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Digital rectal examinations are a fundamental nursing competency, but they are not always performed when required. There are different reasons for this and ways to overcome them
Although nurses should carry out a digital rectal examination before, and sometimes after, administering rectal medication, evidence shows that this does not always happen. A bowel specialist nurse carried out a survey that suggests such examinations are performed by many nurses in community settings, but undertaken less often in hospital. Reasons given include a lack of training and awareness. Employers should ensure accessible training is available, while nurses have a responsibility to attend training and consolidate their knowledge through clinical practice.
Citation: Embleton R, Henderson M (2020) Overcoming barriers to nurses performing digital rectal examination. Nursing Times [online]; 116: 9, 42-44.
Authors: Rebecca Embleton is bowel dysfunction specialist nurse; Michelle Henderson is academic clinical research nurse; both at Durham Bowel Dysfunction Service, County Durham and Darlington NHS Foundation Trust.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
A digital rectal examination (DRE) should be performed before and, in some circumstances, after administering rectal medications; this is made clear in the recently updated bowel care guidance from the Royal College of Nursing (2019). However, from my experience of delivering training on safer bowel care training, it is apparent that there is a lack of awareness around when DRE is indicated and how to perform it competently.
Rationale for DRE
Benefits to the patient
Rectal medication can take various forms, including suppositories and enemas. They are used in many clinical situations, including for managing constipation, haemorrhoids, neurogenic bowel dysfunction, inflammatory bowel disorders and infection.
It is important that the medication is positioned correctly: for example, to manage constipation, placing a suppository against the bowel wall rather than inside a stool enables body heat to soften it (Fig 1). Stimulant suppositories, such as glycerol, must come into contact with the mucous membrane of the rectum because they act as a mild irritant and so stimulate evacuation (Bradshaw et al, 2009). Correctly positioning suppositories is not only necessary when managing constipation; Hagen et al (1991) found that when paracetamol suppositories were given to patients with a significant amount of stool in the rectum, peak plasma levels of the drug were reduced by 32%. The study may be old, but as no contradicting research has been published, it remains relevant. Failing to assess the rectum before administering rectal medication may reduce its effectiveness.
Credit: Francesca Corra
Nurses might also perform DRE after administering a suppository or enema, to assess whether the medication has been successful in stimulating bowel evacuation or further action is needed to empty the bowel. It should be noted that there are situations in which DRE must be performed with caution (Box 1), and it should not be performed without the patient’s informed consent or if the patient’s doctor specifically prohibits it. If the patient does not have capacity to consent, the Nursing and Midwifery Council (2015) states that nurses should adhere to all relevant laws about mental capacity and ensure the patient’s rights and best interests are at the centre of the decision-making process.
Box 1. When to perform a digital rectal examination
Perform a digital rectal examination with caution if the patient:
- Has active inflammation of the bowel
- Has had recent radiotherapy to the pelvic area
- Has rectal or anal pain
- Has had recent surgery or trauma to the anal or rectal area
- Has tissue fragility due to age, radiation or malnourishment
- Has obvious rectal bleeding
- Has a known history of abuse
- Has a spinal cord injury at or above T6 (due to the potential risk of autonomic dysreflexia)
- Has a known history of allergies (for example latex)
- Is unconscious
- Gains sexual gratification from the procedure
Source: Royal College of Nursing (2019)
Benefits to the nurse
The ability to undertake DRE is a fundamental nursing competency. The risks of failing to perform DRE before administering rectal medication may be significant. Although a doctor may already have performed one while assessing the patient, as nurses have a professional responsibility to ensure no harm comes to a patient as a result of an act or omission (Nursing and Midwifery Council, 2018a; Alexis and Caldwell, 2013), the administering nurse is personally accountable for ensuring there is no reason why rectal medication cannot be administered.
DRE can confirm there is no obstruction or stool preventing medications from being safely and effectively administered, and enables the nurse to ensure the patient’s comfort. Professional guidance on the administration of medicines highlights that registered health professionals who administer medicines, or delegate their administration when appropriate, remain accountable for their actions, and should exercise professionalism and professional judgement at all times; it also states that those administering medicines must be appropriately trained, assessed as competent, and meet relevant professional and regulatory standards and guidance (Royal Pharmaceutical Society and RCN, 2019).
In its standards for future nurses, the NMC (2018b) states that, when nurses complete pre-registration training, they must be able to administer enemas and suppositories and undertake rectal examination. This should mean that nurses qualifying after the standards were introduced will be able to perform DRE routinely and competently.
“Failing to assess the rectum before administering rectal medication may reduce its effectiveness”
Why do nurses not always perform DRE?
As a bowel specialist nurse, I wanted to understand the reasons why nurses do not always perform DRE. I designed a simple questionnaire using SurveyMonkey, which I sent to registered nurses in the UK over a two-week period in July 2019. I used Twitter to target nurses by using the hashtags #wenurses and #nursetwitter and encouraging my followers to retweet to their networks. I received responses from 182 registered nurses who administer rectal medication; of these, 92 worked in the community and 90 worked in hospital settings.
To ensure the target group was surveyed, the questionnaire included two screening questions:
- Are you a registered nurse?
- Are you ever involved in the administration of rectal medications?
Respondents were then asked whether they worked in the community or hospital setting, followed by three yes/no questions, along with a free-text response question asking respondents who said they did not perform a DRE before administering rectal medication, why they did not (Box 2).
Box 2. Survey questions
- Have you undergone formal training in digital rectal examination?
- Have you been signed off as competent in digital rectal examination?
- Do you perform digital rectal examination prior to administering rectal medication?
- If not, why do you not perform digital rectal examination before administering rectal medication?
When asked whether they routinely perform DRE before administering rectal medication, 22% of respondents reported that they did not; interestingly, these respondents all worked in secondary care. A total of 100% of respondents working in community settings said they would perform DRE before rectal administration, while only 56% of hospital nurses said they would do so.
Survey responses highlighted many reasons for nurses’ reluctance to perform DRE before administering rectal medication – 38% of respondents said they had not received any formal DRE training. Box 3 gives an overview of the most common free-text responses to the question: “Why do you not perform a DRE before administering rectal medication?”
Box 3. Reasons nurses do not perform digital rectal examinations
Responses to the survey question: “Why do you not perform digital rectal examination before administering rectal medication?” included:
- “Not had the training and usually a doctor has done one”
- “Don’t feel competent”
- “Not trained to do it, but do it if I have any concerns”
- “Not aware it would be necessary in these circumstances”
- “Not taught to and never considered it”
- “There is no training in our trust for this”
- “Didn’t realise I had to”
- “DRE is an invasive procedure that I will only perform when absolutely necessary”
- “Didn’t think I was allowed to”
- “A doctor will have done one”
- “Doesn’t seem to be common practice”
An NHS Improvement (2018) national patient safety alert highlighted a lack of awareness around autonomic dysreflexia and a lack of staff with the competence to perform DRE. The alert stated that “patients have made NHS Improvement aware of difficulties [in] ensuring their regular bowel care is provided when they come into hospital or mental health units”. The results of my survey appear to confirm this, with certain responses implying that the recommended bowel care is not happening in practice:
“There is no training in our trust for this.”
“[I] didn’t think I was allowed to.”
Kyle (2010) indicated that some nurses believe they are prohibited from performing DRE – this belief clearly persists a decade later. However, this is not the case if:
- The DRE is indicated;
- Informed consent has been obtained
- The nurse is competent in the procedure (RCN, 2019).
The largest barrier to performing a skill is competence, which is defined as the “clinical and technical knowledge to deliver effective care and treatments based on research and evidence” (NHS Commissioning Board and Department of Health, 2012). Nurses can gain technical knowledge by attending teaching sessions on the use of DRE. As a result of the patient safety alert, all providers of NHS-funded inpatient and community healthcare are required to provide education and training provision for interventional bowel management (NHS Improvement, 2018). This means training should be available to all registered nurses employed in the NHS. Relevant charities and other organisations also offer training: for example, Bladder and Bowel UK – part of the charity, Disabled Living – offers a one-day course for nurses.
Even when appropriate training is available, there can still be barriers preventing nurses achieving competence in DRE. For example, they need to be able to attend the training sessions and staffing levels in clinical areas can prohibit this; as such, the ward manager’s support is fundamental. Investing in staff training and development can only improve the skill mix in the clinical area.
Theoretical knowledge is the foundation for clinical competence, but attending training sessions and performing simulations on a manikin do not equate to competence in practice. To be assessed as competent practitioners, nurses are required to complete observed DRE practice on patients. This, in itself, can cause difficulties as, in some clinical areas, the opportunity to perform DRE arises infrequently. This not only makes it difficult for nurses to achieve competence, but also means there may be no nurses available with the required competence to observe DRE. In such situations, achieving this clinical competence may require some lateral thinking, for example:
- Finding patients requiring DRE in other clinical areas;
- Asking a doctor to sign off the competence;
- Asking a competent nurse in another area to observe your practice.
Nurses have a responsibility to provide evidence-based practice (NMC, 2018a), and evidence-based guidance is available for those delivering lower-bowel care as part of their role, including nurses administering rectal medication (RCN, 2019). Local policies vary and should always be consulted, but a common theme is the need to perform DRE to assess the rectum before, and sometimes after, administering rectal medication.
It is best practice to perform DRE before inserting rectal medication, both to identify the presence and consistency of any stool in the rectum and to ensure that medication will have the intended action. This also reduces the risk of perforating the bowel wall during administration. DRE may also be performed after administering rectal medication to assess the outcome of the intervention.
A survey carried out via social media demonstrated that there was a lack of awareness of the need for DRE, and a lack of competence in and a fear of performing the procedure. To ensure high-quality, evidence-based care is provided, employers have a responsibility to provide awareness, education and training opportunities in bowel management for their staff (NHS Improvement, 2018). This provision is particularly important in secondary care, as the survey highlighted a lack of training and awareness in this group. Nurses should reflect on their own practice and competence in this area, then access any necessary training and consolidate it through their clinical practice.
- Digital rectal examination is a fundamental competency and should be undertaken before medication is administered rectally
- Nurses are currently not always performing digital rectal examinations
- A survey has identified a lack of awareness and training, especially in secondary care
- Training is available, and nurses need to gain competence in their practice
- Nurses and employing organisations both need to overcome barriers to achieving competence
Alexis O, Caldwell J (2013) Administration of medicines: the nurse role in ensuring patient safety. British Journal of Nursing; 22: 1, 32-35.
Bradshaw E et al (2009) Administering rectal suppositories: preparation, assessment and insertion. Gastrointestinal Nursing; 7: 9, 24-28.
Hagen IJ et al (1991) Absorption of paracetamol from suppositories in geriatric patients with faecal accumulation in the rectum. Aging Clinical and Experimental Research; 3: 25-29.
Kyle G (2019) Why are Nurses Failing to Undertake Digital Rectal Examinations? nursingtimes.net 3 December
NHS Commissioning Board and Department of Health (2012) Compassion in Practice: Nursing, Midwifery and Care Staff – Our Vision and Strategy. DH.
NHS Improvement (2018) Patient Safety Alert: Resources to Support Safer Bowel Care for Patients at Risk of Autonomic Dysreflexia. NHSI.
Nursing and Midwifery Council (2019) Delegation and Accountability: Supplementary Information to the NMC Code. NMC.
Nursing and Midwifery Council (2018a) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. NMC.
Nursing and Midwifery Council (2018b) Future Nurse: Standards of Proficiency for Registered Nurses. NMC.
Royal College of Nursing (2019) Bowel Care: Management of Lower Bowel Dysfunction, including Digital Rectal Examination and Digital Removal of Faeces. NMC.
Royal Pharmaceutical Society and Royal College of Nursing (2019) Professional Guidance on
the Administration of Medicines in Healthcare Settings. RPS.