New to general practice nursing? Practice nurse skills: Part 2
This is the second of two articles on essential treatment room skills, aimed to give a taste of the general practice nurse role for nurses new to the specialty or those who are considering a move to primary care
In part one we looked at a number of treatment room skills undertaken by general practice nurses (GPNs) to give a flavour of the role in primary care. We also discussed principles underlying the delivery of patient care, the need for acquiring and meeting competencies in learning and developing new skills and knowledge, together with a look at the expanding role of the healthcare assistant (HCA). In part two, we will be focusing on the further skills that are the mainstay of the treatment room nurse as well as touching on resources and further reading for expanding practice to encompass a wider brief. Specifically, we will be addressing:
- Ear care
- Cervical screening
- Sexual and reproductive health
- Wound care
- Minor injury
- Travel health
- Health promotion
EAR CARE
Wax, whether it is wet or dry, is a normal constituent of the ear canal which can accumulate, become impacted and cause obstruction leading to hearing difficulties, tinnitus, pain and vertigo. Ordinarily, wax migrates along and out of the ear canal through the ‘conveyer-belt’ action of the epithelial lining, aided by natural lubrication and movement of the jaw to remove debris such as dirt, dust and foreign bodies. However, an excess of dry skin, use of hearing aids, increasing age, anatomically narrow ear canals, hairy ears, discharge, infection, diet and hereditary factors can all contribute to a build-up of wax which may completely occlude the ear canal. Techniques for the removal of excessive ear wax include ear irrigation, micro-suction and aural toilet but must only be carried out by GPNs or HCAs who have undertaken recognised training, supervision and achieved competency to do so. Removal is recommended only if the tympanic membrane is completely obstructed and one or more of the following is also present:1
- Hearing loss
- Earache
- Tinnitus
- Vertigo
- Cough, suspected to be caused by ear wax
- Visualisation of the tympanic membrane is necessary for additional diagnosis
- Prior to aural impression for hearing aid ear moulds
- Whistling hearing aids
The Rotherham Primary Ear Care Centre and Audiology Services provide excellent evidence-based guidelines on otoscopy, aural instrumentation, aural toilet, ear irrigation and micro-suction together with guidance on care and cleaning of equipment.2 Equally, for examination of the ear, the British Society of Audiology ‘Ear Examination’ document provides a thorough and detailed guiding principles for the procedure.3
Preparation of the ear canal for several days prior to irrigation aids removal of the wax and reduces associated risks and complications, such as trauma, dizziness, tinnitus and infection. Cerumenolytics (ear wax solvents) such as sodium bicarbonate drops and hydrogen-pyroxide based drops (water based) or oil-based products, specifically olive oil and almond oil (although exercise caution with nut allergy), are recommended.4 Providing patients with an advice leaflet on how to instill drops correctly and effectively helps to ensure that ears are adequately prepared before the procedure.5,6
However, irrigation should not be carried out if:2
- Previous complications have occurred as a result of the procedure
- History of middle ear infection within the previous 6 weeks.
- Any history of ear surgery
- The patient has a perforated ear drum
- A history within the last 12 months of mucous discharge
- Ear pain and tenderness and inflammation of the ear canal (otitis media)
Micro-suction technique, using a microscope to fully visualise the ear canal together with a fine low pressure suction device, is a specialist skill which may be available in some surgeries although often patients who require it may need to be referred to centres where it is provided.
CERVICAL SCREENING
The aim of the NHS Cervical Screening Programme (NHSCSP) is to reduce the incidence of cervical cancer and ultimately reduce the numbers of deaths caused by it.7 Nationally, women between the ages of 25 and 49 years are invited every 3 years for screening, with women aged 50 – 64 years invited 5 yearly. In the UK, more than 50% of the cases of cervical cancer are diagnosed in women under the age of 45 years with 99.7% of cervical cancers caused by persistent high risk Human Papilloma Virus (HPV) infection.8,9 Currently, liquid-based cytology is the technique used to examine the cervical sample for abnormal cells, and if present, the sample is tested again for HPV. However, changes are afoot for samples to be tested for HPV first to improve the sensitivity and efficacy of the test thus improving outcomes and reducing anxiety for women with false positive results.10 Furthermore, ultimately to reduce the morbidity and mortality of cervical cancer, HPV vaccine is offered as part of the school immunisation programme to adolescent girls in the UK. The two dose schedule provides protection against the most significant persistent high-risk HPV types (16 and 18) responsible for cervical cancer.11
The GPN’s role in cervical screening is to ensure that best practice is maintained to ensure that representative samples are taken in line with NHSCSP guidance. Registered nurses need to have successfully completed a recognised theory course followed by supervised practice to become competent to undertake the procedure. Being an intimate examination, GPNs need to ensure that they address the following when undertaking cervical screening:
- Confident history taking to elicit sexual history, menstrual pattern, abnormal vaginal bleeding, vaginal discharge, dyspareunia, contraceptive measures, menopausal symptoms
- Obtain informed consent and confirm patient identity
- Maintain confidentiality, privacy and dignity
- Offer a full explanation of the procedure and its limitations, and accessing results and their implications
- Provide appropriate empathy and reassurance
- Ensure the patient’s comfort
- Communicate in a way that is consistent with understanding background, culture and preferred language
- Offer a chaperone to all women
- Be fully conversant with the anatomy of the external genitalia and, during internal examination, able to recognise abnormalities and act on them
- Be able to address questions of a sensitive nature which may arise
- Be able to recognise and report female genital mutilation according to practice protocol
- Complete accurate and contemporaneous documentation and request forms
- Know when to refer to colleagues following any concerns
Box 1 highlights useful resources for Practice Nurses undertaking cervical screening and its wider scope of practice.
SEXUAL AND REPRODUCTIVE HEALTH
Sexual and reproductive health (SRH) in primary care is a role that can be developed and extended into a specialism (See Practice Nurse, May 2017). However, at a basic level, and especially if undertaking cervical screening, GPNs need to be able to take a sexual history, undertake oral contraceptive reviews (way beyond just taking a blood pressure!), give essential and accurate information on all contraceptive methods and signpost appropriately, perform routine swabs and recognise when to refer to colleagues. Practices may also take part in the National Chlamydia Screening Programme as well as condom schemes, and local providers should ensure all new staff are appropriately trained in order to provide these services for young people. In addition to locally-provided training, which may be accessed through local colleges, universities or via Clinical Commissioning Groups, The Faculty of Sexual and Reproductive Health (FSRH) runs a one-day ‘SRH Essentials’ course for nurses working in primary care and the e-Learning for Healthcare programme provides a variety of modules in SRH, ranging from exploring contraceptive choices, emergency contraception, risk assessment, sexual transmitted infections and sexual behaviour.
Key guidance and resources for SRH include:
- FSRH UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) evidence based guidance to determine safe use of contraception
- FSRH – Faculty of Sexual and Reproductive Health standards and guidance
- FPA – the sexual health charity
- BASHH British Association for Sexual Health and HIV guidelines
- Terence Higgins Trust
- NSPCC A child’s legal rights: Gillick competency and Fraser guidelines
- NHS Choices
- Sexual and Reproductive Healthcare e-learning accessed via e-Learning for Healthcare
WOUND CARE
Nurses who come into primary care are likely to have a variety of wound care experience, from dressing chronic wounds in the community through to the immediate care of day unit surgical wounds or of traumatic wounds through Accident and Emergency (A&E) nursing. For some, career choices may mean little or no wound care for many years. In practice nursing, wound care can be both challenging and complex and the typical types of wounds encountered include:
- Post-surgical wounds
- Clip and suture removal
- Leg ulceration
- Chronic wounds
- Diabetic foot ulcers
- Neuropathic wounds
- Traumatic wounds including skin tears, lacerations, bites, scalds and burns
Wound care is complex and a holistic approach to it is necessary to ensure the best possible healing for the patient. The patient’s overall health and wellbeing, whether they have any co-morbidities such as diabetes or anaemia, their age, their support network, the type and condition of their skin, as well as their nutritional state and mobility all need to be considered in the bigger picture of wound care. Undertaking training to acquire and update skills, knowledge and competence is essential to maintain best practice and to keep abreast of the rapidly evolving body of evidence in determining choice of dressings and management of the wound.
Understanding the healing process and undertaking wound assessment is paramount. The use of a wound chart, and photography if the patient consents, can be invaluable for documenting the initial presentation, progression and, at times, the deterioration of a wound.12 Being able to describe and document the condition of the wound conveys its stage in healing: what type of wound it is, its location and dimensions; the state of wound bed – whether it is necrotic, sloughy or epithelialising, for example; how much exudate is present; the state of the periwound – is it fragile, excoriated or healthy; how well it is progressing and whether there are signs of infection, such as odour and pain.
Having treatment objectives and choosing the most appropriate dressing is an ongoing and evolving process throughout wound healing. There are a plethora of dressings available and many practices have formularies to guide nurses with the most appropriate, and cost-effective, options. Dressings can be a minefield but it is vital to understand the implications of applying the most appropriate dressing for an individual wound at a specific time. Knowing when to refer to colleagues or seek further advice from specialists such as the specialist Tissue Viability Nurse (TVN) or diabetes foot teams is fundamental.
Best practice can be enhanced by sharing good practice with colleagues, attending practice nurse forums, supervision by and consulting with local TVNs, attending study days and reading journal articles. Box 2 gives some suggestions for further reading for wound care.
MINOR INJURY
Practice nurses may see patients who have had minor injuries to a greater or lesser extent depending on the proximity of the GP surgery to minor injury units and urgent care centres. Rural practices are probably more likely to have people turning up with a variety of injuries such as burns and scalds, animal and insect bites, foreign bodies in various orofices, traumatic wounds as well as soft tissue and bone injuries to name but a few. By their very nature, people with minor injuries usually turn up unannounced – inevitably in the middle of a busy clinic, or just as you are shutting the door at the end of surgery. Clearly GPNs with A&E experience have a distinct advantage in this area but all GPNs need to develop and maintain the theoretical knowledge and practical skills to be competent to deal with the sudden appearance of someone with a minor injury. Managing minor injuries involves taking a sound history of events leading up to the accident or injury, undertaking appropriate examination of the patient and their injury, managing the wound or injury as per practice protocol and within the limitations of experience, referring to colleagues or transferring to external services as necessary and always considering safeguarding issues in children and vulnerable adults. Box 3 provides a list of further reading and resources for minor injury.
TRAVEL HEALTH
The role of the treatment room nurse may expand into travel health. Practice Nurse provides invaluable monthly updates on all aspects of travel health medicine. Nurses new to the speciality may find the whole arena of travel health overwhelming at first but the abundance of evidence-based information available provides indispensable resources and further reading for GPNs to inform practice. Accessing study days and courses, as well as online webinars, provide an essential knowledge base for GPNs venturing into this complex arena. Box 4 provides a list of essential resources for travel health.
HEALTH PROMOTION
Although this is an article about treatment room skills, using interactions with patients when undertaking procedures such as ear irrigation or cervical screening gives opportunities in practice to ‘make every contact count’ to support our patients in making positive improvements to their physical and mental health and well-being. Essential treatment room skills such as calculating Body Mass Index (BMI), taking blood pressure and waist measurements can reveal major risk factors for poor health and underling disease if outside the boundaries of normal. It is worth noting the British Hypertension Society and Medicines Healthcare Regulatory Agency give good ‘top tips’ for taking an accurate blood pressure, while NHS Choices provides a straightforward guide to measuring BMI and waist measurement for both professionals and the public alike.13–15 Practice nurses may well be undertaking these additional ‘tasks’ during a consultation for other procedures and, by doing so, have the opportunity to broach lifestyle factors, including healthy eating and the benefits of maintaining a healthy weight.
DEVELOPING THE GPN ROLE
The role of the treatment room nurse is varied and GPNs new to the speciality may be encountering specific skills for the first time. To become proficient in practice, GPNs need to gain confidence through the learning of theory and the development of each new skill through recognised training provision, together with supervision and mentoring to achieve competence. Practices themselves need to embrace new members of staff to enable them to achieve such competencies through a structured pathway, investing in their education and training, rather than simply expect staff to ‘learn on the job’. As highlighted in part one, the ‘RCGP GP Foundation General Practice Nurse competencies’* and the ‘Health Education East Midlands Competency Framework and Competency Development Plan’ provide a focus for learning, development and enabling progression of individual skills and proficiency. Having such a framework helps nurses to ensure they meet and adhere to the professional standards in the NMC Code.16 There is a wealth of evidenced-based information and resources readily available to help practice nurses learn and develop and explore the role, which itself continues to evolve and develop. As previously mentioned there is sometimes cross-over seen in the role of the treatment room nurse and the HCA working in general practice but clear guidance, protocols, working to national guidance and local formularies, proven competence and practising within the limits of that competency are vital and that each individual is aware that they are accountable for their actions. The role of the GPN is as exciting and challenging as it is varied and for those practice nurses new to it, life in the treatment room is just the beginning.
*The Practice Nurse Curriculum is based on the RCGP GP Foundation General Practice Nurse competencies. Select ‘CURRICULUM’ from the menu at the top of the screen.
REFERENCES
1. National Institute for Health and Care Excellence. Clinical Knowledge Summaries: Earwax. July 2016. https://cks.nice.org.uk/earwax#!scenario
2. Rotherham Primary Ear Care Centre and Audiology Services. Protocols and guidelines. http://www.earcarecentre.com/HealthProfessionals/Protocols.aspx?id=8
3. British Society of Audiology. Recommended Procedure: ear examination. November 2016.
4. British National Formulary. 12.1.3 Removal of earwax. https://www.evidence.nhs.uk/formulary/bnf/current/12-ear-nose-and-oropharynx/121-drugs-acting-on-the-ear/1213-removal-of-earwax
5. Patient. Health Information: earwax. http://patient.info/health/earwax-leaflet
6. Rotherham NHS Foundation Trust. Primary Ear Care and Audiology Services. How to use ear drops. http://www.earcarecentre.com/Patients/Leaflets.aspx?id=15
7. Public Health England. Cervical screening: programme overview April 2015. https://www.gov.uk/guidance/cervical-screening-programme-overview
8. Cancer Research UK. Cervical cancer statistics. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer
9. Public Health England. NHS Cervical Screening Programme. Guidance for the training of cervical sample takers. 2016. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer
10. Department of Health. News story: Changes to cervical cancer screening. 6 July 2016. https://www.gov.uk/government/news/changes-to-cervical-cancer-screening
11. Public Health England. Immunisation Against Infectious Disease. Chapter 18a. Human Papilloma Virus (HPV). June 2014.
12. Healthcare Improvement Scotland.General Wound Assessment Chart. July 2009. http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/general_wound_assessment_chart.aspx
13. MHRA. Measuring Blood Pressure. Top Ten Tips. December 2013. http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/general_wound_assessment_chart.aspx
14. British Hypertension Society. Blood Pressure Management with Manual Blood Pressure Monitors. 2013. http://www.bhsoc.org/files/9013/4390/7747/BP_Measurement_Poster_-_Manual.pdf
15. NHS Choices. What’s your BMI? December 2015. http://www.nhs.uk/Livewell/loseweight/Pages/BodyMassIndex.aspx
16. Nursing and Midwifery Council. The Code. 2015. https://www.nmc.org.uk/standards/code/
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