Nursing at Inflammatory Bowel Diseases

IBD affect more than five million people worldwide, with 1.4 million in the US alone, and three million in Europe [2]. The incidence of IBD is increasing worldwide in adult and pediatric population, especially in traditionally low-incident regions such as Asia, South America and southern and eastern Europe [3-6]. In Turkey the incidence of UC is 2.6/100.000 and the incidence of CD is 1.4/100.000 [7]. Another study in Bolu/Duzce Region in Turkey, while the mean annual incidences were 0.99/105 for UC, 0.45/105 for CD between 2004-2005 years, they increased to 4.87/105 and 2.09/105 for ulcerative colitis and CD respectively between 2011-2013 years. While the prevalence was higher in urban areas in CD (12.60/105), it was higher in rural areas in UC (36.17/105) [8,9].


Introduction
Crohn's disease (CD) and ulcerative colitis (UC) encompass a multisystem group of disorders with specific clinical and pathological features characterized by focal, asymmetric, transmural, and occasionally, granulomatous inflammation primarily affecting the gastrointestinal tract [1]. These two diseases are called as Inflammatory Bowel Diseases (IBD).
IBD affect more than five million people worldwide, with 1.4 million in the US alone, and three million in Europe [2]. The incidence of IBD is increasing worldwide in adult and pediatric population, especially in traditionally low-incident regions such as Asia, South America and southern and eastern Europe [3][4][5][6]. In Turkey the incidence of UC is 2.6/100.000 and the incidence of CD is 1.4/100.000 [7]. Another study in Bolu/Duzce Region in Turkey, while the mean annual incidences were 0.99/105 for UC, 0.45/105 for CD between 2004-2005 years, they increased to 4.87/105 and 2.09/105 for ulcerative colitis and CD respectively between 2011-2013 years. While the prevalence was higher in urban areas in CD (12.60/105), it was higher in rural areas in UC (36.17/105) [8,9].
It is important to closely monitore clinically. In the developed countries such as England, United States, United Kingdom, Australia, various activities are planned in order to train IBD specialized nurses and to increase the number of them. But developing countries do not even have IBD nurses.
IBD nurse is required who has an active role in the multidisciplinary team for IBD management, has the "expertise" authority and sufficient knowledge and skills in this regard. Therefore, we aim at explanation IBD nursing, IBD nurse's tasks and responsibilities in this review. In all IBD patients, effective symptom management, control of multiple drug use, continuous monitoring and close clinical follow-up are required.
Once the symptoms have been checked with effective symptom management and the remission has been reached, it is aimed to maintain the long-term remission and increase the quality of life [10,11].
European Crohn's and Colitis Organisation (ECCO) has some sub-working groups. One of them is called Nurse-ECCO (N-ECCO). N-ECCO group has prepared a consensus report describing the nursing roles in 2012. This report consists of three parts such as Fundamental IBD Nursing, Advanced IBD Nursing and The Perspectives of IBD Nursing [12].
The aims of this consensus are to identify the positioning of nurses in the care of patients with IBD and to provide a consensus on the ideal standard of minimum care that patients with IBD might expect, irrespective of the level of nurse training, title or country. The 'ideal' standard of nursing care was deemed an accurate measure and appropriate by the group in order to provide a standard for all nurses working with people with IBD [12].
IBD management is required a multidisciplinary approach consisting of doctors, nurses, dietitians, social workers and psychologists. In this team the nurse is also key roles. To play an active role of IBD nurse will contribute to an increase in effective disease management process and quality of life [13].
The nurse diagnoses according to the general condition of the patient, plans the blood-based care and turns the theoretical knowledge into practice. The nurse supports the patient and his/her family in the diagnosis and treatment process and plans the necessary trainings with the patient and his/her family. In addition, nurses should develop a constructive and empathic approach to special situations such as fistula, incontinence, sexuality, pregnancy and fertility, pain, fatigue. In order for nurses to fulfill these tasks successfully, they must be seen as part of a multidisciplinary team [14][15][16][17]. There are also some important topics in the job description of the nursing staff: providing nutritional support, performing training and counseling roles, defining and developing IBD services.
Nursing knowledge is underlined in the report of N-ECCO. Nurses need to have basic knowledge of the diseases, know the difference between Crohn's disease and ulcerative colitis and appreciate the importance of establishing timely therapeutic interventions. Timely therapeutic intervention is essential for disease control.
Nurses caring for patients with IBD need an awareness of the extra-physical impact of the illness, of patients' key concerns, and the effect of IBD on health related quality of life [12].
Nursing involves advocacy and effective communication for all patients. These are of the utmost importance to patients with IBD due to the complex, uncertain and chronic nature of the condition. Communication is a two way process. Nurses need to develop an empathetic and active listening role, and be able to provide essential IBD-related information and holistic support [12].
An IBD nurse has been found to have an effective role in costeffective management of IBD. For example [12,18,19]: Providing multidisciplinary team communication between primary and other institutions, Supporting all aspects of patient and caregiver care in the hospital and community, C.
Rapid delivery of services to the nursing leadership, including clinical, telephone support and follow, D. Managing and monitoring of immunosuppression, anti-TNF therapy and nutritional support, Developing research projects, ensuring supervision of projects and participating in projects to support the care of patients with IBD, F.
Making a teaching plan for the development and education of patients and health personnel for the management of IBD.
Specialist nurses working with patients with inflammatory bowel disease can perform these roles while working in polyclinics, medical and surgical clinics, primary care clinics and endoscopy units.Important roles such as clinical care, education, research, counseling, improving disease management, compliance and increasing patient satisfaction are also included in the IBD nursing [17]. Nurses have also important roles in patient education. Training is needed to activate and strengthen the patients and their family to live with IBD. The training program should include the basic information about the disease, nutrition and medical management, the importance of coming to regular checkups and disease coping skills, etc.
As in other chronicdiseases, nurse is responsible for the identification of the IBD. At the first meeting with a patient, an IBD nurse should get IBD history, because it is helpfull and necessary for patient. The N-ECCO Consensus statements aim to provide practical value at a local, national and international level in the development of nursingcare for patients with IBD. These statements are intended to be used as a means of in forming nurses, improving their knowledge and understanding and so raise the standard of care for patients with [19,20].

Conclusion
Due to the many influences and uncertainties of the patients' lives, the nurse in the IBD management process should be counseled with holistic support and carry out a careful care process. In addition, the expert nurse should have adequate knowledge and skills in relation to the disease.
The other conclusion is about nursing training. Development of IBD nursing and post-graduate training programs should be supported. The dissemination of this area of expertise in nursing science and the support of the branching of the nurses will increase the quality of the care provided. Thus, the patients and their family will adapt to the disease, their self-efficacy levels and quality of life will be increased.

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