Workers employed by National Disability Insurance Scheme (NDIS) providers, who deliver supports to NDIS participants requiring complex bowel care, must be able to provide appropriate care.

This article has been updated in response to the release of Version 3 of the NDIS Practice Standards: High Intensity Support Skills Descriptors (HISSD), which came into effect on 1 February 2023.

What is Complex Bowel Care?

Bowel care is a routine component of personal support that is imperative to a person’s quality of life (NDIS 2021a; NHS 2017).

However, NDIS participants at risk of severe constipation or faecal incontinence may require complex bowel care from support workers with a more specialised skill set (NDIS 2022).

Complex Bowel Care in the NDIS Practice Standards

Complex bowel care is a requirement of the NDIS Practice Standards under the High Intensity Daily Personal Activities Module.

This Practice Standard aims to ensure that NDIS participants requiring complex bowel care receive appropriate support that is relevant and proportionate to their individual needs (NDIS 2021).

Under these standards, care providers must meet the following quality indicators:

• Participants are enabled to participate in the assessment and development of a complex bowel care plan. This plan identifies possible risks, incidents and emergencies, and what actions need to be taken to manage these situations, including the escalation of care, if necessary. The participant’s health status is reviewed regularly (with the participant’s consent).
• Workers providing complex bowel care are informed by appropriate policies, procedures and training plans.
• Workers providing complex bowel care have received all necessary training from a qualified health practitioner or another appropriately qualified individual.

(NDIS 2021b)

Who Requires Complex Bowel Care?

Complex bowel care may be required for NDIS participants living with:

• Spinal injury or other conditions causing muscle or nerve damage
• Autism
• Stroke
• Neurological conditions
• Cerebral palsy (with a Gross Motor Function Classification System (GMFCS) level of 3, 4 or 5)
• Acquired brain injury.

(NDIS 2022)

A participant who is receiving non-routine treatment such as non-routine pro re nata (PRN) medication for bowel care may also require complex support (NDIS 2022).

Complex Bowel Care Skills Descriptors and Knowledge

The NDIS high intensity support skills descriptors are additional guidance specifically for NDIS workers who are supporting participants with high intensity daily personal activities (HIDPA). Many of these HIDPAs are high-risk and/or intimate care areas that require a high level of care, competency and communication. The high intensity support skills descriptors set out the skills and knowledge required for NDIS workers to effectively and safely support participants with HIDPAs (NDIS 2022).

The high intensity support skills descriptors have been updated as of 1 February 2023 in order to:

• Ensure they reflect contemporary practice and expert advicev
• Align their format and language more closely to the NDIS Workforce Capability Framework.

(NDIS 2023)

Skills Required for Complex Bowel Care

Workers providing complex bowel care under the NDIS should be able to:

• Understand and follow the participant’s support plan
• Ask the participant about their expectations, capacity and preferences for being involved in the delivery of their care
• Ask the participant about their communication preferences, and communicate in their preferred way
• Follow hygiene and infection control principles, including hand hygiene, disinfecting the environment and wearing gloves
• Ensure required equipment and consumables are available and prepared for use
• Provide support in the least intrusive and restrictive way practicable, in alignment with the participant’s daily routine and preferences
• Recognise that bowel health is highly personal for the participant and provide support accordingly
• Support the participant to position themselves for bowel care
• Use the Bristol Stool Form Scale or other reference guides to observe and record bowel motions, and identify changes that require escalation of care
• Ensure that the participant is clean, comfortable and not experiencing perianal skin irritation
• Identify signs of poor bowel function or other issues and escalate to an appropriate health practitioner immediately
• Work collaboratively with other members of the care team
• Discuss any changes needed to bowel care support with the participant
• Identify, document and report if the participant’s support plan is not meeting their needs
• Support the participant to provide feedback or request changes to their support plan.

(NDIS 2022)

Additionally, workers supporting a participant with a stoma in-situ should also be able to:

• Assist the participant to keep the stoma site healthy and clean
• Repace and dispose of stoma bags
• Monitor and record required information (as indicated by the participant’s support plan), e.g. outputs, hydration and stoma appearance
• Identify issues such as blockages and immediately escalate care to an appropriate health practitioner.

(NDIS 2022)

Knowledge Required for Complex Bowel Care

NDIS Code of Conduct and Practice Standards

Read: The NDIS Practice Standards Explained

The NDIS Practice Standards establish the benchmark of performance, quality and safety that NDIS providers should meet in their delivery of supports and services (NDIS 2021b).

The Standards work alongside the NDIS Code of Conduct to inform NDIS participants about the quality they should be expecting from the supports and services they receive (NDIS 2021b).

The NDIS Code of Conduct sets out expectations for the behaviour of both NDIS workers and participants in order to promote safe and ethical service delivery. For more information of the NDIS Code of Conduct, see https://www.ndiscommission.gov.au/about/ndis-code-conduct.

The Importance of Good Bowel Care

Good bowel management is essential for a person’s physical health, self-esteem and overall quality of life (SCHN 2014).

Bowel conditions, particularly faecal incontinence, are highly stigmatised and can have severe social and emotional consequences (Duyos & Ribas 2019). Therefore, good bowel care can help support participants to gain more confidence and lead the life they choose.

Remember that bowel health is a highly personal and embarrassing subject for some people, so participants should always be treated with empathy and dignity.

Communication Supports

Participants may have a variety of communication needs and preferences, such as the use of communication aids or devices, or access to resources in another language (NDIS 2022). Remember to individualise communication to ensure each participant’s needs and preferences are met.

For more information on communication supports, see the following Ausmed resources:

• Communicating Effectively With People With Disability
• Communication Skills
• Communication for Quality Care

Infection Prevention and Control

It’s essential to be aware of and follow infection control principles, including PPE, handwashing and disinfecting (NDIS 2022).

For more information on infection control, see Ausmed’s Training Module on Infection Prevention and Control.

Scope of Practice

Always work within your scope of practice and your role’s responsibilities. Refer to your manager and/or local policies and procedures for more clarity on your specific role and responsibilities if you are unsure.

Also see Ausmed’s Training Module on Scope of Practice: Care Workers.

Bowel Anatomy and Physiology

When food is consumed, it breaks down in the stomach and passes through the intestines. The walls of the intestines then absorb nutrients from the food. The waste that remains is then passed through the colon and rectum and is excreted (Khan 2022).

Bowel motions are affected by a variety of factors, such as:

• Diet: Fibre adds bulk to faeces, making it easier to pass, while on the other hand, a low-fibre diet can lead to constipation
• Hydration: Insufficient water intake can lead to constipation
• Probiotics: Consuming probiotics has been found to increase the frequency of bowel movements, decrease bowel transit time and improve the consistency of stools.

(Better Health Channel 2014; Healthy Eating Clinic 2020)

Complex Bowel Conditions

Complex bowel conditions in the NDIS high intensity support skills descriptors include:

• Severe constipation
• Faecal incontinence.

(NDIS 2022)

Constipation

Constipation refers to difficulty defecating over an extended period of time. It is defined as the occurrence of less than three bowel movements per week (Premium Health 2022).

Someone who is constipated may simply have difficulty defecating (with a normal defecation frequency), or they may have a delayed colonic transit time of food from the mouth to the anus, which causes stools to become hard, dry and infrequent (Premium Health 2022; RCN 2019).

Common causes of constipation include:

• Insufficient fibre intake
• Insufficuent hydration
• Lack of physical activity
• Ignoring the urge to defecate
• Certain medicines
• Stress
• Pregnancy
• Certain conditions, including Parkinson's disease, multiple sclerosis, depression, irritable bowel syndrome and coeliac disease
• Older age.

(Better Health Channel 2014; Healthdirect 2022)

Signs and symptoms of constipation include:

• Needing to open the bowels less frequently
• Hard, dry stools that might be hard to pass
• Painfully straining to pass a bowel motion
• Feeling as though there is a blockage preventing a bowel movement
• Having to sit on the toilet for long periods of time
• A sensation that the bowel has not fully emptied after a motion
• Bloated abdomen
• Abdominal cramps.

(Better Health Channel 2014; Mayo Clinic 2021)

Faecal Incontinence

Someone experiencing faecal incontinence has difficulty with bowel control, causing involuntary loss of stools (RCN 2019).

Common causes of faecal incontinence include:

• Poor toilet habits e.g. straining to pass stools
• Certain medicines
• Weak pelvic floor muscles
• Constipation
• Diarrhoea
• Certain conditions, including Parkinson's disease, multiple sclerosis, depression, diabetes and bowel diseases.

(Healthdirect 2020)

Signs and symptoms of faecal incontinence include:

• Difficulty holding in a bowel movement
• Needing to rush to the toilet to empty the bowels
• Diarrhoea
• Constipation, which can cause fluid leakage.

(Healthdirect 2020)

Autonomic Dysreflexia

Autonomic dysreflexia is a potentially life-threatening complication that can occur in people with spinal cord injury (typically a SCI above T6). It occurs in response to a strong sensory stimulus below the level of the injury, resulting in severe hypertension (ACI 2014).

Autonomic dysreflexia can be triggered by bowel issues such as constipation and faecal impaction. Therefore, good bowel care for participants with SCI is crucial in order to avoid this complication from occurring (ACI 2014).

Signs and symptoms of autonomic dysreflexia include:

• Sudden high blood pressure
• Pounding headache
• Slow heart rate
• Flushed or blotched skin above the level of the SCI
• Profuse sweating above the level of the SCI
• Pale skin and piloerection (goosebumps) below the level of the SCI
• Chills (with no fever)
• Nasal congestion
• Dilated pupils
• Shortness of breath
• Anxiety
• Irritability or combative behaviour in people with limited cognition or communication skills.

(ACI 2014)

If you suspect autonomic dysreflexia in a participant you are caring for, you should immediately:

• Alert your manager or an appropriately qualified healthcare practitioner (refer to your organisation’s policies and procedures)
• Elevate the person’s head and lower their legs to reduce blood pressire
• Loosen constrictive clothing
• Monitor blood pressure every 2-5 minutes.

(ACI 2014)

Bowel Care Support

Bowel issues can be managed in a variety of ways, including:

• Enemas
• Laxatives
• Suppositories
• Stool softeners
• Abdominal massage.

(NDIS 2022; Better Health Channel 2014)

Stomas

A stoma is a surgically-created artificial opening, where a section or piece of the bowel is brought through the abdomen. This allows waste to be removed from the body directly through the end of the bowel into a collection bag (Healthdirect 2021; Cancer Council Victoria 2021).

There are two types of bowel stoma:

1. Colostomy: made from the colon in the large bowel
2. Ileostomy: made from the ileum in the small bowel.

(Cancer Council Victoria 2021)

The waste that passes through the stoma is collected in a stoma bag, a pouch made from soft, waterproof material (Clinimed 2011).

This bag fits securely around the stoma and adheres to the abdomen using an attached or detachable flange, which is made from a breathable material and attaches to the skin using medical-grade adhesives. The type of bag needed will depend on the type of stoma (Clinimed 2011).

What should a heathy stoma look like?

• The stoma should be pink or red, moist and shiny
• Swelling may be present during the postoperative period but should decrease in size within six to eight weeks
• Minor bleeding may occur but should stop when you apply light pressure to the area
• The border between the stoma and the abdominal skin should be intact, with even, intermittent sutures in situ
• The skin surrounding the stoma should be intact, healthy and look similar to the skin on the other side of the abdomen
• The stoma should be protruding between 2 and 2.5 cm from the skin.

(WACHS 2019)

How to care for skin around the stoma:

• Use warm water and a soft, disposable cloth or tissue to clean the skin
• Try to avoid using soap as this can impair adhesion - if you do need soap, use a mild product that won’t leave residue behind
• Pat the skin dry after cleaning
• Avoid using:
  • Soaps containing lotions
  • Skin care creams and lotions
  • Powders
  • Wipes
  • Isopropyl alcohol
  • Steroidal ointments and medications.

(WACHS 2019; Dansac 2018)

Issues at the stoma site:

The following signs and symptoms require escalation of care to an appropriately qualified medical practitioner:

• Pale, dark, dusky or black stoma
• Excessive swelling
• Bleeding
• Disruption to the mucocutaneous junction
• Dehiscence of the mucocutaneous junction
• Extruding serosal tissue
• Skin redness, erythema, rashes or irritation
• Impaired skin integrity
• Skin pain or tenderness
• Retracted stoma (where the stoma slides back into the abdomen below skin level)
• Prolapsed stoma (where the stoma slides out of the abdomen and protrudes more than 5 cm from skin level)
• Infection
• Parastomal hernia (wherein part of the bowel protrudes through the stoma)
• Diarrhoea
• Dehydration
• Narrowing of the stoma
• Difficulty passing stools through the stoma
• Obstruction of the stoma due to scar tissue
• Impacted faeces
• Kidney stones
• Gallstones
• Necrosis
• Stomal dehiscence
• Decreased output
• Excessive output
• Incorrectly fitted stoma appliance
• Appliance leakage.

(WACHS 2019; CHHS 2014; Finlay, Sexton & McDonald 2018; Better Health Channel 2011)

For more information on stomas and stoma care, see the Ausmed Course Acute Stoma Care.

Management

You may have specific documentation and reporting responsibilities, such as handover, observations and incident reporting (NDIS 2022). Refer to your organisation’s policies and procedures for further information on what is required.

You should also be aware of the process for requesting a review of a participant’s care (NDIS 2022). Refer to your organisation’s policies and procedures for further information.

When to Escalate Care

The participant should be referred to a health practitioner if they are experiencing the following complications:

• Overflow
• Bowel obstruction
• Perforation
• Faecal impaction
• Strangulated hernia
• Infection
• Autonomic dysreflexia
• Undiagnosed rectal bleeding
• Undiagnosed diarrhoea
• Poor nutrition or hydration.

(RCN 2019; NDIS 2021a)

Conclusion

Remember that bowel health may be embarrassing and highly personal for some people. Therefore, it is essential to communicate with participants empathetically.