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Nursing perspectives of patient management in IVF clinics

The IVF team

Fertility nursing offers a diverse and challenging working environment. The work of a fertility nurse is varied and takes in many disciplines and skills. The role is societal in nature, and is flexible as the field of reproductive technology is very fast evolving.

In the early days of IVF, the fertility nurse’s role was very similar to other traditional nursing scenarios. It involved ambulatory outpatients, clinic management, supervision of patients, and data collection. As such it was considered somewhat of a secondary role as compared to the primary role of the physician.

However, the explosive increase in requirements for fertility treatments that took place in the 1980s created an increased demand on both physician and nursing resources. This necessitated a more team-orientated approach to the workspace and a consequent opportunity to re-evaluate the role of the nurse.

Nowadays, depending on the clinic, a fertility nurse can be expected to be involved in all kinds of aspects of the IVF team’s scope of practice.

This now includes:

  • theatre work
  • co-ordinating team meetings
  • participating in decision-making
  • performing procedures
  • providing patient education
  • being a source of emotional support for patients

The key thing here is the focus on teamwork with nurses, clinicians, administration, management and other healthcare providers. Through collaboration the patient experience and care are seamless.

Education

In the field of IVF, the patient is usually self-funded. Anyone with a customer service background will tell you, customers come with expectations! The management of those expectations is key to the customer’s perception of the quality of the service that they receive.

Of course, this management of expectations is a pre-requisite for the entire IVF team. But the lead on this is primarily led by the fertility nurse because they educate the patients.

Education is not just a matter of providing information, but providing it so that it is relevant, timely, easy to absorb and evidence-based. This provides the patient with informed consent. This is particularly important as there is no guarantee that fertility treatment will work.

Patients must be prepared for this eventuality and education plays a key role in this.

Communication

As in all clinical settings, communication between all team members is paramount. The patient is integrated into this communication matrix, and the nurse is often the main interface between the patient and the team.

As such, it goes without saying that patient confidentiality and all forms of communications both written and verbal are recorded accurately.

In order to cut down on communication errors some IVF clinics operate a Primary Nursing Care model. In this instance one nurse, the Primary Nurse, coordinates all aspects of the patient’s care in discussion with the physician.

The language that nurses use is also an important when considering aspects of communication. Generally, the tone of the language is best advised to be cautiously optimistic. Whereby patient expectations are managed with a positive outlook that conveys a realistic picture of the situation. Where there is treatment failure the correct language is also important. In this case honesty is advised! It is fine to tell a patient, honestly that you don’t know why an embryo didn’t implant, without any need for conjecture. Honest language should be used early in-patient conversations to manage patient expectations.

The legal picture – basics

Nurses need to be fully aware of the general medico-legal framework that applies to all medical clinics. This covers aspects of the following main items:

  • Adverse events: understanding how these are classified (serious/notifiable etc), and how these and their remedies are reported

 

  • Open disclosure: knowing the procedure for discussing any incident that results in harm to a patient. This can include expression of regret, factual explanation of events, potential consequences, remedies taken, and future steps to avoid a similar re-occurrence of the situation in the future

 

  • Patient confidentiality: this is a universal precept enshrined in law in most countries. It applies to all forms of information in which the patient is usually named as the subject. This includes all written communications both electronic and paper. The nurse, as a key communicator with the patient should be one of the gatekeepers in ensuring that the precept of patient confidentiality is a watchword of the team

 

  • Informed consent: as mentioned in my previous post on ethics, this is of paramount importance. Although it is ultimately the job of the physician to ensure that consent has been obtained, it is often the nurse who manages the consent process by explaining procedures, risks and chances of success. With that in mind it is often helpful to the team for the nurse to put together a framework for this process if there is not already one in place. This should include rules and regulations for obtaining consent: when consent may or may not be given, whether counselling is available during the process, handling of consent forms and copies of such, procedures for patient sign off on aspects of treatment, consent aspects of donor material etc

 

  • Welfare of the child: as with other IVF healthcare professionals on the team, nurses are also bound to consider the welfare of any child that might be born as a result of treatment at the clinic. The nurse should fully expect to be consulted and involved in any decisions made on the basis of welfare of the child as it applies to particular patients.

Discussing risk

No form of medical treatment is entirely risk free and IVF/ART is no exception. Nurses as communicators and educators need to make patients aware that, occasionally, things can go wrong. This is a major part of the informed consent process, and the main areas of risk include:

  • Pre-treatment and screening: risks usually centre around underlying disease pathology. Sometimes some aspects of this can be remedied by patient education such as treatments to improve sperm quality

 

  • Medication: usually the main problem is ovarian hyperstimulation syndrome (OHSS). The nurse is the best team member to oversee defined management programmes for at-risk patients. Protocols on nurse involvement in the prescribing and dispensing process differ from country to country and from clinic to clinic. However, it is important that the nurse has a thorough knowledge of any drug administered to their patient including administration, features/benefits, interactions and side effects. In some cases, the nurse may be responsible for monitoring the effects of a drug and will need access to the patients notes to make determinations on items like potential drug sensitivity or drug allergies

 

  • Foetal abnormalities: the risk is no greater than for the general population, but nurses are best placed to keep an eye on the development as the pregnancy proceeds

 

  • Surgical risks are relatively low, but there can be complications post oocyte pick-up and post embryo transfer

 

  • Pregnancy risks: the biggest risk here is multiple or ectopic pregnancies. Here many couples are unaware of the risks, which can include miscarriage, preeclampsia, gestational diabetes, as well as other serious issues including risks to the child/children. The best way to manage the risk is to educate patients about the risks of transferring more than one embryo at a time.

Psychological aspects

Counselling is an essential aspect of the care package on offer at any ART facility. in some jurisdictions counselling is a mandatory requirement. Although the nurse is not required to be a specialist counsellor, he/she will need to recognise any potential need for counselling or psychological services. The nurse leads the educational conversation with patients in order to be able to refer them to the correct counselling service.

Conclusion

The role of the nurse in the IVF setting is continuing to evolve at a fast pace, presenting a variety of challenges and opportunities. The overlap between healthcare professionals is essential in creating the seamless blanket of care. Essential to this evolving role as ‘team player is the position of educator. Explaining information in such a way that it is not only retained and understood, but used by the patient to make informed decisions about their treatment and to manage their expectations about what treatment may or may not achieve for them.

Neil Madden, Editor

The Fertility Hub