Training activity information
Details
Perform digital rectal examinations
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What does success look like?
- Identify what is expected of you in relation to performing a Digital Rectal Examination (DRE) accurately to ensure safe intubation with manometric equipment.
- Consider how the learning outcomes apply, specifically in relation to performing the DRE to assess anatomy for safe intubation and demonstrating sensitivity and adapting your approach to the patient’s comfort.
- Discuss with your training officer to gain clarity of what is expected of you in relation to identifying key anatomical structures, assessing sphincter tone, and ensuring adherence to necessary infection control precautions.
- What is your prior experience of this activity?
- Think about what you already know about the anatomy of the anal canal and rectum. Have you performed DREs before, perhaps under supervision?
- Consider possible challenges you might face during the activity, such as ensuring optimal patient comfort, identifying subtle abnormalities (e.g., strictures or fissures) that might impact safe intubation, or difficulty identifying anatomy.
- Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if you identify a significant unexpected finding (e.g., palpable mass or severe prolapse) that might contraindicate intubation, or if the patient reports severe, unmanageable pain.
- Acknowledge how you feel about performing DREs.
- What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as executing the DRE technique sensitively, accurately assessing sphincter tone, and correlating DRE findings with requirements for safe intubation.
- Identify the specific insights you hope to gain into the anatomical variations relevant to safe intubation, and the importance of the DRE in assessing investigation requirements.
- What additional considerations do you need to make?
- Consult actions identified following previous experiences of performing clinical examinations or aseptic procedures.
- Identify important information you need to consider before embarking on the activity, such as reviewing the purpose of the DRE before manometry, reviewing the relevant anatomy, and ensuring necessary supplies (e.g., lubricant, gloves) are readily available.
In action
- Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst performing the digital rectal examination (DRE)?
- Are you encountering situations such as:
- The patient experiences unexpectedly severe pain or discomfort, challenging your technique and communication?
- You find it difficult to identify key anatomical landmarks or unexpected physical findings (e.g., strictures or masses) emerge, complicating the assessment for safe intubation?
- The patient reacts poorly to the sensitivity of the procedure, requiring immediate adaptation of your technique to maintain patient dignity?
- How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to DRE technique or communication to prioritise patient comfort?
- Consider the steps you are taking in the moment, such as:
- Immediately pausing the DRE and using compassionate communication to understand the source and extent of the patient’s discomfort
- Discreetly seeking advice from a senior colleague if unexpected findings (e.g., palpable mass) might contraindicate the intended manometry procedure
- How are you feeling in that moment? For instance, are you finding it difficult to adapt your technique while maintaining a systematic examination? Is it affecting your confidence in performing the DRE safely and identifying required structures?
- What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully modifying the examination to obtain necessary data without causing undue distress? Or are you needing support because the patient’s severe pain or unexpected finding requires immediate senior clinical guidance to ensure safety?
- What are you learning as a result of the unexpected development? For example, are you mastering a more effective empathetic approach to managing discomfort during sensitive procedures? Or gaining insight into the anatomical variations relevant to safe intubation?
On action
- What happened?
- Begin by summarising the key steps you took when explaining the digital rectal examination (DRE), preparing the patient, performing the physical assessment of the anal canal, and documenting findings relevant to safe intubation.
- Consider specific events, actions, or interactions which felt important, such as how you confirmed the patient was adequately draped and comfortable before starting, or how clearly you identified and recorded the resting and squeeze tone of the anal sphincter.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately pausing and adjusting your technique when the patient reported unexpected sharp pain during the examination.
- How did you feel during this experience, e.g., did you feel methodological in applying the DRE technique or stressed by the potential for causing patient discomfort?
- How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding performing a DRE specifically to assess anatomy for safe intubation and maintaining patient dignity
- What strengths did you demonstrate, e.g., applying sterile technique and effective assessment of sphincter tone?
- What skills and/or knowledge gaps were evident, e.g., difficulty confidently identifying subtle anatomical abnormalities?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved?
- Has your practice improved in ensuring appropriate communication during the DRE to guide the patient through the procedure?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding how to proceed when you encountered an unexpected physical finding (e.g., a fissure or severe tenderness) that might affect safe intubation, and how you reacted to this.
- What will you take from the experience moving forward?
- Identify the actions you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to refining your DRE technique and correlating findings directly with the requirements for safe manometric intubation.
- What will you do differently next time you approach performing a digital rectal examination, for instance, by proactively verbalising the next step of the DRE to the patient to manage their expectations and comfort?
- Do you need to practise any aspect of the activity further, such as palpation techniques for subtle anatomical variations or key learning outcomes related to performing a DRE for safe intubation?
Beyond action
- Have you revisited the experiences?
- How have your subsequent experiences of intubating the anorectum or performing the full investigation since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, experiencing difficulty passing the catheter smoothly, forced you to re-evaluate the thoroughness of your anatomical assessment and sphincter tone check during your first attempt at this training activity.
- Considering what you understand about anatomical landmarks, safe intubation, and patient handling during physical procedures now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your DRE technique, ensuring accurate anatomical assessment, based on further learning and experiences? For example, how you proactively focused on palpating the puborectalis muscle after reviewing anatomical diagrams to better assess the likelihood of dyssynergic defaecation.
- Has discussing challenging findings encountered during DREs or the impact of patient discomfort on DRE procedure with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where an unexpected fissure was identified during DRE refined your understanding of the critical nature of systematic visual and tactile examination prior to intubation.
- How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent practical procedure experiences, contributed to your overall confidence and competence in performing a DRE for safe intubation and applying anatomical knowledge, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS)? For example, how your accumulated ability in performing DREs with appropriate technique now enables you to confidently perform a digital rectal examination prior to an anorectal investigation during a DOPS assessment.
- How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to patient assessment and anatomical application in a clinical setting? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or clinical expert immediately when a DRE reveals findings that might contraindicate the manometry procedure, recognising this falls outside routine anatomical assessment scope.
- Looking holistically at your training journey, how has this initial DRE experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to performing a DRE and demonstrating sensitivity? For example, how this foundational experience has supported your development in practicing safely by providing the necessary knowledge base for the subsequent learning outcomes focused on accurate intubation and data acquisition.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Describe the requirements of anorectal physiology investigations including indications and contraindications, and take a patient history. |
| # 4 |
Outcome
Perform a digital rectal examination to ensure safe intubation with manometric equipment. |
| # 7 |
Outcome
Apply and adapt their approach to the patient’s individual tolerance, personal experience and anxieties, demonstrating sensitivity to the emotional implications of intimate and invasive investigations on a patient’s wellbeing. |