Abstract

Functional constipation (FC) in children is a common health issue with reported global prevalence levels of up to 32.2%. Several management strategies have been developed, including diagnostic tests, empirical, and specific treatment. Colonic irrigation is an effective treatment for functionally disordered children. This method performed by trained and qualified healthcare professionals and requires thorough instruction and training. This study aimed to assess the effect of implementing colon irrigation guidance protocol on knowledge and practices of pediatric surgical nurses. Methods: a quasi-experimental design was carried out on 45 nurses who work at the department of pediatric surgery and pediatric intensive care unit affiliated to Mansoura University Children's Hospital (MUCHs), Mansoura City, Egypt. Two tools used to collect the study: a structured questionnaire sheet for assessing the knowledge of nurses about colon irrigation, and the observation sheet to evaluate the practice of colon irrigation by nurses. Results: There was a statistically significant difference in the knowledge and practices of the nurses regarding colon irrigation immediately after and three months later compared to the guidance protocol before. Conclusion: Introducing guidance protocol has had a major positive impact on enhancing the knowledge and practices of nurses about colon irrigation. Recommendations: The best evidence-based practices regarding the importance of practicing colon irrigation techniques correctly for children with functional constipation must be provided to pediatric surgical nurses.

1. Introduction

Functional constipation (FC) is a common health problem in the pediatric age group. Constipation is characterized as Functional constipation if there is no organic underlying cause, which is the case for up to 95 percent of children. The etiology ranges from Hirsch’s sprung disease, anorectal malformations, and neuromuscular disease, metabolic to endocrine disorders in the 5 percent organic cause ¹ and its delayed management leads to significant childhood morbidity. FC in children has a high prevalence (0.7%-29%) worldwide and in girls, this happens more frequently than in boys (ratio 2.1:1) both in developed and developing countries. The peak constipation incidence occurs between the ages of 2 and 4years, when the potty training begins. A recent systematic review found that the median prevalence of constipation in children was 12% & the incidence of constipation reported in infant ranges from 0.05% to 39.3% but the prevalence is estimated at 15% based on expert consensus ².

Functional constipation poses a significant burden on both children and their caregivers and is associated with a reduced quality of life, diminished academic performances and psychological problems ^{3, 4, 5, 6}. In Egypt, Khalil & Alkot ⁷ conducted the first prospective study to evaluate the prevalence of functional constipation among children treated in a Pediatric Gastroenterology Clinic in Alexandria. Their patients are referred from four governorates in the north and west of the Delta. Their results showed that functional constipation is the most common cause for referral to the pediatric gastroenterology clinic which is the usual case in most of the pediatric gastroenterology clinics. Childhood FC is a very persistent condition with recurrent unexplained relapses that need long-term care. It is a clinical diagnosis that is based on medical history and physical testing. The FC management guideline requires a daily consumption of fibers and fluids, moderate physical activity, and additional pharmacological treatment for fecal disinfection accompanied by a pharmacological maintenance procedure. Polyethylene glycol is the first choice for both disimpaction treatment and maintenance treatment. The second line is laxative stimulants or lubricants used when adequate oral laxative treatment is insufficient ⁸. The clinical evidence suggests that emptying that is as high as the sigmoid colon can prevent long term impaction and constipation. Colonic irrigation is considered a treatment line for obtaining such evidence. Colonic irrigation is a common treatment encouraged for a variety of conditions and its synonyms are various, e.g. colonic treatment, colon cleansing, rectal irrigation, colon therapy, and colon hydrotherapy ¹.

Colon hydrotherapy is a natural cleaning procedure in which a healthy and gentle infusion of warm filtered water flows into the intestine in conjunction with an abdominal massage, but without medications or mechanical pressure, and flushes accumulated waste and colon toxins. The great advantage of the cleansing technique is that the environment changes from alkaline to acid ^{9, 10, 11}.

Colonic irrigation is considered to be minimally invasive and has a proven benefit in children with functional constipation neurogenic defecation disorders (e.g., spina bifida or Hirschsprung’s disease), anorectal malformations, and evacuation disorders after anorectal surgery ^{3, 8, 12, 13}. Colonic irrigation is non-pharmacological method used in severe cases of constipation when pharmacological methods failed. There are two types of colon irrigation: antegrade or retrograde colonic irrigation may prove to be effective. Retrograde colonic irrigation, water is infused into the colon through a rectally inserted device to mechanically washout feces bowel. The aim of irrigation is to empty the rectum, sigmoid and descending colon of fecal matter, allowing the patient to exercise more control and be able to predict movements. If well-timed and adequately performed, these washouts can induce regular emptying of the colon and lead to continence in previously incontinent children and it is the primary best standard care is children with neurogenic bowel dysfunction ^{14, 15, 16}.

Furthermore, colon irrigation is an effective, well-tolerated and safe procedure and is more efficient than conservative management ¹⁷. It is a simple therapeutic method as a valid choice for the treatment of chronic neurogenic constipation and fecal incontinence, especially before attempting surgical treatment ^{18, 19}. Moreover, colon irrigation reduces the frequency of UTIs, stoma surgery and hospitalization rates, as well as reduced costs ²⁰. On the other hand, it is time-consuming, the time spent at each procedure is 30 - 45 min and irrigations are usually performed with a volume of 10 -20 mL/kg of water, with the frequency depending on the child’s response ²¹.

Relatively little is known about how professionals who care for these children decide which intervention to recommend for bowel management and how to manage treatment options, such as colonic irrigation. While some clinical guidance highlights the importance of different approaches to bowel management that begin early in the overall health management plan for a child, there are currently no national or international evidence-based guidelines to support the medical management of children with neurogenic bowel conditions, despite having been using irrigation for a number of years ²². Nurses need to be informed of this basic intervention that can enhance or sustain the bowel function, and what will be the best outcome for each child. The practical practice of colonic irrigation in pediatric FC includes active educational efforts and activities for nurses ²³. In Egypt, the first report documenting the prevalence, precipitating causes, and clinical profile of childhood constipation in north-western Egypt, suggest more efforts to improve health care providers' knowledge of management and FC's long-term outcome ⁷.

Significance

Although colonic irrigation has been used with children for over 40 years as bowel management and no serious complications associated with its use have been reported, ^{24, 25} have shown that colon cleansing can cause side effects ranging from cramping to renal failure and death. There are no clear data on the prevalence of colonic irrigation usage to the best of our knowledge, and this is the first research detailing the nursing practice of this technique. In addition, based on the clinical experience of researchers, nurses in pediatric surgical unit make fatal errors for children with FC during the colonic irrigation procedure like incorrect insertion path of the anal catheter, infusing a large amount of solution in one shot forcefully, incorrect positioning during the enema procedure, and the temperature of solution inappropriate to the body temperature which can lead to serious complications as bleeding, laceration, and perforation but no studies support this claim. Therefore, the current study aimed to evaluate the effect of implementing colon irrigation guidance protocol on knowledge and practices of pediatric surgical nurses.

2. Aim of the Study

The aim of the study was to evaluate the effect of implementing colon irrigation guidance protocol on knowledge and practices of pediatric surgical nurses. This aim can be accomplished through:

- Assess pediatric surgical nurses’ knowledge and practices about colon irrigation.

- Designing and implementing guidance protocol regarding colon irrigation on pediatric surgical nurses’ knowledge and practices.

- Evaluating the effect of implementing guidance protocol regarding colon irrigation on pediatric surgical nurses’ knowledge and practices.

3. Method

The implementation of guideline protocol about colonic irrigation will promote knowledge and practices of pediatric surgical nurses.

A quasi-experimental research design using one group (pre, immediate post and follow up) was used.

This study was done at pediatric surgical department and pediatric surgical intensive care unit affiliated to Mansoura University Children’s Hospital (MUCHs), Mansoura city, Egypt.

The subjects were comprised of 45 nurses working in the above-mentioned settings regardless of their age, qualification or years of experience.

Tool I was using to collect the data namely: A structured questionnaire and observational checklist formulated by researchers following the review of recent literature and studies ^{26, 27, 28, 29, 30}.

Tool I: Knowledge assessment tool:

A structured questionnaire sheet consisting of the following two parts:

Part I: Pediatric surgical nurses’ characteristics as age, workplace, qualification, years of experience and involvement in any colon irrigation training session.

Part II: Nurses’ knowledge about colonic irrigation: It includes questions in the form of multiple-choice questions for evaluating knowledge of the colon irrigation by nurses. The tool’s items were related to the knowledge about the definition, aims, difference between an enema and colon irrigation, indications and contraindications, complications and instructions for avoiding complications.

Part III: Nurses' practical knowledge towards colon irrigation: it includes questions related to detection of size and length of rectal catheter used in colon irrigation, types, amount and temperature of solution which used in colon irrigation, time of session for colon irrigation. Warning signs to stop the irrigation or inform doctor and the action done when the total amount of inserted solution does not pass or retain.

Tool II: Observational checklist sheet: It was used to determine nurses' current practices with regards to the guideline protocol on colonic irrigation. The researchers developed a guideline protocol after reviewing the literature and the related research studies ^{31, 32}.

Scoring System

The scoring of the knowledge of nurses was classified as poor knowledge if the percentage score was (< 60%), average knowledge if the percentage score was (60% < 75%) and good knowledge if the percentage score was (≥ 75%). The scoring of nurse's practices results were categorized as competent if their practices score percentage score was (≥ 75%) and incompetent if (< 75%) ³³.

Ethical approval has been received from the Faculty of Nursing Science's ethical committee, Mansoura University. Subsequently, oral informed consent was obtained from nurses after a thorough description of the objective of the study and the process of the researchers obtaining their participation approval. The nurses are assured that their participation in the study is voluntary; they have the right to withdraw. It protected the confidentiality of the information gathered and the anonymity of the nurses.

The tools were revised by seven experts in the pediatric nursing and pediatric surgery fields to test its content validity. The modifications were done on the tools according to their opinions. The reliability of both tools was tested using the coefficient test of Alpha Cronbach, the alpha reliability of tool 1 was (α = 0.86) and tool II was (α = 0.90).

A pilot study was carried out on 5 nurses to test the clarity and applicability of the tools and the modifications were done accordingly.

The data collection process has occurred over a period of 6 months from October 2019 to March 2020. Permission obtained from the Dean of Faculty of Nursing and the director of the previously mentioned hospital before collection of data. Then, the researchers communicated with head nurse of pediatric surgical department and pediatric surgical intensive care unit to explain the study aim and nature. The head nurse introduced the researchers to the nurses, and they invited all nurses for voluntary participation in the current study. The study was conducted in three phases.

Ÿ Educational sessions with nurses carried at pediatric surgical department and pediatric surgical intensive care unit. During their participation, the researchers introduced themselves and explained the purpose and process of the study, the roles of the nurses.

Ÿ Determine knowledge of colon irrigation by nurses. The time allocated to nurses to complete the questionnaire was 20-30 minutes, the time for each session ranged from 30 -45 minutes in the morning and afternoon shift depending upon their available time. As regards nurses’ practices, the researchers observed the nurses during procedure of colon irrigation using observational checklist.

Ÿ The researchers developed a guidance protocol focused on nurses’ needs assessment to achieve the study objectives.

Ÿ Colonic guidance protocol content over 5 sessions was given, composed of two theoretical and 3 practical sessions.

Ÿ According to the morning and afternoon work schedules of the study nurses, researchers divided the nurses into small groups for discussion.

Ÿ The researchers illustrated all clinical aspects of the colonic irrigation guidance protocol and at the end, briefly conclude each session with the nurses.

Ÿ The practices of the nurses were evaluated immediately after application and use of Tool II three months later.

Ÿ The checklist was used to evaluate the nurses’ practice related to guidance protocol about colonic irrigation. This checklist was used to observe the actual nurses’ practices during procedure of colon irrigation. The observation of nurses’ practice was carried out during morning and afternoon shifts.

Ÿ Various teaching methods and media such as group discussion, brainstorming, demonstration and re-demonstration, video film, poster, and booklet were used during the implementation of the colonic irrigation guidance protocol.

Ÿ Immediately and three months after application the colonic irrigation guidance protocol was tested (Tool I - part II; part III and Tool II).

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) for version 19.0. The data were revised, coded, tabulated and presented using descriptive statistics for qualitative variables in the form of frequencies and percentages, as well as quantitative mean and standard deviations. Subsequent statistical measures were used: For the test of significance Chi-square and Wilcoxon Signed Rank test were used. The results for p < 0.05 were accepted as being statistically significant.

4. Results

Table 1 revealed that 40 percent of nurses were aged between 20 and less than 30 years, with a mean age of 28.6 ± 2.4 years. About three-quarters (71.2%) of them had a bachelor's degree and more than two-thirds (62.2%) worked in the pediatric surgical intensive care unit. As for the years of experience of nurses, it has been found that more than one-third (35.6 %) have less than 5 years of experience in the study settings with average years of experience of 7.5 ± 2.1 years. Furthermore, the majority (93.3%) of nurses did not have any colon irrigation training courses.

Table 2 illustrated that there were statistically significant differences in the nurse's knowledge of pre, immediate post and follow-up colonic irrigation following the implementation of the guidance protocol.

Table 3 clarified that the practical knowledge of colonic irrigation pre, immediate post and follow-up after application of the guidance protocol was highly statistically significant.

Table 4 indicated that a highly statistically significant difference existed between the practices of colon irrigation by Nurses before, immediately after and 3 months after the implementation of the guidance protocol as identified (P < 0.001).

This Table 5 illustrated nurses distribution according to their total nurses’ knowledge, it was noticed that 11.1% of nurses had good level of knowledge pre- application of guidance protocol, meanwhile, in immediately post, more than of sixty-five (66.6%) and after three months follow up (68.9%) of nurses had good level of knowledge. In relation to total nurses' practical knowledge, this table showed that 6.7% of nurses had a good level of practical knowledge prior to the guidance protocol, meanwhile, in post, 88.9 % and after three months follows up (93.4 %) of nurses had good level of practical knowledge. Regarding total percent scores of nurses' practices; it was observed that 24.4% of nurses were competent pre-application of guidance protocol compared with 93.3% and 91.1% in immediately post and at follow up respectively.

5. Discussion

Children's functional constipation (FC) is a widespread health condition with recorded global prevalence levels of up to 32.2 percent ⁶. A variety of management techniques have been developed including diagnostic tests, observational treatments, and personalized treatments ³⁴. Colonic irrigation is an important therapy for untreatable defecation disorders and functional disordered children ³⁵. High volume colon irrigation is an easier and less expensive alternative to gastrograffin enemas for treatment of FC ³⁶.

Despite the benefits of emptying the colorectum and preventing fecal incontinence or constipation, this method consumes time and requires thorough training and instruction. Paquette et al, ³⁷ mentioned that it is important to develop clinical practice guidelines based on the best available evidence. Such recommendations are intended for use by both healthcare professionals and practitioners. Instead, nurses are in need of a structured colonic irrigation training process to suit their needs. As this is the first documented study aimed at evaluating the effect of implementing colon irrigation guidance protocol on knowledge and practices of pediatric surgical nurses; we faced a question of lack of references to clarify our findings. Hence our study results were clarified from the point of view of the researchers and supported with the theoretical context regarding colon irrigation.

Regarding nurses’ characteristics, the finding of the current study revealed that about three-quarters of them had bachelor degree and more than two-thirds were worked in the pediatric surgical intensive care unit (Table 1). These results may be due to pediatric surgical intensive care unit is a critical working place which need more qualified nurses. In relation to training courses for nurses, in the current research, most nurses had no training courses on colon irrigation. This result may be justified by nurses considered that colon irrigation is a basic nursing technique and is not a major topic of debate and is not practiced as a nursing skill. Additionally, this could be due to lack of participation by nurses, or even lack of in-service education, ongoing training and staff development in the study settings.

The findings of this study showed that there were highly statistically differences in the theoretical and practical knowledge of nurses about colonic irrigation before, immediately after and after application of guidance protocol (Table 2, Table 3). This means that there is an improvement in nurses' theoretical knowledge of definition, aims, differences between enema and colon irrigation, indications, contraindications, complications and instructions to avoid complications. In addition, practical knowledge concerning colon irrigation skills as a nursing procedure is improved. These findings could be interpreted by those nurses firstly considered colon irrigation as a simple procedure (before implementation of guidance protocol) but they recognized that it can result or lead to serious adverse effects. In this sense, Xin, Fang, Zhu, et al, ³⁸ argued that, given the long history of colon cleansing and current popularity, the literature does not support its supposed benefits. Serrano-Falcon & Rey, ³⁹ added that this procedure may produce undesirable side effects, although adverse events are generally thought to be rare.

Most literature reports note a range of adverse colon cleansing effects ranging from mild (eg, cramping, abdominal pain, fullness, bloating, nausea, vomiting, perianal irritation, and soreness) to severe (eg, electrolyte imbalance and renal failure). If equipment is not sterile and infection prevention protocols are not followed, then the risk for bowel infections to be transmitted ^{31, 40}. In addition, Mishori and colleagues ²⁴ reported that colonic irrigation was identified as an "unwise" procedure because it carries the risk of serious harm and has no documented benefit. On the other hand, Eykelbosh & Wiens ⁴¹ reported that, despite lack of demonstrated benefit, colon hydrotherapy has become a proven procedure and is commonly used.

Concerning nurses’ practices of colon irrigation, it was found that there was a statistically significant difference between the practices of colon irrigation by nurses before, immediately after and 3 months after the implementation of the guidance protocol (Table 4). Furthermore, nurses distribution according to their total nurses’ knowledge, it was noticed that more than ten percent of nurses have good level of knowledge pre application of guidance protocol, meanwhile, in post, more than of sixty-five and after three months follow up more than two-thirds of nurses have a good level of knowledge. In relation to total nurses' practical knowledge, this table indicated that less than ten percent of nurses had good level of practical knowledge pre of guidance protocol, meanwhile, in post and after three months follows up, most and the majority of nurses had good level of practical knowledge respectively.

Regarding total percent scores of nurses' practices; it was observed that nearly one-quarter of nurses were competent pre-application of guidance protocol compared with the majority of nurses in immediately post and at follow up (Table 5). This could be attributed to the impact of implementing colon irrigation guidance protocol, the variety of educational methods that the researcher used as lectures, audiovisual materials, video film, poster, and discussion and then hold a booklet in the settings of the research, which reminds nurses of comprehensive scientific knowledge and accurate steps regarding colon irrigation. Moreover, after implementation of the guidance protocol, nurses became more competent, more compassionate and more mindful of their role in this nursing practice. This is in accordance with the Pyramid of Learning cited by Masters K as by Edgar Dale or by the NTL; as many authors cited, the pyramid showed that people can retain 10% of what they read, and 20% of what they see and understand (audiovisual). The same authors added that some would retain 50% of what he sees and hear as watch live demonstration and 75% by Practice by doing ⁴². This justify is supported by Bazzocchi & Giuberti, ⁴³ who stated that colonic irrigations are not self-administered, However, they are performed by a professionally qualified person and the treatment involves washing the entire colon from the rectum to the caecum using filtered and temperature-controlled warm water that enters and exits the colon through tubing connected to the rectal catheter, until the entire colon is cleaned.

6. Conclusion

The study concluded that after implementing guidance protocol regarding colon irrigation, there was an improvement in the knowledge and practices of pediatric surgical nurses.

7. Recommendation

The following recommendations are suggested, based on previous findings:

Ÿ Pediatric surgical nurses should be presented with the latest concrete evidence of the proper use of colon irrigation procedures for children with functional constipation.

Ÿ To promote the knowledge and attitudes of nurses, unit- and hospital-level nursing educators and Administrators should offer and strongly advise educational programs and assistance, thereby facilitating colon irrigation practice.

Ÿ Lastly, efforts are required to develop and test qualified colon irrigation education programs to correct misinformation.

Conflict of Interest

The authors have no conflicts of interest relevant to this article to disclose.

Acknowledgements

All authors of the study had full access to all of the data in the study and take responsibility for data integrity and data analysis accuracy. All authors approved the final manuscript as presented and agreed to take responsibility for all aspects of the work. The authors have no financial relationships to disclose which are relevant to this article.

References