Posted 21st Jan 2016
There has never been a more exciting time for nurses working in the area of sexual health, and this is despite a backdrop of significant upheaval and uncertainty associated with the service tendering process that is affecting most of us around the country.
The commissioning of sexual health services has changed over the past few years. Most elements of sexual health provision with the exception of HIV treatment and care, vasectomy, cytology screening and abortion services are now funded through Local Authorities (LAs), who have a mandate to commission comprehensive, open access sexual health services. This complex arrangement has caused disruption to clinical services especially when different commissioning bodies are tendering for elements of sexual health at different times.
Given LA commissioners’ requirements for integrated sexual health services, providers must now be able to clearly articulate the knowledge, skills and qualifications available to successfully deliver these services. Nationally recognised qualifications for specialist sexual health nurses are key to delivering the highest standard of care.
Substantial progress has been made in sexual health in defining what competencies and qualifications are required for a specialist sexual health nurse. A significant development has been the decision made by the Faculty of Sexual and Reproductive Healthcare (FSRH) in 2013 to widen its membership to include nurses, paving the way for the development of a new nationally recognised qualification for nurses working in sexual health. Since January 2014 nurses have been able to qualify with the FSRH Nurse Diploma (NDFSRH), following the same route as doctors to complete the diploma. Within the new training structure (both for doctors and nurses) there is an online knowledge assessment (eKA) to test the theoretical knowledge gained from the e-learning for sexual and reproductive health or elsewhere. Those who wish to go on to complete a diploma will attend a ‘course of 5’ workshop, undertake assessments of clinical practice (ACPs) and submit a portfolio of evidence. Nurses will need to be re-assessed every 5 years. It is encouraging to see that at the time of writing some 235 nurses have been awarded the NDFSRH. A total of 38 nurses have the Faculty Registered Trainer qualification meaning they can train both doctors and nurses in the FSRH-led qualifications.
The British Association for Sexual Health and HIV (BASHH) has for a long time enabled nurses to obtain nationally recognised qualifications such as STIF Intermediate Competencies. The process is similar to that described above for the NDFSRH with reaccreditation awarded every 5 years. The STIF competency qualifications are on the whole delivered by sexual health providers with some universities offering additional courses to complement the knowledge assessment, providing a different option to individual learning. So far 390 nurses have been awarded the STIF Intermediate competency qualification.
Nurses who obtain both these qualifications can demonstrate the competencies required to work in an integrated sexual health service which, as mentioned above, is the preferred model detailed in most service specifications by public health commissioners. Evidence generated for both qualifications can of course be used as evidence for Nursing & Midwifery Council (NMC) revalidation.
While we now have more clarity on the qualifications required for nurses to be working in an integrated service there are still a number of issues and challenges to consider and resolve. Many of us struggle to recruit to vacant posts and coupled with an aging nursing workforce we often only entice nurses from other sexual health providers, “robbing from Peter to pay Paul”. Despite many sexual health services attending events held by academic institutions to promote sexual health, nurses often do not see it as a preferred career. This can be addressed in part by working proactively with the universities to advertise and promote sexual health nursing and by providing attractive placements for pre-registration students, to entice the newly qualified into this specialist area. However, recruiting a band 5 nurse who is naïve to sexual health requires a significant investment in training both financially and in staff time. This period can affect productivity and ability to meet targets and has financial implications if the service is being paid by activity and not a block contract.
A solution to recruitment and accelerating the knowledge and skill required to work in an integrated service is the Specialist Community Public Health Nurse-Sexual Health (SCPHN-SH) qualification. There are a few universities around the country which currently offer this course (for example, University of Central Lancashire, University of Cumbria and Northumbria University). The qualification is registered on part 3 of the NMC register as are School Nursing, Health Visiting and Occupational Health Nursing. The SCPHN-SH qualification enables nurses to consider the wider approach to community nursing through understanding the social and economic determinants of health. The course covers the four principles of public health practice: the search for health needs; the stimulation of awareness of health needs; the influence on policies affecting health and the facilitation of health enhancing activities. After completing the course, the practitioner is a specialist community public health nurse who is fit for practice and equipped as a clinician to deliver high quality, accessible, equitable and efficient care as well as able to act as an educator, manager and leader. They can proactively meet changing public health care needs whilst managing the expectations and demands of individuals, groups and populations in a multi-cultural, multi-ethnic society. With the sexual health services working alongside their local universities, it is possible for the student to have passed their FSRH electronic knowledge assessment and be booked on a ‘course of 5’ before they complete their university SCPHN-SH course. Upon completion the nurse undertakes the remaining part of the NDFSRH and the STIF intermediate competencies which are delivered by the local sexual health service.
Health Education England (HEE) funds the SCPHN-SH and pays for temporary hours to fill the positon while the nurse is being trained. It is essential for sexual health services to work with their local Education and Training department as they are responsible for negotiating with HEE as to how many places are awarded. This approach has already been successful in the North West. This model could influence more universities to put on the SCPHN-SH course. The SCPHN-SH qualification complements the certificates awarded by both FSRH & BASHH which are on the whole medically driven and predominantly clinically and task led.
We are all acutely aware that services are expected to deliver more for less money. Public health contracts often require us to demonstrate social value and to make every contact count, offering a routine enquiry at every episode of care. This means we need a workforce that is competent to deliver the core service and has the skills to address the wider issues. Nurses undertaking a SCPHN qualification are being taught these wider skills during their course. In the future, a nurse who has the skills to work in an integrated service could be one who has the SCPHN-SH qualification and within a year of qualifying be awarded the NDFSRH and STIF certificate for Intermediate Competency.
A continuing challenge is the funding for nurse training. Recent informal feedback from sexual health network colleagues indicates that funding for the NDFSRH or BASHH qualifications is being paid for by the sexual health services from already stretched budgets. Previously, funding for university courses such as the Contraception and Sexual Health course (famously remembered as the Family Planning certificate) was centrally provided through the Continuing Professional Development (CPD) credits that NHS organisations had with their local universities. Most large sexual health providers are now delivering their own FSRH courses, meeting the requirements laid out by the Faculty at a cost. Putting a nurse through the NDFSRH and STIF intermediate competency costs a minimum of £600. This cost does not take account of staff time to deliver the course and a reduction in activity while putting nurses through their clinical placements. As both these qualifications become a requirement for nurses to work in an integrated service there is an urgent need for national discussions about the funding of these in the future.
As well as this further clarification on funding, there needs to be more effective collaboration between commissioners, providers, professional organisations, local education and training boards (LETBs) and HEE to ensure a more joined up approach to nurse education and training. Although the focus here has been on nurses working in specialist integrated services, those working in primary care are faced with similar funding issues, and the value of well-defined sexual health competencies and access to sexual health training is equally important. Having a skilled and well-trained sexual health nursing workforce is key to sustaining high quality outcomes for the communities we serve.
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