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12
sexual drive [30, 34]. Carefully selecting clothing to hide potential fecal leakage
restricts women’s expression of sexuality through clothing [29].
Men and women with fecal incontinence have some strategies to maintain a
healthy sexual life. For example, based on patterns of fecal incontinence, the timing
of sexual expression can be modied [34]. Cleanliness is a major concern for men
and women in regard to sexuality, and they make concerted efforts to wash to avoid
odor [29, 39].
Unfortunately, men and women with fecal incontinence did not nd their interac-
tions with health care professionals about their sexual health helpful. Health care
professionals did not talk about sexual issues concerning fecal incontinence in gen-
eral and even after surgeries that would affect sexual functioning [29, 35]. This
represents a signicant knowledge, practice, and research gap for advanced nursing
practice.
1.5.5 Domain V: Living withFecal Incontinence Related
toDietary Issues
Eating and diet are signicant components of quality of life for people with fecal
incontinence (see Table1.5). Responses of persons with fecal incontinence from
several different studies identied consistent types of food and drink that worsen or
result in fecal leakage [1, 28, 32, 45–47]. These foods are often referred to as “trig-
ger foods” (see Box 1.1). Study participants shared numerous strategies for self-
management of fecal incontinence related to adding or restricting intake of certain
foods, changing ways they prepared food, and modifying the timing of eating [27,
28, 32, 39, 46, 47]. These strategies are discussed in Chap. 6.
Box 1.1 Types of Trigger Foods Identied by Individuals with Fecal Incontinence
as Worsening Their Symptoms
• Spicy foods
• Fatty, greasy foods, eggs
• Caffeinated drinks and foods (coffee, chocolate)
• Dairy products
• Fresh apricots, strawberries, citrus fruits
• Popcorn, nuts, seeds
• Onions, beans, cabbage, broccoli
• Alcohol (beer)
D. Z. Bliss et al.
13
1.5.6 Domain VI: Living withFecal Incontinence Related
toBarriers andFacilitators ofSeeking Treatment
andSelf-Management Support
There are barriers to self-managing of fecal incontinence at the individual or per-
sonal and system levels [1, 23, 45]. Individual barriers identied by patients include
a lack of knowledge about how fecal incontinence develops and its treatment,
denial, self-blame, emotional distress, and embarrassment. Considering fecal incon-
tinence as a normal consequence of aging or childbirth are others factors. Healthcare
system barriers to seeking support for self-management and treatment are cost, con-
venient access to a provider, needing to take time off from work for an appointment,
and having a previous negative experience with healthcare providers.
Not all patients seek self-management support and treatment for fecal inconti-
nence in a timely way or possibly ever. Several factors that promote seeking care
have been identied [23, 45]. Promoting factors were practical matters such as fre-
quent need for personal hygiene and cleansing, and interference with daily activities
and productivity, as well as the anxiety and fear of a public accident and psychologi-
cal burden. Positive expectations related to treatment and satisfaction with available
treatment options were other factors. The impact of fecal incontinence on quality of
life can serve as either a barrier or facilitator to seeking treatment and self-
management support from a clinician/healthcare system [1].
Table 1.6 lists barriers to care for fecal incontinence and recommendations to
reduce them to support improved quality of life.
Table 1.6 Recommendations for advanced nursing practice—support of quality of life in persons
with fecal incontinence related to barriers to seeking treatment
Barriers to care for fecal incontinence
Practice implications for the advanced practice
nurse
Individual/personal barriers include lack of
knowledge, and emotional reactions such as
denial, self-blame, distress, and
embarrassment
Educate patients so they can participate in
their fecal incontinence management plan and
be successful in self-management activities
Provide emotional support and offer coping
strategies
Healthcare system barriers include cost and
needing time off from work for appointments,
limited access to care, and negative
experiences with providers
Refer patients for assistance in obtaining
coverage for care for fecal incontinence
management
Offer extended clinic hours and remote/virtual
services to increase access to care
Maintain an empathetic, positive, and
supportive manner in patient interactions
1 Fecal Incontinence: Denition andImpact onQuality ofLife
14
A case study illustrating support of quality of life reduced by altered body image
and low self-esteem due to fecal incontinence is presented in Box 1.2.
Box 1.2 Clinical Exemplar—Body Image and Self-Esteem
Mrs. Finnegan is a 55-year-old woman being seen by an advanced practice
nurse for assessment and management of her fecal incontinence. Mrs.
Finnegan recently had an “accident” of fecal soiling during her pickleball
game. She shared with the nurse that “I have never been so humiliated in my
life. I wanted to cry,” and had tears in her eyes when telling the story. Mrs.
Finnegan said she has not scheduled any future pickleball games or social
activities. She says the friends she was playing with were sympathetic and
helped her nd the public toilet at the court to wash up, but really did not
know what to say. She said she had been having small smears of stool on her
underwear for about a year and had started wearing a pantiliner pad. Mrs.
Finnegan said she should have known better than to play pickleball if this was
happening. She was very anxious about exercising or socializing in public
until this “problem can be xed.”
The advanced practice nurse worked with Mrs. Finnegan to develop a con-
servative management plan for her fecal incontinence. Additionally, she knew,
however, that for Mrs. Finnegan to feel condent to return to her previous
activities, she had to address Mrs. Finnegan’s anxiety over future embarrass-
ment and the negative effect the incident had on her self-esteem. The nurse
started by acknowledging the impact that the public episode of fecal inconti-
nence had on Mrs. Finnegan. She shared with Mrs. Finnegan what she had
learned from her experience with other patients: it is helpful to develop coping
strategies related to both the worry of future incontinence episodes as well as
the actual incontinence.
The advanced practice nurse wanted Mrs. Finnegan to feel prepared in the
event of future incontinence episodes while working on their treatment plan.
She focused on being prepared rather than blaming herself and being fearful
of a future accident. They discussed strategies such as wearing a full brief
absorbent product with a low, non-bulky prole that looked and felt like nor-
mal underwear during her pickleball games and other social activities. She
suggested Mrs. Finnegan carry a change of underpants and shorts and a small
packet of cleansing products in her purse.
Her management plan included monitoring her bowel movement and leak-
age pattern using a bowel diary. The nurse also advised Mrs. Finnegan to try
to time her meals and bowel elimination before going outside and engaging in
activities. She recommended knowing the location of the closest toilet when
out in public. She suggested that Mrs. Finnegan reach out to her closest friend
with whom she plays pickleball and conde that she had been having some
trouble with her bowels and is seeking treatment so she can control the mes-
sage and enlist support from her friend.
D. Z. Bliss et al.
15
The nurse taught Mrs. Finnegan some relaxation and emotional self-support
strategies. For example, she showed her how to engage in progressive relaxation
techniques: a simple strategy of counting while deep breathing and thinking of a
pleasant image. Mrs. Finnegan could try this technique before starting a social
activity if she experienced increased anxiety. The nurse asked Mrs. Finnegan about
what she does well and likes to do. She suggested that Mrs. Finnegan engage in self-
talk about her positive aspects when she feels down about having her condition or
blames herself, explaining that thoughts have real power over feelings. None of
these discussions or strategies were easy for Mrs. Finnegan, but acknowledging the
social impact of her incontinence was critical to fostering hope and engagement
with the treatment plan.
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1 Fecal Incontinence: Denition andImpact onQuality ofLife
19
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Z. Bliss (ed.), Management of Fecal Incontinence for the Advanced Practice
Nurse, https://doi.org/10.1007/978-3-031-94526-7_2
2
Impact oftheCOVID-19 Pandemic
onNursing Care andPatients
withIncontinence
PhanidaJuntasopeepun
, NongyaoKasatpibal
,
PornpunSuithiwong, DonnaZ.Bliss
,
andSheilaHowesTrammel
Abstract
This chapter discusses the signicant challenges to healthcare and nursing care
of incontinent individuals posed by the COVID-19 pandemic worldwide using
the experience in Thailand and the United States’ nursing homes as exemplars.
In Thailand, the United States, and many other countries, nurses faced increased
workloads and stress, reassignments, altered care routines, and shortages of med-
ical supplies. Patients and long-term care residents experienced restricted mobil-
ity, social interactions, and family visits due to infection control, physical
distancing, and isolation measures, leading to higher rates of numerous prob-
lems, including fecal and urinary incontinence, irritant contact dermatitis, pres-
sure injuries, and urinary tract infections (UTIs). Despite these challenges, nurses
adapted care delivery by leveraging telemedicine, collaborating with volunteer
P. Juntasopeepun
.
N. Kasatpibal
Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand
e-mail: phanida.j@cmu.ac.th; nongyao.ka@cmu.ac
P. Suithiwong
Surgical Nursing Section, Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine,
Chiang Mai University, Chiang Mai, Thailand
e-mail: pornpun.s@cmu.ac.th
D. Z. Bliss (*)
University of Minnesota School of Nursing, Minneapolis, MN, USA
e-mail: bliss@umn.edu
S. H. Trammel
Hennepin County Medical Center, Minneapolis, MN, USA
20
groups, and using donated or reusable supplies. The pandemic highlighted the
need for innovative strategies to manage incontinence care effectively, such as
government initiatives to provide free absorbent products in Thailand. The resil-
ience and adaptability demonstrated by nurses established a framework for
improved incontinence care in future healthcare crises. This chapter also reviews
strategies for advanced practice and general staff nurses to re-establish high-
quality incontinence care after the pandemic.
2.1 Introduction
Corona-virus disease discovered in 2019 (generally referred to as COVID-19)
emerged as a global pandemic in early 2020, profoundly affecting healthcare sys-
tems across the globe. Much like past pandemics, COVID-19 has highlighted vari-
ous aspects of the lives and practice of health professionals. The nursing profession,
in particular, was faced with signicant challenges in providing care to individuals
and educating communities during the pandemic. In the context of nursing care for
incontinent patients, the pandemic introduced new complexities. The virus’s high
transmission rate necessitated stricter infection control measures, such as the
increased use of personal protective equipment (PPE) and stringent sanitation pro-
tocols. These requirements amplied the workload and stress on nursing staff, com-
plicating the efcient management of incontinence care. Moreover, the need for
physical distancing and the isolation of COVID-19 patients further complicated
routine care, potentially leading to delays in managing incontinence, skin break-
downs, and a higher risk of infections. As a result, adaptations in care strategies,
including telehealth consultations and adjusted in-person care practices, have
become essential to safeguard patient safety while navigating the challenges posed
by the pandemic. This chapter describes the COVID-19 pandemic situation and its
impact on nursing care, including how nurses have adapted to care for COVID-19
patients during the crisis and specic challenges faced in providing nursing care for
incontinent patients.
2.2 COVID-19 Pandemic Situation
Thailand reported its rst COVID-19 case on January 13, 2020, a Chinese tourist
from Wuhan, marking the rst conrmed case outside of China and highlighting the
early international spread of the virus [1]. Public health and social measures have
been crucial in controlling the virus’s spread and protecting public health. Like the
rest of the world, Thailand implemented measures such as social distancing, mask-
wearing, and hand hygiene to reduce transmission, especially before vaccines
became widely available. Shortly after the outbreak in April 2020, Thailand intro-
duced stringent social measures, including a full-scale national “lockdown” includ-
ing curfew limits on travel, and a 14-day mandatory quarantine for international
travelers to the country. Initially, strict adherence to these measures, supported by a
P. Juntasopeepun et al.
21
whole-of-government approach, allowed Thailand to effectively control the virus.
However, subsequent waves of infection and COVID variants led to a signicant
increase in cases and deaths [2]. As of August 2024, Thailand had reported approxi-
mately 4.8million COVID-19 cases and 34,700 deaths. The country’s case-fatality
rate (CFR) of 0.7% is notably lower than the global average of 0.9% [3, 4].
Nurses played a pivotal role in implementing public health measures and vacci-
nation during the COVID-19 pandemic. COVID-19 vaccines have been critical in
reducing the spread of the virus, preventing severe illness, and saving lives. They
have played a key role in allowing societies to return to a sense of normalcy [5]. The
WHO targeted 100% coverage among populations at increased risk [5]. In Thailand,
following the initial availability of COVID-19 vaccines, the Food & Drug Authority
(FDA) of Thailand approved two vaccines, AstraZeneca-Oxford and Sinovac, both
requiring two doses [6]. These vaccines were offered free of charge to Thai citizens
through public healthcare facilities. Private hospitals were also permitted to import
and sell FDA-approved vaccines. In the rst phase, vaccinations were prioritized for
four groups: (1) frontline healthcare providers, (2) vulnerable individuals with
severe underlying conditions, (3) those over 60years old, and (4) personnel involved
in disease control. Once vaccine supply increased and more options became avail-
able, vaccination was recommended for everyone in the country [6]. In Thailand, as
of the end of March 2023, a total of 57,610,698 (82.8%) Thai people have been
given at least the rst shot of a COVID-19 vaccine [7]. Nurses have been vital in the
vaccination process, not only administering the vaccines but also educating the pub-
lic, addressing concerns, and ensuring the safe and efcient delivery of the vaccine
[8]. Nurses’ involvement in these efforts highlights the broader challenges and sig-
nicant impact the COVID-19 pandemic has had on nursing care as a whole.
2.3 Impact oftheCOVID-19 Pandemic onNursing Care
Like the rest of the world, the pandemic has severely impacted the nursing work-
force in Thailand [9, 10]. The surge in the number of affected patients, particularly
in critical care, placed signicant strain on the nursing workforce. Many nurses
became ill, were quarantined, or experienced burnout, leading to reduced stafng
levels. The prevalence of COVID-19 among Thai health care workers was 4.2%
[11]. Additionally, a large number of nurses were reassigned to priority areas, such
as COVID-19 units or vaccination centers, where their skills were urgently needed.
While necessary, this reallocation further depleted stafng levels in other important
healthcare areas, exacerbating the overall shortage. Despite the pre-existing short-
age of nurses in Thailand, the pandemic exacerbated this issue across all levels of
care and settings nationwide, leading to several signicant consequences, including
increased workloads, interrupted services, and heightened mental health exhaustion
of the nurses.
The nursing workload increased enormously during the pandemic. The nursing
staff’s responsibilities extended beyond managing preventive measures such as quaran-
tine, physical distancing, social isolation, and the use of protective equipment. They
2 Impact oftheCOVID-19 Pandemic onNursing Care andPatients withIncontinence
22
also took on additional tasks, including data collection, case reporting, surveillance,
screening, and public education. With the introduction of COVID-19 vaccines, Thai
nurses faced several challenges in the vaccination process, notably vaccine hesitancy
and other barriers. Vaccine hesitancy among the Thai population was inuenced by
factors such as low education levels, lack of condence in the healthcare system, skep-
ticism about vaccine manufacturers, and receiving vaccines from unanticipated/unof-
cial sources [12]. In addition, Thai nurses encountered signicant barriers to their
participation in the vaccination campaign, including transportation problems to vacci-
nation sites and the complexities of digital booking systems. Although the Thai govern-
ment provided COVID-19 vaccines free of charge to all citizens, additional
administrative costs related to hospital or clinic visits posed further challenges. To miti-
gate these issues, mobile outreach vaccination clinics were implemented to reach older
individuals with disabilities or transportation challenges, including those who were
homebound, construction workers, and immigrant workers [13]. These initiatives
required additional nursing workforce effort and resources.
The suspension of operations in many non-COVID clinics and the reduction of
care for various groups of patients with non-communicable diseases (NCDs) due to
the shortage of healthcare personnel were unavoidable during the COVID-19 pan-
demic. The redirection of Thai healthcare resources towards COVID-19 manage-
ment led to the postponement of regular check-ups, screenings, non-urgent follow-up
visits, and elective surgeries [14, 15]. This disruption in care had several negative
consequences. Patients with NCDs experienced delays in receiving essential care,
which resulted in the worsening of their conditions. Evidence indicates that during
the pandemic, Thai patients with uncontrolled blood pressure tended to adopt
unhealthy lifestyles compared to normal circumstances. This was partly due to gov-
ernment policies that interfered with healthy behaviors, such as home connement
and the closure of public healthcare services, which negatively impacted blood pres-
sure levels [16]. Furthermore, the suspension of operations in some clinics made it
difcult for patients to access their regular medications, leading to poor disease
control and increased complications.
Due to the shortage of nurses, those remaining in the workforce were required to
take on additional duties, work longer hours, and cover for absent/sick colleagues.
This increased workload led to physical exhaustion and stress, which are key con-
tributors to mental health issues. Several studies in Thailand among health care
personnel during the COVID-19 pandemic reported that personnel experienced a
high level of emotional exhaustion, burnout syndrome, stress, anxiety, and depres-
sion, including post-traumatic stress disorder (PTSD) [9, 17–20], particularly
among novice nurses [21].
In conclusion, the compounded challenges of nurse shortages, reassignment of
nurses to priority areas, emotional strain, and added responsibilities during the
COVID-19 pandemic signicantly hindered their ability to provide their usual level
of high-quality care. These factors not only intensied physical and mental exhaus-
tion and stress among nurses but also disrupted essential services for patients.
Consequently, these impacts collectively posed substantial challenges in delivering
optimal nursing care quality during the pandemic.
P. Juntasopeepun et al.