Developing the sexual health
workforce: making every contact
count
Dr. Anne McNall
Claire Robinson
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
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
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 )
1st action research cycle
Critical discourse
analysis
Development of
critical theorem
Informed national
community of
enquiry
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)
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
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)
Paradoxical discourses
Discourse
In policy
In practice
Concept of sexual health
Holistic model
Sex as:
Basic human need
Pleasure
Right for all
Individual choice within
legally defined
boundaries
Medical model
Sex as :
Public health problem
Crisis caused by risk
taking
Acceptance of diversity of
sexual health practice
and need
Normative need for
interventions to prevent
unintended conceptions
and infection
Paradoxical discourses
Discourse
In policy
In practice
Sexual health service
development
Informed by patient and
public involvement (PPI) as a:
Democratic right
Legal requirement
Informed by normative need:
Objectification of service users
into homogenous group of risk
takers
Partnership approach with
patients and public to
understand need
Espoused
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
Discourse
In policy
In 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
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
Ease of access & improved
patient journey
Espoused
Rhetorical, maintained by
medical hegemony
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)
Paradoxical discourses
Discourse
In policy
In practice
Leadership of change
Potential of nurses to lead
change:
Nurses as Consultants
Medical control of nurses:
Workforce development
Nurses as technicians
Disempowered by dominant
ideology of practice
Acceptance of illusory
accounts of reality
Need for development of the Maintenance of silo training
workforce
focused on technical
through integrated education rational practice organized
around medical specialties
& colleges.
Critical discourse
analysis
Developed critical
theorem
Informed national
community of
enquiry
Deconstruction & reconstruction of
sexual health nursing & workforce
development
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 )
Sexual health
advisers
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
Person centred
care
Partnership
approaches
Clinical sexual
health nurses
DEVELOP
KNOWLEDGE & SKILLS
TO
Holistic assessment of
need at individual
level
Provision of
integrated service at
the point of care
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
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)
Enhance individuals
career
chances and salary
Analytical and
creative thinking
Complex decision
making Competent
Authentic work
based learning
and
assessment
Individual
development
linked to KSF
Changing nature of practice: Integrated
services;
Specific competencies within a competency
framework
Knowledge and
skills to fulfil a
defined
workplace role
Graduate level
knowledge and
skills and abilities
Interpersonal skills to
assess need and
provide holistic
support
Adult learning
Andragogy
approach
Helping
organisations
meet their goals
and targets
Contemporary
CPD for
specialist
practice is
about…
(McNall 2010)
Person centred
care
Ability to
understand and
respond to need
Changing the
context & culture
of practice
Enabling practice
development
Making a positive
World Class Commissioning
difference to the
Service standards & specifications
client
Key performance indicators
Quality, innovation, productivity, clinical governance
Patient & public involvement a statutory
requirement –need knowledge and skills to
use participatory approaches
We needed...
A preventative
person centred
nursing model
Based on...
Supported
practice based
learning
Cost effective,
didn’t take
practitioners
out of practice
Which had..
Valid and
reliable
competency
assessment
Which led to..
Which developed
capacity for..
Practice
development
Which led to..
Evidence
based, critical,
analytical
practitioners
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)
An innovation by Northumbria University
(McNall 2012)
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
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
Support
• 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
Providing support via the practice educator role
Claire Robinson, post
hosted by Northumbria
Health Care Trust
Karen Elton, post
hosted by
Northumbria
University
Emma Senior, post
hosted by Northumbria
University
Julie Raine, post hosted by
Tees Assura, subsidiary of
Virgin Care
• 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.
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
Pre entry – mapping and advice, manage applications
Induction day – self assessment of individual
learning need using e learning package, e
portfolio and competency framework
Face to face
foundation moduleknowledge and skills to
discuss sexual health issues
Results. Development of individual learning plan.
Negotiated with practice educator
Self directed use of e learning package
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 Health
Screening
programmes
Cervical &
Chlamydia
Screening
Programmes
Cervical smear
taking
(Local
agreement)
STI management
Breast
Testicular
Prostate
Awarenes
raising
Diagnosis and
management
of STIs
Partner
management
Initiation
Conception &
contraception
Maximising conception
Infertility management
Referral
Providing contraceptive
methods & emergency
contraception
Pregnancy
Pregnancy
testing
Pregnancy
decision making
Sexual Assault &
Domestic
violence
Abortion
Methods
Referral
Initial
management
of sexual
assault
Referral
Sub dermal
implants
Practice based clinical learning, workshops and seminars
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
Sexual difficulty
Hormonal change
Giving permission
and limited
information
approaches
Referral
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
The e learning package
http://hces-online.net/courses/sexual-health/front.html
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
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
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
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
Student evaluation
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
Nurse Education Provider of the
Year (post-registration)
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 SHINENET
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
The model was developed in
partnership with strategic support
E learning package
Include content to
Competency framework
1. meet learning
outcomes
Mechanism for student
1. practice specific
support through
competencies
2. lead to achievement 2. graduate
1. Provision of
of practice competence
formative feedback via
at the level of specialist competence: the
e portfolio
knowledge skills and
practice
abilities to develop and 2. Develop capacity for
competency
lead practice
development &
3. linked to academic
assessment
learning outcomes
Development of validated pathway leading to an academic award
Nursing career framework this model supports
Newly Registered Practitioner, Band 5,
2 additional
underpinning
modules if
need degree
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 Adviser
Pathway
Specialist Community Public Health
Nursing Programme -Level 6 or 7
Community Practice Teacher/
Master in Public Health- Level 7
Clinical Practitioner
Pathway
Specialist Practice Modules, HIV, IUDS,
Sexual Assault, TOP, Sexual difficulty or
accreditation of work based learning
Master of Advanced Practice/ Clinical Practice/
Learning & Teaching – Level7
Nurse Consultant /Manager/Practice Educator
Thank you for your attention
• Transferability of the workforce development
model/practice educator role to other
aspects?
• Observations? Questions?
• anne.mcnall@northumbria.ac.uk
• claire.robinson@northumbria.ac.uk
• karen.l.elton@northumbria.ac.uk
• emma.senior@northumbria.ac.uk
• Julie.raine@virgincare.co.uk
References
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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
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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
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Knowles, M. ( 2011) The adult learner: the definitive classic in adult education and human resource development Oxford :
Butterworth-Heinemann 2011
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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 http://ncoss.org.au/projects/workforce/workforce-development-models.pdf accessed 10.6.10
Roodhouse, S. Mumford, J.(2010) Understanding work based learning. Farnham. Gower
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Williamson, G.(2003) Developing Lecturer Practitioner roles using action research. PhD thesis. University of Plymouth
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http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_
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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
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Preparation The Society of Sexual Health Advisers (SSHA) Funded by the Department of Health. Unpublished
Paper
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develop sexual health services: A workshop. Royal College of Nursing (RCN) National Sexual Health Conference
15 -16 June 2007, London.
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Advisers National Conference. April 2007 Glasgow Hilton.
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services: Informing educational and practice preparation of sexual health advisers through participatory action
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