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Promoting the role of nurses in sexual health issues

Frances Perrow
Freelance Specialist Writer on Sexual and Reproductive Health

In its first annual report the Independent Advisory Group (IAG) for Sexual Health and HIV called for sexual health to be given a higher priority within public health to address continuing high rates of sexually transmitted infections (STIs) and teenage pregnancy and to improve access to abortion services.
During its first year the advisory group had taken a hard look at the way sexual health is approached in this country. Its report outlined what the government could do to tackle rapidly emerging problems, but also set out the role that general practices, primary care trusts, healthcare organisations and nurses could play.
It made 29 recommendations to government, covering the broad areas of boosting sexual health, prevention of problems, delivering better and faster services, and carrying out more research to get a clearer picture of the country's sexual health needs.
Recommendations included:

  • Increasing availability of free condoms through the NHS and removing VAT on all over-the-counter contraceptives.
  • Cutting waiting times to 48 hours or less for appointments at genitourinary medicine (GUM) clinics.
  • The routine offer of an HIV test while at a clinic.
  • Tailored sexual health services for ethnic minority groups.

The annual report also set out the scale of the sexual health problem in the UK. It stated that diagnoses of sexually transmitted infections - including HIV - are continuing to rise. Despite recent reductions, the UK still has the highest teenage pregnancy rate in Western Europe. In 2003 there were over two million visits to GUM clinics in England, Wales and Northern Ireland, and over 670,000 new STIs were diagnosed in England alone.
The IAG's Chair, Baroness Joyce Gould, said it was time to recognise that good education, services and support would improve people's sexual health and impact on their overall physical and mental wellbeing: "Some believe sexual health issues to be a kind of Pandora's box of sins unleashed on a permissive society. It's time to destigmatise sexual health and properly deal with what is and will continue to be a very real consideration for public health."
Abortion provision
One of the areas highlighted in the report was termination of pregnancy. The IAG's report stated that there were significant variations in abortion services in England and Wales and that waiting times in many areas needed to be reduced. It set out a number of proposals that could have a significant impact on the role of nurses. The report said:

"Many women face long and unacceptable waits for an abortion to be carried out in a hospital. We believe that early medical and surgical abortions could be carried out in community settings such as family planning clinics and general practices, thereby making use of existing settings and enabling greater access and choice for women."

The government advisers also outlined the fact that some PCTs were having difficulty in commissioning abortion services from local NHS trusts, despite national guidelines and targets. This was said to be due to some gynaecology specialists being reluctant to undertake terminations, which was contributing to a national decline in abortion services by hospital-based gynaecologists.
The IAG said that enhancing training in abortions was crucial to counteract this problem. The report stated:

"There is a need to widen the pool of professionals able to perform abortions, and to therefore extend training to medical staff such as GPs, family ­planning consultants, and - within the provisions of the law - nurses. This would help to compensate for the lack of suitably trained gynaecologists and would thereby speed up waiting times and improve access."

Nurses' role in abortion
Kathy French, a part-time sexual health adviser at the Royal College of Nursing (RCN) and a member of the IAG, said the recommendation was very positive news and could be a natural extension of the nurse's current role in abortion provision. "The overall view is that we support women's right to abortion. We also know that nurses and midwives have a very big role in abortion care. We're often the first port of call at the initial stage when women access sexual health clinics, contraceptive clinics and primary care. Nurses there very frequently do the counselling, make referrals and have a key role to play. For continuity of care, it would be better for women if nurses could follow them throughout, rather than fragment their package of care."
Nurses sometimes had greater involvement in abortion through nurse-led abortion clinics, where they carried out the counselling, scanning, pre- and postoperative care, assisting in theatre and doing the discharge. They were also able to provide advice on future contraception and sexual health.
Kathy, who was previously a clinical nurse manager for contraception and termination of pregnancy services at King's Healthcare Trust in London, believes that nurses also have a major role in medical abortions, where they could do everything except prescribe the drugs: "There are nurses who would like to be able to take a bigger role - for example, giving out the medical abortion pill in contraceptive clinics or GP surgeries, which would make abortion much more accessible for women."
She said some nurses also wanted to take on the role of surgical termination. But she stressed that nurses could retain their conscientious objection to abortion and should be involved in abortion only if it was their choice and if they wanted to extend their existing skills.
Kathy believes that nurses are also great advocates for women facing unintended pregnancies who get "blocked" by GPs or find it difficult to navigate their way through the referral procedure.
Helen Axby, another member of the IAG, agreed that the nurse's role in abortion provision could be greatly increased and should be explored, to offset the decline in hospital provision. But she stressed that a change in the current law would be needed for nurses to actually perform abortions: "There's no question that we have an ageing population of gynaecologists, a significant number of whom became involved in abortion because they saw the deaths and injury that occurred when women resorted to unsafe terminations before the 1967 Abortion Act came into force. Today's junior doctors have no experience of that situation and are opting out of any knowledge of abortion procedures."
She added: "There is absolutely no reason why nurses can't be involved and trained to do abortion, particularly with very safe procedures such as manual vacuum aspiration, which carries the equivalent risk to inserting an IUD."
Helen, who is Deputy Chief Executive of the global reproductive health agency Marie Stopes International, said that in some US states nurses or physicians' assistants were allowed to carry out surgical abortion using manual vacuum aspiration. "Nurses in the UK should be lobbying hard for a change in the law to allow them to use their skills and experience in this way."

Partnership working
There are many other recommendations in the IAG report that would have an impact on nurses, ranging from HIV testing in primary care to a full roll-out of the national chlamydia screening programme. Nurses in primary care could also do a lot to publicise sexual health services for young people and promote the fact that under-16s are entitled to full confidentiality.
The government will examine the recommendations and respond to them later this year. In the meantime, Kathy French urges nurses to improve the implementation and delivery of sexual health services in this country by engaging in partnership working.
"We need to ensure we talk to each other, we share resources and we share training. Sometimes nurses call the RCN wanting to find out where the services are. Often they are on their doorstep and they simply don't know about them," she said.
Nurses in GP surgeries, sexual health clinics or family planning settings will have an opportunity to do just that at an RCN sexual health conference in London next year (21-22 February 2005). The event will include keynote speakers, networking opportunities and discussion groups to tackle challenges and share best practice (see Resources).
Sexual health by distance learning
The RCN is also working hard to increase nurses' professional development in sexual health. In September it launched a new distance-learning skills course to assist nurses who have a remit for sexual health but have had no training. The course, which costs £150, can be done at home in small modules, plus two full assessment days. It is accredited by the RCN, giving nurses a professional qualification, and they also get an academic one through the University of Greenwich (see Resources).
The RCN will also be launching its "sexual health confidences" in November, which have been developed over the past two years. For more details contact

RCN Sexual Health Skills Distance Learning Course
T:020 7647 3741
Teenage Pregnancy Unit

RCN Sexual Health Forum Conference and Exhibition Questioning the nation's sexual health - ­encompassing the wider picture
25-26 Feb 2005
Royal College of Physicians
For further ­information contact:Sonia Lynch
T:020 7647 3859
F:020 7647 3411