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Developing the sexual health workforce: making every contact count Dr. Anne McNall Claire Robinson.

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1 Developing the sexual health workforce: making every contact count Dr. Anne McNall Claire Robinson

2 Aims of this session To summarise; – the context and nature of my research study – expose the dominant discourses affecting sexual health nursing and nurse education and analyse their impact – explore the challenges of enabling nurses to lead the delivery of patient centred services. – To consider the relevance of participatory approaches to developing the workforce in a modernised NHS

3 Doctoral Study An emancipatory practice development study: using critical discourse analysis to develop the theory and practice of sexual health nursing workforce development Aims To critically review historical and current approaches to developing the sexual health nursing workforce in the UK. To expose and critically analyse the impact of discourses affecting sexual health, sexual health services, sexual health nursing, and sexual health nursing workforce development. To reconceptualise the nature of sexual health nursing. To conceptualise and lead change in the way the sexual health nursing workforce are developed in England to facilitate the development of services which effectively meet the diversity of sexual health need. Methodology 6 cycle participatory action research study using critical social science approach (Habermas 1974, Carr & Kemmis 1986) Working with several communities of enquiry at national, regional and local level to collaboratively critique current practice, agree and implement workforce development solutions The study focused on sexual health advisers and clinical sexual health nurses

4 The art of nursing – “ the expert use and adaptation of empirical and metaphysical knowledge and values. It involves sensitively identifying need and adapting care to meet the needs of individual patients, and in the face of uncertainty, the discretionary use of creativity. It encompasses the ability to care for and care about the client, requiring an ability to work in partnership.” (Fingfeld-Connett 2008 )

5 Critical discourse analysis Development of critical theorem Informed national community of enquiry 1 st action research cycle

6 What is a discourse? “the language spoken in, and constitutive of a particular discipline or community” (Fairclough 1992) “language is never neutral- talk does not represent reality, it creates a version of it, and all versions of reality are designed to produce effects” (Redwood 1999)

7 Impact of discourses Discourses penetrate our sub consciousness and shape what we think, what we know and how we understand issues Language is used to support illusory accounts of reality

8 Critical discourse analysis Focus on forms of social life which subjugate people and ways of thinking which support such subjugation; whether in oppression, or dominance of a particular way of thinking, which makes such oppression seem unproblematic, inevitable or justified CDA can reveal hidden layers beneath taken for granted surface meanings (Traynor 1996)

9 DiscourseIn policyIn practice Concept of sexual healthHolistic model Sex as: Basic human need Pleasure Right for all Individual choice within legally defined boundaries Acceptance of diversity of sexual health practice and need Medical model Sex as : Public health problem Crisis caused by risk taking Normative need for interventions to prevent unintended conceptions and infection Paradoxical discourses

10 DiscourseIn policyIn practice Sexual health service development Informed by patient and public involvement (PPI) as a: Democratic right Legal requirement Partnership approach with patients and public to understand need Espoused Informed by normative need: Objectification of service users into homogenous group of risk takers Disempowered by embarrassment, shame & stigma Silent user perspective Reliance on consultation approach & satisfaction measures with current provision Rhetorical, silenced by lack of planned needs assessment Paradoxical discourses

11 DiscourseIn policyIn practice Integration of services to respond to diversity of need Holistic one stop shop in community based locations: Holistic assessment of need Preventative approach to health & wellbeing Manage all issues at the point of care Ease of access & improved patient journey Espoused Maintenance of silo approach in traditional clinical locations: Address only one aspect of sexual health Reactive approach to problem presenting Medically defined intervention Disjointed patient journey Rhetorical, maintained by medical hegemony Paradoxical discourses

12 Models of integration 3 levels of integration – Integration at provider level (one practitioner providing a complete package of care) – Integration at facility level (internal referral, which may or not occur at the time of the visit) – Referral model ( no integration but effective referral linkages between services) – Church & Mayhew (2009)

13 DiscourseIn policyIn practice Leadership of change Workforce development Potential of nurses to lead change: Nurses as Consultants Need for development of the workforce through integrated education Medical control of nurses: Nurses as technicians Disempowered by dominant ideology of practice Acceptance of illusory accounts of reality Maintenance of silo training focused on technical rational practice organized around medical specialties & colleges. Paradoxical discourses

14 Critical discourse analysis Developed critical theorem Informed national community of enquiry Deconstruction & reconstruction of sexual health nursing & workforce development

15 The art of nursing – “ the expert use and adaptation of empirical and metaphysical knowledge and values. It involves sensitively identifying need and adapting care to meet the needs of individual patients, and in the face of uncertainty, the discretionary use of creativity. It encompasses the ability to care for and care about the client, requiring an ability to work in partnership.” (Fingfeld-Connett 2008 )

16 Sexual health advisers Person centred care Clinical sexual health nurses DEVELOP PUBLIC HEALTH KNOWLEDGE & SKILLS Assessment of need at population, community and individual level Contribute to health needs assessment & development of responsive services Address inequalities DEVELOP KNOWLEDGE & SKILLS TO Holistic assessment of need at individual level Provision of integrated service at the point of care Partnership approaches

17 Critical review of education approaches in sexual health nursing Apprenticeship Continuing professional development Separation of academic provision from service priorities Lack of partnership working between university and service providers Loss of competency based education Reliance on in house training but non transferable Not academically accredited

18 Workforce development is.. “…a multi-faceted approach which addresses the range of factors impacting on the ability of the workforce to function with maximum effectiveness in responding to.....problems. Workforce development should have a systems focus. Unlike traditional approaches, this is broad and comprehensive, targeting individual, organisational and structural factors, rather than just addressing education and training of individual mainstream workers”. Australia’s National Research Centre on Alcohol and other drugs Workforce Development (2002)

19 Contemporary CPD for specialist practice is about… Individual development linked to KSF Knowledge and skills to fulfil a defined workplace role Person centred care Ability to understand and respond to need Enabling practice development Making a positive difference to the client Helping organisations meet their goals and targets Adult learning Andragogy approach Graduate level knowledge and skills and abilities Interpersonal skills to assess need and provide holistic support Patient & public involvement a statutory requirement –need knowledge and skills to use participatory approaches World Class Commissioning Service standards & specifications Key performance indicators Quality, innovation, productivity, clinical governance Changing nature of practice: Integrated services; Specific competencies within a competency framework Enhance individuals career chances and salary Analytical and creative thinking Complex decision making - Competent Authentic work based learning and assessment Changing the context & culture of practice (McNall 2010)

20 We needed... A preventative person centred nursing model Valid and reliable competency assessment Evidence based, critical, analytical practitioners Practice development Supported practice based learning Based on...Which had.. Which led to.. Which developed capacity for.. Cost effective, didn’t take practitioners out of practice

21 From CPD to workforce development “One of the important conceptual leaps involved in a workforce development approach is the shift to ‘systems thinking’. This is fundamental to grasping what workforce development is about. While education and training can be part of a workforce development perspective, they essentially focus on the individual learners or workers. The deficit requiring rectification (through training) is seen to lie with that individual. No further consideration is given to the organisational context in which that person operates or the wider system at large which may ultimately determine whether specific policies or practices can be put into place.” (Roche 2001, pg 11)

22 An innovation by Northumbria University (McNall 2012)

23 Champions Strategic support People who shared the vision Needed to be commissioned and trialled So many people have contributed their knowledge influence, commitment and passion along the way

24 What is blended learning? Blended learning refers to a combination of face to face and technology enhanced learning opportunities, aligned with the principles of androgogy, with the aim of providing realistic practical opportunities for independent learning – (Graham 2005) The workforce development package includes: Classroom based foundation module to develop and practice interpersonal skills e learning package e portfolio supervised clinical experience (mentors & PE) 6 practice based seminars & workshops (PE) academic and competency assessment All facilitated by a practice educator role

25 To enable and enhance high quality learning and assessment in the practice context, Mumford & Roodhouse (2010) identify the critical need for on going support for students Lecturer/ practitioner or Practice Educator roles highly regarded in policy and practice for closing the perceived theory / practice gap and supporting practice based learning(the bridge) No evidence of their use in a sexual health context Support

26 Providing support via the practice educator role Partnership model: PE salaries plus 180 student places commissioned and funded regionally with hub (university) and spokes (geographical practice areas) Cost effective: reduced provision from 7 to 2 modules, reduced time out of practice Practice educators are; Clinical Nurse Specialists in Integrated Sexual Health Practice plus Registered Nurse Teachers Hold honorary contracts to practice in all sexual health service provider services plus the university. Emma Senior, post hosted by Northumbria University Julie Raine, post hosted by Tees Assura, subsidiary of Virgin Care Karen Elton, post hosted by Northumbria University Claire Robinson, post hosted by Northumbria Health Care Trust

27 Practice educator: complex role  Strategic worker & leader: – Mapping workforce need – recruit staff to appropriate pathway, liaise with service leads – Develop greater capacity for practice based learning - mentor preparation, registration and updating to NMC (2008) standards – Supports clinical governance ( integrates practice priorities and outcomes into education  Supporting students on the pathway: – Negotiation of a personalised learning journey with opportunity for direct clinical mentoring or coaching of students – Deliver face to face seminars – The provision of formative feedback and support to students via e portfolio  Facilitator of learning within the practice setting ; – allows a deeper insight into the learning environment – Enables us to recognise and ‘unblock’ blockages affecting the students learning, minimising risk of adverse outcomes of the move to blended learning

28 Induction day – self assessment of individual learning need using e learning package, e portfolio and competency framework Results. Development of individual learning plan. Negotiated with practice educator Core Content:1. Integrated sexual health, current drivers for services. 2. What should be assessed in context of sexual health. How to conduct an integrated sexual health assessment. 3. Legal, ethical & professional issues & defensible decision making in sexual health. 4. Responding to identified sexual health need. 5. Non clinical interventions; recognition and management of sexual and alcohol risk taking & risk reduction 6. Normal Anatomy & Physiology of the reproductive and genitourinary systems. 7. Clinical interventions & appropriate signposting 6. Practice development for quality improvement (QIPP) and person -centred care. Sexual difficulty Hormonal change Sexual difficulty Hormonal change Sexual Assault & Domestic violence Sexual Health Screening programmes STI management Pregnancy Assessment of Integrated Clinical Sexual Health Practice Portfolio to include: Initial self assessment against competency framework Negotiated learning plan Competency booklet with evidence of previous learning and mentor sign off Summative assessment –Proposal for practice development or integrated case study Cervical & Chlamydia Screening Programmes Breast Testicular Prostate Awarenes raising Diagnosis and management of STIs Abortion Methods Referral Sub dermal implants Conception & contraception Maximising conception Infertility management Referral Providing contraceptive methods & emergency contraception Pregnancy testing Pregnancy decision making Giving permission and limited information approaches Referral Initial management of sexual assault Referral Cervical smear taking (Local agreement) Cervical smear taking (Local agreement) Partner management Initiation Face to face foundation module- knowledge and skills to discuss sexual health issues Self directed use of e learning package Practice based clinical learning, workshops and seminars Pre entry – mapping and advice, manage applications

29 The e learning package In the past; – Many e learning packages lack pedagogical principles and theoretical foundations (Schroeder & Spannagel 2006) – The active learning potential of much e learning is not realised ; e reading rather than e learning (Department of Health 2011) THE SHINE package utilises Knowles’ (2011) concept of androgogy – Case based learning can provide an effective means of engaging students with their own learning (general theory integrated with professional guidance, local policy) – Adult learning takes place whilst solving complex and authentic tasks and problems based on issues of relevance to the student, requiring them to articulate their decision making in particular scenarios in collaboration and through interaction with others (seminars). – In built self testing, learning tasks and reflective exercises- shared with Practice Educator via e portfolio gateway

30 The e learning package

31 What is an e portfolio? E portfolios are defined as; “a web-based application for the planning, management and collection of evidence about achievements, experiences and reflections” (DH 2011 ) We use pebblepad e portfolio; Student owned Provides an interface for communication and formative feedback Used to provide consistent support to students even when geographically distant from the university Through regular review of each individuals learning, enables the practice educator to monitor engagement with learning and offer support or intervention where necessary. Assessment for learning as well as assessment of learning

32 Supervised clinical experience Student stays in own workplace wherever possible reduced contact time and travel authentic learning opportunity Students supervised & assessed by practice educators and mentors Students assessed against a regionally agreed integrated competency framework, developed in partnership with clinical and academic staff -updated twice yearly

33 Practice based workshops/ seminars Practical interpersonal skills workshops informed by theory Sexual history taking, including risk reduction strategies such as motivational interviewing Partner notification- how to encourage sexual partners to notify sexual contacts Application/synthesis of various bodies of knowledge to inform practice and articulate professional decision making Complex case management scenarios Sexual Assault, domestic violence and safeguarding issues Reflective practice discussions Developing academic skills Assignment development, review and support

34 Student evaluation “ I liked the structure - the package is really good” “You can pace your learning and study when convenient. It is easy to pick up where you left off as the package 'files' your work for you” “Although there are deadlines for certain things, you can work through the package at your own speed. It is good self learning with support. It is easier than travelling to a university base which is difficult to fit around work” Student evaluations, Cohort 1, Initial evaluation December 2010

35 The second module is delivered as an IT package and self directed learning in practice. Support from the practice educator was always available and there was a series of seminars to ensure everyone was happy with their progress through the package. Practice based mentors were arranged for each student to ensure the competencies could be practiced and achieved. From my experience this worked smoothly and efficiently. I felt encouraged to develop my own learning and practice linked to the knowledge and skills framework gateways and a career structure.” Prison nurse leading the provision of sexual health services 2011 Student evaluation

36 Nurse Education Provider of the Year (post-registration)

37 Challenges of practice educator role  Lack of clarity regarding the role and unclear job descriptions leading to role conflicts and the potential for occupational stress and burnout.  Exacerbated by lack of joint appraisal and means of formal support.  Williamson (2003) identified three new mechanisms that led to better outcomes; orientation and induction policies and materials joint appraisal policies & mechanisms group support network (PE’s co located, regular meetings)Development of SHINE- NET And what is not in the job description...  Simmons (2004) in their concept analysis of facilitation identified the need to influence hearts and minds.  Kouzes & Pozner (2002) similarly refer to the ability of facilitators to ‘encourage the heart’.  Sell the vision of integrated services, practice based learning

38 E learning package Include content to 1. meet learning outcomes 2. lead to achievement of practice competence at the level of specialist practice Competency framework 1. practice specific competencies 2. graduate competence: the knowledge skills and abilities to develop and lead practice 3. linked to academic learning outcomes Mechanism for student support through The model was developed in partnership with strategic support 1. Provision of formative feedback via e portfolio 2. Develop capacity for competency development & assessment Development of validated pathway leading to an academic award

39 Nursing career framework this model supports Newly Registered Practitioner, Band 5, Existing CASH/GUM practitioner Foundation of Sexual Health Practice module (20 credits, level 6) Integrated Clinical Practice in Sexual Health module (40 credits, level 6) = Graduate Certificate in Sexual Health Practice (if already a graduate) Senior Registered Practitioner Sexual Health AdviserClinical Practitioner Pathway Pathway Specialist Community Public Health Specialist Practice Modules, HIV, IUDS, Nursing Programme -Level 6 or 7Sexual Assault, TOP, Sexual difficulty or accreditation of work based learning Nurse Consultant /Manager/Practice Educator 2 additional underpinning modules if need degree Community Practice Teacher/ Master in Public Health- Level 7 Master of Advanced Practice/ Clinical Practice/ Learning & Teaching – Level7

40 Thank you for your attention Transferability of the workforce development model/practice educator role to other aspects? Observations? Questions?

41 References Anema, M. McCoy, J. (2010) Competency-based nursing education: guide to achieving outstanding learner outcomes. New York: Springer Australia’s National Research Centre on Alcohol and other drugs Workforce development (2002) Models of Workforce Development accessed 10.6.10 accessed 10.6.10 Eraut, M (1997) Concepts of competence. Journal of Inter-Professional care 12, 2 127-139 Great Britain. Department of Health. (2011) A Framework for Technology enhanced learning. DH London Great Britain. National Committee of Inquiry into Higher Education (1997) Reports of the National Committee of Inquiry into Higher Education (Dearing Report) Graham, C. R. (2005). Blended learning systems: Definition, current trends, and future directions in Bonk, C. J.; Graham, C. R.. Handbook of blended learning: Global perspectives, local designs. San Francisco, CA: Pfeiffer. pp. 3–21 Griscti, O. Jacono, J. (2006) Effectiveness of continuing education programmes in nursing: literature review. Journal of Advanced Nursing 55 (4) 449-456 Knowles, M. ( 2011) The adult learner: the definitive classic in adult education and human resource development Oxford : Butterworth-Heinemann 2011 Kouzes, J. M. Posner, B. Z. (2002) The Leadership Challenge, 3rd edn, Jossey-Bass, San Francisco, CA. McCormack, B. Manley, K. Garbett, B (Eds) (2004) Practice Development in Nursing. Blackwell Publishing. Oxford McNall, A (2010) Workforce Development in Sexual Health: the way forward. Theme 7: Department of Health National Consultative Conference in Sexual Health- Celebrate - Innovate - Influence. 4 February 2010, London. McNall, A (2012) An emancipatory practice development study: using critical discourse analysis to develop the theory and practice of sexual health workforce development. Thesis submitted for the award of Professional Doctorate in Nursing. Northumbria University Roche 2001, cited in Australia’s National Research Centre on Alcohol and other drugs Workforce development (2002) Models of Workforce Development accessed 10.6.10 accessed 10.6.10 Roodhouse, S. Mumford, J.(2010) Understanding work based learning. Farnham. Gower Schroeder, U. Spannagel, C (2006) Supporting the active learning process. International journal on e learning 5 (2) 245-264 Simmons, M. (2004) ‘Facilitation’ of practice development: a concept analysis. Practice Development in Health Care 3 (1) 36-52 Williamson, G.(2003) Developing Lecturer Practitioner roles using action research. PhD thesis. University of Plymouth

42 Finfgeld-Connett, D. (2008) Concept synthesis of the art of nursing. Journal of Advanced Nursing, 62, 3 381-388 Great Britain. Department of Health (2008a) Sexual Health Advising: Developing the Workforce. DH/SSHA/UNITE 084641.pdf Accessed 14 March 2011 084641.pdf Great Britain. Department of Health (2010a) Sexual Health Worth Thinking About: Celebrate - Innovate - Influence, National Consultative Conference. Theme 7: Workforce development. DH London Great Britain. Department of Health (2010b) Review of sexual health nurse education. Unpublished report References

43 Conference papers & publications McNall, A. (2005a) A Consultation on Initial Sexual Health Adviser Education and Preparation. The Society of Sexual Health Advisers (SSHA) Funded by the Department of Health. Unpublished paper McNall, A. (2005b) A Second Draft of the Consultation Paper on Initial Sexual Health Adviser Education and Preparation The Society of Sexual Health Advisers (SSHA) Funded by the Department of Health. Unpublished Paper McNall, A. (2007a) A practical approach to aligning the service user perspective with public health targets to develop sexual health services: A workshop. Royal College of Nursing (RCN) National Sexual Health Conference 15 -16 June 2007, London. McNall, A (2007c) Sexual Health Advising as a pathway of the SCPHN programme. Society of Sexual Health Advisers National Conference. April 2007 Glasgow Hilton. McNall, A (2008b) Educational preparation of Sexual Health Advisers: The new arrangements. Society of Sexual Health Advisers National Conference. April 2008. Newcastle upon Tyne. McNall, A (2009) Aligning the service user perspective with public health targets to develop sexual health services: Informing educational and practice preparation of sexual health advisers through participatory action research United Kingdom Standing Council for Specialist Community Public Health Nurse Education National Conference, March 21 2009, London. McNall, A (2010a) Developing the theory and practice of public involvement and engagement in developing sexual health services. The Centre for Translational Research in Public Health: Quarterly Research Conference. 18 January 2010. Newcastle University. McNall, A (2010b) Workforce Development in Sexual Health: the way forward. Theme 7: Department of Health National Consultative Conference in Sexual Health- Celebrate - Innovate - Influence. 4 February 2010, London. McNall, A. (2010c) The NHS North East Regional Model of Integrated Clinical Sexual Health Workforce Development. Unpublished paper. Northumbria University McNall, A, Kain, K. (2010) Sexual Health Advising - Developing the Workforce. Increasing capacity in NHS North East Region through Workforce Development Innovation Funding. Final Report- April 2010. NHS North East McNall, A. Hedley, M. (2011) Health needs assessment in black and minority ethnic communities. Is PA the way forward? The Health & Race Equality Forum Conference in partnership with Bridges Clinical Commissioning Group. Newcastle Civic Centre. 26 September 2011 McNiff, J. Whitehead, J. (2006) All you need to know about Action Research. London. Sage Publications McSherry, R. Warr, J. (2008) An introduction to excellence in practice development in health and social care. Maidenhead: Open University Press McTaggart, R. (ed) (1997) Participatory Action Research. New York: Albany.

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