Student Nurse

ELECTIVE PLACEMENT PORTFOLIO: Sexual Health Clinics

ABSTRACT

Having had an elective experience working with individuals in the sensitive areas of nursing at Genitourinary Medicine and Family Planning the author of this report aims to examine the nurse's role in enhancing the patient experience within these departments. Emphasis will be placed on communication skills, confidentiality and dignity. These aspects of attending sexual health clinics cause patients increased anxiety. Female patients in particular tend to have more invasive examinations and are often left exposed for longer periods of time.

Many of the nurses in these settings have completed further training in their chosen area in order to execute skills at an advanced standard. These skills include physical examinations, investigations, treatment, education, counselling and prescribing.

It appears that not all sexual health nurses are aware of both genitourinary and family planning issues although they are often viewed as part of the same service.

INTRODUCTION

Sexual health is an area that the Scottish Executive (2003) promotes through its Improving Health in Scotland document yet the incidence of sexually transmitted infections (STI's) and unintended pregnancy continues to increase. The government blames increased numbers of partners, complacency and better detection rates in clinics for the increase in STI incidence (Department of Health 2004). Unintended teenage pregnancy attracts much media attention however nearly 80% of terminations carried out in Lothian are on those over twenty years old and its estimated that 30% of live births were also unintended conceptions (NHS Lothian 2004). This report focuses on current practices in the field of sexual health nursing within the genitourinary medicine (GUM) clinic and the family planning clinic (FPC) settings and examines the practitioner's role in providing care within this sensitive area of nursing. Care interventions of communication skills, confidentiality and dignity will be critically evaluated and recommendations made to improve practice.

REPORT

As a nurse in a sexual health clinic one of the most important aspects of the role is that of good communication skills and rapport building (Brown 2000, Mansell and Payne 1996). Jolley (2002) recommends that nurses not only require good communication skills but are also confident discussing sexual issues. Not making assumptions or judging individual's lifestyles encourages patients to use the services of the clinics regularly to maintain their sexual health (Adler1999). On a daily basis clinic staff see people from all walks of life in a variety of situations, which could indicate for instance that they have been unfaithful, are intravenous drug users or are prostitutes. This may lead the patient to feel his or her lifestyle choices will be questioned, however it is important that they feel the clinic is a safe place to divulge information and still be treated with fairness and equality. The nurse must be aware that lecturing can make the patient feel uneasy (Jolley 2002). Nonetheless education is an important aspect that should enable the patient to make informed choices although Ewles and Simnett (1999) found that patients do not necessarily comply with the advice. The practitioner must take care not to interrogate but only to ask relevant questions thus preventing patients becoming reluctant to part with information (Jolley 2002), even if it would assist them in achieving a satisfactory outcome.

It is widely accepted that inappropriate language is a barrier to communication (Coleman and Roker 1998, Handy 2000, Jolley 2002). It is therefore necessary to assess the patient's literacy so the nurse can use language that the patient is comfortable with. This could mean having to use slang terms rather than medical terminology or involving an interpreter. It has been noted that in practice slang was often used when dealing with teens and young people.

Backing up verbal data with written instructions has been found to be more effective (Handy 2000) although giving too much information to an individual can cause them to become overloaded. Additionally giving verbal and written information concurrently is not ideal as reading and listening at the same time results in less information being absorbed. Handy (2000) recommends giving patients a brief outline of the facts and reinforcing them at a later date. Patients were always given opportunities to ask questions about their care if they were unsure of anything or need information or advice clarified.

Patients are often distressed, frightened or sometimes angry depending upon their reason for attending (Handy 1996). This can give rise to anxiety and thus poor retention of information (Handy 2000). So leaflets that can be taken away and looked at in the patients own time are useful tools although they may be easily lost and may not suit everybody's needs (Ewles and Simnett 1999).

Confidentiality is an issue that concerns many individuals who attend sexual health clinics (Jolley 2002, Royal College of General Practitioners 2000). Reassuring patients that no information will be divulged is therefore a priority and as nurses we are bound to protect patients confidentiality (NMC 2002). In the GUM clinic patients are given a clinic number, which is unique to them, at their first attendance. This number in no way corresponds to their hospital number and all samples are sent using it. At the FPC patients are also given unique numbers but as the majority of specimens sent are for smear tests they also have the patients name on. Information collected or the fact that individuals have attended the clinic will remain confidential even from their GP if they so desire (NHS Lothian 2003). Additionally some patients may require a referral outwith the department and the GP will be informed of this development with the patient's consent (NHS Lothian 2003). In practice the nurses recommend informing the GP if the patient requires an ongoing prescription but some patients would still rather their attendance was kept confidential. This is particularly the case with underage individuals who are often concerned that their parents will be informed of their attendance (Brown 2000, Coleman and Roker 1998). In 1985 the Gillick enquiry resulted in the production of the Fraser guidelines, which allow young people under sixteen to consent to treatment if deemed competent by a healthcare practitioner to do so (Royal College of General Practitioners 2000). These guidelines make it essential for nurses to establish that individuals are capable of understanding the potential repercussions of any medical intervention they receive. To facilitate this a form is placed in the file of all minors indicating that the competencies have been met.

When a patient receives positive test results for a sexually transmitted infection it is important to treat all partners to prevent cross infection. This can be a particularly sensitive issue for patients. The original patient, known as the index patient (Baker 1996) is encouraged to contact their partners and recommend attending the clinic for treatment. Where the index patient is unhappy to contact the partner Baker (1996) recommends a trained health adviser make the contact from the clinic by letter or phone. This is sometimes difficult to implement where the partners are unknown (McMillan 2002).

Mansell and Payne (1996) report that the clinical skills carried out by nurses varies greatly between clinics. They expand on this by adding that a standardisation of responsibility at each level should be the norm. Nurse practitioners are becoming more commonplace within the sexual health setting offering additional competencies in areas such as ordering investigations, carrying out examinations, providing treatment, counselling and health education of patients (RCN 2002). Nonetheless it is important to ensure that practitioners acknowledge their own limitations (NMC 2002).

Many people attending the clinic for screening, diagnosis or treatment display extreme embarrassment. They verbalise how they feel dirty, unclean and unattractive. The HEBS (2003) summarised that these feelings although unnecessary are quite normal. Intimate clinical examinations can be uncomfortable and embarrassing so patients should be given as much privacy and dignity as possible and reassured that the practitioners caring for them are doing so in a strictly professional capacity (Chlamydiae.com 2002a and b).

Non-verbal communication skills such as eye contact, smiling, touch and listening provide patients with the much needed support and comfort during these procedures. Individuals have the opportunity to request the sex of the professional they see and have a chaperone if they wish (NHS Lothian 2003). The nurse may be able to relax the patient by explaining that infection does not discriminate and could be caught by anybody (HEBS 2003). It is important to ensure patients understand they are being responsible by attending the clinic. However it is essential to emphasise that using condoms will considerably reduce the risks of transmission of infections (McMillan 2002).

Audit and research are important aspects of the GUM and family planning clinics as they enable standards to be set and best practice to be implemented (Handy 1996).

The GUM clinic is proposing a new post registration course to improve practitioner's knowledge, which is hoped, will complement the existing family planning course. Reader et al (1999) felt it was important that all staff working in the areas of reproductive and sexual health should have a wider awareness of STI's, contraception and termination of pregnancy. In a study they found that those in working in the GUM clinic had developed greater learning in reproductive health and vice versa. This need for new knowledge in the opposing area became evident during the combined placement.

CONCLUSION Working in the genitourinary medicine and family planning clinics has given the author insight into the importance of communication skills in helping to reduce anxiety and promote dignity. The issues surrounding confidentiality were highlighted in this report and it was found that the systems in place dealt with confidentiality appropriately. It is important to remember that all women have the right to facts, choice and advice in a confidential environment from non-judgemental professionals (Sutherland 2001).

Although nurses in sexual and reproductive health are viewed by their patients as the same service the practitioner's knowledge is often limited to that of their own area. It would therefore be recommended that nurses not only increase their knowledge in their area of practice but that genitourinary nurses attend the family planning course and the family planning nurses attend the new GUM course to give them a greater all round knowledge required by their patients. The report acknowledges the progression towards specialist and nurse led patient care and good all round knowledge would facilitate this.

This placement, it has been felt, was a beneficial exercise in gaining better communication and people skills overall which can be used for future practice. The experience has rewarded the author with increased knowledge, which will be useful to her intended career path.


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