INTRODUCTION

Gastrointestinal (GI) problems have been known to be affecting a large population here in the
Philippines and across the globe. (Avelino, 2018) Common GI disorders documented internationally are
gastroenteritis, diarrhea with dehydration, infectious diarrhea with dehydration, constipation, and melena.
(Segarra, Rebanal, Sinson, Timbang, Tendilla, Tambio, 2014). Meanwhile, in the Philippines, the most
prevalent GI problems would include gastroenteritis, gastroesophageal reflux disease (GERD) or acid
reflux disease, peptic ulcer, diarrhea and constipation. (Olympia, 2017) These problems are generally
associated with altered bowel habit or movement which is an essential component in assessment and
diagnosis. With regards to this matter, it is then important to assess stool characteristics most specifically
its consistency.

Stool consistency generally refers to the rheology or viscosity of the stool. Stool form can be
considered as a proxy measure for stool consistency and refers to the shape and apparent texture of the
stool which can be assessed visually. Stool form scale is a generalized and inexpensive method of
classifying stool form into a finite number of categories that can be used by health care professionals,
patients and the general population, even in the absence of training. (Blake, Raker, Whelan, 2016).

Although a number of stool form scales have been expanded and validated for utilization in
adults, the most widely used is the Bristol Stool Form Scale (BSFS). The BSFS is an ordinal scale of stool
types ranging from the hardest (Type 1) to the softest (Type 7). It has been acknowledged in the research
as a beneficial instrument in the evaluation of intestinal illnesses, leading to a need for its translation and
validation. This process has already been carried out for English and Spanish, allowing the opportunity
for its use on an international level and for the comparison of data from various research centers in
countries with the latter language. (Martinez; de Azevedo, 2012)

This scale is a comprehensive indicator of how and why different types of stools
look or feel a certain way, namely - Type 1: Separate hard lumps, like nuts. These stools lack
a normal amorphous quality. Type 2: Sausage-like but lumpy. It is bound to cause extreme
straining during elimination. Type 3: Like a sausage but with cracks in the surface. This form
has all of the characteristics of Type 2 stools, but the transit time is faster, between one and
two weeks. Type 4: Like a sausage or snake, smooth and soft. This form is a normal form of
stool for someone defecating once daily. Type 5: Soft blobs with clear-cut edges. This type of
stool is typical for a person who has stools twice or three times daily, after major meals. Type
6: Fluffy pieces with ragged edges, a mushy stool. These kind of stools may suggest a slightly
hyperactive colon. Type 7: Watery, no solid pieces. (Martinez; de Azevedo, 2012)

A research conducted by Chumpitazi, Self, Czyzewski, Cejka, Swank, Shulman,
 (2016) claims
that BSFS has excellent reliability and agreement when used to rate individual stool type by raters. When
assessing stool form, the BSFS also appears to be useful to determine a specific type (1–7) of stool. In
addition to that Chumpitazi et al also stated that the Bristol Stool Chart was implemented to monitor
melaena as it is considered valid and reliable for assessing an individual’s stool. Bayless; Hanauer (2011)
also posited that identifying the stool type, frequency of bowel opening, and the amount of faeces
excreted against an objective chart enabled the correct treatment to be prescribed and administered. On
the other hand, according to Blake et al, The Bristol Stool Form Scale revealed substantial validity and
reliability, however it still aims to authorize investigation in larger clinical populations which will be a
potential for improving validity and reliability through modifications to the BSFS or training in its use
should be explored.
Aims

This study aims to improve not only the awareness of student nurses from Saint Louis University
with the stool characteristics, but also to let them know the indication of these characteristics with the use
of the stool chart. It will then motivate and possibly urge them to seek medical consultations thus earlier
treatment. Furthermore, if the population becomes knowledgeable regarding the type of stool, this would
be of great help when explaining its characteristics to a physician during a consultation.

We further aim that this study would encourage student nurses to consider their bowel health and
give them a better understanding of whether their stool type and pattern is healthy. In cases of
abnormalities assessed in the stool using the Bristol Stool Form Chart, immediate approach to seek
medical help is prompted.

Statistics

According to Lim, Rosita, Chieng, Hazizi, (2016), the universality of functional constipation
among the students was 16.2%, with a significantly higher prevalence among women (17.4%) than men
(12.5%). Hard or lumpy stool, incomplete evacuation, anorectal obstruction and straining were described
as the commonest symptoms experienced. Type 3 was the most recurrent stool consistency encountered
among the constipated individuals (35.2%). Only 4.4% of individuals reported having less than three
defecations per week. Based on the prevalence rate, constipation is a common problem among tertiary
education students (16.2%), with significantly more prevalence among the female respondents.

Furthermore, Lim, et al (2016) also revealed the most common type of stool assessed and
distinguished using BSF scale. The result indicated that type 3 was the most common experienced among
constipated individuals (32.2%). Meanwhile, 2.6% and 18.9% of constipated individuals were self-
reported to have Type 1 and Type 2 stools, respectively. There were 6.6% of constipated individuals
presented to have inconsistent stool type.

Meanwhile, a survey administered by Cotoplast revealed that 14.5 per cent of the 2,001 adults
identified their fecal matter as constipation using the Bristol Stool Form Scale (4.4 per cent with severe
constipation). Just under 5 per cent of adults claimed to have the type 5 (BSFS), with soft blobs indicating
lack of fibre. Meanwhile 4.6 per cent of participants identified with the fluffy droppings of type six -
which could be a sign of cancer and is often caused as a result of inflammation in the bowel. And only 0.8
per cent claimed to have the liquid based stools of type seven - which is an indicator of a bowel problem
such as IBS which has been recorded as the most common functional gastrointestinal disorder.
(Matthews, 2016). Gastrointestinal (GI) diseases are highly prevalent, costly and lead to substantial health
care utilization in the United States. Many of these diseases also affect patients’ quality of life and
productivity. Constipation and anorectal symptoms accounted for 3.0 and 2.6 million visits, respectively.
(Peery, 2015). Hence with that all being said, we believe that it is necessary to spread awareness
regarding fecal characteristics together with its associated GI disorder as well as the need to assess
themselves using the Bristol Stool Form Scale (BSFS).
Gaps of the Study

According to a survey conducted by Matthews, (2018), the survey used the Bristol Stool Chart to
determine the health of adults’ stool and it has revealed that one in five people claim to 'know nothing' about
their toilet health. Only 62.7 percent of people knew what a healthy stool looked like, meaning many of the
population are unsure about their bowel health. And even more worrying is that a quarter of the population
have stools which are not deemed 'medically healthy'. Furthermore, an alarming 20 percent of people claim
to 'know nothing' about bowel health, while a third admitted having 'little' knowledge. Thus, due to lack of
knowledge about how to detect normal versus abnormal stools, the Bristol stool form scale is a tool which is
proven to be reliable in determining some indicators to assess abnormal stools. The Bristol stool form scale
gets people to think about their bowel health and gives them a better understanding of whether their stool
type and pattern is healthy. This might be a simple lifestyle stool form scale but for others, this simple two-
second stool self-assessment that could actually be life changing.

Moreover, Lerche, (2017) stated that a recently commissioned British Poo Survey by the
continence and ostomy expert Coloplast, has revealed that Brits have very limited knowledge and
understanding of their toilet habits. When asked to identify their most common stool shape from the
medically recognised Bristol Stool Chart, 25 percent of respondents identified with types outside those
considered healthy. In addition, Lockett, (2016) claims that the Bristol Stool Chart allows people with
gastrointestinal symptoms to clearly describe to their doctor what they are seeing in the toilet without
having to provide samples. The researchers can take from this that the Bristol stool Form Scale does not
just increase the awareness of individuals but it is also being used in describing stool characteristics
during check ups.

Bristol stool chart is a medical tool that can both be used in clinical and experimental field. It is a
medical aid designed to classify faeces. It shows seven categories of stool wherein every person has a
different stool habit. Even though this tool has been discussed before it is still important to consistently
educate the people on our GIT-health and what all the different stools indicate to be able to identify bowel
symptoms that is causing abdominal pain, bloatedness or constipation for some time. Since the Bristol
Stool Chart explains stool health, it can be used as a guide to help better understand stool characteristics
and explain it more precisely to the physician. Knowing normal frequency bowel movement helps an
individual understand a few things about their feelings.

Awareness

An interview was conducted with three student nurses enrolled in Saint Louis University School
of Nursing varying from levels one to four to assess their knowledge about the assessment of their stool
form or consistency.

“I actually do not know the different stool characteristics. Ang alam ko lang ay constipation at diarrhea
pero yung iba’t-ibang gusting ipahiwatig nito ay hindi ko alam.”

“I can assess my stool’s characteristics by checking its color, consistsency, as well as its form for these
are the main markers to know whether a person has digestive abnormalities. Like for example, if my stool
is watery then I can say that something is wrong with my GIT, I may be having diarrhea or if my stool is
hard then that may indicate that I am having constipation.”

“I think I can characterize my stool by its color and consistency. There is a time after I poop, I saw that
my stool is soft and I just thought that maybe I lack protein and then I will just eat foods containing
protein like banana to make my stool normal again.”

This therefore indicates that the students are not aware and knowledgeable of their own stool form and
consistency as well as its indications.

METHODS

The quality improvement will be conducted in Saint Louis University, Baguio City, Philippines.
Convenience sampling will be used in distributing questionnaires to 75 student nurses from all levels,
with regards to their awareness and knowledge about the stool characteristics, specifically its consistency.
Floating of questionnaires will be done at 3rd-5th floor Silang Building.

The data for the study will be generated using self – constructed questionnaire which can be
answerable by either yes or no. Questions formulated were taken from the Bristol Stool form Scale. The
correct answers are as follows: numbers 1,2,3,4,5, 8,9,10 are Yes and Numbers 6 and 7 are No.

Approval of the Dean of the School of Nursing for the conduct of the study was sought. After
seeking permission, data gathering commenced as follows:

1. Researchers floated questionnaires to 75 student nurses from all levels to identify their
awareness and knowledge about the stool characteristics, specifically its consistency.
2. Floating of questionnaires was done at 3rd-5th floor Silang Building on January 2019.
3. Participants were selected through convenience sampling and was given a letter of informed
consent prior to answering the questionnaire.
4. Accomplishment of questionnaire took around 5-10 minutes. Privacy was observed by
keeping a distance from the respondents to answer the questionnaires. The respondents’ right
to refuse or withdraw from the study anytime they want without any explanation was also
upheld.
5. After the questionnaire was returned by the respondents individually, the researchers checked
if all parts of the questionnaire have been properly accomplished. Items that were incorrectly
marked or were not marked were clarified with the respondents. They were given a chance to
finalize their answer. The questionnaire were collected, tallied and interpreted.
Table 1. Degree of Knowledge and Awareness among student nurses about stool characteristics
Degree of Knowledge and Frequency Percentage
Awareness
Low Knowledge and 17 22.67%
Awareness (0-3)
Moderate Knowledge and 49 65.33%
Awareness (4-7)
High Knowledge and 9 12%
Awareness (8-10)
TOTAL 75 100.00%

The above table revealed moderate knowledge and awareness among student nurses about stool
characteristics with the highest frequency of 49 and a percentage of 65.33%. Meanwhile, low knowledge
and awareness garnered a frequency of 17 and a percentage of 22.67%. While high knowledge and
awareness has the lowest frequency and percentage of 9 and 12%, respectively.
This is supported by a study conducted by Matthew (2018) which revealed that only 62.7% of
people knew what a healthy stool looked like, which implies lack of knowledge about one’s bowel
health. In addition, the study also stated an alarming 20% of people who claim to 'know nothing' about
bowel health, while a third admitted having 'little' knowledge.
As moderate level of knowledge and awareness was revealed in the quality improvement study,
the difference in frequency and percentage among male and female respondents was also documented.
Male student nurses with moderate knowledge and awareness have a frequency of 10 with a percentage of
20.41%, while female student nurses with the same level of knowledge and awareness were reported to
have a frequency of 39 and a percentage of 79.59%.
Meanwhile, frequency and percentage of correct and incorrect answers were also included revealing
items 6,1, and 7 having the highest frequency and percentage of correct answers. Item number 1 refers to the
characteristic of a normal stool which is smooth and soft. Item number 6 refers to a mushy consistency with
ragged edges which is indicative of mild diarrhea. Item number 7 refers to liquid consistency with no solid
pieces which indicates severe diarrhea. However, items with the highest frequency and percentage of
incorrect answers are items 3, 5, and 4. Item number 3 refers to sausage shaped but lumpy stool
characteristic which is indicative of mild constipation. Item number 5 refers to soft blobs with clear cut
edges that indicates the lack of fiber. Furthermore, Item number 4 refers to the type of stools like sausage
but with cracks on its surface which is indicative of a normal stool.
The total percentage of incorrect answers garnering a percentage of 52.13% is higher than the
percentage of correct answers which is 47.87%.
The result is an indicative of a lack of awareness and knowledge among student nurses with
regards to the stool characteristics, hence information dissemination for this matter is imperative. With
this regard, there is a strong need for the implementation of the Bristol Stool Chart Form Scale (BSFS) to
increase knowledge and awareness of stool characteristics among the population group.
 REFERENCES

Avelino, F (2018) Department of health Food and Waterborne diseases. Surveillance report no. 8

Bayless, T; Hanauer, S. (2011) Advanced therapy in inflammatory bowel disease, 3 rd Edition. ISBN-
13: 978-1607950349 ISBN-10: 1607950340

Blake,M; Raker, J;Whelan,K; (2016) Validity and reliability of the Bristol Stool Form Scale in healthy
adults and patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol
Ther 2016; 44: 693–703 doi:10.1111/apt.13746

Chumpitazi, B; Self, M; Czyzewski, D; Cejka, S; Swank
, P; Shulman
, R (2016) Bristol Stool Form
Scale Reliability and Agreement Decreases When Determining Rome III Stool Form
Designations. Neurogastroenterol Motil. 2016 March ; 28(3): 443–448. doi:10.1111/nmo.12738.

Lerche, O. (2017) Is my poo normal? THIS is how your faeces could be an indicator of YOUR health

Lim, Y; Rosita, J; Chieng, J; Hazizi, A (2016) The Prevalence and Symptoms Characteristic of
Functional Constipation Using Rome III Diagnostic Criteria among Tertiary Education
Students PLOS ONE | DOI:10.1371/journal.pone.0167243

Lockett, T (2016) What the consistency of your poo says about your health

Martinez, A; de Azevedo, G; (2012)The Bristol Stool Form Scale: its translation to Portuguese, cultural
adaptation and validation. DOI:10.1590/S0104-11692012000300021

Matthews, S. (2018) A third of us have no idea what a 'normal poo' looks like: Survey reveals manyof us
aren't aware of bowel cancer warning signs

Olympia, E. (2017). Upset stomach making you upset? Inquirer Lifestyle. Retrieved from
https://www.google.com/amp/s/lifestyle.inquirer.net/252896/upset-stomach-making-upset/amp/

Peery, A; Lund, J; Delon, E; Shaheen, N. (2012) Burden of Gastrointestinal Disease in the United States:
2012 Update. DOI: 10.1053/j.gastro.2012.08.002

Segarra, A; Rebanal, L; Sinson, F; Timbang, T; Tendilla, J; Tambio, S; (2014) Philippine ICD 10

Modifications, 2nd Edition
 APPENDICES
Appendix A
Bristol Stool Form Scale

Appendix B
Frequency and Percentage of Correct and Incorrect answers among males and females.
Level of Male Female
Knowledge f p f p
Low Level 4 23.53% 13 76.47%
Moderate Level 10 20.41% 39 79.59%
High Level 0 0.00% 9 100.00%
TOTAL 14 18.67% 61 81.33%

Appendix C
Frequency and Percentage of Correct and Incorrect answers related to the questions provided
Question Items Correct Incorrect
Frequency Percentage Frequency Percentage
1 44 58.67% 31 41.33%
2 29 38.67% 46 61.33%
3 23 30.67% 52 69.33%
4 26 34.67% 49 65.33%
5 25 33.33% 50 66. 67%
6 54 72% 21 28%
7 43 57.33% 32 42.67%
8 38 50.67% 37 49.33%
9 38 50.67% 37 49.33%
10 39 52% 36 48%
TOTAL 359 47.87% 391 52.13%
Appendix D
Cover letter and questionnaire related to the level of awareness about stool characteristics

Saint Louis University

School Of Nursing
Level IV
S.Y 2018-2019

Dear Respondents,

We, the undersigned are 4th year student nurses of Saint Louis University School of
Nursing conducting a quality Improvement study entitled “Awareness and knowledge of nursing
students on the type of stool using the Bristol stool form scale” which aims to identify the
awareness and knowledge of student nurses about the assessment of their stool characteristics
specifically its consistency and implications. In this regard, we would like to ask for your time in
answering this short questionnaire. Your participation in this quality improvement study is
completely voluntary. We assure that your responses will remain confidential and your identity
anonymous and that it will be utilized only for this study.

Thank you for taking time to assist us in our educational endeavors.

Sincerely,

Deocares, Lauderdale. B.
Contact number: 09054553002
Email: lauderdale.deocares@gmail.com

Pacial, Rachelle Gay R. RN,MSN

Contact number: 09088849641
Background Information
Please fill in the blanks or check the box that most accurately reflects your current situation. Please check
only one box per question.

Gender: Female Male

1. A normal stool is characterized as smooth and soft.

Yes No

2. Separate hard lumps, like nuts stool characteristic is indicative of severe constipation.

Yes No
c c
3. Sausage-shaped but lumpy stool characteristic is indicative of mild constipation.

Yes No
c c
4. Stools like sausage but with cracks on its surface is indicative of a normal stool
Yes No
c c
5. You lack fiber when your stool characteristics show soft blobs with clear cut edges which is
passed easily.

Yes No
c c
6. Mushy consistency with ragged edges is not indicative of mild diarrhea
Yes No
c c
7. Liquid consistency with no solid pieces is not indicative of severe diarrhea
Yes No
c c
8. Soft sausage or snake – like stool characteristic is considered a normal stool
Yes No

9. One possible complication associated with your stool characteristics is gastro-enteritis.

Yes No
c c
10. A possible cause of unusual stool formations during defecation is presence of associated
gastro intestinal problems.

Yes No
c c
Appendix E
Answer key for the questionnaire related to stool characteristics

1. A normal stool is characterized as smooth and soft.

Yes No

2. Separate hard lumps, like nuts stool characteristic is indicative of severe constipation.

Yes No
c c
3. Sausage-shaped but lumpy stool characteristic is indicative of mild constipation.

Yes No
c c
4. Stools like sausage but with cracks on its surface is indicative of a normal stool
Yes No
c c
5. You lack fiber when your stool characteristics show soft blobs with clear cut edges which is
passed easily.

Yes No
c c
6. Mushy consistency with ragged edges is not indicative of mild diarrhea
Yes No
c c
7. Liquid consistency with no solid pieces is not indicative of severe diarrhea
Yes No
c c
8. Soft sausage or snake – like stool characteristic is considered a normal stool
Yes No

9. One possible complication associated with your stool characteristics is gastro-enteritis.

Yes No
c c
10. A possible cause of unusual stool formations during defecation is presence of associated
gastro intestinal problems.

Yes No
c c