Service Improvement for Youth Sexual Health

Introduction

The aim of this Service Improvement Project (SIP) is to plan a change within an integrated sexual health service in collaboration with a range of stakeholders, including service users. The proposed change was opening up evening clinic appointments during the week for positive under 16 Chlamydia patients. The aim of this was to deliver open access and encourage young people to attend and engage with the service, ensuring that confidential and non-judgmental services are provided. Confidentiality is a significant aspect in nursing practice, as it enhances therapeutic relationships between health care professionals and service users (Beltran-Aroca et al, 2016). In addition, it is important that young people are encouraged to come into clinic as they can talk to healthcare professionals about other sexual health-related matters such as the safety of the young people, vaccinations for gay and bisexual young people and contraception services.

Background of Study

The Chlamydia is common sexually transmitted disease which is caused by the bacteria known as Chlamydia trachomatis (Giffard et al. 2018). The disease infects both men and women with no initial symptoms of infection being revealed among individuals. According to data in the UK, the rate of diagnosis of the disease was 7% in 2014 indicating 176.3 diagnostic cases per 100,000 populations which was 164.7 per 100,000 population in 2013 (fpa.org.uk, 2016). This indicates that increased diagnosis from 2013 to 2014 was executed for detection of the disease. The rate of diagnosis among the female (190.4 per 100,000population) was higher compared to male (161.6 per 100,000population) for Chlamydia in 2014 within the UK. The young people are mentioned to be disproportionately affected by the disease irrespective of the sexes (fpa.org.uk, 2016). In global condition, it is seen that 127 million people are already affected by Chlamydia as one of the sexually transmitted diseases in 2016. Among the infected, 3.8% are female and 2.5% are men (WHO, 2018). This indicates that women are more prone to suffer from the disease compared to men. As a result of the disease, 200 deaths are reported worldwide (WHO, 2018). This indicates that the condition is fatal to some extent and effective treatment along with early diagnosis is able to control the health issue. The progression of Chlamydia with increased time leads to raise symptoms such a vaginal discharge, burning feeling during urine and discharging and others in female. In male, pain and swelling of testicles are seen along with burning feeling in the penis during discharge are symptoms of Chlamydia (Lewis et al. 2017). The Chlamydia mainly spreads through oral, anal or vaginal intercourse as well as is able to be passed to the baby during childbirth by the pregnant mother (Dukers-Muijrers et al. 2017). The pathophysiology of Chlamydia informs that it has the ability to create long-term association with host cells. However, when the host cells are found to be starved of vitamin, iron and other essential nutrients, the bacteria is unable to live as the nutrients act as life support for the bacteria. In this condition, the starved Chlamydia enters persistent growth stage where they cease cell division and remain morphologically aberrant by showing increase in size. This condition may lead to chronic stage of the disease as the persistent organisms are found to return to normal growth on providing favourable growth environment (Mohseni et al. 2019). Thus, early diagnosis and treatment for the Chlamydia in young people is required as it would lead to chronic condition with delay that is going to further deteriorate their health and sexual life.

The effective screening and diagnosis of Chlamydia among individuals are required as there are chances of getting infected during any sexual intercourse and there is probability people can get reinfected by the disease (Bakshi et al. 2018). This indicates that people once treated for the disease has the ability to face relapse of the condition along with require additional and continuous care intervention. In the study by McDonagh e al. (2017), young people are prone to get affected by Chlamydia as they are more likely to get involved in unprotected sexual intercourse where condom is not used. This is because condom acts as a protective factor to avoid transmitting the bacteria from the semen of men or vagina of women into each other’s body during copulation. The health organisations in the UK are found to provide open-access to sexual healthcare services to people to offer them treatment and information regarding the way risk of sexual transmission of infections can be avoided from spreading (assets.publishing.service.gov.uk, 2018a). This is an effective approach to raise awareness regarding Chlamydia as STI among people because the information of risk factors of the infection makes people educated of the aspects to be avoided to refrain getting infected by the disease. Moreover, such an approach is effective to ensure early intervention in controlling Chlamydia as STI in many young individuals (assets.publishing.service.gov.uk, 2018a). The existing healthcare services in the UK informs that government has guided the local healthcare services to perform routine screening of people under 25 years of age for Chlamydia as STI through range of sexual healthcare services. This process is required to include notification to partners of positive patients and retesting of individuals who are previously diagnosed with Chlamydia. It is to ensure lowering the onward transmission of the disease and subsequent harm to other individuals (assets.publishing.service.gov.uk, 2018a). Moreover, information regarding the positive attitude of sexual health issues is to be educated through high-quality, statutory relationship and sex education to young people in secondary schools. The relationship and sex education are also required to ensure young people are equipped with the skill to maintain enhanced sexual health well-being (assets.publishing.service.gov.uk, 2018a). However, irrespective of the services many young people suffering from STI avoid visiting the existing physical clinic and attend screening of sexual health in person. This is evident from the study of Eaton et al. (2016) where it is mentioned that young people suffering from Chlamydia as STI prefers to avail remote Chlamydia testing attributes such as self-testing, postal sampling and self-sampling compared to testing at clinics. Moreover, a general preference was seen among the young people regarding Chlamydia testing is that they wished the diagnosis to be observed through online compared to availing traditional pharmacy, general practice and services at the clinics. This indicates that physical use of clinic in screening and diagnosis of Chlamydia among the young people is at reduced level. The young people often physically avoid access to sexual health services from sexual healthcare clinic as they fear lack of confidentiality of personal identity and being judged based on their age-specific activity by others. This is because in clinics the person is allowed to be identified by their face and physical appearance which leads to expose their personal identity. Moreover, involving in sex at a younger age is considered to be bold act by the public leading the public to consider the young person to be judged as bad influence to the society (Nadarzynski et al. 2019; Fuentes et al. 2018). The young people are often found to be involved in active work and have to attend school during the day. Thus, it is impossible for the young people out of time constraint to physically avail sexual healthcare services in clinics for treatment and diagnosis of STIs (Allison et al. 2017). The past hindered experiences of waiting for longer time to avail screening test in the clinic often leads young people to avoid physically avail sexual healthcare services and opt for online services which are less time-consuming (Llewellyn et al., 2012). However, there are challenges of availing on-line healthcare services compared to physical health clinics for availing care and treatment for managing STIs in young people. In the study of Steiner et al. (2019), it is mentioned that availing e-sexual healthcare services creates challenges in care as effective engagement of target groups cannot always be achieved. Moreover, health disparities are unable to be managed along with communication inequalities and assurance of quality information can be ensured. Thus, physical healthcare services offered through clinics are more effective as face-to-face interaction between the healthcare professionals and target patients are allowed to be easily established. Moreover, the quality of information delivered and testing efficiency for sexual health issues are enhanced (Reed et al. 2017). However, in the UK, the existing daycare sexual health clinics which offer healthcare physically through the help of staffs are found to have lower attendance rate. In this respect, the current service improvement plan is developed to determine the way evening sexual healthcare clinic can be framed to attract more young people to physically access diagnosis and treatment for STIs such as Chlamydia. This is because evening sexual health clinic is able to offer suitable amount of time to the young people to avail care by managing their working and school activities in the day. Further, to explore the need of evening sexual health clinic on the basis of impact of current services and process to be followed in evening sexual health clinic developed the service improvement plan is framed.

Rationale of Study

The Chlamydia (genital chlamydial trachomatis) is one of the leading bacterial sexually transmitted infections (STI) diagnosed in England. This is evident as in 2015 nearly 46.1% of the diagnosed STI in the country was Chlamydia. In 2015, nearly 200,288 young people are diagnosed with and treated for Chlamydia which indicated a 4% decrease since 2014 in which 208,638 people were diagnosed with the disease (fpa.org.uk, 2016). However, this did not indicate that the prevalence of the disease has lowered because the rate of diagnosis has instead found to had fallen. This is evident as the rate of diagnosis for treatment of Chlamydia in 2015 was 368.7 per 1000,000 populations whereas it was 384.1 per 100,000 populations in 2014 (fpa.org.uk, 2016). It informs that less young people are found to come forward in accessing diagnosis of Chlamydia and availing services for its management due to which lower rate of diagnosis is to be found. The lower diagnosis rate and access towards availing care services for Chlamydia among young people have become an issue because it is leading many adolescent individuals to cause short-term and long-term negative health consequences. As mentioned by Wood et al. (2018), lack of treatment and diagnosis of Chlamydia in women in longer course leads it to be spread to the fallopian tubes and uterus. This leads them to develop pelvic inflammatory disease and complications during pregnancy. As argued by Tisler-Sala et al. (2018), lack of early diagnosis and treatment of Chlamydiain men leads to negatively affect their uterine muscles. This leads to create complication of swollen and tender testicles which leads to create hindrance during copulation. In 2018, continuous decline of participation of 15-24 years old in the Chlamydia Screening Activity is seen for non-specialist sexual services with exception in rise of participation increased in e-Sexual health services (assets.publishing.service.gov.uk, 2018). This indicates that currently less young people are showing willingness to physically access diagnosis and treatment of Chlamydia in England and prefer use of electronic healthcare services which provided brief care for the issue and not effective for enhanced management of the disease. The study by Minichiello et al. (2013) mentions that e-healthcare are more frequently accessed due to its convenient timing and better protection of identity of the people. Therefore, it indicates that care services for increasing diagnosis and treatment of Chlamydia require the clinics to be arranged in such a way that they offer convenient timings and better confidentiality to the patients. Thus, this study focus on service improvement for implementation of evening clinics to diagnose and treat Chlamydia among young people is to be done to determine its effect in promoting the health of the individuals and condition regarding the disease. This is because during night the young people coming to access care regarding Chlamydia would not be noticed like done in the broad daylight. It would help them to cover their identity to some extent as well as offer them convenient timing to access care as during the day they may be busy studying or at work.

Aim

The aim of the study is to create service improvement plan to create evening clinic appointments for young people suffering from Chlamydia to ensure better promotion of their health as well as increase diagnosis and treatment for the disease.

Methodology

Search Strategy

The search strategy is referred to the organized structure of key terms to be used for searching evidence within a database. The strategy includes key concepts to be focused on the research question so that accurate results can be retrieved (Lennox et al. 2018). In evidence-based practise (EBP), incorporation of three components are made which are external evidence in the form of systematic review, randomized control trial, best practice and others; internal evidence which are healthcare institutions based quality improvement, care management initiatives and others and patient experience (LoBiondo-Wood et al. 2018). In this study, the search strategy for formulating evidence-based practice (EBP) is to be used. This is because EBP is essential for nursing and medical practice as it aims to offer most effective scientific facts and data to be used in care for improving the quality outcome for the patients. Moreover, EBP helps to lower error in care and increased efficiency of nurses to delivery support along with lower healthcare cost and ensure empowerment as well as the satisfaction of role for the healthcare providers (Melnyk et al. 2017). Thus, formulating strategies to form EBP is needed to ensure better quality study to be presented. The initial step for executing EBP is formulating detailed and well-structured research question based on which the aim of the entire study can be understood (Greenhalgh, 2017). This is because a good research question helps the researcher to focus on the key concepts to be explored in the study so that information can be unfolded and study can be directed in resolving the identified research problem in the study. The identification of appropriate research database and way of searching information is required to be identified in formulating EBP. This is because it offers the opportunity to determine the search terms to be used and database to be focused in gathering required evidence for the EBP (Greenhalgh, 2017). The further steps of search strategy for EBP include identifying ways of data extraction and critical analysis of the data for presentation of authentic and well-directed evidence to be used in practice.

Formulating Research Question

The PICO framework is to be used for formulating the research question in the evidence-based practise (EBP). The PICO tool has focus on Population, Intervention, Comparison and Outcome of qualitative study where it helps the researcher to develop well-focused literature search in formulating the study (Shea et al. 2017). The population is referred to specification of the target participants in forming the study. The intervention is referred to the approach to be taken in relation to the identified problem and target population in the study. The comparison is referred to indicating the alternative characteristics to be focused in the study to compare them with the identified variables of the study. The outcome is referred to the results or findings wished to be developed by performing the study (Butler et al. 2017). The research question based on the PICO tool in the study is: Does accessible sexual health services can promote young people to effectively engage in availing care and reduce prevalence of Chlamydia amongst young people?

Literature Database

The selection of appropriate database from which information are to be gathered in formulating the EBP is to be determined. In this study, the electronic database which is searchable electronic collection of academic resources is to be used for gathering information. This is because electronic database allows online search to be executed by use of specific keywords identified in the study to allow gathering potential and valid data needed in resolving raised and identified issues. Moreover, these kinds of databases include increased number of updated information and articles from all over the world to be used in formulating the study is a valid and reliable way. It also allows easier and quicker identification of information compared to lengthy search time used in manual research (Bollaerts et al. 2020). The electronic databases used in the study for gathering information are Cochrane Library, MEDLINE and CINHAL. The Cochrane Library has vast number of updated clinical articles and journals which are able to reflect on the evidence required based on the findings to present a well-structured result and conclusion for a study (cochranelibrary.com, 2018). Thus, Cochrane Library is used as it offers valuable sources of information that can be involved in practice to provide effective evidence-based care. The CINHAL database contains indexing of top nursing and allied health literature focused on various topics to be used by the health professionals around the globe (health.ebsco.com, 2019). Thus, the database is used in the study because it allows easy access to potential source of information regarding to explore the current the study topic. The MEDLINE contains increased number of scientific and biomedical information which offers authoritative and complete data to be gathered by the research in formulating any study. The MEDLINE database is used in the study because of its increased breadth of content where research results are presented vividly along with the place of research is indicated to inform researcher where the study has been conducted (nlm.nih.gov, 2019).

Search Terms

The selection and identification of effective search terms in the study are essential to gather required journals and articles that would lead to conduct a comprehensive and in-depth search for the research (Dewa et al. 2017). The search terms to be used for the topic includes “Chlamydia”, “young people”, “ adolescent”, “sexual health”, “sexual reproductive services” and others. The determined search terms are to be customised according to the different electronic database so that appropriate journals and articles relevant to the study topic can be gathered. The search terms are to be arranged and connected through the use of Boolean operators such as “AND”, “OR” to find specific and sensitive information.

Inclusion and Exclusion criteria

The inclusion criteria are referred to prospective characteristics that are essential to be included in the study whereas exclusion criteria are the prospective characteristics that are disqualified to be involved in the study (Demaerschalk et al. 2016). The criteria are required to be properly considered as they form the basis on which the searches are made and selection of articles is done to be presented in the study. In this study, the inclusion criteria are qualitative and quantitative research articles, journals which are fully accessible, articles written in English, articles published not before 2013, journals and articles that focus on services related to Chlamydia management among young people of all sexual origin and contains academic information. The exclusion criteria for the study are articles written in language other than English, published before 2013, partially available, articles focusing of services for Chlamydia in adults, editorial or policy documents and articles that do not contain academic data. The qualitative and quantitative studies are to be included in the research for gathering evidence because they provide convincing data which are proved through scientific intervention and experiments in the study. The editorial or policy documents are excluded from use as they provide data which may be written in compromised manner through influence of the writer making the original information to be presented in unauthenticated manner. Thus, to avoid presentation of hindered data they are not to be used. The articles published on and after 2013 is to be used as it would allow valid data to be informed and obsolete along with backdated information to be avoided from inclusion in the study. The article and journals which are fully accessible with abstract are included because they offer in-depth and detailed information required for the study allowing the researcher to analyse wide amount of evidence. The articles written in English are to be involved in the study as it is the widely understood and supported language in the England which is the area of execution of the study. Moreover, the researcher involved in formulating the study only have knowledge regarding English as language due to which information written in other languages in articles could not be interpreted by them to be involved in the study and thus those articles are excluded. The journals and articles related to Chlamydia among young people are to be included as it is the key topic and target population in the study. Thus, by avoiding their consideration would lead to gathering of inappropriate and hindered results that would not allow the researcher in creating EBP regarding the topic. The academic articles are to be considered in the study as they provide relevant and reliable information to be used as potential evidence in exploring the study topic.

Data Analysis

The extractions of data from the selected articles are to be done through independent assessment and are to be analysed based on themes through thematic analysis. The thematic analysis is the process in which the researcher minutely examines the data and determines common themes based on ideas, patterns and topics within the study (Hudon et al. 2017). This indicates data sets are to be theoretically interpreted on the basis of the themes developed.

Ethical Consideration

The ethics in research are referred to the moral principles to be followed by individuals in formatting the study to avoid legal issues. In this study, to avoid deceptive practices to be performed where information are shared in misleading manner by creating impression that they are written by the researcher, the person is going to reference all information accessed from articles and journals of others authors (Stolt et al. 2018). This is to be done by mentioning their name and year of execution of the study. Moreover, to avoid any harm to the target participants no personal information is to be shared to maintain confidentiality. In case any health study of individuals is presented, prior permission for the activity would be taken from the individual through informed consent by the researcher. The articles considered to be used as reference in the study would be avoided from inclusion if the owner of the articles shows indication to withdraw the use of such information. Further, the anonymity of any participants from previous studies is to be ensured to offer them protection of their personal information (Stahl and Coeckelbergh, 2016).

Review of the research evidence impacting on the project aims

Based on the literature findings around young people’s attendance and accessibility to sexual health services, it was evident that chlamydia testing amongst young people was hindered by fears of stigma, concerns over confidentiality and lack of accurate information (Tilson et al, 2004). Unprotected sexual intercourse is a significant risk factor for STIs, therefore it is essential that sexual health services are accessible to young people to make them aware of the process and activities to be followed for safe sexual intercourses and avoid the spread of STIs such as Chlamydia. In this context, young people are required to be able to access contraception and condoms in order to prevent unwanted pregnancies and diseases. Chlamydia screening programmes have been executed with the objective to increase Chlamydia testing in high-risk groups, thereby improving the control of Chlamydia (Theunissen, et al, 2015). In addition, pharmacies in England provide services such as addressing STIs and unintended pregnancies as well as advice about immunisations for MSM (Mossialos et al, 2015). It is important that Chlamydia diagnoses are made early in order to reduce the burden of STIs, as these infections can be asymptomatic and affect both index patients as well as their partners (Low, 2006). At the individual level, strengthening the clinical care of patients with curable STI focuses on case management which requires correct diagnosis, adequate antibiotic treatment, establishment of prevention measures, and notification and treatment of sexual partners.

Effectiveness of home testing kits vs clinic-based testing

Home testing kits are used as an alternative to attending clinics for testing, therefore the management of home-based testing might differ from clinic-based testing. Based on my experience at the Sexual health clinic, patients would either attend for testing or do some home testing as suggested by the NCSP. A systematic review by Fajardo‐Bernal et al. (2015), had objectives to assess the effectiveness and safety of home-based specimen collection as part of the management strategy for chlamydia patients. In addition, this was in comparison with clinic-based specimen collection. Sexually active individuals were included in these trials, which included both male and female as well as individuals from high risk groups such as MSM and sex workers. 3 of the trials were from Denmark, 4 from the USA, and one each from the Netherlands, South Africa and Brazil. Graseck (2010) included young people from the age of 14. Four of the trials found that patients adhered to and complied with using home self-testing kits however there was evidence of lower proportion of positive tests in this group of participants. In order to test for STIs, a pelvic examination or a swab from the urethra is needed, which has been identified to be a barrier to young people accessing services (Hood, 2011). Home testing kits concede these barriers, as individuals can screen by using urine samples and self-acquired vaginal swabs (Cook et al., 2005). The evidence suggests that the use of home testing kits improves outcomes of case management for chlamydia, however, the safety of these kits was not evaluated. The body of evidence about the use of home-collected specimens for chlamydia testing included in Fajardo-Bernal et al, (2015) contains mainly RCTs that only evaluated the proportion of people that returned a specimen for testing. Home-based specimen collection seemed to motivate more people to be tested, but the individuals attending clinics who undergo testing are more likely to have an STI. The additional yield of tests from those who collect specimens at home might, therefore, include people at lower risk of an STI, whilst people who attend the clinic are those who are likely to be infected, following an anonymous notification from a sexual health service through PN. These contrasting effects demonstrate why home-based and clinic-based testing resulted in similar rates of completed testing and treatment in the few trials that reported this information. However, an article by Graseck et at. (2011) highlighted that there was an increase in screening rates in the USA due to the availability of home testing kits. According to data from PHE (2018), there has been a decrease in chlamydia screening for 15-24-year-olds in sexual health services due to the NCSP however, the use of online sexual health services has increased by 54%. This is the most up to date data available from PHE. Fajardo-Bernal et al. (2015) and Grillo-Ardilla et al. (2020) both highlighted that early diagnosis of chlamydia is essential, as mentioned before as this is essential for the reduction of chlamydia amongst the population as this infection is mostly asymptomatic. In addition, both authors identified the necessity of screening programs as well as identifying and treating sexual partners via PN or self-disclosure as this is an important factor in reducing the risk of reinfection. Similarities were found in both these reviews as rapid tests at point of care from urine, urethral, or endocervical specimens were obtained in clinic-based settings. Grillo-Ardilla's review suggested that "POC testing based on antigen detection had minimal sensitivity but good specificity", Overall, both reviews identified similar outcomes that effectiveness of home-based specimen collection should be designed to measure biological outcomes of STI case management through PN, such as the proportion of participants with negative tests for the relevant STI at follow-up here are uncertainties that need to be addressed as part of research in this area, including the development of tests with higher sensitivity (Fajardo-Bernal et al., 2015). Given the significance of the disease, and evaluating the accessibility of safe and effective therapeutic interventions, it is essential to have tests that detect chlamydia, predominantly in asymptomatic people, in order to be able to allow timely treatment.

Behavioural interventions

Similar findings were identified in systematic reviews by Lopez (2015) and Picot et al (2012) which were behavioral interventions for improving condom use to reduce STIs. Picot et al (2012) focused on young people aged between 13-19 and Lopez (2015) focused on hetereosexual males and females at reproductive ages, however no specified age was identified. The behavioral interventions identified addressed the encouragement or improvements on the use of condoms through education or counseling for individuals and couples. Both reviews identified the significance of these interventions in order to reduce transmission of STIs and STDs as well as unwanted pregnancies. Picot et al. highlighted that behavioural interventions had a statistically significant effect on improving individuals knowledge about sexual health. Lazarus et al. (2010) suggests that behavioural interventions can lead young people to practise safer, however, most studies in Picot et al s review highlighted the delivery of interventions in schools to encourage young people to practice safer sex to reduce risks is limited due to difficulties of engaging young people. For example, it may be embarrassing for young people to discuss topics related to sexual activity therefore it is paramount that young people can access sexual health services where they can acquire confidential and non judgmental services (Lanjouw et al., 2010).

Patient experience

As mentioned before, the patient experience of lack of adequate information and fears of testing positive acts as barriers in successful screening of chlamydia. This is evident as lack of adequate awareness of the importance of diagnosing sexual health issues at the earliest makes individuals remain unaware of the risk and deteriorated negative consequences being build-up by them towards their health (Currie et al. 2019). Moreover, young people develop anxiety with testing positive for STIs as they feel they would be unable to have further sex with their partners. The young people on testing positive for STIs also fear that the condition would lead their health condition to be revealed to the parents who are unaware of them being sexually active at the early age. It makes the young people fear of experiencing an embarrassing situation and avoid participating in diagnosis and testing for STIs such as Chlamydia (Currie et al. 2019). The PN process also plays a role as patients fear guilt and shame if they have to notify other sexual partners (Pavlin et al, 2006). Care methods have been executed to enable testing in high risk groups such as MSM, sex workers and young people. Studies in Australia suggested that online testing programs and home based testing strategies have been facilitated to overcome barriers that hinder individuals from accessing services, and the same strategies have been applied in Europe and the USA, as suggested by the review by the Burnet Institute (2010). A study on the use of pharmacies to access sexual health by Cooper, (2008) identified that some of the participants found pharmacies suitable and easy to access as no appointment was required. However, some patients were dissatisfied with using pharmacies as trained staff were not always available to deliver information to patients (Cooper, 2008). Some patients feared lack of privacy as they expressed concerns of being overheard by other people over the counter. A qualitative study by Balfe (2010) found that information on EC in pharmacies was not as educative as information provided in sexual health clinics. In addition, some qualitative studies had similar key findings such as some pharmacy staff were not willing to provide EC to patients under 25 and most young users were not comfortable with requesting condoms (Ryder, 2015). The proposed SIP adds a different perspective that is greatly overlooked by previous studies as only a few such as Picot et al 2012 look at individuals aged between 13-19. Most chlamydia studies focus on young people aged between 15-24 as chlamydia is most prevalent in these age groups. The age of consent to engage in sexual activities is 16 in the UK however a National Survey of Sexual Attitudes and Lifestyles 2000 “found that nearly a third of men and a quarter of women aged 16–19 had heterosexual intercourse before they were 16”. In addition, this SIP will encourage younger patients who are under 15 and engaging in sexual activities to attend sexual health services as they are vulnerable and at greater sexual health risk.

Importance of Evening Sexual Healthcare Clinic

The young people report that in day sexual health clinics they have to wait longer time in queues to avail care. This is because increased number of people is found to avail day sexual healthcare services. However, the young people due to their commitment to work and studies are unable to spent increased amount of time in the day to wait and avail care and diagnosis for their sexual health condition (Kerry-Barnard et al. 2020). Thus, evening sexual health clinics are effective to offer care to the young people in their convenient time. The study by Arnet et al. (2018) informs that evening sexual healthcare clinics are able to provide urgent care and assistance to young people regarding any sexual health issue. This is because the evening clinics like that of Greenwhich Contraception and Sexual Health are opened till 12 am allowing young people needed to access urgent and immediate help related to sexual issues at night have enough time to avail the services (oxleas.nhs.uk, 2018).

Developing the Change management

Service improvement plays a role in enhancing patient safety and is essential in nursing practice, as it promotes the delivery of safe and effective care. This tallies with evidence based practice as Garbett and McCormack (2002) highlights that the improvement of practice encompasses a number of changes that are used to improve practice as well as patient experience. In addition, this requires a continuous process of improvement towards increased effectiveness in patient care (Garbett and McCormack, 2002). In this study, the service improvement project aims to address examples of staff led service improvement, with the probability of enhancing services for young individuals. Previous studies and reviews have identified how home based testing kits may be beneficial to young people, however, lack of access to sexual health services could lead to lack of information about chlamydia treatment, contraception and accessing condoms (Dabrera, 2011). This service improvement is initiated on the evidence that suggests young people would like to get tested, however, the stigma associated with attending sexual health services prevents them from doing so (Theunissen et al, 2015). Therefore this project aims to assist young people to access appropriate sexual health services. Janes (2007) highlights how reflective practice plays a role in service improvement, as nurses are able to recognize improvement or change that is required. However, sometimes due to lack of skills and knowledge about service improvement, it is difficult for them to act inorder to improve patient care (Janes, 2007). In order to execute service improvement, four key elements involved in service improvement were highlighted. Involvement of service users, staff and carers is key as this enables one to understand the needs and experiences of the patient. In addition, in order to successfully implement change it is important to have an understanding of the processes that are involved in order to expand capacity and minimize waste. Professional and organisational development is also essential as it encourages the recognition and appraisal of differences in preference and initiates a culture of improvement which can be adapted and applied to one’s daily work. Royal College of Nursing (2012) recognised how continuous service improvement continued to be a focal point following the negligence and delivery of poor quality care as those highlighted by the Francis report (2010). Leadership is essential in service improvement, nevertheless, involvement of others encourages teamwork and enables others to lead in order to develop and attain the shared vision (Taylor, 2007). In order to attain the overall aim of this SIP, involving other partners and staff was essential as it allowed me to establish an innovative and supportive environment in order to promote constructive thinking.

Leadership Approach for Change Management

In the Service Improvement Plan (SIP), transformation leadership is to be used for planning to implement the change. The change is arranging evening sexual healthcare services for managing and controlling increased diagnosis, testing and improved treatment of Chlamydia among young people in lowering the prevalence of the STI. As mentioned by Deschamps et al. (2016), transformational leadership is the leadership process in which the leader works in line with the team for identifying ideas and creating vision in making the change. This is mainly executed by the transformational leader by motivating employees and executing change actions in tandem with the team. In change management, the benefit of transformation leadership is that it helps leaders to achieve greater productivity from the team members involved in making the change. This is because in the process the leaders are able to understand the needs and demands of their followers to be accomplished to make them inspired in accomplishing the change with improved efficiency (Broome and Marshall, 2020). Thus, transformation leadership would be effective in implementing the change suggested in this SIP because the needs and demands of the healthcare staffs and nursing professionals for working at night as mentioned in the plan would be resolved. This would make the staffs inspired and feel increased zeal to work appropriately in making evening sexual healthcare clinic successful to diagnose, provide enhanced care and treat increased number of young people for Chlamydia to prevent its increased prevalence. The transformational leadership is effective approach in change management as this nature of leaders has broad vision regarding the way change is to be managed allow effective execution of the change activity (Choi et al. 2016). Thus, transformation leadership is to be used for implementing the SIP as the leaders directing the change would have broad and well-defined vision regarding the way it can be established in offering care to the young people. In transformation leadership, effective corporate vision in making change can be developed successfully within limited time. This is because the leaders along with the team members develop discussion to determine any gaps present in the vision helping them to resolve it to ensure successful accomplishment of the change is established (Schell, 2019). Thus, transformation leadership is to be used in making the change as resources required resolving barriers posing for implementation of evening sexual health clinic, if any, can be appropriately managed to ensure its success. The transformation leaders in change management are able to create enthusiasm among the team members to show higher morale and productivity at work (Giddens, 2018). Thus, using this leadership to implement the SIP is beneficial as increased morale and productivity at work would lead the healthcare staffs provided high-quality and highly efficiency sexual healthcare required for increased testing, improved treatment and diagnosis among increased number of young people in controlling spreading of the disease. The transformation leadership is beneficial as in the process effective communication is established by the leaders with the team members to inform them in detail the job duties, project stipulations and change expectations. This leads to avoid conflict and confusion among the team members regarding the task each individual is required to perform to accomplish work goals (Steaban, 2016). Thus, in the SIP, transformation leadership is to be performed so that effective communication of the roles and responsibilities to the healthcare staffs and professionals are provided. This would ensure successful management of evening sexual healthcare clinic by the staffs where young people are appropriately diagnosed and treated for Chlamydia as STI. The transformational leaders are found to effectively manage low-morale situations and promote ethics (Głód, 2018). Thus, it is effective to use for establishing the SIP as through transformation leadership better passion and zeal to work by the healthcare staffs for accomplishment of managing evening sexual health clinic can be created to ensure success of the plan.

Kotter’s Change Management Model

In order to ensure successful achievement of service improvement, systematic steps are to be determined through which it can be accomplished. For this purpose, effective change management theory is required to be determined which can be followed in achieving the plan. Thus, in making service improvement to initiate evening sexual health clinics, the Kotter's Change Management theory is to be followed. This is because it provides information about the steps to be followed to ensure the success of change management plan (Vokes et al. 2018). The eights steps in Kotter’s change management model includes sense of urgency, forming coalition, developing vision, communicating vision, resolving problems, creating short-term wins, consolidating gains and anchoring change (Carman et al. 2019). In the sense of urgency stage, effective discussion is to be created by the leader among their team members to make the staffs understand the importance of the change and support it (McIntosh et al. 2018). This is because without effective support from the staffs the change cannot be accomplished. Therefore, leader going to direct the service improvement plan is to initially make the healthcare staff aware of the importance and need of evening sexual healthcare clinic for controlling among young people. This is because in this way sense of urgency among the staffs can be created to support the execution of the plan. In the coalition forming stage, the leaders are to form collaboration with the team members who are to be involved in making the change. The weak areas among the team are to be identified and resolved along with requires to ensure the team members are selected from different level of the organisation or field in which the change is to be implemented (Chowthi-Williams, 2018). This indicates that in the SIP for forming effective coalition the leader is required to include healthcare staffs from all levels of the medical field who are required in management of evening sexual healthcare clinic. Moreover, effective collaboration and assessment of conflicting situations are to be done for resolving them to ensure the team members work together in accomplishing the change. In the development of revision and strategy phase, the leaders based on the core values are to develop goal and strategies to be followed in success of the change (Teixeira et al. 2017). This indicates that strategies to be followed in setting evening sexual healthcare clinic is to be determined in this stage along with the goal that effective management of Chlamydia among the young people are to be performed through the change is to be developed. In communicating vision phase, the vision and strategies developed are to be interacted with the team members to be involved in the change. This is because the it makes the team members aware of the actions to be accomplished and vision to be met for success of the change tin turn leading to avoid confusion of formation of change (Carman et al. 2019). Thus, in this phase, the leader involved in making the SIP are to communicate to the internal and external stakeholders about the strategies and vision to be followed in making the change or improvement for sexual healthcare clinic services. In removing obstacles phase, the leaders are to analyse the framed strategies and vision in accomplishing the change for identifying the barriers to be faced and way they are to be removed. This is because barriers would hinder the accomplishment of the change making team members unable to successfully make improvement (Stouten et al. 2018). Thus, in this phase, risk assessment of the strategic plan developed for service improvement is to be analysed to determine the probable problems to be faced and identify ways to resolve them. This is because it would act as proactive step by the leader to avoid error and hindrance to ruin the change from being executed. In creation of short-term win phase, the leaders are to develop small goals to be accomplished an analyse them to determine the probable success of their long-term plan (Lv and Zhang, 2017). This is because it would help to create less possibilities of failure in the long-term and lower expensive loss. Thus, in this phase, the leaders developing the SIP are to create short-term wins to determine the way they framed strategies is able to meet short-term plans for the determined change. In consolidating gains phase, continuous improvement of strategic plan is to be made based on individual experiences of team members in accomplishing the determined change (Lv and Zhang, 2017). Thus, the phase indicates that in the SIP in this study, the leaders are to determine the continuous improvement in the plan they can established to ensure successful operation of evening sexual healthcare clinic for treatment patients with Chlamydia as STI. In anchoring the change stage, the change is to be internalised in the organisational culture and ensure continued support from the team members along with leaders are gained in accomplishing the change (Lv and Zhang, 2017). Thus, in this phase, the leader involved in the SIP is required to ensure that the proposed change strategy developed by them in operating the evening sexual healthcare clinic are supported by all in the healthcare field to ensure its appropriate success and ensure further expansion of such services. In this study, the use of NHS Institute for Innovation and Improvement played a role in the process of this SIP as it provided a six-stage framework that helped break down this SIP into manageable stages. Using this framework to structure this service improvement enabled to identify whether this change had been trialed, as Gage (2013) highlights that it can sometimes be difficult to apply change to ways that have been tested as it might cause feelings that demoralise and disengage staff. The use of effective communication with those affected or likely to be affected by change is essential at every stage of the process (Gage, 2013). Thus, in planning the change effective interaction regarding the change is developed with the healthcare staffs to be responsible in managing the evening sexual healthcare clinics and young people who are going to avail the services. The Health Foundation (2013) highlights that lack of support from high level leadership when taking initiatives to improve practice will lead to failure. Therefore, it is important to seek advice from a senior member of staff with a pertinent level of responsibility as they might be affected by the adjustments of the SIP. Thus, in formulating and executing the service improvement plan for evening sexual healthcare clinic, effective involvement of the supervisor and mentors who have wide experiences in managing sexual healthcare clinics is done.

Planning the Change

Process Mapping

A process map provides a visual representation of the service pathway by understanding how the pathway works. This is because the process mapping involves activity of developing a workflow diagram with the aim of creating a clear understanding regarding the process to be followed in accomplishing a determined work (Antonacci et al. 2018). The process mapping is important as it increases efficiency at work by providing insight into process of working, assisting to brainstorm ideas for process improvement, enhancing communication and developing documentation (DeGirolamo et al. 2018). Thus, by developing the process map any problems can be identified. Throughout this SIP, it was evident that long waiting times also played a role in hindering young people from coming to the clinic. With the queue and wait service, there was no guarantee that all patients in the waiting room would be seen as the number of patients who needed to see a healthcare professional were significantly high almost every day except on Sundays when the service is closed. Following these observations and undertaking conversations with patients, it was also evident that patients felt uncomfortable to wait in one waiting room with all the other patients as some stated that they felt judged despite the type of service they would like to access at the clinic. By introducing evening appointments, young people will be able to attend the clinic at a time they feel comfortable as the clinic will be less busy at this time and less patients accessing the service. By completing the process map, assumptions around the process may be avoided (Antonacci et al. 2018). In addition, conducting a process map allows you to identify replication, waste and unnecessary steps within the process. A process map specific to the process of encouraging young people to attend the clinic following a positive Chlamydia result or informing index patients through PN, was completed by myself and the lead consultant. In addition, this was then shared with the rest of the team at the service.

1st Process Map:

The aim of the first process map is to inform steps to be followed for developing awareness regarding Chlamydia presence among young people and reporting them about their diagnosis for the condition. In this purpose, the nurses in the evening sexual health at first are to initially diagnose the young people for Chlamydia to determine if they are positive or negative in relation to the health issue. In the process, the patients who are to be identified as positive for Chlamydia is to be provided phone call to make them aware of the condition along with risk to be faced and importance of immediate treatment. As commented by Jiang et al. (2017), without awareness of the risk regarding the disease being faced by the individuals towards their health they do not develop concern to avail healthcare services for resolving it. This is because the patients with low perception of the risky impact of the disease on their health understand that the condition is not severe and avoids developing control on their actions regarding to avoid spreading the disease. In case, the patient does not respond to the call for informing their regarding their positive results, nurses in the evening clinic are to wait for three days and recall the patients. The patient in case does not respond to the call again the nurses are to email and text message their positive report along with risk related with their health for creating awareness among them to try and avail care for managing the health issue. (Refer to Appendix 2)

2nd Process Map:

The aim of the second process map is to offer treatment for Chlamydia to the positive patients to control the spread disease and enhance their well-being. In this purpose, the nurses are to develop appointment with the patients who are diagnosed to be positive with the condition according to their convenient time in the evening to visit in the sexual healthcare clinic. The nurses then take patient’s personal information and discuss probable source of contact for spread of the disease. The nurses also develop discussion with the patients to determine their needs and demands in care as well as involve them in making shared decision regarding their care. This is because the NMC Code of Conduct informs that decision regarding care for the patients is to be developed by including them to decide regarding the care by the nurses (NMC, 2018). This is because shared decision making make patient’s feel valued by the nurses and develop satisfaction with the care as their specific needs are effectively planned to be fulfilled by the nurses. The process would further act to determine specific nature of treatment to be provided to the patients and update their care accordingly. (Refer to Appendix 3) As NHS Improvements suggests that process mapping should be undertaken with the rest of the team to allow different ideas to be explored. However, it was not possible to do this as the service was often busy, however I was able to work with the nurses and the MDT from the service therefore I was able to witness the process. From completing the two process map , the lead consultant and I were able to identify some unnecessary steps within the process. One of the steps was that the patients would be placed on hold for a few minutes, to give the nurse that chance to find the next available appointment. This was an inconvenience as the patient would be on hold, then later find out there is either no available appointments for at least a week or the patient was unable to attend on the available date. This resulted in patients having to wait for at least a few days until an appointment was available as a postal treatment would not be suitable for young people. Postal treatment would not be suitable for young people as nurses would miss the opportunity to utilise the CSE proforma as per BASHH guidelines. The CSE proforma enables healthcare professionals to recognize any young people who visit sexual health services who may be at risk of or are experiencing sexual exploitation. Furthermore, lack of appointments resulted in delayed treatment and delayed identification of index patients who may be chlamydia positive through retrieving information via PN. Sometimes the patients would not answer their phones, therefore if they did not call back, a follow up would be required. Nwokolo et at. (2015) suggests that if chlamydia is left untreated, it can result in significant complications such as pelvic inflammatory disease (PID), tubal infertility as well as ectopic pregnancies. In addition, BASHH guidelines state that all patients that are chlamydia positive should discuss PN at the time of diagnosis as this will allow other partners to be tested and treated. The process map in Appendix 2 and 3 shows how the patients would either not be able to attend the available appointment, not answer their phone to be informed of the positive results possibly due to the fact that the number that calls patients is withheld, therefore leading to the delayed treatment of the infection. Through conducting this process map, there was evidence that an accessible sexual health service is paramount, as some of the patients did not have their own mobiles therefore it would be difficult to find out about their positive result if they did not consent to text the results of their guardians or parents’ phone.

PDSA Cycle

Janes and Mullan (2007) identify that service improvement requires preparation and structure which can be achieved by implementing the Plan, Do, Study, Act cycle (PDSA). In addition , this service improvement will explore the use of the PDSA cycle and how it can be used to improve practice. The PDSA cycle is a tool that contributes to ideas on service improvement as it permits changes to be evaluated before being implemented (Penny, 2002). Janes and Mullan (2007) suggests that nurses should feel competent to use the PDSA cycle in service improvement as it is parallel to the nursing process, specifically assessing the needs of a patient, planning, implementing and evaluating care.

Plan:

The first stage of the PDSA cycle is the planning stage in which the team to be recruited in making service improvement is to be determined, aim of the service improvement or change is drafted, ideas to form the change or improvement is brainstormed, problem to be faced are determined and alternatives in the plan are developed. The model for change Framework allows you to measure improvement on the idea that is being tried as the intended results might not be achieved, therefore it is safer and more beneficial to try out improvements on a smaller scope before implementing them (Martin et al., 2013). Langley et al. (2009) suggests that 3 key questions must be asked in order to complete the project by setting goals through establishing the aim of the improvement as shown in Table 3.

As Janes and Mullan (2007) suggested that when planning to improve a service it is important to speak to colleagues who may be affected by the change, therefore I undertook some discussions with staff before commencing this SIP. This was so that I could hear the staff’s thoughts and feelings about the changes that might occur due to this SIP. I also undertook a stakeholder analysis as this is a key process in service improvement. Stakeholders are individuals who might be involved and affected by the proposed change, therefore it is essential to conduct a stakeholder analysis in order to avoid disagreements and obstructions, generated by accidentally not involving key people (Bourne, 2015). Evidence suggests that involving staff, patients and stakeholders will allow viable change to be continuous, as one person will not be directing the project (Janes and Mullan, 2007). As the stakeholder analysis is undertaken at the beginning of the project, it is essential to bear in mind that the perceptions of the stakeholder might change during the PDSA cycle. The first stage of conducting a stakeholder analysis is to identify the stakeholders. According to NHS Improvements (2017a), there are 9C’s which help undertake a successful stakeholder analysis as all key people will be included by using this approach. The 9C’s are:

commissioners- those who pay the organisation to do things

Collaborators- those with whom the organisation works to develop and deliver products

channels- those who provide the organisation with a route to a market or customer

Commentators- those whose opinions of the organisation are heard by customers and others

Consumers- those who are served by our customers: especially patients, families, users

competitors- those working in the same area who offer similar or alternative services (NHS Improvements, 2017a)

NHS Improvements (2017a) suggest that these categories are not precise, as they assist in searching for a number of stakeholders who may be included in the project, as some of these categories may not apply to setting. Channels, contributors and commentators were disregarded as they were irrelevant to this SIP. below are the remaining categories

Customers- Young people including MSM who require chlamydia treatment, STI information, EC etc

Collaborators- Staff working at the Sexual health clinic

Champions- Mentor, Service manager, clinical lead, lead consultant

It is essential to identify the impact and authority of each stakeholder, therefore this can be achieved by using the NHS stakeholder table as shown in Table 4. This allows the analysis of stakeholders in terms of power, impact and the extent to which they will be affected by the project or change (NHS Iprovements, 2017a).

Do

Discussions were undertaken with stakeholders to finalise any issues regarding the day of the week the appointments would be provided and the times that it will be accessible to young people. During this stage, the appointments were tested and the findings and observations were documented. The idea of accessible appointments for young people was deemed suitable by staff at the service as well as by the lead nurse and consultant. The appointments were trialled for 2 weeks on specific days. These days were Monday, Wednesday and Friday, between 4 and 6pm.

Study

Due to the change being trialled, patients were unaware of the accessible services therefore not many young people attended resulting in wasted appointments which could have been given to other patients who need them. In addition, this resulted in staff having more free time and they felt uneasy about being uncertain whether young people would attend or not. Due to few young people attending the evening appointments, staff argued that this was not going to work as not enough information about improved access had been provided to the young people

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Act

Based on the feedback from stakeholders, the financial implications of the intended SIP were identified. Therefore some amendments were made as shown in PDSA 2

Conclusion

The above discussion informs that in the UK many young people are affected by Chlamydia as a prominent sexually transmitted infection. The current service improvement plan is developed to arrange evening sexual healthcare clinic for the young people to attain the clinic for availing healthcare for Chlamydia to prevent it from spreading to others. The service improvement is developed with the intention to make more young people willing to avail care for which they are presently not executing due to long waiting time in day care centres, fear of stigma, preference to use home testing kits and others. The Kotter’s Change management model is to be followed for determining the systematic way the change will be achieved. The process mapping and PDSA Cycle is used to develop to develop the plan for the service improvement. The stakeholder analysis is done for the service improvement by considering the guidance provided by the NHS Institute for Innovation and Improvement.

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