Practice MattersUncategorized

Refining stool consistency descriptors can help prevent adverse outcomes


Stool consistency and form are significant aspects of a GI assessment, providing valuable information about the patient’s bowel motility. Properly identifying and describing these components can help prevent adverse outcomes and promote patient comfort and well-being. Historically, though, clinicians’ interpretation of stool consistency has been subjective due to lack of appropriate and consistent descriptors. To ensure the entire healthcare team has accurate information, all healthcare workers who document in the electronic health record (EHR) need to document stool consistency and form using standardized, consistent terms.

On our long-term care (LTC) unit, we identified the need for a standardized tool to describe stool consistency and form. We recognized that the older adults we serve have unique needs for accurate stool assessment—namely, avoiding discomfort and adverse events, such as bowel obstruction. When describing stool, our nursing staff met challenges because the only relevant terms in our EHR were “formed,” “soft,” “unformed,” and “multiple diarrhea stools.” Also, based on chart reviews, we found inconsistent documentation of stool characteristics on that unit. This raised the risk of adverse events and patient discomfort, as clinicians were making important care decisions without accurate data.

Then we developed a pilot project for this unit, with the purpose of implementing an evidence-based standardized tool to describe and document stool consistency. Our goal was to support evidence-based practices that optimize care. The American Nurses Association (ANA) has identified the use of appropriate evidence-based assessment techniques, instruments, and tools to obtain accurate information as crucial to nursing practice. ANA’s gerontologic nursing standard states that nurses enhance the quality and effectiveness of nursing practice when they use the results of quality-improvement activities to initiate nursing practice changes.

Plan-Do-Study-Act framework

We used the quality-improvement process of Plan-Do-Study-Act (PDSA) as the framework for our pilot project.


We examined data from the medical records of patients on our LTC unit and reviewed current best evidence in the literature. Initially, our team consisted of two staff registered nurses from the unit, in consultation with the nursing governance council. Over time, the team expanded to include the unit’s nurse educator, clinical nurse specialist, and medical center nurse scientist.


We adapted the Bristol Stool Form Scale, an evidence-based tool, to our setting because of its apparent ease of use, validity, and reliability. We titled it “Bristol Stool Chart” for simplicity and because we adapted it from the original scale. (See Bristol Stool Chart.)

Our unit-based shared governance practice council reviewed and approved the pilot project before its full implementation. We implemented the Bristol Stool Chart on the unit as part of the current documentation method. All unit clinicians were informed of this practice change through just-in-time education on the floor and at unit meetings. Education included an overview of the pilot project and review of the chart. Opportunities were provided for questions and answers. Nursing staff verbalized their understanding of the chart, the documentation requirement, and the importance of standardizing stool descriptors.


Bowel-movement documentation was collected for 30 days after the Bristol Stool Chart was implemented. After implementation, the stool documentation rate improved from 90% to 99%. Using informal methods, we asked nursing staff about the education process and chart usability. Their comments included “It’s very self-evident” and “I can figure this out by looking at it.”


The Bristol Stool Chart is now the standard method for documenting stool description on our LTC unit. Based on the success of the pilot project, the Bristol Stool Chart was recommended for implementation throughout our medical center’s inpatient and outpatient areas. The hospital-wide nursing practice council, which is responsible for approving and implementing practice changes, approved use of the chart throughout the medical center.

The education/professional development council approved an educational plan, which included a simple online educational module of nine slides designed to meet the learning needs of all staff roles. Flyers were made and placed in each inpatient and outpatient care unit. For easy access, the stool chart was placed on the clinical-resource local Intranet site. We worked with the information technology department to alter the EHR so the Bristol Stool Chart could be an aspect of the intake and output section of our documentation. The nursing practice change was communicated formally to nursing staff, providers, and chiefs of services at meetings and published in the nursing newsletter. We also solicited feedback from nurses in all patient care areas related to tool usability; 90% of respondents said the tool was easy to use.

Opportunities for improvement

We recognized opportunities for improvement in the rollout of this practice change. Although we piloted the Bristol Stool Chart in the LTC unit, we realized that piloting it in other patient care areas before house-wide implementation might have yielded benefits. We also learned that while the chart was pertinent to all units, our medical center uses several different documentation methods; in some areas, implementing the chart proved difficult. In addition, although the practice change was vetted through our shared governance practice council and by providers, to sustain use of the tool, we should have considered the need for buy-in from staff in various roles and units.

A second opportunity to improve practice was to include patients. In view of our patient-centered approach to care, we concluded that providing education on the tool for LTC patients would be helpful. Our medical center incorporates the relationship-based care model as the foundation for delivering care. This model provides a holistic approach that centers on the patient and family and promotes patients as active participants in their care.

So we considered how the Bristol Stool Chart would work with patients. A group of nurse residents helped create a patient-education handout that meets health literacy standards. Currently, we are implementing this handout throughout LTC unit, with broad interest and acceptance by patients. A similar quality-improvement process will be used to implement the handout throughout the medical center.

Areas for future research may include:

  • determining the reliability of Bristol Stool Chart use for LTC patients
  • examining barriers to using the tool
  • exploring the tool as an improved assessment and stool descriptor for decision making related to GI infectious illness management.

Selected references

American Nurses Association. Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring, MD: Author; 2010.

American Nurses Association. Gerontological Nursing: Scope and Standards of Practice. Silver Spring MD: Author; 2010.

Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920-4.

McPeake J, Gilmour H, MacIntosh G. The implementation of a bowel management protocol in an adult intensive care unit. Nurs Crit Care. 2011;16(5):235-42.

O’Donnell LJ, Virgee J, Heaton KW. Detection of pseudodiarrhoea by simple clinical assessment of intestinal transit rate. BMJ. 1990;300(6722):439-40.

Saad RJ, Rao SS, Koch KL, et al. Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol. 2010;105(2):403-411.
The authors work at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. Mark P. Mueller is a case manager, Tom Ustruck is a staff nurse, Stephenie Cerns-Rach is a clinical nurse specialist, Linda A. Cayan is a nursing professional development specialist, and Mary E. Hagle is a nurse scientist. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Veterans Affairs or the United States Government.

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