2018). Both documents highlighted widespread patient safety concerns with regards to bowel care and AD, which is a potentially life-threatening condition associated with spinal cord injury at T6 and above. It is characterised by a sudden, and potentially lethal, rise in blood pressure, risking cerebral haemorrhage and death (Spinal Injuries Association, 2013). Faaborg et al (2014) also state that other signs and symptoms of AD include headache, feelings of anxiety, bradycardia, cardiac arrhythmias, profuse sweating above level of injury, pale colour below level of injury, blurred vision and nasal congestion.
Apart from patients with SCI (above T6), a small number of patients who experience stroke, severe Parkinson's, multiple sclerosis, cerebral palsy or spina bifida may also be susceptible to AD (NHSI, 2018; Patient Safety Wales, 2018). AD in these patients can be triggered by non-adherence to individual patient's usual bowel care or routine interventional bowel care (NHSI, 2018; Patient Safety Wales, 2018). Individuals with SCI have made both NHS Improvement England and the Welsh Government aware that they have difficulties accessing regular bowel care when they are admitted into acute care, mental health units and some community care (NHSI, 2018; Patient Safety Wales, 2018).
A search of the national reporting and learning systems (NHSI, 2018; Patient Safety Wales, 2018) identified the following issues associated with AD and bowel care:
These issues were also supported by Inskip et al (2018) who identified that, while bowel care is a significant concern for individuals with SCI and affects quality of life, most individual bowel care is not being changed due to a lack of bowel management training, which raises questions over current guidance. There is little evidence to refute these statements apart from the NHSI patient safety alert (NHSI, 2018), which states that opportunities to learn/practice routine bowel management are limited outside spinal units and community teams where these procedures are undertaken. However, there are few spinal units in the UK overall, and few in Wales, and community teams rely on updating educational packages and up-to-date guidelines, as well as experience in treating/managing SCI patients.
Both the English and Welsh documents required identified providers of NHS-funded care, both acute and community, to review clinical policies, guidance relating to bowel assessment and management, training and education (NHSI, 2018; Patient Safety Wales, 2018).
What have we done in Wales?
Wales, as a devolved nation, has its own health service provision and all health boards were obliged to undertake the requirements of the patient safety notice. It was soon identified that not all health boards fulfilled the patient safety notice requirements. The All Wales Continence Forum discussed how to improve care nationally, resulting in a multidisciplinary subgroup from across Wales, with representation from spinal, continence, colorectal and community services being established, specifically focusing on bowel care in spinal cord injury patients.
Initial terms of reference were drafted and subdivided into short-, medium- and long-term goals.
Short-term goals included:
The medium-to long-term goals were identified as:
To date, the study day has taken place, with over 50 assessed attendees. Evaluation of the day reported it being ‘very good’ to ‘excellent’, and repeating this day across Wales is being discussed and taken forward. Forum members took part in the TREAT autonomic dysreflexia awareness study day and have established links with this charity. Bowel posters have been designed and distributed throughout acute hospitals and community venues in Wales for professional information. The questionnaire has been designed and disseminated and responses are being analysed. An application has been approved for development of an all Wales bowel e-learning course linked to individual employment staff records. An initial meeting via the office of the CNO for Wales to discuss dissemination of the information produced has also taken place.
The main goal of reviewing of current guidelines and development of an all Wales bowel policy has yet to be completed. This has been delayed by the COVID-19 crisis and the Forum has been temporarily disbanded. However, during this pause, updated bowel care guidance has been published by the Royal College of Nursing (RCN) (2019a). While this guidance is of national use there is one important section missing, competency. The RCN catheter guidance (2019b) includes a whole section on competency, outlining what the professional requires to remain competent in the skills. This includes gaining theoretical knowledge, observation/practice on models/manikins, observation and supervision on patients and, finally, to be able to undertake the skill without direct supervision (RCN, 2019b).
One of the most important aspects of the guidance (RCN, 2019b) is advice on updating skills. The RCN suggest that skills are formally updated every 5 years or more often, if appropriate. However, the RCN bowel care guidance (2019a) states that competency for ‘digital rectal examination (DRE) can be undertaken by a registered nurse who can demonstrate professional competence to the level determined by the Nursing and Midwifery Council (NMC) in its Code of professional conduct (NMC, 2015)’. Thus no specific competencies are outlined, which is an opportunity missed.
So, during this pause, another requirement will be added to the All Wales Bowel Forum's goals. It will look at specific competencies for bowel care and set out a competency framework that will be standardised for all of Wales. This will help to implement all of the recommendations of the Welsh patient safety notice (Patient Safety Wales, 2018), but also support, influence and monitor bowel care, management and education of professionals not only for dealing with SCI patients, but for all future bowel care.