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HIV pre and post test counselling Nursing core competencies


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At the centre of HIV nursing care is the practice of social justice and the promotion of human rights. HIV pre and post-test counselling supports the 3 C’s framework of consent, counselling and confidentiality.  These standard counseling guidelines will be discussed to raise awareness of when and how to test for HIV, client centred needs, provider versus client initiated HIV testing, and the overall challenges regarding individual versus public health.  Every effort will be made to ensure that you have the information, skills, and ongoing support to be more comfortable talking about HIV. HIV doesn't just affect individuals, it affects communities, and all of us.

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HIV pre and post test counselling Nursing core competencies

  1. 1. HIV PRE AND POST TEST COUNSELLING Nursing Core Competencies 2/15/2016 ANAC National Training Forum February 15 16 17 2016
  2. 2. A nurses journey in the land of HIV… Mine started when he walked down the hall…
  3. 3. GOALS AND OBJECTIVES Goal: To increase confidence and competence in HIV pre & post test counselling. Objectives: • Nursing Core Competencies – CANAC • To tell you some stories, and now you are a part of the story. • To get you interested in people who are at risk • We will discuss how to talk about HIV, and tell you about Lynn • We will talk about pre and post test discussion, informed consent and confidentiality • 3 C’s consent, counselling and confidentiality • Attitudes towards PLWH or PHA or APHA • Aboriginal and HIV 2/12/2016
  4. 4. NURSING • Nurses are often the first point of contact in caring for those who at risk for contracting HIV/AIDS • Nurses have a duty to provide safe, competent, ethical care • Our role and professional responsibility is to protect dignity and choice and to support social justice CNA, 2007
  5. 5. CANAC POSITION PAPER • Process • Developed by CANAC working group • Approved at CANAC AGM in April 2013 • Published in May 2013 • Position statement • Essential education in HIV/AIDS nursing • Core competencies > • Minimum of 6-12 hours in theory • Clinical experiences with PLWH • Elective courses in HIV/AIDS nursing
  6. 6. CANAC CORE COMPETENCIES - FRAMEWORK • Based on framework by Relf et al. (2011) • Association of Nurses in AIDS Care (US) • Core competencies 1. Prevention / testing / treatment / care 2. Psychosocial / spiritual / ethical / legal 3. Psychomotor skills 4. Professional expectations
  7. 7. HIV CORE COMPETENCIES • 1. HIV prevention, testing, treatment, and care • 2 Psychosocial, spiritual, ethical, legal issues related to HIV • Right to confidentiality • 3 Psychomotor skills necessary to provide HIV nursing care • 4 Professional expectations in delivery of HIV nursing care 2/12/2016
  8. 8. COMPETENCY NO.1 HIV prevention, testing, treatment, and care • HIV epidemic and epidemiology of HIV in Canada • Risk factors and modes of transmission • HIV prevention counselling • Care and services for women of child bearing age • Prevention of perinatal transmission • Post-exposure prophylaxis • HIV testing modalities • Offer of HIV testing • Pre- and post-test counselling
  9. 9. COMPETENCY NO.1 (CONTINUED) HIV prevention, testing, treatment, and care • Interpretation and discuss of HIV test results • Antiretroviral treatment • Laboratory values • Adverse effects and complications of antiretroviral treatment • Supportive care for client on treatment • Opportunistic infections and cancers • Consultation in complex situations • Collaboration in health promotion activities
  10. 10. COMPETENCY NO.2 Psychosocial, spiritual, ethical, legal issues related to HIV • Care sensitive to and respectful of diversity • Culturally competent and safe care • Holistic approach to care • Supportive care to client living with HIV • Trauma-informed care • Right to be informed and make decisions • Right to confidentiality • Social determinants of health • Broader social issues (including legal issues)
  11. 11. CONFIDENTIALITY – MORE THAN NICE TO KNOW • HIPA identifies several rules that trustees must follow for the collection, use and disclosure of your personal health information. Among them are: • The primary purpose for collecting personal health information must be for the benefit of the INDIVIDUAL. • Trustees should only collect, use or disclose personal health information required to provide the client with a service. • Trustees must also have practices in place that will ensure the safekeeping of personal health information. • Consider: • Who will have access to the information? • Why they would need to know particular information? The Health Information Protection Act (HIPA) Canadian Nurses Protective Society (CNPS®)
  12. 12. COMPETENCY NO.3 Psychomotor skills necessary to provide HIV nursing care • Standard (routine) and transmission-based precautions • Skills related to HIV and TB diagnosis • Assessment skills for HIV/AIDS nursing care • Skills related to HIV management • Safe I.V. injection techniques (education & harm reduction) • Safe S.Q. and I.M. injection techniques (education) • Application and removal of condoms
  13. 13. COMPETENCY NO.4 Professional expectations in delivery of HIV nursing care • Nursing core values and ethical responsibilities • Therapeutic nurse-client relationship • Professional and practice standards • Evidence-informed knowledge into practice • Collaboration with health care team • Client involvement • Linkages with community programs and local services
  14. 14. HIV 101 • HIV is first and foremost a preventable disease. • Every effort should be made to ensure people have the information, skills and support to prevent the spread of HIV. • HIV doesn't just attack individuals, it attacks communities. • (Leading Together An HIV/AIDS Action Plan for All Canada, 2004 – 2008) Knowing if you have HIV can save your life! 2/12/2016
  15. 15. HIV 101 - SOCIAL SUPPORT • Waiting for test results, or considering an HIV test can generate significant anxiety. • Shame and stigma often keep people from sharing their concerns with family or friends. • It is important to assess the social supports available to individuals in the community. 2/12/2016
  16. 16. WHEN TO TEST FOR HIV • All patients are offered HIV counseling to make sure testing is right for that person at the time. • Health Care Providers need to be informed and up to date of the latest information. • It should be the client’s choice to get tested…and there is a difference of client initiated testing, or provider initiated testing. • Health is a Provincial issue for the most part, and many provinces have their own testing and counselling guide/lines policies and protocols. • SK All patients aged 13 to 70 receiving primary or emergency health care who do not know their HIV status… 2/12/2016
  17. 17. ETHICAL & LEGAL CONSIDERATIONS • Informed Consent • Competent, Understanding and Voluntary • Refusal to be Tested • Respect and Explore • Confidentiality • Any disclosure requires consent • Requirements for Partner Notification • Inform about ethical obligations 2/12/2016
  18. 18. LEGAL ISSUES IN NURSING PRACTICE • Testing without consent is an assault in most places in Canada. • The person must know and understand all of the potential consequences of getting tested that a reasonable person would want to know. • Being HIV positive can result in criminal liability • Very important to understand legal implications in pre-test counseling, prior to consent being obtained. • HIV and the Law Update, Ruth Carey, April 20th, 2004 2/12/2016
  19. 19. ABORIGINAL ISSUES • Issues such as : • Caregivers of the communities. • Often lower socioeconomic status. • Factors associated with gender and power imbalance. • Safe housing and water, basic needs take precedence. • Disclosure within the communities. • Issues within and impact on the family unit. 2/12/2016
  20. 20. WHAT TO SAY? “As part of my job I am required to let people know when they may have come in contact with certain infections. The infection you have been named as a contact to is HIV. Do you know what HIV is? This does not mean that you have HIV. When someone tests positive for HIV they are asked for the names of people they have had sex with, injected drugs with, or people who they think should be tested. Someone who is HIV positive gave your name. I don’t know who the person is, but it’s important to remember that he or she was concerned enough to give your name so that you have the chance to be tested.” 2/12/2016
  21. 21. PRE AND POST TEST EDUCATION OBJECTIVES:  Understand the principles and recommendations for Pre and Post Test Education as part of Routine HIV testing.  Develop basic skills in delivering: - Pre and Post Test Education - Positive HIV diagnosis with accompanying referrals 2/12/2016
  22. 22. PRE AND POST TEST EDUCATION OBJECTIVES:  Be able to complete necessary documentation following Pre and Post Test Education.  Identify ways to incorporate Pre and Post Test Education into existing service delivery. 2/12/2016
  23. 23. ROUTINE HIV TESTING IN SK WHO? –all pregnant women –all TB/Hepatitis C positive clients –all clients seeking STI/BBI testing/care (regardless of setting) –all clients exhibiting clinical signs/symptoms consistent with HIV infection –all clients who request HIV testing –all clients 13-70 years of age* receiving primary or emergency care if: • They are sexually active and not tested in the past 12 months. • They have never been tested. • And older or younger if evidence of risk factors 2/12/2016
  24. 24. 2/12/2016
  25. 25. PRINCIPLES • HIV testing: • Can/should be offered as routine by any physician or qualified health care provider. • Is an effective part of HIV prevention. • Requires 3C’s in all settings: • Confidential • Counselling - varies • Consent (informed) HIV is a reportable infection in Saskatchewan. 2/12/2016
  26. 26. CONSENT • Informed • voluntary • ability to decline • impact on personal safety • disclosure • Documentation • Document whether consent is received or not. 2/12/2016
  27. 27. PRE AND POST TEST EDUCATION People who receive pre and post test counselling are less likely to suffer adverse psychological effects such as depression and suicidality if they are found to be HIV+. Inadequate counselling is not only unethical and poor practice, it is contrary to the legal doctrine that medical interventions require a patient’s informed consent. Canadian HIV/AIDS Legal Network 2/12/2016
  28. 28. CONFIDENTIALITY • HIV is a reportable infection. • requirement to report to Medical Health Officer • Case Report Form • partner/contact notification • Disclosure • requirements under the Public Health Act • legal implications → Supreme Court decision 2012 • Results • circle of care • kept in confidential provincial database with strict controls on access 2/12/2016
  29. 29. COUNSELLING • interactive • client-centred • Non-judgmental, open discussion • Adaptable to client needs • Feelings, concerns, reactions • in-depth counselling is required in settings which have a broader STI mandate Minimum counselling is adequate in most settings. 2/12/2016
  30. 30. MINIMUM COUNSELLING • Clinical and prevention benefits of testing. • Right to refuse (opt out). • HIV, like other communicable infections (Influenza, food- borne illness, TB, Chlamydia) is reportable to Medical Health Officer and kept in confidential databases. • Follow up services are available and will be offered. 2/12/2016
  31. 31. MINIMUM COUNSELLING • Partner/contact information will be requested (if positive). • Under the Public Health Act, disclosure to future/current sexual contacts is required – may also apply to people who use injection drugs & their contacts (in the context of shared works). Additional in-depth counselling is NOT required in most settings. 2/12/2016
  32. 32. IN-DEPTH COUNSELLING • HIV basics • chronic, manageable illness • window period, acute infection, seroconversion • need for further testing • Benefits vs. Risks • Benefits  confirm HIV status  reduce anxiety  address ongoing risk reduction  earlier diagnosis/access to care • Risks • inability to cope • concern re: self-harm/suicide/violence 2/12/2016 “Is there any reason that we shouldn‘t test you for HIV today?”
  33. 33. IN-DEPTH COUNSELLING • Nature of test/testing process • voluntary • window period • meaning of results - Positive, Negative, Indeterminate • type of test offered (standard screen, point-of-care) • how quickly results will be ready 2/12/2016
  34. 34. IN-DEPTH COUNSELLING • Risk of transmission  sexual, IDU, needle stick, etc.  safer sex, safer injecting  What parts touch what parts? • Exploration of contextual factors  balance of power, abuse, addictions, mental health • Readiness for change  related to risk activities • Provision of harm reduction supplies  safer sex/safer drug use 2/12/2016
  35. 35. IN-DEPTH COUNSELLING • Supports/coping • while waiting for results • on return for results • after results • is client expecting positive/negative result? • How to obtain results • face-to-face • if client does not return – how to find/contact • Referrals • clinical and community supports 2/12/2016
  36. 36. POST TEST EDUCATION Post-test education provides opportunity to: • Review meaning of result. • Discuss prevention and risk reduction. • Provide support and referrals. 2/12/2016 PRE&POSTEDUCATION
  37. 37. NEGATIVE RESULT • Discuss result. • Review window period. • Review need for further testing. • Opportunity to discuss prevention and risk reduction. • Discuss risks and client-centred, reasonable strategies to reduce risk. • Provide support. • Client-directed, as appropriate. 2/12/2016
  38. 38. POSITIVE RESULT • Ensure confidentiality. • Prepare before giving result. • urgent but not emergent • Health care providers with experience in HIV may choose to provide results to the client him/herself. Public Health may be contacted to explore options with provider on how to disclose. “You do the test, we’ll do the rest.” 2/12/2016
  39. 39. DELIVERING THE DIAGNOSIS • Give result - Have a hard copy of the result for client to see. • Face to face. • Be direct: “You have tested positive for HIV.” • Always alone with client, never with a partner present until client has been told result. May not be safe for Index to have a partner present. 2/12/2016
  40. 40. DELIVERING THE DIAGNOSIS • Address the unspoken question: • “Am I going to die?” or “When am I going to die?” • Provide hope. • Allow time for client to process result • Use silence appropriately. • Allow client to express emotions. 2/12/2016
  41. 41. DELIVERING THE DIAGNOSIS 2/12/2016  Recognize reactions will vary. – Expect emotion.  calm acceptance, disbelief, shock, anger, guilt, fear and uncertainty, anxiety, blaming, relief  Reassure that individual client reaction is normal.  Ensure client feels valued and understood.  Not appropriate to try to work through the client’s reaction; this is a longer term process.
  42. 42. DELIVERING THE DIAGNOSIS • Discuss the client’s immediate concerns. • Do not overwhelm. • Convey enough information. • Be compassionate and honest. • Provide safe, private environment. • Plan to link to care, treatment and support. • Population/Public Health. • Permission is required for referral to: • HIV/Infectious Disease specialist. • Other support services, Community Based Organizations, Peers as needed. 2/12/2016
  43. 43. OTHER CONSIDERATIONS • Acknowledge the personal nature of the discussion. –Regarding sex, substances & partners –To assess risk factors for STI, HIV & BBP transmission –To provide the appropriate prevention education • Be aware of your language; keep it neutral. –Ask what you need to know to make an assessment of actual risk 2/12/2016
  44. 44. OTHER CONSIDERATIONS • Don’t make any assumptions. • Be aware of your own values, thoughts & beliefs. – About sex & sexuality, substance use & life situations. – Know when to refer to someone else. • Be non-judgmental. • Listen, ask questions & provide information. – Be open, honest & sensitive. – Ensure confidentiality. 2/12/2016
  45. 45. OTHER CONSIDERATIONS • Avoid medical terminology. • Utilize pamphlets or other education materials when needed. • Be available for support; make further referrals when necessary. • Be flexible with your approach to meet client’s needs. 2/12/2016
  46. 46. Many people who have just been told they are HIV Positive will often hear NOTHING else except for the diagnosis! 2/12/2016
  47. 47. EDUCATION AND SUPPORTS • Assess client understanding. • What is their perception? • Reinforce the chronic nature of HIV. • Support, care and treatments are available and accessible. • Determine source(s) of support. • Emotional, mental, spiritual. • Assess client’s own safety from harm (self/others). • What people in their personal/family life do they want involved? Who can they trust to maintain their confidentiality? 2/12/2016
  48. 48. TIPS FOR PROVIDER • Be prepared. • Have resources available. • There is no one right way – scripts must be adapted prn. • Take cues from client. • Be aware of non-verbal communication. • Expect and plan on follow up visits. • Provide client-centred, harm reduction care. • Establishing good connections at diagnosis makes linking to care easier! 2/12/2016
  49. 49. You do not have to be the expert… Provide support and education. Provide link to care. Most Population/Public Health Departments advise: You do the test, we’ll do the rest! PRE&POSTTESTEDUCATION 2/12/2016
  50. 50. NURSING CULTURE We Don’t See Things As They Are, We See Them As We Are. 2/12/2016
  51. 51. 2/12/2016
  52. 52. CONTACT INFORMATION Greg Riehl RN BScN MA •Aboriginal Nursing Student Advisor •Aboriginal Nursing Student •Achievement Program •Saskatchewan Polytechnic •Regina Campus • •@griehl Marilou Gagnon RN PhD • Associate Professor • Faculty of Health Sciences • School of Nursing • University of Ottawa • Director, Unit for Critical Research in Health • •
  53. 53. 2/12/2016