Sexual health healing: my elective placement in a GUM clinic

People coming to sexual health services experience a wide range of emotions; from embarrassment and fear to shame, guilt and anxiety. Sexual health carries with it some serious baggage and stigma that other areas of health don’t, but why is that? We wouldn’t think twice about going to the doctors for other health conditions, yet for some reason feel like we need to sneak in to sexual health clinics cloak and dagger, desperately hoping that we won’t be recognised. Sex is one of the most normal and natural things imaginable and anyone taking proactive steps to look after their sexual health should be celebrated…yet it is an area of health that many still find embarrassing or taboo.

This summer I completed a seven week placement in a sexual health clinic. I was excited to start as I’d always been interested in sexual health, but I must admit I was also a little nervous. Discussing sex openly and frankly can sometimes be just as intimidating for the healthcare professional as the patient – especially for an inexperienced student nurse still finding her feet! I’d be lying if I didn’t say I had the odd awkward moment over the placement – I struggle to hide my emotions and definitely felt my cheeks blush on the odd occasion during my first few solo interviews – but I soon realised that patients took their cues from me and the more relaxed I was, the more at ease they seemed. Before too long I was discussing STIs and sexual preferences as casually as the weather or what they had for tea last night. It was rewarding though, seeing people arrive at the clinic looking nervous, upset or worried and leave, free condoms in-hand, looking relieved and reassured. Along the way I also learnt a thing or two about the broad skills and expertise of sexual health nurses. Here is what I learned:

They can keep a secret

Confidentiality is one of the fundamental principles of sexual medicine. All staff working in sexual health, from consultants to student nurses, must sign a confidentiality agreement on entering the department. Of course this principle applies across all areas of healthcare, but it is particularly precious in sexual medicine where a patient’s right to privacy is central. Patients are not obliged to give their real name or date of birth when accessing sexual health services, nor will you hear a nurse calling people in the waiting room by their full name. Patient notes are also kept completely separate to other systems in the NHS and information will not be passed to services like GPs without consent or unless absolutely necessary. Explaining this to patients at the start of their appointment is often a good basis for gaining their trust and confidence.

They are expert communicators

Specialist sexual health and HIV nurses are incredibly skilled in taking detailed histories, asking the most personal questions imaginable, while remaining non-judgemental. Those questions can seem extremely intrusive and many people wonder why they need to share details of foreign partners, drug-taking or exactly what type of sex they had, so it takes a highly-skilled communicator to gather this information in a matter-of-fact, caring and non-judgmental way. As the interview unfolds, you can sometimes visibly see people recoil at the questions – in the cold light of day, sitting in a clinical room opposite someone in a uniform asking you about some of the most intimate parts of your life can be extremely difficult. Sexual health nurses completely understand that; they want to make the process as painless as possible, so will adopt many different communication strategies to put their patients at ease.

They know their stuff

The majority of sexual health and HIV nurses are specialists, with many years of experience and additional qualifications or training in sexual medicine. While in the past nurses in sexual health clinics would have assisted the doctors, they now work autonomously, often in nurse-led clinics. Nurses are the backbone of gentio-urinary medicine (GUM) clinics, working closely with consultants and experienced healthcare technicians. It’s a highly-skilled role that requires in-depth knowledge of sexual health conditions including their symptoms, methods of diagnosis and the latest evidence-based treatments, some of which they are now able to prescribe themselves under Patient Group Directives (PGDs). They work hand-in-hand with the doctors, undertaking the same assessments and doing the same tests and examinations. They also tend to be the clinicians delivering the treatments, from antibiotics or deep IM injections to wart freezing. They can do the whole lot.

They are un-shockable

Believe me, they have heard and seen it all. They are not there to judge your sexual behaviour and they don’t. They ask such personal questions because they want to make sure they carry out the most relevant tests, ensuring that they pick up any potential sexually transmitted infections (STI) someone could have been exposed to. Knowing whether someone has had foreign sexual parters or taken drugs, for example, can influence whether they decide to add in blood tests for hepatitis B and C. It pays to be as honest and frank as possible because it means that they do the full range of relevant tests.

They care about your physical AND mental health

WHO define sexual health as both absence of disease and healthy attitude towards sex. Sexual health nurses aren’t just concerned with detecting and treating STIs and giving out free condoms; they also play a therapeutic role, helping to ease anxieties and educate individuals about safe sex.  They can play a big part in helping someone overcome a bad sexual experience, often taking on a support and counselling role, especially nurses who choose to be sexual health advisors. Even for patinets who don’t specifically open up about their worries, you can see how a skilled sexual health nurse can make someone feel better just by being kind and matter-of-fact. Conditions like HIV of course sadly come with some of the greatest stigma and potential to impact mental health. HIV specialist nurses therefore are key in helping people come to terms with their diagnosis and cope with the wide range of emotions they may experience. They are often the first port of call for patients, sometimes being the only person that a patient has disclosed their HIV status to and feel comfortable phoning up to discuss worries and fears. As well as managing and monitoring their treatment HIV specialist nurses often become a trusted confidant, helping individuals to regain their confidence and self-worth or access local networks where they can access peer-support.

All-in-all, my placement in a sexual health clinic revealed the nursing role to be fascinating and rewarding. Sexual health nurses are a down-to-earth bunch who come into contact with people from all walks of life and use a broad range of advanced nursing skills to make a positive impact on physical and mental health. There’s a lot more to it than giving out free condoms, that’s for sure!

If you’re interested in sexual health, there are some brilliant websites out there. The British Association for Sexual Health and HIV (BASHH) guidelines for example share evidence-based clinical guidance for diagnosis and treatment of STIs. There are also some fantastic Manchester-based charities and organisations with a focus on improving sexual health such as Manchester Action on Street Health (MASH), a charity supporting women engaged with sex-work in Manchester; George House Trust, a charity supporting people living with HIV; LGBT Foundation, who offer sexual health testing for LGBT communities among many other services; and Sexpression Manchester a student-led organisation that offers informal sex and relationship training for young people.

Do you have an experience or reflection from placement that you would like to share with other student nurses and midwives? We think every student nurse or midwife has a unique and interesting perspective to offer so we are always keen to welcome new student bloggers to our team. If you have a story to share please do get in touch via our Facebook page @UoMPlacementProject or email studentnurseplacementproject@gmail.com. 

Advertisements

Mind your language!

I have realised as I’ve reviewed my previous blog posts that they tend to be quite personal. This post started as a very non-personal post but then, as I rolled ideas around my mind, I was reminded of times when the language used by Healthcare Professionals (HCP) had profound effects on me; some of these were positive and some negative but all forever imprinted in my memory and all influenced my experience of particular situations so, once again, this post will include my own experiences!

Late summer is a very bad time for me as in August 2013 my beautiful husband left me and our 3 sons and disappeared for 3 hauntingly long, soul crushing days when he made a serious attempt on his life only saved by the fact he was a pretty clean living fella with a nice healthy liver which did its job and chucked the massive paracetamol/ibuprofen overdose out of his body causing permanent liver damage but leaving him alive. This is not a post about mental health or suicide so the details of the lead up to this are not relevant here but suffice to say those 3 days were the worst of my life. I envisioned having to tell our 3 young sons their daddy was never coming home and having to raise my boys without my best friend and soul mate by my side. I imagined trying to support my in-laws with the grief of a second child having already buried their daughter…..they were the darkest 3 days of my life. The reason I am sharing this is to demonstrate the importance of the language we use as HCP.

By day 3 of this nightmare I was fully expecting a suicide note to turn up in the post, instead I got a phone call from a nurse from an emergency department in a hospital ‘down south’. She rang to tell me my husband had turned up and was being treated for the overdose he had taken. Now, the past 3 days had pretty much broken me but I did not break down in tears on the phone for many reasons, one of them being I was a practising counsellor at the time and was familiar with the language of attempted suicide and depression and I heard the news in a seemingly calm way. I then came off the phone and broke down both physically and emotionally.

My husband informed me, during a conversation much much later when we were debriefing during one of hundreds of conversations we had about that time that the nurse told him she thought I was “very clinical and a bit cold considering what she had just told me”. This stayed with me and continues to. I felt judged and misrepresented. I wanted to ring her and tell her that the reaction she heard was the result of 3 days without food and very little sleep, the reaction of a desperate wife and mother clinging to the only version of herself which was solid (the counsellor). I doubt that this particular nurse would even remember that conversation  a week later never mind 4 years later, but I remember it and my husband remembers it. He didn’t need to hear his wife had been clinical; he had no idea what sort of reception he was going to receive when we finally spoke to each other but what he needed to hear was that I had been informed and was ready to talk to him when he felt ready (which is actually exactly what I had said).

In situations of high emotion if you don’t know what to say, stick to the facts. Do not include your opinion and do not pass judgement.

So, onto another example of poor communication and the use of language.

During and after the traumatic delivery of my eldest son (for the midwives amongst us he was an undiagnosed malpresentation and a 36 hour induced labour ended with a rush to theatre for a trial forceps then emergency c-section). Things midwives said to me included:

During labour:

“what do you mean you aren’t getting the sensation to push, everyone gets the sensation to push” (not true, however I believed I was weird and not a ‘proper woman’ as I wasn’t ‘doing it’ right)

“you aren’t trying hard enough” (I used quite a lot of bad language at this point)

“Please try to push harder we need to see more maternal effort” (I cried)

post delivery:

Well, if you had pushed that baby out you’d have broken his neck” (Yes, yes this was actually said to me – his ear was the presenting part so it was probably true but I did not need to hear it)

“We took bets that you wouldn’t deliver him naturally” (so many things wrong with this sentence I do not know where to begin!)

So….therein ends a couple of examples of the poor language used to me personally during interactions with hcp (I have lots of examples from friends but I won’t share them as they are their stories!)

I now want to share some good examples of when HCP have used language in a positive way and how these have also stayed with me.

Following the above traumatic delivery my community midwife (who I respected so much she is a major reason I wanted to be a midwife and who I now know as a colleague) said to me “none of this was your fault. You did nothing wrong and nothing you did could have changed the outcome” (she knew I had wanted a homebirth with candles and words of love not theatre lights and words of terror). These words alone gave me permission to let myself off the hook for not being good enough to have a ‘normal’  birth.

*side note*  Please be mindful of using the word normal it can be very damaging. In terms of delivery I feel ‘vaginal delivery’ is enough without the word normal in front of it, its unnecessary. 

When my middle son broke his wrist and I waited 24 hours to take him to a&e because I thought it was just a ‘bit bruised’ I felt like the worst mother in the world and told anybody who would listen how awful I was and how could possibly I leave him 24 hours in pain poor little soul etc etc. A lovely radiographer took me to one side and whispered in my ear “I am a radiographer, my son broke his ankle and it took me 24 hours to bring him in; I thought he was just moaning”! Brilliant! Still makes me smile and instead of coming out of that situation feeling awful I came out feeling forgiven (although the middle boy still mentions it when he is wanting sympathy!)

All my sons have been in hospital for one reason or another most of which were when they were babies and the language used when communicating with me as a terrified mother has mostly been lovely and comforting (we will ignore the paediatrician who told me I would not be ‘allowed’ in the room when my 8 week old son was having a cannula sited in his head as we mothers tend to get ‘hysterical’ AND the paediatrician who looked at the 90ml bottle of breastmilk it had taken me AGES to express and said “is that all you’ve managed?”……we shall ignore them!!!!).

But this is what I want to leave you with (and something I remind myself of when working with women and their families)…

We may not remember all the people we work with and support or all the things we say but they remember us and they remember what we have said.

…………………….Years and years later.

Ask your friends and family about the midwife who delivered their babies….ask them what she was like (my Nana,at aged 95, could still remember the midwife telling her to stop screaming when she was delivering my 11lb mother as she may disturb the neighbours!).

Ask your friends and relatives about their GP and the things they have said to them over the years,  or the nurse who looked after them when they had their tonsils out when they were 7 years old (“eat the cornflakes or your mummy won’t be able to come and see you” ….I realise I have not had great experiences with HCP!!!!); ask them about the student midwife who took them to one side when their wife was haemorrhaging post delivery and explained who all the scary people who had just rushed into the room were and what they were doing; ask them about the consultant who told them there was nothing more they could do for their beloved dad; ask them about the importance of language and words.

Also, don’t lose sight of the influence of non-verbal communication: our body language speaks VOLUMES. Being clinically good is fundamental to being an effective HCP but being kind and respectful ensures the experience of the people we care for is remembered for the right reasons not the wrong reasons.

What we say matters. It MATTERS. If we are having a bad day and we are a bit too blunt with our language or we are too harassed to sit down and explain a procedure or we are tired and turn a blind eye to somebody you know is on the verge of tears and needs a friendly ear…..these things matter. Of course we have bad days but share these with your colleagues and friends; try really really hard to not let this influence the experience of the people we care for as they are mostly vulnerable and usually scared.

Thank you x

 

 

 

International #hellomynameis Day

July 23rd marks International #hellomynameis day. The #hellomynameis campaign was started by Dr Kate Granger MBE, a lady who set up a campaign in August 2013 using social media after receiving treatment in hospital for terminal cancer and realising that not all of the staff helping to support her introduced themselves. The campaign has raised awareness about the importance of healthcare professionals telling service users their name and role to help improve communication and increase the quality of patient care. The 23rd of July sadly marks the anniversary of Kate’s passing, though her husband Chris Pointon continues to travel the world delivering talks about Kate’s story and how we as healthcare professionals can improve people’s experiences of being cared for.

hellomynameis

Hello, my name is Abbie and I am a student mental health nurse. As I am a couple of weeks away from the end of my first year I have had lots of contact with service users on practice placements so I’ve been able to get a flavour of how much of a difference introductions can make from a professional perspective. From a personal perspective when I’ve been treated myself and accompanying loved ones to the hospital or the doctors I’ve witnessed professionals assessing not just the physical health but also the personal thoughts and feelings (mental health assessments are very thorough – see here) of people without telling them their name. Not doing so can put up a barrier to communication as the service user may feel awkward and uncomfortable with disclosing very sensitive information that they may previously have never shared with anybody before to a nameless stranger. A simple introduction can make the service user feel more valued and willing to talk about things like what they’ve been experiencing and what they wish to gain from treatment, which helps professionals deliver person-centred care that is tailored to each individual’s needs. Kate’s #hellomynameis campaign strives to improve patient experiences and aligns with the 6 Cs, values underpinning effective nursing practice that were set out in Compassion in Practice: Evidencing the Impact (2016).

6csSome University of Manchester students find themselves on placement within the Tameside and Glossop Integrated Care NHS Foundation Trust, which is where a number of nurses dubbed ‘Kate Granger nurses’ are the first in the UK to have been appointed. Kate Granger nurses will wear special identifiable badges and aim to encourage staff members in the trust to demonstrate effective communication and uphold the standards of compassionate care that Kate and her husband Chris have spent years campaigning for.

Searching #hellomynameis online brings up a wealth of posts showing healthcare professionals and service users pledging their support for the campaign. Visit the campaign’s website to see what events Kate’s husband is attending and find out more about how you can get involved.

 

Handling complaints: what I never learnt as a waitress

I have never been good at receiving complaints. Before I started my nursing degree, I worked as a waitress for 5 years. It was not uncommon to deal with customer complaints on a daily basis, and I would always just say “I’m really sorry about that. I’ll speak to my manager” which was always a fail safe. 98% of the time, the customer didn’t want to speak to me anyway!

Image result for waitress

Accurate picture of me listening to customer complaints

But that changed when I started my nursing. Suddenly, whilst trying to make small talk with patients, I was being confronted with complaints about care they had received in the past or at that very moment. I couldn’t get away with my usual spiel because care complaints are more specific, more personal. You have to say something, and sorry doesn’t quite cut it.

I remember, very vividly, the first time I saw a nurse deal with a complaint efficiently. The patient in question was raising her concerns about the referral system for district nurse visits after a stay in hospital. Her care had been delayed due to this. The nurse I was working with listened to her very carefully, occasionally (when appropriate) asked for more detail and did not seem flustered at all. She then thanked the patient, said she would follow this up but urged her to voice her complaint at PALS.

PALS stands for Patient Advice and Liaison Service. It is confidential, and designed to provide support for patients, relatives and carers.

I was amazed at how calmly the whole situation went. Although the patient was upset initially, she was clearly at ease by the end of the visit, and I felt it was due to her being able to voice her opinion. And she was actively encouraged to talk about her concerns as Image result for complaintsit helps the NHS grow as an organisation! And it inspired me!

Since this event, I feel as though I have been inundated with patient complaints. Sometimes I feel as if there is a secret sign on my head that says please voice your thoughts at me!. I have now had endless practice at being calm and friendly, with some situations leading to me having to be a little firm (I will not be shouted at). I find that listening a lot, speaking barely at all, seems to work. Asking them to expand, answering questions when needed, and most importantly not denying their claims. It is extremely important, I think, to acknowledge that not every care interaction is perfect or goes to plan. We must embrace feedback, negative or not! Whether it comes from a staff member, a patient or a relative; complaints should be listened to!

Always speak to your mentor or a staff member about a patient’s complaints. 

Be Resilient, Stay Brilliant

Student nursing takes many different skills: patience, compassion, dedication, the ability to plaster a smile on your face for 12 hours even when you’re exhausted, and more. But there is one skill I never thought would be so useful; resilience!

Resilience is when you’ve made a simple mistake and you can feel the embarrassment creeping up, but you carry on caring and learning. It’s what makes you keep going when someone doubts your ability. It is what you use to take in constructive (but sometimes not!) criticism on an essay, a presentation or an act of care. Resilience is the ability to bounce back!

I didn’t realize how important resilience was until I was having an incredibly busy day on my last placement on an acute medical ward. Myself and my mentor had ended up with a few very poorly patients, an astonishing amount of paperwork, delayed transport for a patient and some awkward available beds mix ups. To help out, I offered to call a unit an explain that patient they were transferring to us needed to be delayed slightly, due to late transport. I was greeted with what I describe as understandable anger and frustration. I spoke as calmly as possible, explaining that we were sorting the situation and that the patient would not be delayed much longer. The nurse I spoke to continued to berate me on the phone, and eventually hung up.

Luckily, within 10 minutes, we had managed to sort the entire situation out. No more angry phone calls for the day! I spoke to my mentor about what had happened, and she reassured me that it was just a tough situation and not to take it to heart. I still get slightly annoyed when I think back, but I have to remind myself that we are all just looking out for our patients. Sometimes that comes across in different ways! I think if I was a qualified nurse, I would have had a better understanding of how to deal with the situation. But I know for sure that I will not forget this phone call.

Remember; if you have experienced a situation like mine, please talk to someone about it! Whether it is your mentor, a fellow student, the PEF, your AA, friend, family dog etc. Difficult situations should be discussed, and you are allowed to vent. I can highly recommend writing a reflection about it!

Have you had any moments of resilience? Let us know in the comments, or on Facebook/Twitter. Or, if you’re feeling creative, write us a blog post!

 

 

 

 

 

 

 

Pressure Sores 101

One of the most common nursing buzzwords- pressure sores (AKA pressure ulcers). They can be developed by anyone, and in a wide range of places on the body. As nurses (student or not!) it is our responsibility to report, treat and prevent them.

What is a pressure sore?

A pressure sore is an area of skin that has been deprived of oxygen, due to continuous pressure. This prevents the area of skin getting enough blood, causing the skin to “blanch” (become white due to lack of blood flow). This can then develop into varying degrees of tissue damage; ranging from grade 1 to 4 depending on the severity (NHS Stop the Pressure, 2009).

Grade 1-  skin is intact but blanching, may be some heat/oedema as well 

Grade 2- partial thickness skin loss, looks like an abrasion or a blister. 

Grade 3- full thickness skin loss, some fat may be visible. Possible ‘undermining’ or ‘tracking’ as there is usually depth, depending on the location. This depth can sometimes be covered by slough, which needs to be removed before proper grading can take place. 

Grade 4- full thickness tissue loss, with exposed bone or tendon. There tends to be undermining or tracking, depending on the location. 

Where do they crop up?

Areas that have a hard bony prominence are at risk of pressure sores. This is because they have the least amount of skin protecting itself.

What factors lead to a higher risk of pressure sores?

There are many factors that increase the risk of pressure sores:

  • poor circulation – this could be caused by kidney problems, heart diseases or diabetes.
  • reduced/no mobility- it doesn’t have to be long term! even short term loss of mobility (e.g. after an operation) leads to a pressure ulcer risk.
  • friction- this is where good practice comes in. People who transfer frequently between bed-hoist-chair or just bed-chair, and being moved up/down a bed are at risk. This is why we use slide sheets!

How can they be treated?

  • regular re-positioning/ turns are vital! This helps distribute the pressure, and reduce the risk of the pressure sore from getting worse. You must assess whether the patient is able to do this themselves, or if they require help. Asking the patient (if they have capacity) is always best.
  • pressure relieving devices such as airflow mattresses or pressure cushions can be obtained through physiotherapists, occupational therapists, some trusts require nurses to send the referrals (depends on the area).

  • regular cleaning of the area. Special washes can be used such barrier creams or sprays like ‘Sorbaderm’. This is especially useful for pressure sores on the buttocks/sacrum as they are subjected to lots of moisture.
  • dressings! There are a wide range of dressings which can be used on pressure sores, those that have foam are good for extra protection.

 

How can they be prevented?

Similar to the above treatment! Encourage your patient to mobilize frequently (if possible) and explain the reasons why. Those who are at risk will be identified by their Waterlow Score (10+). If in the community and the patient has carers/relatives helping with their care, speak to them and ask them to update you on any concerns re: pressure sores. Completing bodymaps whenever a new patient arrives and update it regularly is also important. This allows you to assess the patient’s skin integrity, and keep an eye on any possible developments.

 

If you have any ideas for another ‘101 guide’, please get in contact via facebook, twitter or email us on enhancingplacement@gmail.com.

 

 

“The doctor says I’m dying”: tough conversations about death

One of my most vivid placement memories was my first conversation with a patient about dying. One afternoon I went to check on Joan (name changed), a lady in a side room on an elderly ward. I was helping her to have a drink when she looked up and said: “the doctor says I’m dying.”

I froze. My stomach turned and my mind started racing, taken aback by a statement I felt totally unprepared to respond to. I had grown fond of Joan and to see her so distressed was upsetting. I felt a sense of panic, worried that I might say the wrong thing.

I knew from the handover that morning that Joan was receiving end of life care and from what the other nurses had said, she was deteriorating and it was unlikely that she would get any better.

Taking a deep breath, I thought back to our communication lectures which covered how to deal with difficult questions. I drew up a chair next to Joan and holding her hand, I asked some straightforward questions like ‘when did you discover that?’ and ‘how does that make you feel?’, trying my best to mask my own anxiety and appear relaxed.

pexels-photo-271341

While I think I started off ok, all of a sudden I panicked; I didn’t know what to say next.  Almost without thinking, I said: “Don’t worry Joan, we’re all doing everything we can to get you better and back to your normal self.”

I immediately felt awful and her face said it all; she knew I was covering. I said it out of a desire to help Joan stay hopeful, optimistic, but in reality it sounded trite, like I was brushing her off and trying to avoid a deeper conversation. I think that it made her feel worse.

Kicking myself, I spoke to my mentor who reassured me that she too struggled with questions like those and some research when I got home that night revealed that I wasn’t alone – apparently it’s common for healthcare professionals to avoid or block difficult questions, particularly about death or dying. I suppose we like to focus on how we can ‘fix’ things and don’t want our patients to lose hope.

Looking back, I wish I’d spent more time with Joan, even just to sit quietly by her side. She may have had more questions that she wanted to ask and as a student nurse, I may not have known the answers but I could have found out on her behalf.

Honesty and courage are such important parts of nursing, especially at the end of someone’s life. Sometimes the best thing we can do is to be there; to listen, answer questions and ease fears – or just to hold someone’s hand and let them know that they are not alone.