The Joint United Nations Programme on HIV/AIDS (UNAIDS) advocates a “3 C’s” approach to HIV testing: Confidentiality, Counselling and informed Consent (UNAIDS, 2004). According to this principle, only one of the three criteria was being met, in that the testing was confidential. As no counselling was provided, this criterion could not be met. Also, by omitting the counselling, it is questionable whether informed Consent was obtained from the patient, as no attempt to ascertain his level of understanding was made.
This again can be related to the NMC guidelines. Although the NMC Code of Conduct (NMC, 2008) does not explicitly demand that informed consent to be obtained from a patient, it does call for nurses to ensure that patients are given the information that they need in a way that is accessible to them: they must understand what is being said. In this case, Mr. A may not have wanted information, as he did not ask, but he may have needed to have appropriate information regarding testing provided to him, so that he could make an informed choice regarding testing.
In relation to the patient’s perceived need for information and counselling before testing, it appeared that Miss D found this to be unnecessary, as Mr. A had not requested any. This is contrary to research conducted by Weinhardt et al. (1999). It appears that simply the act of counselling a patient before HIV testing can reduce their chances of having unprotected sex again, therefore making pre- and post-testing counselling an effective strategy for primary prevention of HIV transmission. In this circumstance, it appears that Miss D seemed quite unsure as to how to provide pre-test counselling, and what form this should take.
Her parent NHS trust did not provide any specific guidance on this topic. Therefore, more general guidelines should have been used. Examples of pre-test counselling questions are provided by Australian Family Planning Association (AFPA, 2005), and include details of what services should be offered, including pre- and post-test counselling. Although no guidance was explicitly provided by the trust, the NMC Code of Conduct does specify that nurses should keep their skills up to date and only work within their sphere of competence (NMC, 2008).
In this case, it appears that Miss D was working outside of her sphere of competence by providing only half of a necessary service: for example, Health Protection Agency (HPA) guidelines (HPA, 2007) state that HIV counselling and testing should be offered routinely to all men who have sex with men (MSM) presenting at a GUM clinic for testing. Miss D only provided half of this service. According to the document “An NMC guide for students of nursing and midwifery” (NMC, 2005), nursing students are not professionally accountable for their actions.
This, however, does not mean that students cannot question their mentors and challenge their practice. In fact, this guidance document encourages just that. Unfortunately, in this case Miss D was not challenged until after the patient had left, therefore having little benefit for the patient concerned. However, in challenging the qualified nurse, it is hoped that the student can guide the qualified nurse to change their practice, in effect trying to ensure that debateable actions are considered and possibly changed.
In conclusion, it would appear initially that this entire scenario was quite badly handled. This, in fact, is untrue. The fact that counselling was not offered to the patient in line with current best practice is lamentable, but should not overshadow the fact that the nurse involved showed a great deal of professionalism in her manner dealing with the patient. The very fact that my mentor established a professional relationship with the patient in such a short time would have gone some way to engaging and reassuring the patient: very important factors in an outpatients setting.
According to Ottenheimer (2007), non-verbal communication skills are of great importance, and help to reassure and draw a patient into a conversation, something that my mentor did extremely well. From my perspective, I feel that I should have perhaps challenged my mentor as to why she omitted pre-test counselling. Although I am not professionally accountable to the NMC for my actions, morally I should have spoken up and made sure that the patient received the best care possible.
By not speaking up, my mentor was not given the chance to correct her omission, and by extension, it cannot be known whether the patient had been giving informed consent. Unfortunately, I do not thing that I could have actually offered the counselling, as I am not experienced enough in either the field of nursing or counselling to have conducted this act properly had the patient requested it. Although, perhaps offering the counselling may have prompted my mentor to pass this task along to another member of staff, or possibly attempt it herself.
Of course, the very fact that I did question my mentor may have sparked something within her that will enable to her to alter her practice, and therefore ensure that all following patients get the best experience of GU medicine that they can. If I found myself in this situation again, I feel more confident with respect to the guidelines and processes surrounding HIV pre-test counselling. The very fact that I found myself in a situation that I was unsure of and therefore unable to deal with left me feeling that I should perhaps have researched more thoroughly the role of counselling in HIV testing, something that I have now done.
I would therefore feel much more confident speaking up on behalf of the patient and ensuring that they were cared for following the best evidence available.
References
AFPA (2005) HIV Testing Cue Card. Available at: http://www. ashm. org. au/images/publications/patient%20fact%20sheets/hiv/fpa-counselling-guide. pdf AVERT (2009) HIV Testing Information. Available at: http://www. avert. org/testing. htm/ [Accessed: 25 May 2009]. BHIVA (2008) UK National Guidelines for HIV Testing 2008. Available at: http://www. bhiva. org/cms1222621. asp [accessed 28th May 2009]