The Role of the Professional Nurse in Relation to Sti`S

The Role of the Professional Nurse in Relation to Sexually Transmitted Infections
Introduction
Sexually transmitted infections (STIs) have been described as “a major public health problem in Europe” (Fenton & Lowndes, 2004, p. 255). There is evidence that there is an increasing number of persons infected with STIs in the UK (Fenton & Lowndes, 2004; Cassell et al., 2006), and primary health care and specialist clinics play a significant role in the diagnosis and treatment of these infections (Cassell et al., 2006). STIs pose a significant public health problem not least of all because many of the most common infections have few or no visible symptoms (Weinstock, Berman & Cates, 2004). In addition, if left untreated, STIs such as Chlamydia and gonorrhoea may lead to complications such as pelvic inflammatory disease. This then may create lasting health problems such as pelvic pain and ectopic pregnancy (Silva et al., 2007). The professional nurse plays a significant role in prevention and treatment of STIs. This essay examines the various roles of the nurse in STI prevention and treatment strategies.
Role as Educator
There are a number of public health strategies which may be pursued in order to address the current situation with regard to STIs. In particular, it has been identified that proactive public health promotion is likely to be one of the most beneficial tools in addressing the current levels of STIs identified in the UK and the rest of Europe (Fenton & Lowndes, 2004). For example, condom usage has been shown to significantly reduce the risk to both men and women of a number of different STIs including Chlamydia, gonorrhoea, herpes, syphilis and HIV/AIDS (Holmes, Levine & Weaver, 2004). This is therefore one of the most common public health strategies which is pursued, in a number of different locations including schools, GP surgeries, specialist clinics and hospitals.
It may be the role of nurses to ensure that patients are aware of appropriate preventative sexual health practices and where they may go to access appropriate services. Lack of knowledge may present a significant barrier to infected patients seeking help for STIs (Malta et al., 2007), which is a further indicator that the role of the nurse in educating patients may be critical. This means that all nurses may have a role in public health promotion for preventing STIs, whether school nurses counselling students, nurses working in GP offices or hospitals, or those specifically employed in sexual health. It may be that nurses work to educate patients who are actively seeking advice related to sexual health issues. For example, nurses working in GUM (genito urinary medicine) clinics and GP surgeries may regularly deal with patients who are specifically seeking advice related to contraception. In this instance it is the role of the nurse to ensure that choices made account for STI prevention as well as unplanned pregnancy.
It may also be the responsibility of the nurse to offer this advice even where it is not specifically sought by the patient, where the nurse identifies that there may be a need for such advice. For example, the RCN (Royal College of Nursing) stipulates that a crucial component of nursing is “influencing individuals in such a way that human potential is used for maintaining and promoting health” (RCN, 2003, p. 9). This therefore indicates that the role of educator is something which should be proactively pursued by nurses, offering guidance and support to those where there is identified as being a need for education. This may lead to improvements in sexual health in those who do not recognise that there is a need for such improvements to prevent STIs, thereby overcoming the barrier of a lack of knowledge (Malta et al., 2007).
Facilitating Communication
Offering vaccines such as the newly developed human papillomavirus (HPV) vaccine may also offer an opportunity to improve sexual health and decrease the workload of GUM clinics (Dempsey, Koutsky & Golden, 2007). There may however be some barriers to the acceptance of these vaccines, many of which nursing staff may be in an ideal position to overcome. For example, communication with parents and adolescents has been suggested to be crucial to increasing comfort with the vaccine (Zimet, 2006). Nursing staff may be in the ideal role to develop and maintain these communication channels, both between nursing staff and patients as well as between doctors and patients. This is important given that patients have to consent to the vaccine before it may be given (Dempsey, Koutsky & Golden, 2007).
It has been identified that engagement with different stakeholders may be a crucial step in addressing the current STI situation (Fenton & Lowndes, 2004). The position of the professional nurse places them in an appropriate place to offer sexual health promotion in addition to offering treatment for those specifically seeking support with sexually transmitted infections (STIs) (Saewyc et al., 2006). This is due to the staff-client interaction being so important when dealing with STIs (Lichtenstein & Bachmann, 2005), and nurses are possibly the clinicians in the best position to build a client rapport. In fact it is part of overall nursing accountability that patients are advocated for, through communication between all parties, as a means of ensuring no harm comes to the patient (Arford, 2005).
In addition to the other methods discussed, tracing of patient histories may be a key strategy in reducing the spread of STIs (Wilson et al., 2009). This therefore indicates that the role of the nurse in record keeping may be crucial to prevention of STIs, as it is from their history taking and record keeping that such histories may be traced. There are certain nursing frameworks which have been identified which may facilitate for nursing staff to address sensitive issues such as STIs with patients. For example, the use of the Motivational Interviewing framework has been shown to be useful in addressing HIV and STI prevention with patients, although this is something which nurses may require further development in to be useful (Byrne et al., 2004).
A further key element identified in improving current trends in STIs is a greater collaboration between clinicians, public health staff, laboratory staff and surveillance teams (Fenton & Lowndes, 2004). This collaboration may allow for better levels of knowledge sharing. Ethically, it is considered a moral obligation for nurses to provide clear communication pathways between patients and all healthcare staff (MacDonald, 2007), but nurses may also need to facilitate communication between different members of the health care team too.
Facilitating Access for and Promoting Testing and Diagnosis for STIs
Nurses also have a significant role in enabling patient access to STI testing and diagnosis. Most STI tests are non-invasive and may be easily offered alongside other services in the clinic environment (Silva et al., 2007). Despite this, there may be many who do not seek testing in a timely manner. There may be high numbers of individuals who do not perceive themselves to be at risk of STIs (Silva et al., 2007) although this may be due to poor awareness of the actual risk factors and prevalence of many STIs. It is important that awareness is developed in patients where nursing staff with their greater knowledge do recognise there to be a risk. This is crucial given that testing for STIs, in particular HIV testing, requires written informed consent. The nature of informed consent also means that ethically nurses should ensure that patients consenting are fully aware of the consequences and risks associated with doing so (Hamill et al., 2007).
Concerns with confidentiality may be a particular barrier to adolescents seeking support with STI diagnosis and treatment (Lehrer et al., 2007). However there are certain times where it is acknowledged that there is a need to break confidentiality in order to protect others. Confidentiality therefore becomes quite complex when dealing with certain STIs, HIV and AIDS in particular. It has been ruled in the court of law that doctors may disclose a patient’s HIV status to a known sexual contact where it is believed that person may also be in danger of having contracted, or in the future contracting the infection (Kausar & Bradbeer, 2006). This is something which would never be disclosed by nursing staff, but is something which they should be aware of in order to better address confidentiality concerns when dealing with patients, whether adolescents or adults.
Equality of Care
Stigma associated with STIs has been identified as a significant barrier to those infected seeking help (Malta et al., 2007). It is important that bias should not be allowed to affect the quality of care which is offered by nursing staff to those with STIs. For example Khan and colleagues (2007) found that those who felt uncomfortable dealing with certain groups infected with STIs were more likely to report barriers to treatment. This then led to less successful influence over sexual health behaviours. In particular, groups such as sex workers and those engaging in same sex relationships were identified as those who clinicians may have problems treating. It is therefore crucial that nursing care takes account of the differences of individual patients, but does not allow these to influence the care given in a negative way. As part of the role of the nurse as advocate (Arford, 2005), it is also important that the nurse ensures that this lack of bias in treatment diffuses through the entire health care team delivering care to the patient.
Creating Care Pathways
Another crucial element of preventing further spread of STIs is to counsel infected patients so as to reduce the spread of these STIs. It has been suggested that perceptions of counselling failing to alter patient behaviour may lead to poor levels of this counselling taking place (Grodensky et al., 2008). This is further evidence that the nurse should not let their own bias influence the care which is offered to the patient, as this may adversely impact on the outcomes. Instead it is crucial that when patients are referred to GUM clinics from primary care that there are clear pathways put in place to ensure that treatment and prevention of further spread are followed up on (Mercer et al., 2007).
Recognising the Limitations of the Nursing Role
The UK is quite unique in that unlike most other European countries it has health care centres and clinics which are dedicated specifically to treatment of STIs, in the form of genito-urinary medicine clinics (GUM clinics) (Fenton & Lowndes, 2004). However the regulation of nurses in the UK which prevents non-practitioners from prescribing drugs means that GUM nurses may not act as autonomous practitioners in most clinics (Miles et al., 2003). For example the regulation of nurses in the UK prevents even nurse practitioners from prescribing some controlled drugs which would be used in the treatment of some STIs (DOH, 2004).
There may also be a significant number of professional nurses who either lack the requisite knowledge to deal with sexual health issues, or perceive themselves to lack this knowledge. In particular there may be certain specific issues related to STIs where the knowledge is particularly lacking, for example less may be known about HIV and AIDS than other more common STIs (Saewyc et al., 2006). This therefore indicates a further barrier to nurses being able to carry out their role in STI prevention and treatment, and this may be something which needs to be addressed on a wider scale nationally.
Conclusions
There is a role for all nurses to play in STI prevention and treatment, whether that is in educating patients, promoting good sexual health, helping them access appropriate services, or counselling and treating patients identified as being infected. The main roles of the nurse in these processes focus on education, communication and advocacy. The nurse is recognised as being in the ideal role to build a rapport with patients and open channels of communication with other healthcare providers, something which is crucial when dealing with sensitive issues such as sexual behaviour. There may however remain some barriers to nurses being able to carry out these roles. In particular, limitations on the regulation of nurses in the UK which prevent them from being a true front-line provider of sexual health care in many situations and a lack of knowledge shared by many working in non-specialist roles may be areas which need to be addressed through national policy.

References
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References: Arford, P.H. (2005) Nurse-physician communication: An organizational accountability. Nursing Economics, 23(2), 72-77. Byrne, A., Watson, R., Butler, C. & Accoroni, A. (2004) HIV/STI prevention by training nursing staff in motivational interviewing. International Conference on AIDS, July 11-16, 2004, 15. DOH (2004) Mechanisms of Nurse and Pharmacist Prescribing and Supply of Medicines. Department of Health: London. Fenton, K.A. & Lowndes, C.M. (2004) Recent trends in the epidemiology of sexually transmitted infections in the European Union. Sexually Transmitted Infections, 80, 255-263. Grodensky, C.A., Golin, C.E., Boland, M.S., Patel, S.N., Quinlivan, E.B. & Price, M. (2008) Translating concern into action: HIV care providers’ views on counselling patients about HIV prevention in the clinical setting. AIDS Behavior, 12, 404-411. Hamill, M., Burgoine, K., Farrell, F., Hemelaar, J., Patel, G., Welchew, D.E. & Jaffe, H.W. (2007) Time to move towards opt-out testing for HIV in the UK. BMJ, 334, 1352-1354. Holmes, K.K., Levine, R. & Weaver, M. (2004) Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization, 82(6), doi: 10.1590/S0042-96862004000600012. Kauser, S. & Bradbeer, C.S. (2006) Patient confidentiality in STIs: Current guidance and legal issues. The Obstetrician & Gynecologist, 8, 240-244. Khan, A., Plummer, D., Hussain, R. & Minichiello, V. (2007) Does physician bias affect the quality of care they deliver? Evidence in the care of sexually transmitted infections. Sexually Transmitted Infections, 84, 150-151. Lehrer, J., Pantell, R., Tebb, K. & Shafer, M. (2007) Forgone health among U.S. adolescents: Associations between risk characteristics and confidentiality concern. Journal of Adolescent Health, 40(3), 218-226. Lichtenstein, B. & Bachmann, L.H. (2005) Staff affirmations and client criticisms: Staff and client perceptions of quality of care at sexually transmitted disease clinics. Sexually Transmitted Diseases, 32(5), 281-285. MacDonald, H. (2007) Relational ethics and advocacy in nursing: Literature review. Journal of Advanced Nursing, 57(2), 119-126. Miles, K., Knight, V., Cairo, I. & King, I. (2003) Nurse-led sexual health care: International perspectives. International Journal of STD & AIDS, 14, 243-247. RCN (2003) Defining Nursing. London: Royal College of Nursing. Saewyc, E.M., Bearinger, L.H., McMahon, G. & Evans, T. (2006) A national needs assessment of nurses providing health care to adolescents. Journal of Professional Nursing, 22(5), 304-313. Weinstock, H., Berman, S. & Cates, W. (2004) Sexually transmitted diseases among American youth: Incidence and prevalence estimates. Perspectives on Sexual and Reproductive Health, 36(1), 6-10. Zimet, G.D. (2006) Understanding and overcoming barriers to human papillomavirus vaccine acceptance. Current Opinion in Obstetrics and Gynecology, 18, S23-S28.