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. 

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Enabling quality of life in very difficult circumstances, by Kate Plant

19964730_1773600412654889_568888045_nA thought provoking guest blog, second year CYP student nurse Kate Plant shares her experiences and insights into palliative care from her DILP summer placement…


Before starting my nursing degree, I volunteered as a Sibling Support Worker at my local Children’s Hospice. So, I already had some idea about how special these places are. But it was not until I undertook my Elective Placement there that I realised how rewarding a nursing role, in the provision of Palliative Care, can be.

The first thing I noticed was the difference in pace, compared to my previous placements. I was used to dashing around on hospital wards and barely having a moment to drink. So, when I was offered a cup of tea on my first day (half an hour into my shift) I was completely taken aback. But, obviously, there were more significant differences than having the time to quench my thirst. A patient would be allocated both a nurse and a care support worker, on a 2:1 basis, due to the complexity of the patient’s needs. This 2:1 care gave nurses time to listen and understand what really matters to the patient and their family. There was no rushing around. The environment was relaxed. Families would allow a nurse and other staff members to enter their lives in very difficult circumstances and build strong relationships with them. This is where the satisfaction came in.

CYPIn addition, I have by no means observed doctors, nurses and care support workers work together as well as within palliative care. There was no division but instead, a sense of unity. This enabled a pleasant atmosphere to bloom within a setting which, stereotypically, has connotations of being constantly surrounded by upsetting situations. All staff members were part of a team, encouraging a family atmosphere so families were as comfortable and happy as possible. Staff were able to take away a families’ everyday stresses so children and their families could treasure the remaining time they have together as a family, however long this may be.

The thing that struck me the most was the parent’s enormous strength to keep a pleasant face for their terminally-ill child and their other children, in one of the hardest times they can ever face. A parent’s strength is aided through their ability to effectively plan, with help from compassionate and empathetic staff members, any wishes they have in the care their child receives before death. This includes preferred place of care, spiritual and cultural wishes and anticipatory symptom management planning.  With such a wide array of resources available at the hospice (including sensory rooms, adapted garden swings, music rooms, parent bedrooms, bereavement rooms – the list could go on and on) these wishes were almost always met.

TOGETHER_LIVES_RESIZE_800_450_90_s_c1_c_cLast year, the ‘Together for Short Lives’ charity reported a national shortage of children’s palliative care nurses which is negatively impacting on the care provided to children and families. I truly believe if other students and qualified nurses were to gain a deeper understanding and/or even experience how rewarding roles in Palliative Care can be, this could help bridge the care gap. After all, you’ll never regret making a difference in the quality of care a child or young person received, during their last moments of life.

DILP Week 5 – Teaching and Learning in Maternity ft Muetzel

Well the outrageous fact that next week is my FINAL WEEK is madness. Right now I’m sitting pretty at 208 hours (40 to go) but it almost feels like a dream: I’m so full of questions about the culture and the way of working out here so I feel like I’m always engaged in some sort of discussion, which makes each day really rush by.

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Shout out to my amazing Nursing Therapeutics Seminar Lead – you know who you are!!!

After one such discussion with the ward Matron, she said she felt the staff could improve their communication and social skills with patients, creating more of a rapport (this took a while to figure out as she speaks rather broken English). So I briefly explained Muetzel’s model of the therapeutic relationship, which is based around Partnership, Intimacy and Reciprocity. She was so interested I ended up making a couple of posters and giving talks to staff members in little groups over the course of the week. It was a really rewarding experience for me to see these Nurses taking on this academic knowledge and applying it, almost immediately, to practice.

It was also wonderful for me to realize how much I’ve learnt during these last 2 years at UoM. Lots of what I was teaching hasn’t come up in exams and I haven’t been fastidiously revising it, but it was still there in my brain, informing how I interact with patients and being able to pass this on was such a great feeling.

All my questions though did make for a slightly awkward discussion with a consultant this week when I asked why it was the normal procedure in Sri Lanka to give Episiotomies, no matter the size of the baby: “Because Sri Lankan women are far more petite than Western women” Fair enough, I thought (the average height of a Sri Lankan woman is 4ft11) but that wasn’t what he was getting at… Gesturing with his surgical scissors he added; “For example this woman’s vagina is far smaller than yours would be”. THANKS DOCTOR. I almost died of embarrassment.

My questions haven’t all had such uncomfortable endings though. For instance I’ve become fascinated by the many superstitions and traditions deeply woven into everyday Sri Lankan life. One very common belief is that the exact time of a person’s birth is holds great importance over the course of their life.

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Its a bit of a cross between buddhism with a big emphasis on horoscopes, couples are often matched based on Birthdays

It is always noted to the minute and this information is taken to a spiritualist (Tamil or Buddhist astronomer) who produces a big document/graph thing that contains key dates to be wary of and dates of good fortune. These can be days or years. During the times of misfortune the family can offset this bad energy by giving alms, doing charitable work or attending the temple more regularly. Equally there is some level or risk management that is involved. For example if someone is predicted a bad 2016 because they were born at 4.33 instead of 4.34 then even if it made sense with every other facet of their life, big dates such as having a baby or getting married would be delayed until they were back in good favors.

I personally would not respond well to such strict time frames but I was far too curious to know what my prophecies would be. So, luckily, I was able to take a short 20-minute stroll from my apartment to the hospital where I was born, 20 years, 6 months and 5 days ago. After a quick 5 minute trip to the records room a nurse produced a huge leather-bound book, identical to the one I have been writing baby’s birth records in for the last two weeks. Except in this one, “Baby Girl Wragg” made an appearance! Thanks to this hand-written entry I am now armed with my birth time and am setting a meeting to speak to a tamil astrologer to find out how things are going for me! Hopefully 2017 with my dissertation looming, will be a very very lucky year for me or else I’ll just have to find a Buddhist temple somewhere near Stretford.

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Baby Girl Wragg OG Sri Lankan

DILP Week 4 – Switching Hats in Maternity!!

Well what a difference a day makes! Because I had my “weekend” on Thu/Fri last week and worked Sat/Sun in A&E, it was very strange waking up the next morning and starting as the new girl again in Maternity. Quite the change!

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All I new for sure was that I’d get to hold some babies – I was HYPED

I didn’t expect it to be drastically different actually. In my mind, rushing into either A&E or Maternity would involve a certain amount of stress, drama and concern. In fact, during the 40 hours I’ve been diligently posted in Maternity, only 3 natural vaginal deliveries have taken place. So my expectation of blood, guts and placenta flying all over the show twinned with concerned Fathers pacing around and screaming Mothers rushing into the ward, hasn’t come to fruition.

Mary Cooke, a Lecturer from our University explained to me this week that during her time in Sri Lanka she learnt about the 4 arms of Sri Lankan healthcare. These 4 arms are divided into:

  • “Western” Publicly available care
  • “Western” Private care (Me)
  • Ayurvedic Medicine
  • Rural Folk Medicine

 

Public care, or the Sri Lankan version of the NHS is extremely thinly stretched across the country. My friends in Anurhadapura have been working (with Work the World) at one such hospital that has open-air wards of 60 beds which has one bar of soap for the entire ward. These institutions do an amazing job with what they’re given and treat a huge number of patients who otherwise would have to rely on traditional Sri Lankan remedies.

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Dhanvantari, God of Ayurveda

Ayurvedic Medicine has a history of over 3,000 years in Sri Lanka and is based around the balancing of 8 components to bring about physical and mental wellness. Treatments range depending on the ailment but can vary from “surgical” intervention to use of chiropractic massage.

Folk medicine is becoming increasingly rare as the country develops but involves treating ailments such as snake or insect bites, infections and such like using herbal and natural remedies.

Private Healthcare in Sri Lanka is the closest to hospitals in the UK you can get here. Therefor patients I see have a source of income that allows them to be there but again there are levels within this. For example the Presidential Suite on the top floor of my hospital costs around £350 per night and has wifi, cable TV, a kitchen and en suite guest room. Or for around £30 a night you can stay in a non air-conditioned room and still see the same consultants, doctors, physios etc.

For whatever reason, which I haven’t quite got to the bottom of yet, C-sections are overwhelmingly popular. I could not count the number of caesarians that have happened during this week compared to the lowly 3 vaginal births. I think it is considered to be less risky and carries fewer consequences than vaginal delivery and equally also demonstrates a level of wealth.

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CTG scan – this can show us if Baby is getting distressed during contractions or has a depressed HR

The first vaginal delivery I witnessed was in the first hours of my second day in our CTG room (Cardiac Tocograph – a scanner that is used to track the babies heart rate and the Mother’s contractions simultaneously). Usually Mothers wait for 20 minutes for the CTG to be taken then move into a normal room but in this instance there was no time to be wasted in moving this Lady. She delivered a beautiful baby girl at 34 weeks (full term being 40 weeks), and I was privileged enough to hold her hand and support her throughout the difficult delivery. Because of the hastiness of the whole procedure, when it became apparent she required an episiotomy the consultant Obstetrician only had a few moments to quickly inject some lidocaine before, seconds later, taking some sterile scissors to her perineum. I have never been so in awe of the strength and power of the female body.

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Ouch – I’ve got no other words for it… at least none that I can write on this public platform

With, and I’m not exaggerating here, nothing more than a few high pitched gasps and squeals, even during her midline episiotomy, her glorious tiny little baby was delivered and I am very pleased to say, the little lady is still doing very well.

I’ve been trying to learn on my feet as much as I can about the processes of pregnancy and childbirth but I very much see why our Midwifery colleagues are always so hard at work. Things can change in an instant during labour and the differences between each case makes each birth spectacularly valuable to my rough and ready education in this area.

I could write all day about the differences I’ve seen in Maternity but I’ve got to save some juicy tit-bits for next week so I’ll finish up here.

But PLEASE ASK QUESTIONS!!!

I have an entire hospital full of people who are so helpful and open to answering any questions I have about healthcare, life and culture in Sri Lanka so please do drop us a comment on our Facebook page or email us at:

enhancingplacement@gmail.com

DILP Week 3 – A&E lessons learnt

This last week has absolutely flown by!! I’ve kept myself very busy both in and out of placement which has been tiring but so rewarding!

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Scans following the admission of a lady with drowsiness and weakness following loss of consciousness

I can now run triage efficiently and effectively on my own and have been working with some really great nurses for the last two weeks who have taught me a bit of singhalese in between tasks. Key phrases you need to know as a tourist e.g. What’s your date of birth? What is your pain scoring between 0-10? Etc.

I’ve managed to get all the nurses to ask the patient for pain scores now which is a really vital thing. I only realised they weren’t asking properly when a woman who couldn’t speak with the pain in her abdomen or open her eyes fully had a 5/10 for pain written on her triage documents.. I’m in no way saying this is the only time I’ve come across falsified pain scores, unfortunately. It wasn’t at all rare to see Ward rounding forms where all patients conveniently had a pain score of 0 on my first placement in the UK. It wasn’t the case of course but writing this down meant less paperwork and less hassling the already over worked doctors. So it was sort of left unsaid and when I did rounding a and was accurate with pain scores it was met with a general groan from the staff because they had to chase up altering patients analgesia.

Pain is such a vital symptom to understand – this should be evident by the fact that all of our hospitals have a devoted “Pain Team” of specialist nurses that are like ache whisperers.

Changes in pain, not just the score but the type or the frequency can be the biggest clue you get about what’s going on with your patient and if their records aren’t accurately reflecting this evolution of their pain then we have failed that patient. For example, a headache.

It can be cause my 101 different things but if the patient is complaining of a sharp throbbing headache associated with noise or lights and also has a rash on their abdomen.. This could be meningitis. This patient might require urgent interventions. Equally, they might be having an allergic reaction or be dehydrated. However, without going into the details, we are pretty much running blind.

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This is not where anyone wants to be is it?? 

Literally 3 hours ago as I write this a woman who originally came in suffering from loose stools for 4 days arrested! She started coughing up frothy pink sputum then her heart failed, I was lucky enough to assist in giving chest compressions and ambu-bagging her to keep oxygen pumping around her system.

I had no idea what to expect from the other staff members in such a high-pressure situation but the respect and trust they showed me was pretty moving.

Having the doctors from CCU direct their questions at me about the patient, as a humble Nursing Student, was really empowering. I’m also very pleased to say that the patient’s vitals were stable when she left our care to recover in CCU.

Experiences like that today just remind me how privileged I am to be able to not only be a Nurse but to have this opportunity to travel half way across the world and still be respected, trusted and appreciated for all the hard work I have put into the degree so far. Nursing has always been a great passion of mine and it’s a truly wonderful thing when you can see that that passion exists in Nurses across the world who will work tirelessly next to you for the good of each patient that needs our care.

Week 2 – DILP Questions Answered!

At the end of my second week working in a Sri Lankan hospital I am pretty exhausted. It’s been a really full on week; my first ever in A&E and it’s been absolutely invaluable. I’ve observed lots of amazing Nursing and care but can’t seem to keep myself from thinking “Oh, that’s not how we do it in England” every time something surprises me.

IMG_7797.JPGAfter last week’s post a few of you had some questions about the DILP and how myself and others went about it. Since I have organized my placement independently I referred to my friends currently working in Andhupura who have gone through Work the World for their DILP about their experiences too. They explaned that they chose Andhupura because it seemed to have a richer culture compared to Kandy and was near the beaches of Trincomalee which is one of Sri Lanka’s best preserved pieces of coast-line with clear blue waters and lots of snorkeling opportunities.

Firstly and often most crucially going abroad for this placement is an expensive undertaking. Going through an agency condenses all the costs however into one lump sum you pay directly to them to organize accommodation, flights etc. this can be paid in installments or in one go but the deadline is a couple of months before you fly. It has been known for people to fundraise to pay for their DILP but none of the lovely Ladies in Andhupura did but we were told by the DILP unit lead to expect to pay around £3000 through an Agency so fund raising may be a very good option.

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Our ECG machine – complete with metal suction cups

Since I organized mine independently it cost a lot less, around £1500 for flights, accommodation, visa’s, insurance and the cost of living whilst I’m here. Although recommending someone to go it alone abroad is much like recommending someone to do a home birth without alerting a midwife. It can be super rewarding and great but if something goes wrong – it can be really disastrous.

Work the World have been really wonderful with all the students who worked with them, really helpful and easy to contact which made the whole process very straightforward and stress-free. Also the students (who come from all over and include OTs and Medics) with Work the World all stay near to eachother which is nice to have a little support hub of people all going through the same thing.

People were curious about time off and whether or not we have the ability to actually experience the country and the culture whilst working 37.5 hours a week. We were unanimous in our answer of YES!! 7.5 hours a day with early starts does mean it’s not advisable to be staying up late every night having cocktails at a beach bar but there is always the weekends for that!

I’ve been working 8 hour shifts (excl. breaks) 7-3.30 each day which leaves me a big chunk of the afternoon to do as I please. With a coupe of 12 hour night shifts thrown in I’m finishing placement in 6 weeks (30 days) as opposed to the 7 weeks (33 working days excl. bank holidays) allocated by the university. This means I’ll have a week at the end of my placement exclusively for free time.

I’m lucky enough to be able to stay on for a while after placement is done to travel around the island a bit and holiday with my family and boyfriend which is a really nice goal to aim for when I’m missing home.

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“Difficulty walking, slurring speech, brain stem stroke”

The language barrier can be frustrating at times but all medical terms are spoken and written in English so you can spot quite easily what each case is about. Most of the Nurses I’ve encountered have a good grasp of English so if you ask questions, they will try their hardest to explain. The best thing about working abroad is the independence. You are relying on your Nursing instincts and knowledge, I’ve learnt a lot from my mentors and patients but I have taught them a lot as well. I’ve introduced a new standardized handover tool, which has been saving hours of staff time. I’ve been screenshot-ing and explaining tools such as the Bristol Stool Chart and the SBAR in an effort in increase the use of evidence based assessment tools. The staff are really keen to learn as am I which makes for a really engaging and exciting atmosphere in the ward.

Again any more questions you have about working abroad, working independently or the DILP in general please do comment on our Facebook page or email us at enhancingplacement@gmail.com

DILP – Sisters are doing it for themselves!

I’m standing on my own two feet out here in Colombo, Sri Lanka for my final placement of second year – the DILP (Developing Independent Learning in Practice) placement. After only a week I hardly know where to begin?

I’ve been working in a surgical ward of a private hospital in Sri lanka’s capital so it’s pretty much the best you can expect from medical care in the country.Sri Lanka is a developing country so I knew it wouldn’t be like working in the swish NHS hospitals of Manchester but the main thing that’s surprised me is the difference in the nursing role!

Here nurses are very much still at the beck and call of the medics. All the transcribing, paperwork and admin goes through the nurses here compared to back in England. In fact, even the bread and butter of British nursing – the obs – are done by doctors here! 13348906_10209649421382561_788601227_n

In one awkward exchange a doctor began to take a patient’s BP and I said “Oh don’t worry I just took it – it was 138/80” the other nurses looked horrified and the doctor looked shocked and confused but swiftly the moment passed and he carried on taking the patient’s blood pressure. I felt insulted! Like my skills weren’t being trusted? But this is a different culture and with different ways of doing things. I had to come to terms with the reality –  It wasn’t me!  – It was the system!

13393017_10209649420822547_236201728_nThe nursing hierarchy is very different, with  no matrons or specialist nurses. The sister’s usually muck in and take on patients therefore leadership within the ward is much more abstract.

I’m very much enjoying the start of this new adventure in my nursing education and feel very privileged to have been afforded such an experience.

I’ll keep you all informed of progress week by week, any questions you have for me or questions you’d like me to ask the staff please do email in or comment on our Facebook page!