Presentation on theme: "Developing the sexual health workforce: making every contact count"— Presentation transcript:
1 Developing the sexual health workforce: making every contact count Dr. Anne McNallClaire Robinson
2 Aims of this session To summarise; the context and nature of my research studyexpose the dominant discourses affecting sexual health nursing and nurse education and analyse their impactexplore 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 StudyAn emancipatory practice development study: using critical discourse analysis to develop the theory and practice of sexual health nursing workforce developmentAimsTo 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 solutionsThe study focused on sexual health advisers and clinical sexualhealth nurses
4 The art of nursing 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 1st action research cycle Critical discourse analysisDevelopment of critical theoremInformed national community of enquiry
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 discoursesDiscourses penetrate our sub consciousness and shape what we think, what we know and how we understand issuesLanguage 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 justifiedCDA can reveal hidden layers beneath taken for granted surface meanings (Traynor 1996)
9 Paradoxical discourses In policyIn practiceConcept of sexual healthHolistic modelSex as:Basic human needPleasureRight for allIndividual choice within legally defined boundariesAcceptance of diversity of sexual health practice and needMedical modelSex as :Public health problemCrisis caused by risk takingNormative need for interventions to prevent unintended conceptions and infection
10 Paradoxical discourses In policyIn practiceSexual health service developmentInformed by patient and public involvement (PPI) as a:Democratic rightLegal requirementPartnership approach with patients and public to understand need EspousedInformed by normative need:Objectification of service users into homogenous group of risk takersDisempowered by embarrassment, shame & stigmaSilent user perspectiveReliance on consultation approach & satisfaction measures with current provisionRhetorical, silenced by lack of planned needs assessment
11 Paradoxical discourses In policyIn practiceIntegration of services to respond to diversity of needHolistic one stop shop in community based locations:Holistic assessment of needPreventative approach to health & wellbeingManage all issues at the point of careEase of access & improved patient journeyEspousedMaintenance of silo approach in traditional clinical locations:Address only one aspect of sexual healthReactive approach to problem presentingMedically defined interventionDisjointed patient journeyRhetorical, maintained by medical hegemony
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 Paradoxical discourses In policyIn practiceLeadership of changeWorkforce developmentPotential of nurses to lead change:Nurses as ConsultantsNeed for development of the workforcethrough integrated educationMedical control of nurses:Nurses as techniciansDisempowered by dominant ideology of practiceAcceptance of illusory accounts of realityMaintenance of silo trainingfocused on technical rational practice organized around medical specialties & colleges.
14 Deconstruction & reconstruction of sexual health nursing & workforce Critical discourse analysisDeveloped critical theoremInformed national community of enquiryDeconstruction & reconstruction ofsexual health nursing & workforcedevelopment
15 The art of nursing 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 nursesDEVELOP PUBLIC HEALTH KNOWLEDGE & SKILLSAssessment of need at population, community and individual levelContribute to health needs assessment&development of responsive servicesAddress inequalitiesDEVELOP KNOWLEDGE & SKILLS TOHolistic assessment of need at individual levelProvision of integrated service at the point of carePartnershipapproaches
17 Critical review of education approaches in sexual health nursing ApprenticeshipContinuing professional developmentSeparation of academic provision from service prioritiesLack of partnership working between university and service providersLoss of competency based educationReliance on in house training but non transferableNot 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 (McNall 2010) Enhance individuals career chances and salary Contemporary CPD for specialist practice is about…Individual development linked to KSFKnowledge and skills to fulfil a defined workplace roleAbility to understand and respond to needPerson centred careEnabling practice developmentMaking a positive difference to the clientHelping organisations meet their goals and targetsAndragogy approachAdult learningGraduate level knowledge and skills and abilitiesEnhance individuals careerchances and salaryChanging nature of practice: Integrated services;Specific competencies within a competency frameworkAnalytical and creative thinkingComplex decision making - CompetentInterpersonal skills to assess need and provide holistic supportAuthentic work based learning and assessmentChanging the context & culture of practice(McNall 2010)World Class CommissioningService standards & specificationsKey performance indicatorsQuality, innovation, productivity, clinical governancePatient & public involvement a statutory requirement –need knowledge and skills to use participatory approaches
20 We needed... Based on... Which had.. Cost effective, A preventative person centred nursing modelValid and reliable competency assessmentEvidence based, critical, analytical practitionersPractice developmentSupported practice based learningBased on...Which had..Cost effective,didn’t take practitionersout of practiceAnneWhich led to..Which developedcapacity for..Which led to..
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 Academically accredited Making every contact count (McNall 2012)An innovation by Northumbria UniversityTechnology enhancedAcademically accreditedMaking every contact countAnne: what it isPractice basedCompetency assessedInnovative blended learning approach
23 Thanks! Champions Strategic support People who shared the vision Needed to be commissioned and trialledSo many people have contributed their knowledge influence, commitment and passion along the wayThanks!
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 skillse learning packagee portfoliosupervised clinical experience (mentors & PE)6 practice based seminars & workshops (PE)academic and competency assessmentAll facilitated by a practice educator roleAnne: What blended learning is and what it means for the student
25 SupportTo enable and enhance high quality learning and assessment in the practice context, Mumford & Roodhouse (2010) identify the critical need for on going support for studentsLecturer/ 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 contextKaren
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 practicePractice educators are;Clinical Nurse Specialists in Integrated Sexual Health PracticeplusRegistered Nurse TeachersHold honorary contracts to practice in all sexual health service provider services plus the university.Claire Robinson, post hosted by Northumbria Health Care TrustKaren Elton, post hosted by Northumbria UniversityKaren: Skills base of the PE role – practitioner plus educator – current credibleJulie Raine, post hosted by Tees Assura, subsidiary of Virgin CareEmma Senior, post hosted by Northumbria University
27 Practice educator: complex role Strategic worker & leader:Mapping workforce need – recruit staff to appropriate pathway, liaise with service leadsDevelop greater capacity for practice based learning - mentor preparation, registration and updating to NMC (2008) standardsSupports clinical governance ( integrates practice priorities and outcomes into educationSupporting students on the pathway:Negotiation of a personalised learning journey with opportunity for direct clinical mentoring or coaching of studentsDeliver face to face seminarsThe provision of formative feedback and support to students via e portfolioFacilitator of learning within the practice setting ;allows a deeper insight into the learning environmentEnables us to recognise and ‘unblock’ blockages affecting the students learning, minimising risk of adverse outcomes of the move to blended learningClaire
28 Assessment of Integrated Clinical Sexual Health Practice Pre entry – mapping and advice, manage applicationsInduction day – self assessment of individual learning need using e learning package, e portfolio and competency frameworkResults. Development of individual learning plan. Negotiated with practice educatorFace to facefoundation module-knowledge and skills todiscuss sexual health issuesSelf directed use of e learning packageCore 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 Health Screening programmesSTI managementConception & contraceptionPregnancySexual Assault & Domestic violenceSexual difficultyHormonal changeCervical & ChlamydiaScreeningProgrammesBreastTesticularProstateAwarenes raisingDiagnosis and management of STIsPartner managementInitiationMaximising conceptionInfertility management ReferralProviding contraceptive methods & emergencycontraceptionPregnancytestingdecision makingAbortionMethods ReferralInitial management of sexual assaultReferralGiving permission and limited information approachesReferralClaire briefly explain the process, some face to face, induction, self assessment, selective use of e learning, seminars, practice based learning, leading to competencyCervical smear taking(Local agreement)Sub dermal implantsPractice based clinical learning, workshops and seminarsAssessment of Integrated Clinical Sexual Health PracticePortfolio to include:Initial self assessment against competency frameworkNegotiated learning planCompetency booklet with evidence of previous learning and mentor sign offSummative assessment –Proposal for practice development or integrated case study
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 androgogyCase 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 gatewayKaren- mention PE contribution to el package -
30 The e learning package http://hces-online Here is the front page of the package, I’ll send you a separate with access details to view it – you should be able to get in if you have internet access if you want to show them a preview section – need sound on to hear the voiceover.
31 What is an e portfolio? We use pebblepad e portfolio; Student owned 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 ownedProvides an interface for communication and formative feedbackUsed to provide consistent support to students even when geographically distant from the universityThrough 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 learningClaire Pebble pad interface to ensure learning is being done and can be linked into practice context.
32 Supervised clinical experience Student stays in own workplace wherever possiblereduced contact time and travelauthentic learning opportunityStudents supervised & assessed by practice educators and mentorsStudents assessed against a regionally agreed integrated competency framework, developed in partnership with clinical and academic staff -updated twice yearlyKaren – talk about primary care development to improve authentic learning
33 Practice based workshops/ seminars Practical interpersonal skills workshops informed by theorySexual history taking, including risk reduction strategies such as motivational interviewingPartner notification- how to encourage sexual partners to notify sexual contactsApplication/synthesis of various bodies of knowledge to inform practice and articulate professional decision makingComplex case management scenariosSexual Assault, domestic violence and safeguarding issuesReflective practice discussionsDeveloping academic skillsAssignment development, review and supportKaren: How we know we are supporting all of the above and that it working!!
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 Prison nurse leading the provision of sexual health services 2011 Student evaluationThe 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
36 Nurse Education Provider of the Year (post-registration) Karen: ENDING ON A POSITIVE NOTE!!
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 materialsjoint appraisal policies & mechanismsgroup support network (PE’s co located, regular meetings)Development of SHINE-NETAnd 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 learningClaire: difference between titles, lack of understanding from practice/HE as to what we are doing in our ‘other time’. Mastering professions. Discourse working between 2 management structures/ organisations.But...examples of how we have improved practice by Primary care/mapping sexual health services and identifying gaps in practice i.e. pre reg students/Sexual assault disclosure management…… facilitated regional improvement and the vision of integration.Positivity.
38 The model was developed in partnership with strategic support E learning packageInclude content to1. meet learning outcomes2. lead to achievement of practice competence at the level of specialist practiceCompetency framework1. practice specific competencies2. graduate competence: the knowledge skills and abilities to develop and lead practice3. linked to academic learning outcomesMechanism for student support through1. Provision offormative feedback via e portfolio2. Develop capacity for competency development & assessmentDevelopment of validated pathway leading to an academic award
39 Senior Registered Practitioner Nursing career framework this model supportsNewly Registered Practitioner, Band 5, Existing CASH/GUM practitionerFoundation 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 Practitioner2 additional underpinning modules if need degreeSexual Health Adviser Clinical PractitionerPathway PathwayPoint out that this is meant to provide a career framework where education is available to help them progress down either the clinical path, or into a public health pathwayFurther work based modules will be available at level 7 (masters)Specialist Community Public Health Specialist Practice Modules, HIV, IUDS,Nursing Programme -Level 6 or 7 Sexual Assault, TOP, Sexual difficulty or accreditation of work based learningCommunity Practice Teacher/Master in Public Health- Level 7Master of Advanced Practice/ Clinical Practice/ Learning & Teaching – Level7Nurse Consultant /Manager/Practice Educator
40 Thank you for your attention Transferability of the workforce development model/practice educator role to other aspects?Observations? Questions?
41 ReferencesAnema, M. McCoy, J. (2010) Competency-based nursing education: guide to achieving outstanding learner outcomes. New York: SpringerAustralia’s National Research Centre on Alcohol and other drugs Workforce development (2002) Models of Workforce Development accessedEraut, M (1997) Concepts of competence. Journal of Inter-Professional care 12,Great Britain. Department of Health. (2011) A Framework for Technology enhanced learning. DH LondonGreat 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. 3–21Griscti, O. Jacono, J. (2006) Effectiveness of continuing education programmes in nursing: literature review. Journal of Advanced Nursing 55 (4)Knowles, M. ( 2011) The adult learner: the definitive classic in adult education and human resource development Oxford : Butterworth-Heinemann 2011Kouzes, 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. OxfordMcNall, 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 UniversityRoche 2001, cited in Australia’s National Research Centre on Alcohol and other drugs Workforce development (2002) Models of Workforce Development accessedRoodhouse, S. Mumford, J.(2010) Understanding work based learning. Farnham. GowerSchroeder, U. Spannagel, C (2006) Supporting the active learning process. International journal on e learning 5 (2)Simmons, M. (2004) ‘Facilitation’ of practice development: a concept analysis. Practice Development in Health Care 3 (1) 36-52Williamson, G.(2003) Developing Lecturer Practitioner roles using action research. PhD thesis. University of Plymouth
42 ReferencesFinfgeld-Connett, D. (2008) Concept synthesis of the art of nursing. Journal of Advanced Nursing, 62,Great Britain. Department of Health (2008a) Sexual Health Advising: Developing the Workforce. DH/SSHA/UNITE Accessed 14 March 2011 Great Britain. Department of Health (2010a) Sexual Health Worth Thinking About: Celebrate - Innovate - Influence, National Consultative Conference. Theme 7: Workforce development. DH LondonGreat Britain. Department of Health (2010b) Review of sexual health nurse education. Unpublished report
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 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 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 , 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 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 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.