Supporting children to be 'boss of their bowels': chronic constipation and faecal soiling are very difficult for children and their families. A Hawke's Bay nurse's specialist service is giving these children and families new hope.
Constipation (Care and treatment)
|Publication:||Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 New Zealand Nurses' Organisation ISSN: 1173-2032|
|Issue:||Date: March, 2012 Source Volume: 18 Source Issue: 2|
|Topic:||Event Code: 200 Management dynamics|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
Hawke's Bay District Health Board (DHB) paediatric nurse Lisa
Smith says she's very I privileged to be running a bowel management
clinic. Given the humiliation a child who soils themselves often feels,
and the shame the family often feels, it's just as well they have a
passionate and articulate advocate.
"Chronic constipation and soiling is a very common problem but it is not talked about. Families often delay seeking help because it is a particularly embarrassing problem. Often parents feel it is something they have done wrong in their parenting. They hope it will go away, or the child will grow out of it," Smith explains.
Working at Hawke's Bay Regional Hospital's paediatric ward, Smith was "vexed" for the children coming in for bowel clear outs. "I don't think the health professionals in contact with these families appreciated the stress the situation created for the kids and their families."
When United Kingdom specialist paediatric health visitor and an expert in bowel management in children, Jackie Wade, came to work on the ward, she provided Smith with the impetus and the necessary practice guidelines to make a case for a specialist nursing service. It aims to improve continuity and consistency of care, reduce demands on the hospital service, and provide support and education for all involved in the care of these children.
Smith, a 28-year veteran of paediatric nursing, is no stranger to developing and running specialist paediatric services. In her home town Dundee, she ran a paediatric asthma liaison service for six years. She was also an associate lecturer at Dundee University's school of nursing, co-ordinating clinical skills teaching for paediatric students, while working as a charge nurse in a paediatric high dependency unit. She and her family immigrated to New Zealand in 2004.
The DHB supported her case for a service and it began in 2009. Since then, Smith has realised a low fibre diet or a lack of exercise, are not causes of "stool withholding" behaviour, as traditionally thought. "Children hold onto their poos when defacecation is painful. This sets up a vicious cycle of stool withholding, leading to constipation. If this continues for many months it results in faecal impaction, with overflow soiling," she explained.
Triggers for setting off this cycle can include stress within the child or their environment. Often the start of the behaviour can be traced back to an illness the child has suffered or to an emotional stress, eg the death of family member, parental separation, shifting house or starting school.
Chronic constipation and soiling is one of the top ten reasons for referral to a paediatrician, Smith says. Children are referred to the service by the paediatricians. At the first visit, which takes place at the hospital, Smith undertakes a comprehensive assessment of up to two hours, getting all the information from the family. "You have to get the family on board and ask them what is going to work for their child and come up with such a plan."
After the initial assessment, Smith designs a detailed individualised bowel management plan--"toilet gym". Communication has to be direct and she uses a vast number of different terms to describe bowel motions--"the words I use have to be relevant to their age, but all these kids want to be 'boss of their bowels.'" She treats children up to the age of 14, with those aged six to 11, the most common.
Once a child is with the service, Smith contacts them every week for a month, either by visiting, a phone call or an email. When things are going well, reviews are reduced to every two weeks, then monthly. Early identification and close intervention are the keys to success, as are the "five Ps"--play, praise, patience, practice and perseverance. Working closely with the multidisciplinary team is another key to success.
Explaining the physiology of the problem and that the child is not to blame is very helpful for all concerned. If there are behavioural problems or lack of compliance with the bowel management plan, Smith will admit the child to the paediatric ward for a week. She has done some intensive education with the ward nurses and play therapists to ensure they do everything possible to help break the negative cycle the child and family are going through. "The staff have a very detailed management plan for the child, so there is consistency of care and no confusion. I think many staff now see these children as a challenge, whereas previously they were often viewed negatively. And they have also come to understand more fully the family dynamics and the distress families have been through."
The service has proved very popular--"the paediatricians have welcomed me with open arms because these children used to take up so much of their time." With 50 children on her books, some for up to two years, Smith was struggling to provide the best possible service. "In the middle of last year I emailed the paediatricians saying I couldn't take any new referrals in the foreseeable future because I wanted to give the children already enrolled the best possible service."
In December the service was increased by one day and Smith now works three days a fortnight and her caseload is up to 70. Smith is adamant she won't give up her acute paediatric work. "I enjoy a bit of this and that. And I think specialising in one area can increase the risk of burnout."
In May last year, Smith won the DHB's International Nurses' Day Award for innovation in nursing practice. "Every DHB needs to have a nurse-led bowel management service. There's plenty of evidence of their success. Many public health nurses are running with it now. I might do myself out of a job--that would be real success."
|Gale Copyright:||Copyright 2012 Gale, Cengage Learning. All rights reserved.|