Sexual Health Chlamydia

This essay seeks to discuss a topical health promotion issue in the United Kingdom and to explore the topic in terms of current research findings, support mechanisms currently on offer and the role of the nurse in promoting health and well being. Relevant health promotion models, terms relating to health and health promotion will also be analysed. Primarily the focus will be on sexual health promotion of sexually transmitted infections such as chlamydia, its effect on young people including barriers that are inhibiting sexual health promotion.

Rationale for choosing sexual health and targeting young people has been the increased concern by the government to promote sexual health in young people necessitated by the rise in figures of sexually transmitted infections. The Department of Health (DoH, 2008c) acknowledges that due to new evidence from research, sexual transmitted infections (STIs) and Human immunodeficiency virus (HIV) are causing a wide range of illnesses and are a significant cause of long term and serious disability in the United Kingdom.

It goes on to mention about the arrival of HIV epidemic in the 1980’s, high infection rates and risky sexual behaviours as the reasons for increased concern among health professionals, the government and the public (DoH, 2008c).

Chlamydia is the most common STI diagnosed in genitourinary medicine clinics in England with high prevalence among young men and women under 25 years old. The highest rates are among the 20-24 year age group in men and 16-19 years in women (DoH, 2008c).

Because of these reasons the government has targeted chlamydia for sexual health promotion through published reports and implementing educational programmes with the help of different public bodies and organisations. Prior to that, ‘pilot studies of opportunistic screening for genital chlamydia’ were carried out in Portsmouth and Wiral between 1999 and 2001, and they revealed high figures of chlamydia infection (DoH, 2008b).

DoH (2003) reiterated that another reason why chlamydia had been targeted was because of serious health problems associated with it since it is asymptomatic and at least three quarters of women and half of men with the infection have not been treated. Furthermore, one in ten young people are unaware of the infection.

Chlamydia is known to cause pelvic inflammatory disease, ectopic pregnancy and infertility in women and in men it can cause arthritis, epididymitis and Reiters Syndrome (DoH, 2008c).

The anticipated change in the National Health Service (NHS) in dealing with sexual health matters was facilitated by the government through programmes such as the National Strategy for Sexual Health and HIV which was implemented in 2001 in conjunction with the DoH and the NHS.

It outlined among other issues the need for a National Chlamydia Screening Programme which was subsequently established in 2003 with the aim of controlling chlamydia in young adults, detecting and treating the infections thereby preventing further infections and complications associated with it (DoH, 2008b).

In 2005 there was a re-launch of the National Chlamydia Screening Programme in collaboration with the Health Protection Agency to raise awareness of Chlamydia amongst young people by offering free confidential screening, a website with factual information on chlamydia which also addresses some commonly asked questions (DoH, 2008c).

This in itself indicates some failings in the programme between the time it was first established in 2001 until the re-launch in 2005. Nevertheless, this also shows the commitment of the government in promoting sexual health by aiming to improve the services and continuing to try different ways of reaching out to the public.

It is interesting to note that the idea of health promotion was initiated as early as 1977 with targets and legislative policy and guidance being put in place but little seems to have been done practically. Kart (2000 p.6) mentioned that ‘In 1977 Health for All by the year 2000 was launched at the 30th World Health Assembly.

This policy initiative formulated a range of performance indicators by which progress towards better health might be judged, such as reduction in rates of disease, increased levels of nutrition and improved primary healthcare.’ One can certainly conclude that the battle is still ongoing and much more practical interventions to facilitate sexual health promotion calls for serious consideration. However, Johnson et al, (2001) agrees that HIV and STI transmission is a major public health challenge.

Davey et al (2001) sought to obtain views from the public on the definition of health. Their definitions included health as the absence of disease, as physical fitness, as energy, as a social relationship, as function and as psycho-social well-being. Davey et al (2001) concluded that the differences in definitions were influenced by sex differences and age groups.

The World Health Organisation (1986) emphasised health as a two-way process of critical consciousness raising, clarifying values, exploring attitudes, educating policy makers and taking control over one’s own health. This definition seeks to empower the individual who is in need of assistance by giving them the opportunity to identify and learn from their experience alongside professional support.

Evidence has proved the ambiguity of the term health promotion. Many authors have defined health promotion in various ways. Terms such as health education and public health have been used in place of health promotion but conflicts still arise in terms of what is to be included in the definition and what has to be excluded.

Tones (1994 p. 14) defined health promotion as ‘health promotion = health education x health public.’ While French (1990) questioned the exclusion of disease management as a way of promoting health. Most authors agree that health promotion cannot be discussed without mentioning health education in the process. Perhaps, it should be acknowledged that the two work effectively when used concurrently.

Health education also emphasizes the large part of health promotion offered by nurses, as their intervention seeks to empower the patient with knowledge. Kartz et al (2000) described health education as a form of communication that offers knowledge and skills essential in making healthier choices through behavioural changes that will benefit the wider community.

The Department of Health asked the National Institute for Health and Clinical Excellence (NICE, 2007) to produce public health guidance on interventions to reduce the transmission of chlamydia, including screening and other STI’s including HIV reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups. This guidance focuses on one to one interventions to prevent STIs and under 18 conceptions.

In 2004 the DoH on behalf of the government published a report by Tony Blair titled ‘Choosing Health: Making healthy choices easier.’ This white paper explained how the government intended to support the public in making informed healthy choices and tackling the causes of ill health without discrimination. It also aimed to set realistic goals and offer ongoing health support into the 21st century.

The government also initiated the accessible services provided by adults who feel confident working with young people through youth services such as Young People’s Development Programme and outreach services with a particular focus on those who are experiencing or are at risk of experiencing, poor outcomes because of mental health problems or substance misuse (DoH, 2004). Furthermore, the government provided £300 million in support of the White Paper: Choosing Health as a constructive measure to sexual health promotion and introduced a reduction in value added tax for condoms if one has to buy them (DoH, 2004).

Due to inadequate access of specialist sexual health, the DoH (2008a) introduced the Evaluation of One-Stop Shop (OSS) model of sexual health provision for different specialist care under one roof for easy accessibility and effectiveness of services. However, there was much debate on the issue with some professionals welcoming the idea while others did not think that this would make much difference after considering costs and opening times of different clinics.

Measor et al (2000) points out the discrepenses in policies or lack of consideration when it comes to making policies that involve young adults such as the lack of a clear national policy. This has had a number of negative effects on sexual health promotion. The result has been a confused mix of messages for adolescents about sexuality. A research done by Blenkinsop et al (2004) on adolescents highlighted that young people were not in agreement with the government’s view of the rights of parents over children. They challenged this view of the balance of power between the generations.

However, the children acknowledged the need for adults to be involved in sexual health promotion but the vast majority preferred to discuss sexual concerns with teachers, nurses and other health professionals. On the other hand, the children expressed their right to withdraw if they suspected that information was going to be shared with their parents, which is a breach of confidentiality. Confidentiality and trust should be guaranteed and where possible maintained at all times and this is in accordance with the NMC code of professional conduct (2008).

Some cultures need to depart from traditional health communications and beliefs that do not permit sexual health issues to be discussed with a parent as the DoH (2003) highlighted cultural differences, stigma, discrimination, inequalities and poverty as barriers to sexual health promotion. An important aspect that parents have to keep in mind is to refrain from the blame culture, being judgemental or dominating conversations when their children seek advice on sexual matters.

The government through the document ‘Choosing Health’ intend to develop new ways of supporting the parents of teenagers so that they feel equipped to help their children make informed choices, particularly on sensitive issues such as sex and relationships (DoH, 2004).

Some Primary Care Trusts have begun to implement the government’s plan by involving young people in projects that offer communication on sexual health through magazines.

In Manchester Your Life magazine which covered sexual health issues has published and distributed over 7,000 copies of the magazine through Manchester Secondary schools, attracting a positive response from both pupils and education professionals. The response of young people towards the magazine was exceptionally overwhelming (DoH, 2004).

There seem to be more need to change behaviour now than ever before. Dines et al (995) points out that there is research evidence of increased risky sexual behaviour mostly amongst young people and also across the population. NICE (2007) elaborates on behaviours that increase the risk of STIs as including drug and alcohol abuse, early onset of sexual activity, engaging in unprotected sex and frequently changing sexual partners. Therefore NICE (2007) recommends health professionals working in general practice, genito-urinary medicine (GUM), community health services (including community contraceptive services), voluntary and community organisations, school clinics to actively facilitate health promotion programmes .

Benzeval et al (1995) also highlighted the interconnections of lifestyle and environmental factors, suggesting that action was required to combat inequalities at various levels. Assumptions, different beliefs and values also play an important role in how people react to health promotion as well as prioritising it. However, evidence from research has to be embraced to avoid conflicting ideas and approaches in analysing and implementing the health models individually and in the society.

Ewles et al (1999) defined five approaches to health promotion as medical which promotes health by providing medical intervention, behaviour change which encourages attitude and behaviour change by adopting healthier lifestyles, educational which empowers individuals with knowledge and understanding to make informed decisions, client centred which facilitates choice of health actions as identified by the client, last but not the least is the societal approach which seeks to change the physical and social environment to enable choice of healthier lifestyle. One can conclude that these theories are direct input to health promotion which is provided by facilitators of health promotion such as nurses, other health care professionals and teachers.

Young people need to learn about behaviour change. Changing behaviour can be challenging, stressful and bring uncertainty in one’s life but support from friends, families and professionals is of paramount importance in convincing the individual that they are doing the right thing. Ewles (1999) further suggests that the individual should implement and adopt behaviour that promotes health.

Maslow’s hierarchy of needs as cited by Wagner (2008) identified basic needs such as self actualisation, esteem, social, safety and physiological needs. Young people should be encouraged to realise these needs, have a sense of belonging and fulfil love needs through working with families and groups. Self actualisation assists in having a deeper understanding of self through realising personal potential, growth, peak and self fulfilment.

Nurses play an important role in facilitating awareness of sexually transmitted infections in young people at an early stage through school nursing. The nurses work closely with children, teenagers, their parents, carers and teachers providing advice and support about health issues such as puberty and sexual health.

As Murphy (2004) suggests that nursing intervention aims to control genital chlamydia infections through early detection and treatment. This reduces the chance of onward transmission and prevents the development of complications.

NICE (2007) recommend action from health professional to identify individuals at high risk of STIs using their sexual history. Opportunities for risk assessment may arise during consultations on contraception, pregnancy or abortion, and when carrying out a cervical smear test, offering an STI test or providing travel immunisation. Risk assessment could also be carried out during routine care or during registration of new patients.

One to one structured discussions with individuals at high risk of contracting STIs offer more privacy, is assuring to the individual and encourages good rapport. The discussions should be structured on the basis of behavioural change theories. They should address factors that can help reduce risk-taking and improve self-efficacy and motivation. Ideally, each session should last at least 15–20 minutes. The number of sessions one can receive depends on individual need.

As difficult and embarrassing as it may be for young people, the acceptance of behavioural change should prepare them to take action and ensure their sexual partners also seek help. NICE (2007) remind facilitators of health promotion to ensure that sexual health services, including contraceptive and abortion services, are in place to meet local needs. Services should include arrangements for the notification, testing, treatment and follow-up of partners of people who have an STI.

The government also highlighted the need to combat health inequalities by targeting young people from poor and disadvantaged backgrounds who are socially excluded such as those who are in care, disabled, from black and minority groups, with low educational attainment or those who are or have experienced homelessness (DoH, 2004 & NICE, 2007).

GPs, nurses and other clinicians working in healthcare settings such as primary care, community contraceptive services, antenatal and postnatal care, abortion and GUM services, drug/alcohol misuse and youth clinics, and pharmacies other clinicians working in non-healthcare settings such as schools and other education and outreach centres should take responsibility of health promotion (DoH, 2006).

Nurses also have a responsibility whenever possible, to provide one to one sexual health advice on, preventing and getting tested for STIs and preventing unwanted pregnancies by introducing methods of reversible contraception, including long-acting reversible contraception, how to get and use emergency contraception and other reproductive issues and concerns. Another group that seem to be forgotten is the vulnerable young women aged under 18 who are pregnant or are already mothers (NICE, 2007).

The unique function of the nurse is to assist the individual who has ill health to perform activities that contribute to health or its recovery that he would perform unaided if he had the necessary strength, will or knowledge (McBean, 1992). Nurses must not be judgemental or make assumptions of situations. Young people would benefit from being given time to explore their feelings uninterrupted and the nurse must seek to consider health promotion activities that best suit the individual and offer flexible alternatives as well.

Watterson (2003) suggested that affected young people should have influence over the outcome of their health as young people often feel powerless because of the way issues are addressed as nurses at times unconsciously exclude them in decision making. He goes on to say that it is more effective to empower young people by involving them in decision making processes, giving them a voice and valuing what they know and believe about matters that affect their health.

This encourages behavioural change by using the patient centred approach model of health promotion. The role of the nurse is to encourage the youths to discuss issues of sexual health with their parents, approach teachers and to provide them with information about services available such as Young People’s Development Programme and National Chlamydia Screening Programme. Nevertheless, parents need to realise the need for open dialogue and creating relationships built on trust.

The DoH in 2006 launched a campaign through the website known as the ‘Condom Essential Wear’ to raise awareness of sexual health by encouraging the use of condoms. It encourages safe sex and communication about condoms as means of minimising the risk of sexually transmitted infections and unwanted pregnancy among young people.

However, an independent advisory group (IAG) as cited by the DoH (2008c) found out that of the original £50 million budget for sexual health awareness campaign only £4 million had been released. IAG raised concern as to whether enough free condoms were being distributed to recommended places such as GUM clinics, GP surgeries, schools, community contraceptive clinics and youth centres. Consequently, it is arguable that the issue of funding jeopardizes sexual health promotion services to prosper. Nurses need to educate young people on the correct use of condoms. Posters can also be placed in private and public toilets for young people to read and condoms can also be distributed via this channel.

In view of GUM clinics, the government mentioned about the prioritisation of the 48 hour GUM access target as one of the NHS top six targets and the access to specialist sexual health services. However, these clinics are not as wide spread as they should be to accommodate and provide services to youth. The recommended quality service is not consistent at both national and local level as stipulated in the 2005/2006 annual report (DoH, 2008c).

Opening hours are about an hour and a half for two times a week which is not sufficient or beneficial at all to young adults. This does not encourage young people to come forward because they would have to wait long in the queue and being seen by other people is quite embarrassing for them. This further complicates the problem and better services need to be put in place to encourage increased uptake of sexual health services.

To conclude this essay, it can be said that nurses must provide supporting information in an appropriate format to encourage young people to take responsibility for their own actions as far as sexual health promotion is concerned. Cultural differences, age and gender differences can be barriers for health promotion.

Nurses should therefore acknowledge these facts and seek to deal with situations accordingly. In this case, the failure or success of this aspect of health promotion is largely influenced by the interpersonal skills of the nurse. Health promotion is also everyone’s responsibility and the government has incorporated community needs in health promotion programmes to try and meet individual needs.

REFERENCES

• Benzeval, M., Judge, K & Whitehead, M. (1995) Tackling inequalities in health: An agenda for action. London: Kings Fund.

• Davey, B. Gray L., & Seale C. (2001) Health and Disease: A Reader. Third Edition. Biddles Ltd: Great Britain.

• Department of Health (2004) Choosing Health: Making health choices easier [Online] Available at: http://www.dh.gov.uk (Accessed 10 May 2008).

• Department of Health (2006) Condom Essential Wear [Online] Available at: http://www.dh.gov.uk (Accessed 19 April 2008).

• Department of Health (2008a) Evaluation of One- Stop Shop (OSS) Model of Sexual Health Provision [Online] Available at: http://www.dh.gov.uk (Accessed 1 May 2008).

• Department of Health (2008b) Members of the Independent Advisory Group on Sexual Health & HIV. London: ++++

• Department of Health (2008c) The National Chlamydia Screening Programme [Online] Available at: http://www.dh.gov.uk (Accessed 5 May 2008).

• Dines, A. & Cribb, A. (1993) Health Promotion. Concepts and Practice. London: Blackwell.

• Elwes L. & Simnett l. (1999) Promoting Health. 4th Edition. London: Bailliere Tindall.

• French, J. (1990) ‘Boundaries and horizons. The role of health education within health promotion,’ Health Education Journal, 49 (1): pp. 7-10.

• Johnson, A. M. et al (2001). ‘Sexual Behaviour in Britain: Partnerships, practices and HIV risk behaviours. vol 358: pp.1835-42.

• Katz J., Peberdy A., & Douglas J. (2000) Promoting Health. Knowledge and Practice. The Open University. Oxford: Palgrave.

• McBean, S. (1992) Definition of Health and health promotion. Britain: The Open College.

• Measor, L. Coralie, T., & Katrina M. (2000) Young Peoples views on sex education. Education, Attitudes and Behaviour. London: Routledge Falmer.

• National Institute of Health and Clinical Excellence (2007) NICE. Clinical Guidelines [Online] Available at: http://www.dh.gov.uk (Accessed 5 May 2008).

• Nursing and Midwifery Council (2008) Code of Professional Conduct. London: NMC.

• Tones, B.K., & Tilford, S. (1994) Health Education: Effectiveness, Efficiency and Equity. London: Chapman Hall.

• Wagner, K. V. (2008) Maslow’s Hierarchy of Needs. [Online ] Available at:http//www.psychology.about.com (Accessed 15 May 2008).

• Watterson, A. (2003) Public Health in practice. Great Britain: Palgrave.

• World Health Organisation (WHO) 1986. Ottawa. Charter for Health Promotion. Geneva: WHO.

Stress may be defined as the physical and emotional response to excessive levels of mental or emotional pressure, which may arise from issues in both the working and personal life. Stress may cause emotional symptoms such as anxiety, depression, irritability or low self-esteem, or even manifest as physical symptoms including insomnia, headaches, loss of appetite and difficulties concentrating. Individuals experiencing high levels of stress may experience difficulty in controlling emotions such as anger, and may be more likely to experience illness or consume increased quantities of alcohol (NHS Choices, 2015). In the UK a survey undertaken by the Health and Safety Executive (HSE) has estimated that in the year 2013-2014, 487,000 of work related illnesses (39%) could be attributed to work-related stress, anxiety or depression (HSE, 2014). Additionally the survey found that as many as 11.3 million working days were lost in the year 2013-2014 as the direct result of work-related stress (HSE, 2014).

Studies have shown that healthcare professionals, particularly nurses and paramedics, are at an increased risk of work-related stress compared with other professionals (Sharma et al., 2014). This is likely to be due to the innate long hours and high pressure of maintaining quality care standards in the job, as well as pressures caused by staff shortages, high levels of patient demand, a lack of adequate managerial support as well as the risk of aggression or violence towards nurses from patients, relatives or even other staff (Royal College of Nursing (RCN), 2009). Indeed, a 2014 survey of nursing staff by the RCN showed that up to 71% of staff surveyed worked up to 4 hours more than their contracted hours a week, 80% felt that work-related stress lowered morale, and that 72% reported that understaffing occurred frequently in their workplace. As a result of these issues, 66% of respondents in the survey considered leaving the NHS or the nursing profession altogether (RCN, 2014b). A separate report by the RCN suggested that over 30% of absence due to illness was due to stress, which was estimated to cost the NHS up to £400 million every year (RCN, 2014a).

In addition to the physical and emotional symptoms of stress previously discussed, studies in this area have shown that nurses experiencing high levels of work-related stress were more likely to be obese and have low levels of physical exercise, factors which increased the likelihood of non-communicable diseases and co-morbidities such as hypertension and type 2 diabetes (Phiri et al., 2014).

Stress and staff absence

Chronic stress has been linked to “burnout”(Khamisa et al., 2015; Dalmolin et al., 2014), or a state of emotional exhaustion under extreme stress related to reduced professional fulfilment (Dalmolin et al., 2014) and “compassion fatigue”, where staff have experienced so many upsetting situations that they find it difficult to continue empathising with their patients (Wilkinson, 2014). As previously discussed, reducing staffing levels contribute to stress in nursing staff, and in this way chronic stress within the workplace launches a self-perpetuating cycle of understaffing; increased stress leads to increased illness, more staff absence and increased understaffing. In turn, these negative emotions also reduce job satisfaction and prompt many staff to consider leaving the nursing profession, further reducing staffing availability for services (Fitzpatrick and Wallace, 2011).

Reasons for work-related stress amongst healthcare professionals

Studies amongst nursing staff have also reported stress occurring as the result of poor and unsupportive management, poor communication skills amongst team members, institutional and organisational issues (e.g. outdated or restrictive hospital policies) or bullying and harassment (RCN, 2009). Even seemingly minor issues have been reported as exacerbating stress amongst nursing staff, for example a lack of common areas to take breaks in, changing shift patterns, and even difficulty and expense of car parking (Happell et al., 2013).

Work related stress can particularly affect student or newly qualified nurses, who often report higher expectations of job satisfaction from working in the profession, they have worked hard and aspired to join, and are therefore particularly prone to experiencing disappointment on discovering that they do not experience the job satisfaction that they presumed they would do whilst training. Student and newly qualified nurses may also have clear ideas from their recent training on how healthcare organisations should be run and how teams should be managed, and may then be disillusioned when they discover that the reality is that many departments could in fact benefit from improvements and further training for more experienced staff in these areas (Wojtowicz et al., 2014; Stanley and Matchett, 2014). Nursing staff are also likely to, on occasion, find themselves in a clinical situation that they feel unprepared for, or do not have the necessary knowledge to provide the best possible care for patients, and this may cause stress and anxiety (RCN, 2009). They may also be exposed to upsetting and traumatic situations, particularly in fields such as emergency or intensive care medicine (Wilkinson, 2014).

Moral distress can also cause strong feelings of stress amongst healthcare professionals. This psychological state occurs when a discrepancy occurs between the action that an individual takes, and the action that an individual feels they should have taken (Fitzpatrick and Wallace, 2011). This may occur if a nurse feels that a patient should receive an intervention in order to experience best possible care, but is unable to deliver it, for example due to organisational policy constraints, or a lack of support from other members of staff (Wojtowicz et al., 2014). For example, a nurse may be providing end of life care to a patient who has recently had an unplanned admission onto a general ward but is expected to die shortly. The nurse may feel that this patient would benefit from having a member of staff sitting with them until they died. However, due to a lack of available staffing this does not happen as the nurse must attend to other patients in urgent need of care. If the patient dies without someone with them, the nurse may experiences stress, anger, guilt and unhappiness over the situation as they made the moral judgement that the dying patient “should” have had a member of staff with them, but were unable to provide this without risking compromising the safety of other patients on the ward (Stanley and Matchett, 2014). One large scale questionnaire based study in the USA on moral distress amongst healthcare professionals has shown that moral distress is more common amongst nurses than other staff such as physicians or healthcare assistants. The authors suggested that this may be due to a discrepancy between the level of autonomy that a nurse has in making care decisions, (especially following disagreement with a doctor, who has a high level of autonomy), while experiencing a higher sense of responsibility for patient wellbeing than healthcare assistants, who were more likely to consider themselves to be following the instructions of the nurses than personally responsible for patient outcomes (Whitehead et al., 2015).

Recommendations for policies to address work related stress

It is acknowledged that many individuals find that being asked to perform tasks that they have not been adequately trained or prepared for can be very stressful. As such management teams should also try to ensure as far as possible that individuals are only assigned roles for which they have adequate training and abilities, and support employees with training to improve skills where necessary (RCN, 2009).

Surveys have frequently reported that organisational issues such as a lack of intuitive work patterns, overloading of workloads and an unpleasant working environment can all contribute to work related stress. Organisations can reduce the impact of these by developing programmes of working hours with working staff and adhering to them, making any necessary improvements to the environment (e.g. ensuring that malfunctioning air conditioning is fixed), and that incidents of understaffing are reduced as much as possible (RCN, 2009). Issues such as insomnia and difficulty in adapting to changing shift patterns can also be assisted by occupational health, for example by encouraging healthy eating and exercise (Blau, 2011; RCN, 2005). For example, in 2005 the RCN published an information booklet for nursing staff explaining the symptoms of stress, ways in which it can be managed e.g. relaxation through exercise or alternative therapies, and when help for dealing with stress should be sought (RCN, 2005). More recently, internet based resources are available from the NHS to help staff identify if they need assistance, and how and why it is important to access it (NHS Employers, 2015).

Witnessing or experiencing traumatic or upsetting events is an unavoidable aspect of nursing, and can even result in post-traumatic stress disorder (PTSD). However, there are ways in which staff can be encouraged by their management teams and organisations to deal with the emotions that these circumstances produce, limiting the negative and stressful consequences of these events. This may include measures such as counselling or even peer support programmes through the occupational health departments (Wilkinson, 2014). Staff should also be encouraged to use personal support networks e.g. family, as this can be an important and effective source of support, however studies have shown that support within the work place is most beneficial, particularly if this can be combined with a culture where healthcare professionals are encouraged to express their feelings (Lowery and Stokes, 2005).

One commonly cited reason for work related stress amongst nurses is the incompetence or unethical behaviours of colleagues, and a lack of opportunity to report dangerous or unethical practice without fear of reprisal. Therefore it is important that institutions and management teams ensure that there is an adequate care quality monitoring programme in place, and a culture where concerns can be reported for further investigation without fear of reprisal, particularly with respect to senior staff or doctors (Stanley and Matchett, 2014).

It has been reported that in the year 2012-2013, 1,458 assaults were reported against NHS staff (NHS Business Service Authority, 2013). Violence and abusive behaviour towards nursing staff is an acknowledged cause of stress and even PTSD, and staff have a right to provide care without fear (Nursing Standard News, 2015; Itzhaki et al., 2015). Institutions therefore have a responsibility towards their staff to provide security measures such as security staff, workplace design (e.g. locations of automatically locking doors) and policies for the treatment of potentially violent patients e.g. those with a history of violence or substance abuse issues (Gillespie et al., 2013).

As previously discussed, nurses are more likely than other healthcare professionals to experience moral distress as the result of a discrepancy between the actions they believe are correct and the actions they are able to perform (Whitehead et al., 2015). However there are policies that can be introduced into healthcare organisations to reduce its occurrence, and the severity with which it can affect nursing staff. Studies have shown that nurses who were encouraged to acknowledge and explore feelings of moral distress were able to process and overcome these in a less damaging manner than those who did not (Matzo and Sherman, 2009; Deady and McCarthy, 2010). Additionally, it is thought that moral distress is less frequent in institutions and teams that encourage staff to discuss ethical issues with a positive attitude (Whitehead et al., 2015). For example, institutions could employ a designated contact person for staff to discuss stressful ethical issues with, or set up the facility for informal and anonymous group discussion, for example on a restricted access internet-based discussion board (Matzo and Sherman, 2009)

Conclusion

Work related stress is responsible for significant costs to the NHS in terms of staffing availability and financial loss from staff absence from stress itself or co-morbidities that can be exacerbated by stress (RCN, 2009), for example hypertension and diabetes (Phiri et al., 2014; RCN, 2009, 2014a). The loss of valuable and qualified staff from the profession is also a significant cost to health services, and of course exacerbates the situation by increasing understaffing further, which in turn increases stress for the remaining staff (Hyrkas and Morton, 2013). It can also exert a significant cost to healthcare professionals who experience it, in terms of their ability to work, their personal health, effects on personal relationships (Augusto Landa et al., 2008) and job satisfaction (Fitzpatrick and Wallace, 2011). However, organisations can implement recommendations to reduce work related stress, for example by encouraging a positive and supportive culture for staff by offering interventions such as counselling (Wilkinson, 2014; RCN, 2005). Furthermore, interventions such as encouraging the reporting of unsafe or unethical practice – a commonly cited source of stress amongst nurses (RCN, 2009; Stanley and Matchett, 2014) – may also contribute to improving the quality of patient care.

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Purpose: Transitioning to an evidence-based practice (EBP) environment is a new and often over-whelming challenge for many organisations. The most effective strategies to implement EBP have yet to be determined. In this study an accelerated development EBP program, which was administered to nurses from five hospitals was evaluated. At each hospital, nurses were selected as an “EBP champion” whose role would be to help facilitate the transition within that organisation.

Aims: The purpose of this study was to evaluate the effectiveness of an accelerated educational program on the attitudes toward and implementation of EBP among nurses employed in acute-care facilities.

Methods: Forty-nine nurses from five acute-care facilities participated in an 8-week program to develop into EBP champions. Participants attended a 2-hour class each week conducted by four faculty members of a local university. Pre- and post-test mean scores of the EBP barriers (EBPB) and EBP implementation (EBPI) scales were compared using paired t tests to determine the effect of the accelerated development program.

Results: Respondents reported higher scores on both the beliefs and implementation scales at the end of the program. Paired t tests indicated a significant difference in means for both the EBPB (p < .01) and EBPI (p < .01).

Conclusions: Nurses who attend an accelerated educational program have the potential to significantly improve beliefs and attitudes about EBP. Administrative support and collaboration between academia and service are essential for successful intervention.

KEYWORDS evidence-based practice, EBP champions, EBP mentors, EBP education

Worldviews on Evidence-Based Nursing 2008; 5(4):172-181. Copyright © 2008 Sigma Theta Tau International

One can argue that when nurses’ knowledge of evidence-based practice (EBP) in clinical settings is well developed and organisational support is present,

more nurses will likely use best evidence in their decision making. What is less clear is the most effective means of instilling the knowledge to change nurses’ beliefs and be-haviours about EBP. Even though the importance of EBP has been well documented in the literature, the Nursing In-

Gayle Varnell, Associate Professor, Assistant Dean for Advanced Practice, Barbara Haas, Associate Professor, Director of Doctoral Program, Gloria Duke, Associate Pro-fessor, Associate Dean for Research, Kathy Hudson, Senior Lecturer, The University of Texas at Tyler, Tyler, Texas.

Address correspondence to Gayle Varnell, The University of Texas at Tyler, 3900 University Blvd., Tyler, TX 75799; gvarnell@uttyler.edu

Accepted 28 November 2007

Copyright © 2008 Sigma Theta Tau International 1545-102X/08

formatics Expert Panel of the American Academy of Nurs-ing reported in a national survey that the majority of regis-tered nurses do not feel competent in EBP (Pravikoff et al. 2005). Barriers to EBP implementation include lack of knowledge of the EBP process, lack of ability to critically appraise research, and lack of administrative support (Para-hoo 2000; McCaughan et al. 2002; Melnyk & Fineout-Overholt 2002). Implementation of EBP is further hindered by increased patient loads, and the extensive proliferation of research findings related to clinical practice (Sackett et al. 1997; Melnyk et al. 2000). The study reported in this pa-per was a test of the effectiveness of an accelerated (in-tense and heavily participatory) and collaborative (univer-sity and local community hospitals) educational program to change existing beliefs about EBP and to increase the frequency that nurses utilised EBP behaviours. The inves-tigators anticipated that the participants would assist their organisations with the necessary cultural change required

172 Fourth Quarter 2008 Worldviews on Evidence-Based Nursing

to effectively implement EBP into patient care throughout the institution.

BACKGROUND

EBP is a process of using best available evidence in the context of individualised needs and values to direct clini-cal decision making with the goal of improving outcomes. Best evidence includes research, benchmarking, and clin-ical expertise (Melnyk & Fineout-Overholt 2005). Some researchers have suggested that the best outcomes for pa-tients and their families occur when nursing-care decisions are based on sound clinical expertise and the best scientific evidence (Heater et al. 1988; Melnyk 1999). A professional expectation is that nurses will use the best available evi-dence in their clinical decision making (Kitson 2004). For example, the International Council of Nurses (ICN) notes that “In the era of evidence based practice and knowledge-driven health care. . .. Nurses have a professional obligation to society to provide care that is constantly reviewed, re-searched and validated” (ICN, nd, p. 1).

Even though the importance of EBP has been well doc-umented in the literature, an Institute of Medicine (2001) report showed that: (1) only 55% of adult patients re-ceived recommended care for prevention, and for acute and chronic conditions; (2) the average lag time between dis-covery and care improvement implementation is 17 years; and (3) providers are inadequately prepared to apply latest knowledge and highest standards of known quality. Even though EBP is now part of the curriculum of most nursing schools, 70% of practicing nurses graduated before 1990 and consequently were not exposed to this information during their education (Spratley et al. 2001). Results of studies in the U.S. and the Netherlands indicate that about 30-40% of patients do not receive care according to present scientific evidence, and about 20-25% of care provided is not needed or is potentially harmful (Schuster et al. 1998; Grol 2001).

In a survey of 1,097 registered nurses, the Nursing Infor-matics Expert Panel of the American Academy of Nursing found that the majority did not feel competent to conduct EBP (Pravikoff et al. 2005). Researchers reported that the most frequent source of information was a peer or col-league, almost half of the nurses were unfamiliar with the term “EBP,” more than half of the nurses had never identi-fied a researchable problem and did not believe that their colleagues used research findings in practice, and 73% had never had instruction in using electronic databases such as PubMed or CINAHL to search for information. Time and “lack of value for research” were cited as the greatest per-sonal barriers to EBP, and “presence of other goals with a higher priority” was cited as the greatest organisational barrier (Pravikoff et al. 2005).

Educational Intervention Toward Evidence-Based Practice

Collaborating

Given the evolving shift in health care toward EBP, nurses need to develop skills to base their practice on best ev-idence. An ICN statement is that “National Nursing As-sociations, . . . educational institutions, managers and em-ployers can create a climate of inquiry, increase access to education in research methods and increase the applica-tion of research to health care” (International Council of Nurses 1999, paragraph 4). Sigma Theta Tau International’s white paper on clinical scholarship (1999) indicated the environment that was most conducive to clinical practice scholarship. Support of the delivery of high-quality patient care and the evolution of the nursing profession via closer communication between nursing education and practice was clearly advocated.

Valuing

Melnyk and Fineout-Overholt (2002) argue that nurses must first believe that basing their practice on the best evidence will lead to the highest quality of care and out-comes for patients and their families. In order for change to occur, “there must be a clear vision, written goals, and a well-developed strategic plan, including strategies for overcoming anticipated barriers along the course of the change” (Melnyk et al. 2004, p. 83). Additionally, admin-istrators must be committed to provide the necessary re-sources such as EBP mentors, computers, and EBP educa-tion. Some administrators have tried to encourage a change to EBP by integrating EBP competencies into clinical pro-motions. However, Miller & Rollnick (2002) argue that this extrinsic motivational strategy is unlikely to be as effec-tive as when people are intrinsically motivated to change. Melnyk et al. (2004) argue that if people are involved in the strategic planning process, they are more likely to change to EBP.

Additionally Fineout-Overholt, Melnyk, et al. (2005) ar-gue that mentors and “champions” can play a key role in implementing EBP because nurses in the clinical arena are in the best position to question nursing practice. How-ever, they typically need assistance in refining their clini-cal questions, searching for best evidence, and critiquing what they find. The best approach to educating practicing nurses utilises a collaborative partnership that facilitates active learning, thus avoiding a top-down push approach (McWilliam 2007).

Teaching EBP

Fineout-Overholt & Johnston (2005) discuss the advance-ment of EBP in nursing as a major but essential challenge and the need for educators to be informed about the most effective methods and techniques for teaching EBP. Nu-merous authors suggest strategies to meet the challenges

Worldviews on Evidence-Based Nursing Fourth Quarter 2008 173

Educational Intervention Toward Evidence-Based Practice

of successful EBP education (Fineout-Overholt & John-ston 2005; Johnston & Fineout-Overholt 2005; Dewey et al. 2006; Koch et al. 2006; McWilliam 2007; Smith et al. 2007). However, recognising that teaching EBP is different from teaching other more traditional topics is an important first step that includes helping nurses to perceive themselves as “evidence-users” as opposed to “evidence-generators” (Fineout-Overholt & Johnston 2005, p. 38). Educators must generate an enthusiasm about EBP con-cepts to help diminish the commonly found negative at-titudes many nurses have about research. A first step is to facilitate novice clinicians to question their practice, to develop a sense of “uncertainty” about the effective-ness of traditional practices (Johnston & Fineout-Overholt 2005) that leads into the development of what Levin (2006) refers to as the “burning clinical question,” which even-tually leads a clinician to search the literature for evi-dence to answer this question (Melnyk & Fineout-Overholt 2005). This requires a clinician to learn and develop searching skills through a maze of databases and informa-tion, in addition to valuing the importance of document-ing search strategies and organising evidence (Fineout-Overholt, Hofstettler, et al. 2005). Yousefi-Nooraie et al. (2007) demonstrated through a Delphi process that early EBP education should include development of clinical questions, literature searches, and basic information about systematic reviews and critical appraisal, and more in-depth information should be provided in an advanced course about critical appraisal and quantitative decision making.

Learning has three components: knowledge, skills, and attitudes (Dawes et al. 2005). Effective EBP education re-quires more than just a comprehension of skills and knowl-edge approach (Dewey et al. 2006). Learning requires a social, inter-dependent process of shared educator-student experiences (Feldman & Levin 2006). Feldman & Levin (2006) emphasise the importance of the educational pro-cess being learner-centred, not using the “talking head” but rather the “dancing feet” approach, where learners are actively involved in the learning process, and not just passive learners. From a medical perspective Richardson’s (2005) ideas are also applicable to nursing. He suggests that teaching EBP can be best accomplished as an inte-grated component of actual practice that includes role-modelling, the weaving of “evidence in among the other facts and skills being taught” (p. A11) during clinical rounds, and the application of selected EBP skills during clinical rounds (Richardson 2005). This approach along with application of concepts from the Socratic method and Knowles theory of andragogy (Lieb 1991) facilitate a col-laborative/cooperative learning environment (Feldman & Levin 2006).

Several authors have written about the importance of collaboration between academia and practice. Others have emphasised the importance of creating a culture in which EBP is valued. However, few studies exist that have in-dicated the effect of an EBP educational intervention on beliefs and behaviours; representing a critical gap in the literature.

Theoretical Framework

The transtheoretical model of organisational change, which evolved from the transtheoretical model of behavioural change (Prochaska et al. 2001) is a 10-stage matched-interventions approach (Table 1). Individualised interven-tions are implemented at each stage to improve the likeli-hood that participants will incorporate EBP principles into their daily practice. This project was guided by stages I- V of the model and these stages and related activities are described below.

During Stage 1, “Consciousness-Raising,” nurse edu-cators of participating acute-care facilities became active in the East Texas Consortium for Evidence-Based Practice (ETCEBP); a collaborative project among nursing faculty and nurse clinicians to facilitate translation of research into practice within a non-EBP culture. In addition, formal and informal discussions about EBP had been taking place at all of the institutions for at least 6 months to a year. Three of the five institutions were pursuing “magnet” status so nursing research activities were becoming more of a fo-cus. However, no concrete plans to implement EBP had yet been developed. During this phase, the researchers met with chief nursing executives at each of the five acute-care institutions and proposed the accelerated EBP development program.

During Stage 2, “Dramatic Relief,” represents emo-tional arousal and inspiration for successful change. Recog-nising that most clinical nurses are not research-focused and may be intimidated by the term EBP, the researchers asked nurse administrators to select nurses to participate in the educational series who could be potential EBP champi-ons. Attendance at the educational series was by invitation only and those invited knew they would eventually men-tor others. When the nurses were asked to be a part of this project, they knew they had the support of their chief nurs-ing officer and had paid time off to attend the series.

During Stage 3, “Self Re-evaluation,” nurses believe that change is important to one’s success. At this stage the pre-test assessments of attitudes and barriers were con-ducted. During the introductory session and following the pre-test, nurses were challenged to think about their cur-rent practices and the evidence that supported nursing in-terventions. This group activity helped to highlight that much nursing is done by tradition.