1. Hysterosalpingogram- the patients perspective Maggie Williams Clinical Lead Nurse Radiology Gateshead Health NHSF Trust

2. Hysterosalpingogram Outpatient procedure Varying levels of importance Doctor who is free, radiology/gynaecology consultant, specialist nurse. Fitted in around other procedures.

3. Patients experience before appointment 18 months to 2 years infertility. Highly emotional Referred via GP Gynaecology OPD Referral for HSG

4. Following referral for HSG Written information leaflet Verbal information at Gynae OPD Letter asking to telephone for appointment on first day of menstrual cycle.

5. How well does this prepare our patients? Still asked: Where do you put the injection? How do you get the dye into my tubes? Do I have to take my pants off? Will it hurt? My friend says it is awful.

6. This made us think: Are we preparing our patients well enough? What do our patients want from us?

7. We decided to investigate 2 areas: Women’s perception of pain Women's expectations and emotions around time of HSG

8. Perception of Pain Audit of Pain during the HSG Type and length of pain

9. Patient audit 60 patients asked to complete and return questionnaire 45 responses

10. Results Type of Pain(%)

11. Results (cont) Duration of Pain

12. Results (cont) Pain Score(%)

13. Summary The majority of patients experienced crampy pain for the duration of HSG. A smaller but significant number of patients had pain for length of time after HSG Majority of patients had pain score of 5 or more.

14. Changes. Amended patient information leaflet to advise patients to take simple analgesia prior to procedure. Re audited patients.

15. Second audit. Same audit with additional questions: Did you take any painkillers before the HSG? What type of painkillers? 35 responses.

16. Results Type of Pain (%)

17. Results (cont) Duration of Pain

18. Results (cont) Pain Score (%)

19. Type of Analgesia taken.

20. Summary of results 68% of patients took analgesia prior to HSG examination 97% of patients still experienced pain during or after HSG. 34% during HSG only 34% for a couple of hours, but 20% for a number of days after.

21. Summary of results (cont) 82% of original group and 80% of second group scored pain 5 or higher Pain scores of those who hadn’t taken analgesia ranged from 2-10. Were mainly towards higher end of scale. Use of simple analgesia in this group had little effect on pain scores.

22. Summary of results (cont) Women who took simple analgesia prior to HSG seemed to have little benefit. Pain scores 80% 5 or more This did not correlate with our perception of patient pain

23. Other studies Duffy et al 2008: Reviewed current practice in 104 UK centres. 50% gave formal advice re pain relief 35% offered no analgesia Did not review the effect of analgesia

24. Women's emotions and expectations We decided to progress our work to look at: What are women's emotions and expectations of HSG? Do we meet their needs?

25. Research Study Patients referred for HSG Sub fertility Referred from within Trust

26. Aims To inform our knowledge about the specific needs of this group of women. Discover the underlying issues that women have at the start of sub fertility investigations Raise awareness of the need of research by nurses in areas where they are practicing.

27. Conclusion of literature review High incidence of anxiety and depression in sub fertile women Low incidence of qualitative studies addressing this situation

28. Method Qualitative study using grounded theory research We used interviews and scheduled them prior to HSG During interview we asked 12 Core questions allowing the women to expand their answers to each question 10 Recorded Interviews: approx one to one and half hour duration.

29. Question Categories Background to their sub fertility or their story Expectations: pain, dignity, results. Importance of HSG to them Formal support from professionals Informal support from families

30. Results

31. A number of themes developed Written information does not meet all of the patients needs Women see HSG as a defining moment Sub fertility is still a taboo subject

32. Written information does not meet all of women's needs. Information giving is not as simple as often thought Written information not always read and often produces additional questions One woman said “I was horrified” after seeing the information leaflet

33. Written information does not meet all of women's needs. (cont) Verbal explanation needed to support written information When asked “..do you have any questions” at an out patient appointment women do not know if they have any questions because they have not read the information leaflets

34. Women see HSG as a defining moment Women rated the importance of HSG between 8 and 10. 10 being the most important Signpost to further treatment Watershed moment ‘No progress can be made without it’

35. Sub fertility- a taboo subject Loss of well being Loss of self confidence Anticipatory grief at potential childlessness.

36. Sub fertility- a taboo subject (Cont) Women found infertility hard to talk about. ‘I don’t want to be the source of other peoples gossip’

37. Anxiety permeated all themes Conclusions directed towards anxiety reduction

38. Implications for Practice Recognition that written information meets only part of the information requirements of women. Women need verbal support from professionals along with written material: this allows their specific needs to be addressed leading to an increased ability to cope and reduction in anxiety

39. Implications for Practice The role of the Advanced Nurse Practitioner should be reviewed Nurse Practitioners can take a lead Nurse Practitioners can use their role to advance education and communication between all specialities involved in the sub fertility field This would produce a seamless service

40. Implications for Wider Practice Health care professionals should recognise that written information may not reduce patient anxiety levels – verbal support should be available to compliment the patient information leaflet. Sub fertility should stop being a taboo subject. Raising the profile of focus groups.

41. Overall Conclusion Women do find HSG painful Do we offer effective analgesia? Do we meet women's information needs? Do we address women's anxieties? Do we prepare HSG patients adequately?

42. References Duffy,JMN, Gaity A, Watson AJS (2008) Pain Relief during Hysterosalpingography: A national survey.Human Fertility 11(2) 119-121 Williams M, Green L & Roberts K (2010) Exploring the needs & expectations of women presenting for hysterosalpingogram: A qualitative study. Currently unpublished.

43. Any Questions?