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Chlamydia and Gonorrhea Clinical Protocol: Development for a Pregnancy Resource Medical ClinicMaureen KovalFerris State UniversityAbstractChlamydia and gonorrhea are the two most commonly reported sexually transmitted diseases (STDs)/sexually transmitted infections (STIs) in the United States (CDC, 2012a). People infected with chlamydia and gonorrhea may not experience obvious symptoms. This results in infections going untreated which can lead to infertility in women (CDC). It is recommended that females 25 years old and younger, who are sexually active, be tested annually. Increased testing is expected to lead to in increased treatment and possible prevention of avoidable infertility in women (CDC). Sound Choices Medical Clinic (SCMC) offers free pregnancy tests and ultrasounds to women experiencing crisis pregnancies and is considering offering STD/STI testing to its patients. The development of a clinical protocol to test for chlamydia and gonorrhea is needed to allow SCMC to offer this service to the community. A clinical protocol was developed by a graduate nursing student using current literature and an examination of regional practice, while considering adherence to legal, ethical, nursing, and organizational considerations. STD/STI clinics use clinical protocols to guide their practice. Considerations for the implementation of STD/STI testing include testing, treatment, partner notification, retesting or test of cure, and protection of patient privacy (CDC). Chlamydia and Gonorrhea Clinical Protocol: Development for a Pregnancy Resource Medical Clinic Chlamydia is the most commonly reported sexually transmitted disease (STD)/sexually transmitted infection (STI) in the United States (CDC, 2012a). People infected with chlamydia and gonorrhea may not experience obvious symptoms. This results in infections going untreated which can lead to infertility in women (CDC). It is recommended that females 25 years old and younger be tested annually. Increased testing is hoped to lead to in increased treatment and possible prevention of avoidable infertility in women (CDC).Sound Choices Medical Clinic (SCMC) is a not-for-profit medical clinic that is based on Christian beliefs. In the past, these circumstances have led to a community perception that the clinic is not an authentic medical clinic. The use of evidence-based protocols is essential in demonstrating SCMC’s commitment to providing high-quality medical services to the community. The clinic provides pregnancy tests and limited obstetrical ultrasounds free of charge to women in the community. SCMC is considering offering STD/STI testing at the medical clinic.The population at-risk for sexually transmitted diseases, in Wexford County, currently has the option of seeking STD/STI testing at their family doctor’s office, gynecologist’s office, or the public health department. The public health department has indicated that additional testing centers are needed in the community (personal communication, Beth Klimp, June 14, 2012). Local gynecologists have expressed excitement about the opportunity to refer male partners to the clinic (Klimp, 2012). Providing STD/STI testing at SCMC would serve the mission of the organization by providing health services to an underserved population at high risk for developing STDs/STIs. There has been conflicting information presented regarding the accuracy of urine tests to diagnose chlamydia and gonorrhea (personal communication, Beth Klimp, June 14, 2012). The SCMC director was interested to know what type of diagnostic test (urine or cervical swab) is most effective for women and to develop a protocol for urine testing for men. Clinic leadership wanted to establish an evidence-based protocol to conduct testing for chlamydia and gonorrhea to serve its clients and community. The purpose of this paper is to provide an analysis of the information gathered and the experiences during a graduate student’s scholarly project. The focus of the project was to develop a clinical protocol to be used at SCMC to provide chlamydia and gonorrhea testing for men and women. Goals and ObjectivesThe goals of this scholarly project were to develop a best practice protocol for obtaining specimens from both men and women to test for chlamydia and gonorrhea and to present the clinical protocol to agency leadership for their approval and implementation. The objectives included the following: conduct a thorough literature search to gather current evidence-based data available on chlamydia and gonorrhea testing procedures and protocols, collaborate with other health care agencies, through site visits, to identify best practices in the area of specimen acquisition, work with a multidisciplinary team to achieve a common goal, write a clinical protocol for testing for chlamydia and gonorrhea, and develop a presentation to explain the clinical protocol to agency leadership.A literature search was conducted using the PubMed database. Peer-reviewed articles less than five years old were chosen to be included in the resource list as well as information and presentations found on the CDC website. The information gathered during the literature review is the foundation for the clinical protocol. A thorough literature review establishes what is known about a topic (Polit & Beck, 2012). This information can be used to identify gaps in care or to establish clinically relevant protocols. Clinic field work is sometimes used to determine how care is being delivered (Levin & Lewis-Holman, 2011). Conducting clinic site visits is a type of clinic field work. Six clinic site visits were conducted. Four of the six were done in person and two were conducted over the phone. Clinic leadership was interviewed using the same questions. The information gathered was compiled in a table for easy comparison and to identify patterns and trends. This information was used to determine how other clinics are conducting testing and to understand why some clinics choose different approaches than others. The identification of this information was used to determine what type of approach would be best suited for SCMC.The student worked with a multidisciplinary team, which included agency leadership and the project preceptor. The student met with the agency leadership and preceptor every two weeks. An agenda and supporting documents were prepared for each meeting. The agency leadership consisted of SCMC’s executive director and clinic director. The project preceptor was Lynn King, MSN, WHNP-BC. Meetings were held on mutually agreed upon days and times. During the meetings, the student updated the agency leadership and preceptor on the progress of the project. There was also time for feedback and suggestions from the agency leadership and preceptor.The clinical protocol was written using the information gathered during the literature review and clinic site visits. A thorough literature review was conducted as well as five regional clinic site visits. The protocol was written as a policy and procedure to be used by SCMC when STD/STI testing is implemented.A presentation explaining the details of the scholarly project was developed. The presentation contains information about the outcome of the project, recommendations for future projects and suggestions for implementation of the clinical protocol. This information will be presented to the agency leadership, staff, volunteers, and board members in November.Personal and Professional AccountabilityThe student was responsible for nearly every aspect of the project. A significant amount of collaboration occurred with the agency leadership and project preceptor. Nurse administrators are expected to effectively collaborate with other disciplines to develop plans for care delivery (American Nurses Association (ANA), 2009). The goals and objectives of the project were established through collaboration between the student and agency leadership and validated by the project preceptor. The timeline was established by the student and approved by both the agency leadership and project preceptor. Meeting dates and times were set by the student. The student prepared for each meeting by developing an agenda and providing supporting documents for agency leadership and the project preceptor to review prior to the meeting. Nurse administrators often use literature and an examination of current practice to develop clinical protocols (Polit & Beck, 2012). The literature review was conducted by the student independently. The resource list was approved by the agency leadership and project preceptor prior to the literature review. Five of the six site visits were conducted by the student independently. The first clinic site visit was conducted by SCMC clinic director and the student.The student wrote the clinical protocol, synthesis paper, and prepared the presentation on her own. Drafts of the protocol and presentation were reviewed by the agency leadership and project preceptor during bi-monthly meetings. Feedback and suggestions were received by the student at that time and changes were made to the documents.Review of Current Literature and Regional PracticeA review of current research was conducted as described previously. Reasons for screening and the types of testing are described below as well as an analysis of the information gathered during the clinic sites visits. Comprehensive review of the literature on a given topic, in tandem with clinic field work, are measures taken when developing a clinical protocol (Polit & Beck, 2012).Reasons for ScreeningChlamydia is the most commonly reported infectious disease in the United States and the most common bacterial STD in the world (Mangin et al., 2012; Muvunyi et al., 2012; United States Preventative Services Task Force (USPSTF), 2007). Gonorrhea is the second most commonly reported STD (CDC, 2012c). Young people are most affected. 80 percent of women with a chlamydial infection do not have symptoms (Muvunyi et al.; Shaw et al., 2011). 50 percent of men with chlamydial infection are asymptomatic (Shaw et al., 2011). Lack of symptoms leads to under treatment which results in increased spread of the disease to other persons and further medical complications for women. It is estimated that two million new cases of chlamydia go unreported annually (Meyers, Halvorson, & Luckhaupt, 2007). It is estimated by the World Health Organization that 100 million new of chlamydia cases occur worldwide annually (Shaw et al.). More than 300,000 cases of gonorrhea were reported in the United States in 2011 (CDC, 2012c).Untreated chlamydia can have severe long-term health consequences such as chronic pelvic pain, potentially fatal ectopic pregnancy and infertility in young women (CDC, 2012a; Mangin et al., 2012; Shaw et al., 2007; USPSTF, 2007). Infertility, ectopic pregnancy, and pelvic inflammatory disease may also be caused by gonorrhea (CDC, 2012b). Infertility in women may be the result of adhesions and tubal occlusions (Muvunyi et al., 2012). In developing countries, tubal pathology accounts for 85 percent of the cases of sub-fertility and 10 to 30 percent of the cases in developed countries (Muvunyi et al.). Chlamydia infection can lead to pelvic inflammatory disease (PID). Estimations indicate that, 20% of women with PID become infertile, 18% experience chronic pelvic pain, and 9% may have a tubal pregnancy (Meyers et al., 2007). Incidence of PID can be reduced through screening and treating of young women at increased risk for chlaymidal infection (Meyers et al.; USPSTF). Recent studies have demonstrated a reduction in PID when chlamydia screening programs were initiated. United States and Danish randomized controlled trials demonstrated a 56 and 50 percent reduction in pelvic inflammatory disease, respectively (Shaw et al.). Treatment for sub-fertility due to chlamydia includes tubal surgery and in vitro fertilization. These treatments are expensive and cost health systems billions of dollars annually (Shaw et al.). Risk factors for chlamydia and gonorrhea include: history of similar infection, commercial sex work, illegal drug use, single marital status, early onset of sexual activity, low socioeconomic status, and young age (Manhart et al, 2007; Shaw et al., 2007; USPSTF, 2007). African American race is the strongest and most consistent predictor of risk for gonorrhea in most United States’ studies (Manhart et al.). Black and Native American women were 4.4 times more likely to have gonorrhea than were women of other ethnicities (Manhart et al.). Race and geography were consistent indicators of risk for gonorrhea. One study found that risk factor-based testing would identify 75 percent of gonorrhea cases and geography-based testing identified 85 percent of the cases (Manhart et al.). Age is the strongest predictor of risk for chlamydia (Meyers et al., 2007; Shaw et al.).Women at increased risk for chlamydial infection should be screened annually (Meyers et al., 2007; USPSTF, 2007). Young women age 24 years and younger, who are sexually active, are most at risk for chlamydial infection. In the United States screening rates for chlamydial infection among young women remain very low (USPSTF). Data from 2004 demonstrated screening rates among women ages 16 to 20 years were 32.6 percent in commercial health plans and 45.9 percent in Medicaid plans. Rates among women ages 21 to 25 years were 31.7 percent in commercial plans and 49.0 percent in Medicaid plans (Meyers et al.). The National Survey of Family Growth conducted a survey from 2006-2008 which gathered data from young women ages 15 to 25 in the United States. The CDC analyzed the data and concluded that 38 percent of the young women who were sexually active received screening for chlamydia (CDC, 2012a). African-American women, those who had multiple sex partners, and those who received public insurance or were uninsured were the most likely to have received testing (CDC). Data from 2007 indicated that 42 percent of eligible young women received annual chlamydia screening (Forhan et al., 2009). Opportunities to protect the reproductive health of young women are being missed (National Chlamydia Coalition, 2010). Screening programs have demonstrated to be cost effective due to the reduction in long-term health consequences such as PID and infertility (Shaw et al., 2007). Prevention of chlamydia and gonorrhea infection may decrease the incidence of PID and associated infertility. Preventing these conditions may decrease the incidence of sub-fertility and reduce the need for expensive tubal surgeries and in vitro fertilizations. Routine screening is recommended for those most at risk for chlamydia or gonorrhea. Routine screening is not indicated for women not at risk whether pregnant or not (USPSTF, 2007). Pregnancy ComplicationsChlamydia has been associated with negative outcomes during pregnancy including postpartum endometritis, neonatal chlamydia infection, infant mortality, low birth weight, preterm labor, premature rupture of membranes and miscarriage (Meyers et al., 2007, Shaw et al., 2007; USPSTF, 2007). Screening for all pregnant women is recommended at the first prenatal visit (USPSTF). Rescreening during the third trimester should be done on women who remain at risk for chlamydial infection during their pregnancy (USPSTF).Testing and TreatmentTreatment is simple and effective once the disease is detected. Testing is needed to identify disease. Clinics that are not able to perform pelvic examinations are using urine-based testing (Manhart et al., 2007; National Chlamydia Coalition, 2010). The use of urine specimens for screening has expanded screening programs by providing a low-cost medical staffing model where trained non-medical personnel can obtain specimens. Urine is preferred by some patients because it does not require and invasive procedure. Health care providers and laboratory staff prefer it as well because it is easy to obtain a specimen from the patient (National Chlamydia Coalition). Urine is an ideal clinical specimen for diagnostics because it is excreted in large quantities (Tuuminen, 2012). Clinician-performed specimens are not necessary for asymptomatic females (National Chlamydia Coalition). Urine specimens are appropriate to use for asymptomatic females and may result in cost savings due to ease of use and ability to obtain a specimen without the need for a clinician (National Chlamydia Coalition).Disadvantages of urine collection and processing include spillage, and reluctance of patient to provide a specimen due to fear of undisclosed drug testing. Urine is unlikely to be used for home-based testing. The volume of urine needed to perform the test (30 ml) can result in bulky packaging (National Chlamydia Coalition). Nucleic-Acid Amplification Tests (NAAT) is more sensitive than past methods (Mangin et al., 2012). NAATs are the most commonly used assays for chlamydial and gonococcal infection (Manhart et al., 2007; National Chlamydia Coalition, 2010; USPSTF, 2007). Chlamydial and gonococcal infections can be tested simultaneously using several available commercial tests (Manhart et al.; National Chlamydia Coalition). Urine specimens for NAAT are commonly first-void specimens. Tests for urinary tract infection are commonly mid-stream specimens. Vaginal swabs, mid-stream specimens, and first-void specimens were compared in known chlamydia positive patients. The mid-stream specimens resulted in positive results 96 percent of the time. Guidelines in the United States indicate that first-void specimens are slightly less sensitive than cervical and vaginal swabs (Mangin et al.). Cervical and vaginal swabs are equivalent in sensitivity (Mangin et al.; Meyers et al., 2007). Despite this, NAATs can identify chlamydial infection in asymptomatic men and women, including asymptomatic pregnant women, with high test specificity (0.99) and sensitivity (0.90) (Meyers et al.; USPSTF). NAATs detect non-living bacteria. This allows expanded handling, storage, and transportation of specimen times from collection site to laboratory (National Chlamydia Coalition, 2010).When symptoms are present or a Pap test is required, pelvic examinations are performed (National Chlamydia Coalition, 2010). A cervical swab is preferred as the sample type in these cases. A slightly higher organism load is present in cervical swabs than in urine specimens (National Chlamydia Coalition, 2010). A recent study indicated that women would be more likely to be screened for STDs if they could obtain their own specimens. This has generated interest in the idea of self-obtained vaginal specimens (SOVS). This type of specimen collection has been approved by the FDA in the clinical setting only. When NAATs are performed, SOVS specimens have been shown to be equal to cervical swabs and slightly better than urine specimens with regards to sensitivity and specificity (National Chlamydia Coalition). The use of self-collected samples for chlamydia testing may eliminate barriers to screening. This type of specimen collection is recommended by the CDC for screening for asymptomatic females because it is slightly more sensitive than urine (National Chlamydia Coalition). Recommended treatment for Chlamydia is Azithromycin one gram orally in a single dose or Doxycycline 100 mg orally twice a day for seven days (National Chlamydia Coalition, 2010). Gonorrhea treatment has been complicated by the development of antimicrobial resistance (CDC, 2012c). Combination therapy with ceftriaxone 250 mg intramuscularly and either azithromycin one gram orally as a single dose or doxycycline 100 mg orally twice daily for seven days is recommended by the CDC (CDC, 2012b). Ceftriaxone provides high and sustained bactericidal levels in the blood and is highly efficacious at all anatomic sites of gonorrheal infection (CDC, 2012c). Effective treatment for gonorrhea may limit the transmission of the disease as well as prevent complications and interfere with resistance.Test of CureNAATs measure non-living bacteria. Test of cure should be performed three months after treatment for chlamydia or gonorrhea (National Chlamydia Coalition, 2010). Pregnant patient are recommended to have a test of cure three weeks after treatment (National Chlamydia Coalition). If an alternative agent is used for the treatment of gonorrhea, the patient should return one week after treatment is completed for a test of cure at the site of infection (CDC, 2012c). A test of cure for gonorrhea should be a culture, if possible.RetestingAnyone diagnosed with chlamydia should be retested three months after initial treatment to ensure that those who may have become re-infected can be promptly treated with antibiotics (CDC, 2012a). Retesting rates remain low and many re-infections likely are being missed (CDC). The spread of the infection and serious future health consequences can be prevented through retesting. The CDC’s Infertility Prevention Project gathered data on 60,000 men and women from 2007 to 2009. Analysis of the data revealed that only 14 percent of men and 22 percent of women were retested (CDC, 2012a). 25 percent of men and 16 percent of women, who were retested, tested positive for chlamydia again. There are simple ways to improve retesting rates. Patient counseling and early reminders to return to the clinic improved The University at Buffalo (New York) student health center’s retesting rate from 16 percent to 89 percent (CDC). Pop-up reminders within the electronic health record increased retesting rates of patients at several California family planning clinics (CDC).Partner NotificationAn essential part of STD/STI care management is partner notification (PN) (Mercer et al., 2011). Recurrent transmission can be prevented by ensuring that all sexual partners of infected individuals are tested and treated if infected, or treated presumptively (USPSTF, 2007).Partner notification rates have been reported to be less than 60 percent (Shaw et al., 2007). People with casual sexual partners typically have greater numbers of partners than those with regular or live-in partners. Treating a chlamydia patient's regular sexual partner could prevent re-infection. Treating the patient's casual partner, or multiple partners, may prevent both re-infection and onward transmission and is recommended (Mercer et al.; Shaw et al.). Transmission occurs more often with live-in partnerships because they are less likely to use condoms. Condoms are more likely to be used by younger people in casual relationships (Mercer et al.).The British Association for Sexual Health and HIV recommends a look-back period of 4 weeks for symptomatic patients and 6 months for asymptomatic patients with chlamydia (Shaw et al., 2007). The CDC recommends a look-back period of 60 day for symptomatic chlamydia patients and recommends that the patient’s last sexual partner be evaluated and treated even if the encounter was more than 60 days before symptoms were evident (Shaw et al.). The look-back period for patients with gonorrhea is 60 days (CDC, 2012c).Clinic ConsiderationsMinimum requirements for a STD/STI clinic include the ability to accurately diagnose and treat bacterial STDs (CDC, 2012b). Both chlamydia and gonorrhea are bacterial infections. Clinics should also have the ability to distribute medications for the diseases diagnosed at that clinic. Medications should be available for conditions prevalent in that community with prescriptions written for those conditions that do not routinely occur (CDC). The clinic should also have a referral system for services not provided at their location. These might include family planning, prenatal care, adult immunization and drug counseling (CDC).Primary patient considerations include promoting confidentiality and demonstrating respect (CDC, 2012b). Patients should always be treated courteously by clinic staff. Patient should be fully informed of what procedures and tests will be conducted during their clinic visit. This includes informing them of what STDs/STIs they will be tested for. The clinic should have an established system which keeps time in the waiting room to a minimum. Verification of the patient’s address at every visit is essential to ensure that follow up communications are received by the right patient. The clinic should establish a system of reporting test results on the phone which protects patient confidentiality (CDC). Each of these measures can be taken to protect the confidentiality of the patient and showing them respect.Regional PracticeFive clinic site visits were conducted. These include two area health department offices, a pregnancy resource center, a family practice, and a university health clinic. Four of the five site visits were actual visits to the clinic. One clinic site visit was conducted over the phone, as requested by that clinic’s leadership. The information gathered during the clinic site visits is briefly presented.All of the clinics perform screening for chlamydia and gonorrhea. Three of the clinics test for chlamydia and gonorrhea as well as syphilis and HIV. Two of the clinics test for chlamydia, gonorrhea, syphilis, HIV, herpes, and trichomoniasis. Two of the five sites use urine specimens for chlamydia and gonorrhea testing. Two other sites use urine specimens for men and cervical swabs for women. One site uses swabs for both men and women. All of the clinics had providers available to assess the patient most of the time. One clinic performs urine tests when a provider is not available. Swab specimens are obtained by providers in each clinic. Blood and urine specimens are obtained by either nurses or specially trained technicians in each clinic. Three of the five clinics send the laboratory specimens via United States mail or FedEx. The other clinic uses a lab courier. Two of the clinics use the state laboratory in Lansing, one clinic uses the Center for Disease Detection (CDD) lab in Texas, one clinic uses the Mecosta County hospital lab, and the other clinic uses Quest. The average turnaround time was 3-7 days for each laboratory. Three of the clinics charge 77 dollars for the combined test (chlamydia and gonorrhea). One clinic charges 20 dollars for any type of testing and does not bill insurance. One clinic does not bill the patient. The lab bills the patient directly for the service.Four of the five clinics provide partner treatment. One of the five clinics only provides treatment to partners if the partner is an established patient in the clinic. The health department provides partner treatment, but the partner must be seen in the family planning clinic to receive treatment. Four of the five clinics refer partner notification to the local health department. The other clinic, the health department, performs partner notification for its clinic and any referrals from mandatory reporting.All of the clinics that provided answers to the project questions provide similar services. All of the clinics screen, test, and treat for chlamydia and gonorrhea, among other STDs/STIs. Each of these clinics has providers present to examine patients. The health department does perform urine testing when a provider is not available. Two of the five clinics have providers available one day a week. The other three have a provider available every day the clinic is opened.Clinical ProtocolA clinical protocol for the testing and treatment of chlamydia and gonorrhea in both men and women was established using information gathered during the literature review as well as insights and best practices gleaned during clinic site visits. This information was compiled and analyzed to develop a protocol for the testing and treatment of chlamydia and gonorrhea at SCMC. Additional protocols were developed in the areas of test of cure, results notification, positive results notification, and guidelines for referrals. Protocol documents can be found in Appendix A.Application of TheoryThe Theory of Human to Human Interaction was the framework for the project because of the degree of collaboration with other professionals involved. The project required a great deal of collaboration between the student, preceptor, and agency leadership as well as between the student and the clinic site staff. The Theory of Human to Human Interaction stresses the importance of developing rapport when building relationships. This is a useful concept to employ during this project because many of the stakeholders were not well known to each other.The Theory of Human to Human interaction was established by Joyce Travelbee (Travelbee, 1971). Her theory emphasizes caring and the emotional aspects of nursing. It stresses the need for rapport, sympathy, and empathy when interacting with patients (Tomey & Alligood, 2006). The primary nursing intervention is the therapeutic use of self in the physical act of being there for a patient, while simultaneously providing the psychological presence of being with the patient (Nursing Theory Network, 2011). The purpose of these interventions is to meet the patient’s health care needs (Nursing Theory Network). In this project, the concepts ‘use of self’ and ‘psychological presence’ was used to establish a rapport with the people the student interacted with. Establishing rapport leads to communication, which is necessary for true healing in the nurse-patient relationship (Travelbee). In the context of the project, the development of rapport may have improved communication, which contributed to an open exchange of ideas between the student, the agency leadership, the project preceptor, and other health care agency staff visited.Issues, Concerns, and ChallengesLegal, ethical, nursing, and organizational considerations were taken into account when developing the tasks and activities of the scholarly project. The student discussed these concerns with agency leadership and the project preceptor prior to participating in project activities. Taking time to identify potential areas of concerns and developing a plan to avoid or lessen their impact provider greater insight into the needs of the stakeholders involved in the project activities or those who would be affected by the outcome of the project (Project Management Institute, 2008).Nurse administrators must follow federal, state, and local laws as they apply to professional practice (ANA, 2009). Legal considerations include what information clinics would be willing to share, definition of the roles and responsibilities of clinic staff including who obtains specimens and provides result notification, licensure of clinic staff, and protecting the privacy of clinic patients. These were addressed through the use of standardized questions and by setting up appointments with clinics prior to site visits. Questions included on the questionnaire were determined to inquire about information that most clinics would be willing to share with other clinics. This was determined by the student, agency leadership and preceptor. The student phoned each clinic and requested a meeting and offered to send the questions prior to the meeting to allow the staff to review the questions and determine what information they would be willing to provide. The student chose to set up appointments with clinic staff rather than visit unannounced to demonstrate respect and consideration for both the clients seeking services from the clinic and the clinic staff.Nurse administrators are often faced with ethical considerations due to competing demands between nursing goals and organizational goals (ANA, 2009; Toren & Wagner, 2010). One of the first steps taken during an ethical dilemma is to calriy the personal and professional values, ethical principles and laws involved (Toren & Wagner, 2010). Once these are defined and possible solutions are discussed a course of action can be determined. This course of action should be guided by a managerial code of ethics, which includes the widely accepted moral principles of fidelity, veracity, autonomy, justice, non-maleficence, and beneficence (Toren & Wagner). Ethical considerations include the student being honest with everyone she came in contact with at the clinic sites, agency, and preceptor and do what she said she would do. Nurse administrators are expected to communicate openly and honestly as a demonstration of quality practice and respect to those they are working with (ANA, 2009). With this in mind, the student addressed these considerations by demonstrating honesty and trustworthiness during her course work and encounters with others. Honesty was demonstrated by the student through identifying herself as a Ferris State University (FSU) graduate student and a SCMC volunteer. The student could have represented herself only as a FSU graduate student. This could have been seen as misleading and may have led to distrust by clinic staff once they realized the student was gathering information for SCMC. Trustworthiness was also demonstrated by the student through careful documentation of tasks and open communication with both the agency leadership and project preceptor. The student kept scheduled appointment with clinic staff, agency staff, and the project preceptor. One two occasions an appointment had to be rescheduled. One appointment was a meeting with agency leadership the other was a preceptor meeting. The meeting was rescheduled for a time agreed upon by both parties. Patient confidentiality was protected during site visits. In circumstances where the student was present during patient visits, no notes were taken and no personal identifying information was recorded. Patient clinical presentation was discussed only with clinic staff as it pertained to the development of a clinical protocol.Nursing considerations include providing care and services that are within my licensure as an RN. These were addressed by conducting the literature search using a well-known database. Only government documents or peer-reviewed articles less than five years old were used. There was no internet search performed to gather information. Only scholarly sources were anizational considerations include the use of research and current practice to base clinical decisions on and representing the clinic in a positive way that would not interfere with the implementation of STD/STI testing at SCMC. Nurse administrators often use research and field work to gather information about a subject (Levin & Lewis-Holman, 2011). The agency leadership is concerned with maintaining its good reputation in the local community. Staff is very careful in their interactions with other agencies. Volunteers are held to the same standard. Organizational considerations were addressed by the student conducting a literature search using scholarly sources, including CDC documents. Clinic site visits were held to gather information regarding how similar services are provided in other clinics. A variety of clinic sites were chosen to identify similarities and differences in practice among them. The student interacted with clinic staff in a respectful and polite manner. She was considerate of their time. This was demonstrated by calling to make appointments with clinic staff, offering to send interview questions to clinic staff prior to the scheduled appointment, and keeping the clinic site visits less than one hour in length. The student was polite to clinic staff. This was demonstrated by verbal expressions of appreciation during phone calls and the clinic site visit both before the meeting and after. Thank you notes were sent to each of the clinic sites after the visit to again express the student’s appreciation for the clinic staff time.Evaluation of Scholarly ProjectEvaluation forms were completed by the student, preceptor, and agency leadership. The evaluation requested information on how well the student met the goals and objectives of the project. Each was asked to rate the student’s accomplishment of project goals and objectives using a Likert scale. A Likert scale contains structured questions with fixed alternatives and is useful when subjects’ answers need to be compared so that the question order does not impact the evaluator’s response (Wood & Kerr, 2011). The evaluation tool requests comments from the agency leadership, preceptor, and student regarding the identified strengths and weakness of the student. This provides qualitative information regarding the perception of the student, preceptor, and the agency leadership with regards to the success of the learning experience. The evaluation included categories such as the student’s completion of a thorough literature search, collaboration with other health care agencies in a professional manner, demonstration of professional behavior and communication with local agencies and with members of an interdisciplinary team, scheduling and leading preceptor and agency meetings, effective use of evidence-based research to develop a clinical protocol, and development and presentation of a professional quality presentation. The executive director, clinic director, and project preceptor strongly agreed that the student had met these goals and objectives. The student also strongly agreed that she had met the goals and objectives for the project in all of the project categories except collaboration, leading meetings, and development of a presentation. The student agreed that she had met these goals, but did not strongly agree due to some small deficiencies in these areas. The original goal was to conduct six site visits. Only five site visits were completed due to lack of response from clinic site staff. Never the less, the goal was not met. Two meetings had to be rescheduled due to patient needs in the clinic, and attendees of the presentation did identify areas in the presentation that could have been improved upon. Overall, the student evaluation was favorable. The process of self-reflection was beneficial to the student. Self-reflection is a method to acquire personal knowing. Personal knowing is essential for nursing practice because it improves relationships and allows the nurse to be fully present with her patient (Chin & Krammer, 2011). Examining perceptions and beliefs related to the project may assist the student in developing personal knowing. Copies of the completed evaluations are found in Appendix B.Recommendations for Future Implementation of Similar ProjectRecommendations for similar projects would be to include research and field work in the areas of treatment, test for cure, retesting, and clinic considerations as well as an adjustment in the sequencing of activities in the time line. The topics treatment, test for cure, retesting, and clinic considerations, were included into the project after literature review. Information regarding these areas is critical for the clinic to consider when preparing to offer STD/STI testing. It was very beneficial to review current literature prior to conducting the clinic site visits. These tasks were to be done simultaneously, according to the timeline. Due to the student’s schedule, the review of the literature occurred prior to the clinic site visits. Having knowledge of the most recent information in the area of STD/STI testing assisted the student to feel more confident during the clinic site visits. A working knowledge of the issues and concerns related to STD/STI was essential for developing reasonable and valuable questions to ask clinic staff. ConclusionChlamydia and gonorrhea are the two most commonly reported STDs/STIs in the United States (CDC, 2012c). Many people who are infected are asymptomatic and do not seek treatment (Mangin et al., 2012). This contributes to onward transmission and increased prevalence of the disease as well as long term health consequences for women. Chlamydia and gonorrhea can both be easily treated with antibiotics once diagnosed (CDC, 2012a). Clinics that are not able to perform pelvic examinations are using urine-based testing (Manhart et al., 2007; National Chlamydia Coalition, 2012). The use of urine-based testing has demonstrated to be an effective, low cost method to begin STD testing (National Chlamydia Coalition). Other considerations for STD clinic implementation include treatment, test of cure, partner notification and clinic considerations. SCMC is proposing to offer STD/STI testing to its clients. The use of urine-based testing would allow the clinic to begin to offer this service. Review of the literature and examination of regional practice supports the use of urine-based testing for chlamydia and gonorrhea in both men and women. ReferencesAmerican Nurses Association. (2009). Nursing administrators: Scope and standards of practice. Washington, D.C.: .Centers for Disease Control and Prevention (2012a). National estimate shows not enough young women tested for Chlamydia: Gaps in testing threaten reproductive health. National Center for HIV/AID, Viral Hepatitis, STD, and TB Prevention. [web site]. Retrieved from for Disease Control and Prevention. (2012b).Program operations guide for STD prevention: Medical and laboratory services. [web site]. Retrieved from for Disease Control and Prevention (2012c). Update to CDC’s sexually transmitted diseases treatment guideline, 2010: Oral Cephalosporins no longer recommended treatment for gonococcal infections. Morbidity and Mortality Weekly Report, 61(31), 590-594.Chinn, P., & Kramer, M. (2011). Integrated knowledge development in nursing (8th ed.). St. Louis: Mosby. Forhan, S. E., Gottlieb, S. L., Sternberg, M. R., Xu, F., Datta, S. D., McQuillan, G. M.,…& Markowitz, L. E. (2009). Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics, 124, 1505-1513. doi: 10.1542/peds.2009-0674Levin, R. F., & Lewis-Holman, S. (2011). Developing guidelines for clinical protocol development. Research & Theory for Nursing Practice, 25(4) 233-237. doi:10.1891/1541-6577.25.4.233Mangin, D., Murdoch, D., Wells, J. E., Coughlan, E., Bagshaw, S., Corwin, P., Chambers, S., & Toop, L. (2012). Chlamydia trachomatis testing sensitivity in midstream compared with first-void urine specimens. Annals of Family Medicine, 10(1) 50-53.Manhart, L. E., Marrazzo, J. M., Fine, D. N., Kerani, R. P., & Golden, M. R. (2007). Selective testing criteria for gonorrhea among young women screened for chlamydial infection: Contribution of race and geographic prevalence. The Journal of Infectious Diseases, 196, 731–737.Mercer, C. M., Aicken, C. R., Brook, M. G., Estcourt, C. S., & Cassell, J. A. (2011). Estimating the likely public health impact of partner notification for a clinical service: An evidence-based algorithm. American Journal of Public Health, 101(11) 2117-2123. doi: 10.2105/AJPH.2011.300211Meyers, D. S., Halvorson, H., & Luckhaupt, S. (2007). Screening for chlamydial infection: An evidence update for the U.S. preventive services task force. Annals of Internal Medicine, 147, 135-142.Muvunyi, C. M., Claeys, L., De Sutter, T., De Sutter, P., Temmerman, M., Van Renterghem, L.,… & Padalko, E. (2012). Comparison of four serological assays for the diagnosis of chlamydia trachomatis in subfertile women. Journal of Infection in Developing Countries, 6(5), 396-402.National Chlamydia Coalition. (2010). Developments in STD screening: Chlamydia. Research Briefs, 1, 1-6.Nursing Theory Network. (2011). Human to human relationship model. [website]. Retrieved from , D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Wolters Kluwer Health.Shaw, K., Coleman, D., O’Sullivan, M., & Stephens, N. (2011). Public health policies and management strategies for genital chlamydia trachomatis infection. Risk Management and Healthcare Policy, 4, 57-65. doi: 10.2147/RMHP.S12710Tomey, A., & Alligood, M. (2006). Nursing theorists and their work. (6th ed.). St. Louis, MO: Mosby.Toren, O. & Wagner, N. (2010). Applying an ethical decision-making tool to a nurse manager dilemma. Nursing Ethics, 17(3), 393-402 doi: 10.1177/0969733009355106Travelbee, J. (1971). Interpersonal aspects of nursing. (2nd ed.). Philadelphia: F.A. Davis Company.Tuuminen, T. (2012). Urine as a specimen to diagnose infections in twenty-first century: Focus on analytical accuracy. Frontiers in Immunology, 3, 1-6. doi: 10.3389/fimmu.2012.00045United States Preventive Services Task Force. (2007). Screening for chlamydial infection: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 147, 128-133. Retrieved from , D. F., & Ross-Kerr, J. C. (2011). Basic steps in planning nursing research: From question to proposal (7th ed.). Sudbury, MA: Jones and Bartlett Publishers.Appendix AClinical ProtocolsPOLICY: SCREEING AND TESTING FOR CHLAMYDIA AND GONORRHEATesting for chlamydia and gonorrhea will be offered when a patient is identified to be at risk for these infections or when a patient requests testing.Risk factors for women include: Age younger than 24 years oldAge over 24 years of age and one of the following:new sexual partner more than one sexual partnercervical ectopyinconsistent use of barrier contraceptivesRisk factors for men include:Men who have sex with menMen whose partners have chlamydia or gonorrheaMen in juvenile justice facilitiesAge younger than 30 years old that arein the militaryin prisonChlamydia and gonorrhea testing will be done using a urine specimen for both male and female patients using a first stream void.Specimens will be sent to CDD lab for processing.PROCEDURE:Gather suppliesSterile urine cupBiohazard bagPatient specific labelShipping containerGlovesHave the patient obtain a urine specimen.Instruct patient to urinate directly into the cup immediately (first stream void) and secure with lid.Do not use a clean catch method (mid stream void) to obtain the specimen.It is preferred that the patient has not voided two hours prior to the test. Before handling specimen, done gloves. Verify correct specimen volume (30 mls).Secure lid of container.Apply patient specific label.Place specimen container in biohazard bag and place in shipping container.Arrange for pick up of specimen. Schedule patient for a one week follow up appointment for results notification and treatment if warranted.POLICY: CHLAMYDIA AND GONORRHEA FOLLOW UP TEST OF CUREPatients found to be positive for chlamydia and/or gonorrhea infections will be offered treatment and scheduled for a follow up test of cure in three months unless otherwise indicated. Pregnant patients will be scheduled for a test of cure three weeks after treatment.Patient positive for gonorrhea that are treated with alternative therapy will be scheduled for a test of cure one week after treatment.PROCEDURE: FOLLOW UP TEST OF CUREGather suppliesSterile urine cupBiohazard bagPatient specific labelShipping containerGlovesHave the patient obtain a urine specimen.Instruct patient to urinate directly into the cup immediately (first stream void) and secure with lid.Do not use a clean catch method (mid stream void) to obtain the specimen.It is preferred that the patient has not voided two hours prior to the test. Before handling specimen, done gloves. Verify correct specimen volume (30 mls).Secure lid of container.Apply patient specific label.Place specimen container in biohazard bag and place in shipping container.Arrange for specimen pick up. Schedule patient for a one week follow up appointment for results notification and additional treatment if warranted.POLICY: CHLAMYDIA AND GONORRHEA TREATMENTTreatment of chlamydia and gonorrhea will be provided according to CDC guidelines.PROCEDURE: TREATMENTLicensed medical staff will: verify allergies to medicationsprovide oral medications to the patient or administer injections as appropriateprovide patient with medication bottle and follow up instructionsnotify local health department of positive test resultsprovide information for partner notification to the local health department, if availableschedule three month follow up test of cure for non-pregnant men and womenPregnant women will be scheduled for a three week follow up test of cure. All patients positive for gonorrhea that are treated with alternative therapy will be scheduled for a one week follow up test of cure.Treatment for chlamydia (non-pregnant women and men):Azithromycin 1gm orally in a single doseORDoxycycline 100 mg orally twice a day for seven daysTreatment for chlamydia (pregnant women):Azithromycin 1gm orally in a single doseORAmoxicillin 500 mg orally three times a day for seven daysTreatment for gonorrhea: Azithromycin 1gm orally in a single doseORDoxycycline 100 mg orally twice a day for seven daysANDCeftriaxone 250 mg intramuscularly in a single dosePOLICY: CHLAMYDIA AND GONORRHEA RESULTS NOTIFICATIONPatients who receive testing for chlamydia and gonorrhea will receive their test results at a one week follow up appointment with licensed clinical staff member.PROCEDURE: RESULTS NOTIFICATIONThe patient will be escorted to the counseling room. Test results will be provided by licensed medical staff.Patients with positive results will be offered treatment.Patients with negative results will be offered education on risk reduction.POLICY: POSITIVE TEST RESULT NOTIFICATIONPatients will be scheduling for a one week follow up appointment to provide them with the results of the STD/STI testing.If the patient does not attend this appointment clinic staff will attempt to contact the patient either by phone or email.Three attempts will be made to contact the patient by phone or email. If unsuccessful, clinic staff will send the patient a certified letter requesting they contact the clinic for their test results.POLICY: GUIDELINES FOR REFERRALS (STD/STI)Patients may present for STD/STI testing and have additional risk factors or a clinical presentation that would warrant obtaining a swab specimen, additional testing, and referral to a health care provider.Risk factors that would warrant a swab specimen rather than a urine specimen:Patients who engage in oral or anal sexMen who have sex with menChildren suspected to be victims of sexual abuseSuspected sexual assault victimsClinical presentation that would warrant a swab specimen rather than a urine specimen:Obvious infection or report of symptoms of infectionPatients with these risk factors and/or clinical presentation will be referred to their primary care provider, health department, or urgent care clinic.Appendix BAgency Leadership EvaluationsPreceptor EvaluationEvaluator Name: Lynn King, MSN, WHNP-BC Date: November 14, 20120- Strongly disagree 1-Disagree 2-Neutral 3-Agree 4-Strongly agreePlease indicate the number that best reflects your evaluation of the student’s attainment of the objectives and include any comments that may support the level chosen.The student conducted a thorough literature search of evidence-based and scholarly resources to use as references for the clinical protocol. 0 1 2 3 4Comments:The student collaborated with other health care agencies in a professional manner to identify best practices in the area of specimen acquisition.0 1 2 3 4Comments:The student demonstrated professional behavior and communication with local agencies during site visits.0 1 2 3 4Comments: Unable to evaluate, I was not present for any of Maureen’s site visits.The student demonstrated professional behavior while working with a multidisciplinary team to achieve a common goal.0 1 2 3 4Comments: Maureen presents herself as a professional and promotes the value of all levels of the team. The student scheduled and led meetings with the preceptor and agency leadership every two weeks at agreed upon times and was prompt and prepared for the same.0 1 2 3 4Comments: Meetings were on time and considerate of my time and she came prepared.The student demonstrated the use of evidence-based research, scholarly sources, and best practices as references for the clinical protocol developed.0 1 2 3 4Comments:The student developed a professional quality presentation that fully explained the clinical protocol. 0 1 2 3 4Comments:Student’s Strength: Maureen is very professional in her approach. She is organized and has the ability to present a concise, detailed agenda.Student’s Weakness: Weakness related to this specific project was her lack of experience in STI’s in general.How were these overcome? Maureen spent the time needed to research the topic and become educated on treatment options as well as diagnostic criteria.Student: How will you use the information you learned during this project in your professional career? N/ASelf EvaluationEvaluator Name: Maureen Koval, RN Date:11/19/20120- Strongly disagree 1-Disagree 2-Neutral 3-Agree 4-Strongly agreePlease indicate the number that best reflects your evaluation of the student’s attainment of the objectives and include any comments that may support the level chosen.The student conducted a thorough literature search of evidence-based and scholarly resources to use as references for the clinical protocol. 0 1 2 3 4Comments: The sources chosen were government publications or peer reviewed articles less than five years old. The resource list was approved by agency leadership and the project preceptor.The student collaborated with other health care agencies in a professional manner to identify best practices in the area of specimen acquisition.0 1 2 3 4Comments: I met with five clinic sites during the course of the project. I made every effort to be respectful of their times. I asked standardized questions to each clinic site. The questions were approved by agency leadership and the project preceptor.My goal was to visit six clinic sites. I was unable to obtain this goal due to some clinic sites were not willing to meet with me and others did not return my calls or emails.The student demonstrated professional behavior and communication with local agencies during site visits.0 1 2 3 4Comments: My initial contact with each of the agencies was by phone. I requested to set up a time to speak with someone in their office. I let them know what my intentions were at the beginning of each call. I offered to email my questions to them prior to our visit. I arranged visits that were convenient for them. I kept my phone calls short and direct. I kept the clinic site visit time to less than an hour and informed the clinic staff ahead of time how long the visit would last.The student demonstrated professional behavior while working with a multidisciplinary team to achieve a common goal.0 1 2 3 4Comments: I was prompt and prepared for appointments. I listened to others and elicited their feedback on issues discussed.The student scheduled and led meetings with the preceptor and agency leadership every two weeks at agreed upon times and was prompt and prepared for the same.0 1 2 3 4Comments: All but one of the meetings was held as scheduled for both agency leadership and the project preceptor. The meeting was rescheduled for a later date due to patient needs at the clinic. An agenda was prepared prior to each meeting and provided to agency leadership and the preceptor at least three days before the scheduled meeting. The student demonstrated the use of evidence-based research, scholarly sources, and best practices as references for the clinical protocol developed.0 1 2 3 4Comments:The student developed a professional quality presentation that fully explained the clinical protocol. 0 1 2 3 4Comments: The content of the presentation was thorough. A few of the attendees indicated that the organization of the content could have improved upon a little by including information about the clinic site visits earlier in the presentation. Some of the attendees also indicated that they would have liked to see some of the data represented in graphs.Student’s Strengths: I feel I demonstrated good organization in how I approached the project activities. I followed the timeline closely and actually finished some tasks earlier. I communicated effectively with agency leadership and my preceptor. I demonstrated respect and appreciation for the members of the team I worked with as well as clinic staff. The clinical protocol was developed using relevant evidence and regional best practice. Student’s Weakness: I have never worked in women’s health and I began the project with a very basic knowledge of STDs/STIs. I had some difficulty with keeping the focus of the project narrow, in the beginning. How were these overcome?I addressed my lack of knowledge in women’s health and STD/STI testing by performing a thorough literature review prior to conducting any clinic site sites. Reviewing the literature gave me a foundation of knowledge, which I used to ask pertinent questions of the clinic staff.To keep my focus on the goals and objectives of the project I arranged my schedule so that I spent less time in the clinic. This allowed me to focus on what I was trying to accomplish and not be tempted to try to assist in other areas of the clinic.Student: How will you use the information you learned during this project in your professional career?I will use the information I learned during the project in my professional career when I am engaged in group work or the development of a new protocol. What I learned is that nurse administrators do not have to have all the answers, but they do have to know where to get the answers. Conducting a literature review on a topic I knew little about and then using that information to develop a clinical protocol provided me with the comfort that the answers are out there if you are willing to do the work and put in the time. I have always been and instinctual nurse. That approach has served me well as an individual nurse providing care. Nurse administrators develop care delivery systems that will be employed by nurses with various skills, talent, and abilities. These systems of care should be based on evidence and best practice. I value my instincts, but I value evidence and best practice as well. ................
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