Practice nurses and sexual health care Enhancing team care within general practice

General practice is well placed to access at-risk patients¹¹ and acceptability to patients of general practice-based sexual health care is high.^12,13 Public sexual health clinics are valuable, but have limited reach into the general population¹⁴ and most STI care is delivered in general practice.¹⁵ However, barriers to GP-delivered sexual health care include time pressure, limited confidence in history taking and screening,^9,16 fear of patient embarrassment,⁹ and perceived gender barriers to discussing sexual health.^17,18 Some of these barriers may be overcome by enhancing team care in general practice through increasing the PN role. Sexual health is better recognised as part of general practice nursing in the United Kingdom (UK), though barriers such as lack of PN confidence, skills and training have been identified.^4,17 To date there has been little research on the role of Australian PNs in sexual health care and how that role may be supported. This study explores how GPs and PNs deliver sexual health care, with particular attention to perceived roles and teamwork.

Methods

The research was conducted as part of an evaluation of the ‘GP Project’, a project undertaken in 2008–2010 by the New South Wales Sexually Transmissible Infections Programs Unit (STIPU)¹⁹ to enhance evidence-based sexual health care within NSW general practice through increasing GP and PN access to STI education and resources. In the GP Project evaluation,²⁰ 217 PNs and 214 GPs undertook an online survey and were asked to indicate interest in a subsequent interview.

Interviewees were purposively sampled to maximise diversity of gender, age, years of experience, location, patient-base and use of the resources. Interviews were conducted by telephone by two members of the research team (HH, AD) and lasted 25–70 minutes, with an average duration of 50 minutes. The participants’ views on the GP Project resources and sexual health care in general practice, including GP and PN collaboration, were explored. Interviewees were offered monetary recompense for their participation. Sampling continued until thematic data saturation was achieved.²¹ Using an iterative process,²² four members of the research team independently analysed and interpreted the interview transcripts (PA, AD, MK, WH) to generate, develop and revise themes.²³ One member of the research team (PA) then compared and contrasted themes and synthesised the interpretations.

Results

We report on the interviews undertaken with 10 PNs and nine GPs (Table 1), focusing on themes related to teamwork in general practice-based sexual health care. The participants varied widely in terms of prior training and experience in sexual health.

Roles of practice nurses in sexual health care

Practice nurses reported a wide range of sexual health care activities. These included ‘well women’s clinics’ in which education and screening occurred at the same time as pap tests; sourcing and distributing patient education resources; providing community education including school visits; managing the pathology and recall component of STI screening; contact tracing; chaperoning during consultations and taking sensitive histories from female patients on referral from the GP. Sexual health screening and education also occurred during other PN activities, such as in patient triage prior to GP consultation, care planning and Aboriginal health assessments.

Patients did not usually seek PN advice on sexual health directly, but were engaged opportunistically.

“I’ve never once had a patient come in and just start the general conversation about an STI...My way of bringing that up is during a pap smear consultation or for another reason they have come in, perhaps a breast check or post-natal issues maybe or blood-taking.” (PN, female, urban)

Some PNs and GPs viewed sexual health as an important part of PN work and others considered it incidental to the role. The strength of the PN role and GP–PN collaboration was influenced by practice location and gender of the GPs working in the practice. PNs had a stronger role in rural practices and in practices where there were no female GPs.  

“If I found something that is hard to progress with a consult, I try to ask my nurse...[and also invite her] to accompany me for the examination.” (GP, male, rural)

Identified advantages of a greater PN role in STI screening and education were increased professional satisfaction for PNs and a greater proportion of target populations receiving STI screening and education.

“I just think the uptake would be higher in all aspects of that, in terms of screening, cervical screening, and in terms of STI screening.” (PN, female, urban)

Organisational factors

Workloads, practice systems and structures were important influences on collaboration. When GPs were under more time pressure such as in rural locations there was more support for PN involvement in sexual health care.

“They still go to the male GP as well, just that I have more time than the GP to go through a lot of things. He’s more into curing it; I’m into the health promotion and doing women’s health and wellness checks. That gives me the opportunity to give out more information to those who want it.” (PN, female, rural)

Conversely, in some urban locations, PNs were supporting large numbers of GPs and had little time to expand their work into the area of sexual health.

Some practice systems were enabling to both sexual health care and PN involvement through building sexual health teamwork into usual practice activities. In some practices, STI recall and contact tracing systems were managed by PNs and sexual health items included in routine care planning and health assessments. Such strategies gave PNs an acknowledged role. The specific Medicare Benefits Schedule (MBS) item numbers for well women’s checks by PNs had encouraged development of supportive systems, which were seen to be at risk due to the recent removal of these items.

“It is the older GPs that perhaps need education on how to utilise their nurses. That’s where I think taking away the item numbers from practice nurses is really going to have a big impact.” (PN, female, rural)

Importantly, a confidential space in which to carry out nursing consultations was not always available. Without practice systems and structures facilitating PN involvement, nurses were unable to create and maintain a role in sexual health even if interested.  One PN noted when she moved to another practice without supportive systems, she could no longer work the way she wanted.

“The practice I was working at really encouraged my independence...I was more involved in giving more advice to the clients at the time and things like that, whereas now I’m just fulfilling more of the basics.” (PN, female, urban)

Recognition of the PN role

The personal interest of PNs in sexual health was identified as an important facilitator of involvement. However, several PN participants perceived a conflict between this interest and the duties accepted by GPs and the practice to be part of their role. PN roles in immunisation and chronic disease services were well recognised but a role in sexual health was not.

“The main problem is that I don’t necessarily feel heard with the knowledge that I have actually got in an area where I have a great deal of interest.” (PN, female, rural)

This was supported by several GP and PN participants who indicated that a role for PNs in sexual health was either not something they had thought about, or did not consider a priority.

 “I haven’t had any teamwork happening in STI management; we do have a practice nurse, but I don’t know in what way she would be involved in that.” (GP, female, urban)

In addition to GP support of the PN role being vital, GPs’ personal interest in sexual health strongly affected the PN role. It was difficult for PNs to provide sexual health care in isolation from the GP, even if the GP was supportive.

“What I’m actually really looking for is the change of practice of the GPs so that they’ll be more proactive...I am really passionate about STI testing, about testing for chlamydia...I have pushed it with the GPs and a few of them have gone [sound indicating unwillingness] and then it has come back positive. So that has given me a bit of evidence towards getting them to do it.”(PN, female, rural)

Marketing of an increased PN role in sexual health to GPs, other nurses, patients and Medicare Locals was recommended by interviewees, as was increased opportunities for PN education.

Affirming the PN role through a practice resource: The Practice Nurse Postcard

One of the resources of the GP Project held particular relevance to the PN sexual health care role, namely the Practice Nurse Postcard (Figure 1). The resource was designed to guide preventative women’s health checks, building on the then Medicare-funded role of PNs in well women’s checks by also prompting sexual health care, particularly chlamydia screening, during these consultations. It was reported by several PN participants to be effective in increasing their confidence and skills, thus enabling their work in both women’s health and sexual health screening.  However, importantly, for some its greatest value lay in its validation of the PN role in sexual health care, offering explicit evidence of their role to both colleagues and patients.

Figure 1. Practice Nurse Postcard (reprinted with permission from NSW STI Programs Unit)

“I can’t tell you the excitement when I got it...I’m saying to all these people at work, ‘Look, it shows you the MBS numbers...We have to look at these things...and it’s my responsibility to do this’.” (PN, female, rural)

Discussion

Practice nurses and GPs who participated in this study reported a wide range of PN roles in the area of sexual health care, varying from no substantive role to extensive roles in education, history taking, screening and follow-up care. Similarly, collaboration in delivery of sexual health care was variable, with well-developed teamwork more commonly reported in rural areas and where a female PN was working with a male GP. Several nurses and GPs had not considered an active PN role in sexual health, while some PNs with an interest in sexual health believed they could not exercise their skills due to limited support from GPs and practices.

Similar to previous findings in the UK,¹⁷ this study suggests that PNs would welcome an expanded role in sexual health, if given the support required. A stronger PN role in delivery of sexual health care may increase the number of services provided to patients, reduce time pressure on GP services and enhance PN professional satisfaction. The more commonly seen PN work in pathology collection and patient resource distribution can be collaborative, but it does not take full advantage of the potential of practice nursing that is employed more effectively in other clinical areas of general practice in Australia.³ Engagement in well women’s health checks alone is inadequate. As the population targeted for chlamydia screening is younger¹⁰ and of both genders, pap smear screening is a limited STI testing opportunity in general practice.

In this study, the most crucial facilitator of PN involvement in sexual health care was GP recognition of a PN role. The strong theme of lack of GP recognition and support of substantive teamwork in sexual health illustrates the negative power differential which exists between GPs and PNs²⁴ and aligns with previously described frustration amongst PNs that their clinical skills are undervalued in general practice.³ Many of the GPs interviewed had not considered this potential area of practice nursing. PN interest in sexual health was also an important facilitator. Finally, even if the GP or practice as a whole was supportive of a PN role in sexual health, and PNs were themselves interested, systems needed to be in place to enable team care. These included support for sexual health training, provision of a nursing room allowing privacy and confidentiality, and incorporation of sexual health into routine health assessments, care planning and triage processes.

Much of the impetus to promoting practice nursing has been in response to the increasing chronic and complex care delivered in general practice.²⁴ However, the lack of adequate STI testing and management within the general practice sector^7,8 suggests increased involvement of PNs in sexual health care should be encouraged. This research suggests that affirmation of the PN role in sexual health is needed. This role should be promoted at multiple levels: PNs, GPs, patients, Medicare Locals, professional associations and educational institutions. One strategy would be use of practice resources building on the lessons from the GP Project. The Practice Nurse Postcard was a clinical support tool to facilitate knowledge translation for PNs, but had additional value through affirming the legitimacy of the PN role in sexual health care to GPs, patients and practice staff. This suggests that resources for PNs designed with role advocacy in mind may assist in promoting and supporting the PN role in sexual health delivery in general practice, thus improving management of STIs.

This study has some limitations. While interviews with the mostly female PN and GPs provide evidence of how teamwork may increase provision of sexual health care in general practice, it is possible male PNs and GPs may have different views and experiences. Furthermore, given that the Postcard was developed to take advantage of the link to PN-delivered women’s health checks, for which the Medicare rebate has since been removed, broadening of lessons learnt is required. Finally, although the purposive sampling assisted us to interview GPs and PNs with a range of views on sexual health care, all were initially recruited after responding to a survey about sexual health and so may have had a pre-existing interest. However, it is possible that with a wider group of GPs and PNs who did not identify a special interest in sexual health, the study finding that increased recognition of PN roles in sexual health care was needed would be even more prominent.

Implications for general practice

• General practice is ideally situated to deliver sexual health care.
• The role played by PNs and a team approach to sexual health care in Australian general practice is underdeveloped. Increased recognition and support of enhanced PN roles in sexual health is needed, including access to training and supportive practice systems, such as incorporating sexual health into triage, care planning and health assessments.
• Simple practice resources which affirm PN roles in sexual health care may assist.

Competing interests: None.
Ethics approval: Human research ethics approval was obtained from the University of Western Sydney, H8886.
Provenance and peer review: Not commissioned; externally peer reviewed.