COUNSELLING WITHIN SEXUAL HEALTH ADVISING - ETHICAL CONSIDERATIONS Ian Boss Sexual Health Adviser...

COUNSELLING WITHIN COUNSELLING WITHIN SEXUAL HEALTH SEXUAL HEALTH

ADVISING - ADVISING - ETHICAL ETHICAL

CONSIDERATIONSCONSIDERATIONS

Ian BossIan BossSexual Health AdviserSexual Health Adviser

September 2009September 2009

MY CONCERNMY CONCERN

In the rush towards professionalism In the rush towards professionalism and statutory regulation for Sexual and statutory regulation for Sexual Health Advisers are we ignoring the Health Advisers are we ignoring the ethical boundaries for good ethical boundaries for good counselling practice and patient care counselling practice and patient care within health advising?within health advising?

AIMSAIMS In light of the requirements for statutory regulation In light of the requirements for statutory regulation

for healthcare professionals. The main aims are:for healthcare professionals. The main aims are: 1). Check that the standards for offering counselling 1). Check that the standards for offering counselling

within Health Advising meet the national within Health Advising meet the national recommendations set out by the BACP for counselling recommendations set out by the BACP for counselling within the NHS.within the NHS. This was done by an audit of the counselling elements within This was done by an audit of the counselling elements within

job descriptions that were advertised throughout 2008.job descriptions that were advertised throughout 2008. Comparing these against the standards for offering Comparing these against the standards for offering

counselling within the NHS.counselling within the NHS. Also reviewing these against the standards set down by the Also reviewing these against the standards set down by the

SSHA National Job Description.SSHA National Job Description.

AIMSAIMS

2). To review the standards set out 2). To review the standards set out by the NMC for SCPHN in sexual by the NMC for SCPHN in sexual health and SSHA “Developing the health and SSHA “Developing the workforce” that they are fit for workforce” that they are fit for purpose.purpose. This was done by reviewing the SSHA & This was done by reviewing the SSHA &

NMC competencies for Health Advising.NMC competencies for Health Advising. Conclusion & recommendations.Conclusion & recommendations.

STATUTORY STATUTORY REGULATIONREGULATION

Professional regulation becomes statutory regulation at a Professional regulation becomes statutory regulation at a point where the State regards it as so important for point where the State regards it as so important for public safety that it legislates for a ban on either using public safety that it legislates for a ban on either using the professional title or doing certain things unless your the professional title or doing certain things unless your name appears in the register. This protects the patients name appears in the register. This protects the patients from the harm caused by people practising a profession from the harm caused by people practising a profession which they are not fit to. It engenders public confidence which they are not fit to. It engenders public confidence by allowing members of the public and the employers of by allowing members of the public and the employers of professionals to check on a person’s registration status, professionals to check on a person’s registration status, knowing that the information they find will be correct knowing that the information they find will be correct and up to date.and up to date.

The Department of Health (July 2006). The Department of Health (July 2006).

The regulation of the non-medical healthcare professionals. The regulation of the non-medical healthcare professionals.

London DHLondon DH

AUDIT OF H. A. JOB AUDIT OF H. A. JOB DESCRIPTIONS & PERSON DESCRIPTIONS & PERSON

SPECIFICATIONS - 2008SPECIFICATIONS - 2008 Job descriptions were collected for one year: Job descriptions were collected for one year:

January 2008 to January 2009January 2008 to January 2009 www.jobs.nhs.uk (search ‘health adviser’)www.jobs.nhs.uk (search ‘health adviser’) Number of Job Descriptions reviewed: n = 65Number of Job Descriptions reviewed: n = 65 Aim to look at the counselling qualifications Aim to look at the counselling qualifications

required to provide the counselling tasks.required to provide the counselling tasks. To check these against BACP/FHCP To check these against BACP/FHCP

standards for offering counselling within the standards for offering counselling within the NHS.NHS.

CODES FOR DATA CODES FOR DATA COLLECTIONCOLLECTION

Job Descriptions: TasksJob Descriptions: Tasks OC = Ongoing Counselling.OC = Ongoing Counselling. HV = Giving HIV positive results with HV = Giving HIV positive results with

ongoing/ or counselling. ongoing/ or counselling. RR = Familiar with health promotion RR = Familiar with health promotion

strategies, strategies, motivational change motivational change and counsellingand counselling

models.models.

CODES FOR DATA CODES FOR DATA COLLECTIONCOLLECTION

OT = Other Crisis Counselling InterventionsOT = Other Crisis Counselling Interventions Initial crisis intervention, assessment and Initial crisis intervention, assessment and

counselling e.g.: TOP, depression, sexual counselling e.g.: TOP, depression, sexual identity, sexual assault, substance misuse, sexual identity, sexual assault, substance misuse, sexual dysfunction.dysfunction.

or = Assess psychological / emotional distress, or = Assess psychological / emotional distress, provide containment and / or referral (assess provide containment and / or referral (assess immediate suicide risk).immediate suicide risk).

or = Respond to frequent situations which can be or = Respond to frequent situations which can be highly emotive, distressing and unpredictable.highly emotive, distressing and unpredictable.

BREAKDOWN OF THE BREAKDOWN OF THE DATADATA

Number of job descriptions reviewed: Number of job descriptions reviewed: n=65.n=65.

‘‘Ongoing counselling’: OC = 34 (52.4%).Ongoing counselling’: OC = 34 (52.4%). Post HIV positive counselling: HV = 55 Post HIV positive counselling: HV = 55

(84.6%).(84.6%). Crisis counselling interventions: OT = 56 Crisis counselling interventions: OT = 56

(86.2%).(86.2%). Risk Reduction: RR = 8 (12.3%).Risk Reduction: RR = 8 (12.3%). Psychological / Counselling support, includes Psychological / Counselling support, includes

all and/or any of the above: = 64 (98.5%).all and/or any of the above: = 64 (98.5%).

QUALIFICATIONS QUALIFICATIONS SUMMARY TABLE 1SUMMARY TABLE 1

QUALIFICATIONS QUALIFICATIONS SUMMARY TABLE 1SUMMARY TABLE 1

A): 14 (21.5%) of clinics were not asking A): 14 (21.5%) of clinics were not asking for any counselling qualification.for any counselling qualification.

B): Counselling Training / Counselling B): Counselling Training / Counselling Qualification, did not indicate the level.Qualification, did not indicate the level.

C): Only one clinic asked for a diploma in C): Only one clinic asked for a diploma in counselling. (This is consistent with counselling. (This is consistent with BACP/FHCP & UKCP/CPC guidelines for BACP/FHCP & UKCP/CPC guidelines for offering counselling within the NHS).offering counselling within the NHS).

D): With the MSc Counselling; this was D): With the MSc Counselling; this was optional with other either/or qualifications.optional with other either/or qualifications.

Nine ‘person specifications’ asked for two Nine ‘person specifications’ asked for two or more counselling qualifications.or more counselling qualifications.

EXPERIENCE SUMMARYEXPERIENCE SUMMARYTABLE 2TABLE 2

EXPERIENCE SUMMARY EXPERIENCE SUMMARY TABLE 2TABLE 2

A): 24 (36.95%) of clinics were not asking A): 24 (36.95%) of clinics were not asking for any counselling experiencefor any counselling experience

B): Request that the HA has ‘counselling B): Request that the HA has ‘counselling skills or 1:1 counselling experience’. skills or 1:1 counselling experience’. (Counselling comes across as something (Counselling comes across as something that is picked-up on the job rather than an that is picked-up on the job rather than an academic qualification).academic qualification).

18 ‘person specifications’ asked for more 18 ‘person specifications’ asked for more than two elements for counselling than two elements for counselling experience.experience.

14 CLINICS THAT DID NOT ASK 14 CLINICS THAT DID NOT ASK FOR COUNSELLING FOR COUNSELLING

QUALIFICATIONS TABLE 3QUALIFICATIONS TABLE 3

14 CLINICS THAT DID NOT ASK 14 CLINICS THAT DID NOT ASK FOR COUNSELLING FOR COUNSELLING

QUALIFICATIONQUALIFICATIONTABLE 3TABLE 3

14 (21.5%) of clinics were not asking 14 (21.5%) of clinics were not asking for any counselling qualification.for any counselling qualification.

Equates to: 9 (13.9%) carrying out ‘ongoing Equates to: 9 (13.9%) carrying out ‘ongoing counselling’ without counselling qualifications.counselling’ without counselling qualifications.

5 (7.7%) were carrying out high level 5 (7.7%) were carrying out high level counselling with either none or little experience counselling with either none or little experience of having previously used counselling.of having previously used counselling.

NB: All these clinics are in breach of SSHA, BACP NB: All these clinics are in breach of SSHA, BACP & UKCP guidelines for offering counselling & UKCP guidelines for offering counselling within the NHS. within the NHS.

OVERALL ASSESSMENT OF OVERALL ASSESSMENT OF THE DATATHE DATA

1). Generally fair to say that all 1). Generally fair to say that all clinics carry out some form of clinics carry out some form of counselling support or ‘ongoing counselling support or ‘ongoing counselling’.counselling’.

2). Primarily in the area of giving 2). Primarily in the area of giving HIV positive results and crisis work.HIV positive results and crisis work.

EVALUATION OF THE JOB EVALUATION OF THE JOB DESCRIPTIONS (1)DESCRIPTIONS (1)

‘‘Nursing’ Within The Job Nursing’ Within The Job DescriptionsDescriptions

RGN as an essential qualification RGN as an essential qualification was in all the job descriptions.was in all the job descriptions.

58% of the ‘job descriptions’ did not 58% of the ‘job descriptions’ did not have any nursing task within them.have any nursing task within them.

14% only had PDGs as the only 14% only had PDGs as the only nursing task.nursing task.

EVALUATION OF THE JOB DESCRIPTIONS (2)EVALUATION OF THE JOB DESCRIPTIONS (2)

Two ‘job description’ from the same clinic Two ‘job description’ from the same clinic demonstrate how the essential qualifications demonstrate how the essential qualifications

in general are becoming more nursing in general are becoming more nursing orientated. In both cases the ‘job descriptions’ orientated. In both cases the ‘job descriptions’ remained the same. There was also very little remained the same. There was also very little

in both of them that required you to be a in both of them that required you to be a nurse.nurse.FROM:FROM:

Sexual Health Adviser / Sexual Health Adviser / Nurse PractitionerNurse Practitioner

QualificationsQualifications Registered Nurse 1st Registered Nurse 1st

level/CQSW/Diploma Social level/CQSW/Diploma Social Work or relevant degree Work or relevant degree e.g. psychology (E)e.g. psychology (E)

Counselling Qualification Counselling Qualification (D)(D)

SkillsSkills Counselling skills (E)Counselling skills (E) Special Knowledge: To have Special Knowledge: To have

knowledge and knowledge and understanding of clinical understanding of clinical and psychological aspects and psychological aspects of STI’s and related sexual of STI’s and related sexual health issues (E).health issues (E).

TO:TO: Nurse Practitioner / Nurse Practitioner /

Health AdviserHealth Adviser QualificationsQualifications

Registered Nurse 1st Registered Nurse 1st level (E)level (E)

Counselling Counselling Qualification (D)Qualification (D)

EVALUATION OF THE JOB EVALUATION OF THE JOB DESCRIPTIONS (3)DESCRIPTIONS (3)

Only one job description mentioned Only one job description mentioned the BACP as a professional body and the BACP as a professional body and was asking for BACP Accreditation.was asking for BACP Accreditation.

COUNSELLING COUNSELLING STANDARDS WITHIN STANDARDS WITHIN

THE NHS (1)THE NHS (1) SSHA Manual for Sexual Health SSHA Manual for Sexual Health

Advisers recommend:Advisers recommend: For contract based counselling – to For contract based counselling – to

work within BACP Ethical Framework work within BACP Ethical Framework for Good Practice in Counselling & for Good Practice in Counselling & Psychotherapy.Psychotherapy.

COUNSELLING COUNSELLING STANDARDS WITHIN THE STANDARDS WITHIN THE

NHS (2)NHS (2) BACP/FHCP & UKCP/CPC BACP/FHCP & UKCP/CPC

recommendations for qualifications for recommendations for qualifications for counselling with in the NHS:counselling with in the NHS:

‘‘qualification to diploma level or qualification to diploma level or equivalent, which comprises a equivalent, which comprises a minimum of 450 hours of, taught minimum of 450 hours of, taught theory and skillstheory and skills’. ’.

A4C Band 6 or above ‘A4C Band 6 or above ‘to be accredited to be accredited in counselling or psychotherapy in counselling or psychotherapy recognised by a professional bodyrecognised by a professional body’’. .


NHS (3)NHS (3)Guidance for best practice: the employment of Guidance for best practice: the employment of

counsellors and psychotherapist in the NHS. BACP counsellors and psychotherapist in the NHS. BACP 2004.2004.

A ‘counselling skills’ course: “A ‘counselling skills’ course: “do not result in do not result in a professional qualification……as counselling a professional qualification……as counselling competency is not tested at this level and that competency is not tested at this level and that course tutors may not be qualified course tutors may not be qualified counselling practitionerscounselling practitioners”.”.

A ‘certificate in counselling’: “A ‘certificate in counselling’: “may combine may combine both practical and theoretical components….. both practical and theoretical components….. successful completion of this programme successful completion of this programme usually enables the student to access the usually enables the student to access the diploma in counsellingdiploma in counselling”.”.


NHS (4)NHS (4) These are only guidelines for best These are only guidelines for best

practice as legally there are no practice as legally there are no statuary requirements. statuary requirements.

Statutory regulation takes place in 2 Statutory regulation takes place in 2 – 3 years for the BACP through the – 3 years for the BACP through the HPC.HPC.

REVIEW OF SSHA REVIEW OF SSHA NATIONAL JOB NATIONAL JOB DESCRIPTIONDESCRIPTION

Next two slides show the national SSHA ‘job description’Next two slides show the national SSHA ‘job description’ The counselling aspects are highlighted in ‘yellow’The counselling aspects are highlighted in ‘yellow’ A ‘counselling certificate’ is the only essential A ‘counselling certificate’ is the only essential

counselling qualification. (This would be prior to A4C counselling qualification. (This would be prior to A4C and is against both SSHA & the BACP guideline for and is against both SSHA & the BACP guideline for offering counselling within the NHS). offering counselling within the NHS).

The MSc in Counselling is optional, along with other The MSc in Counselling is optional, along with other masters qualifications.masters qualifications.

The Job Summary / Main Responsibilities both state The Job Summary / Main Responsibilities both state ‘ongoing counselling’.‘ongoing counselling’.

There are no nursing elements within this job There are no nursing elements within this job description.description.

This is a ‘health promotion / counselling’ Job Description This is a ‘health promotion / counselling’ Job Description and has nothing to do with nursing.and has nothing to do with nursing.

NMC MIGRATION FOR NMC MIGRATION FOR SCPHN IN SEXUAL SCPHN IN SEXUAL

HEALTHHEALTH Application Pack 4Application Pack 4: Migration To NMC : Migration To NMC

Register as a Specialist Community Public Register as a Specialist Community Public Health Nurse (SCPHN) in Health Advising, Part Health Nurse (SCPHN) in Health Advising, Part 3 of the NMC Register.3 of the NMC Register.

The NMC have seemingly taken the ‘public The NMC have seemingly taken the ‘public health’ recommendations from the DoH health’ recommendations from the DoH documents, and have created the Application documents, and have created the Application Pack 4.Pack 4.

This now has become the gold standard adopted This now has become the gold standard adopted by SSHA for Sexual Health Advising, (Develping by SSHA for Sexual Health Advising, (Develping The Workforce).The Workforce).

These days nationally most HA jobs are These days nationally most HA jobs are excluding non-nurses from application. excluding non-nurses from application.

MY CONCERNS ABOUT MY CONCERNS ABOUT THE NMC ‘APPLICATION THE NMC ‘APPLICATION

PACK 4’PACK 4’ It doesn’t adequately equip the nurse to deal with the more It doesn’t adequately equip the nurse to deal with the more

complex patient issues.complex patient issues. It doesn’t ensure that the nurse is qualified to carry out the It doesn’t ensure that the nurse is qualified to carry out the

counselling task, nor doesn’t it suggest any formal counselling task, nor doesn’t it suggest any formal counselling training for the nurse.counselling training for the nurse.

For example; Principle 3For example; Principle 3 1a) Critically analyse communication, teaching and 1a) Critically analyse communication, teaching and

counselling models theories, and their application to sexual counselling models theories, and their application to sexual health advising practice. health advising practice.

1b) Develop self awareness and interpersonal skills to feel 1b) Develop self awareness and interpersonal skills to feel comfortable, responding to sexual health need or referring comfortable, responding to sexual health need or referring appropriately. appropriately.

2) Demonstrate skill in the application of motivational and 2) Demonstrate skill in the application of motivational and behaviour change theories to practice. behaviour change theories to practice.

There is very little in this ‘Application Pack 4’ that requires There is very little in this ‘Application Pack 4’ that requires you to be a nurse. The only nurse specific task is for you to be a nurse. The only nurse specific task is for prescribing medications under PGDs.prescribing medications under PGDs.

SEXUAL HEALTH SEXUAL HEALTH ADVISING – ADVISING –

Developing The Workforce (London DH Developing The Workforce (London DH June 2008)June 2008) This document presents as a fait accompli that the NMC This document presents as a fait accompli that the NMC

set the standards for health advising.set the standards for health advising. Nurses are the only professional group valued within Nurses are the only professional group valued within

this document.this document. It does not mention counsellors, counselling or the BACP It does not mention counsellors, counselling or the BACP

as a professional body.as a professional body. It is also negligent in failing to acknowledge the It is also negligent in failing to acknowledge the

complexity of patients presenting issues.complexity of patients presenting issues. The competencies for nurses within this document are The competencies for nurses within this document are

very good for the ‘health promotion’ aspects of HAing, very good for the ‘health promotion’ aspects of HAing, which could be for all HAs and not just for the nurse which could be for all HAs and not just for the nurse HAs.HAs.

My concern is that by putting nurses into a job they are My concern is that by putting nurses into a job they are not qualified or skilled enough to do, may compromise not qualified or skilled enough to do, may compromise patient care, inadvertently keeping the patient patient care, inadvertently keeping the patient psychologically maladjusted and within the ‘sick role’.psychologically maladjusted and within the ‘sick role’.

CONCLUSION / CONCLUSION / RECOMMENDATIONS (1)RECOMMENDATIONS (1)

1). Due to poor counselling standards within HAing 1). Due to poor counselling standards within HAing over the years, many clinics are in breach of over the years, many clinics are in breach of BACP/FHCP and SSHA guidelines for offering BACP/FHCP and SSHA guidelines for offering counselling within the NHS.counselling within the NHS.

2). Over the past 18 months with the move by SSHA to 2). Over the past 18 months with the move by SSHA to align HAing to the NMC, most clinics usually only align HAing to the NMC, most clinics usually only want RGN (level 1) as the only essential qualification:want RGN (level 1) as the only essential qualification: New tasks are also being added which exclude non-nurses New tasks are also being added which exclude non-nurses

from application.from application. Job description still expect HA to carry out complex Job description still expect HA to carry out complex

counselling task without any formal counselling qualifications.counselling task without any formal counselling qualifications. The majority of job descriptions (58%) don’t have any nursing The majority of job descriptions (58%) don’t have any nursing

tasks within them, yet some form of counselling was in 98.5% tasks within them, yet some form of counselling was in 98.5% of them, including ‘ongoing counselling’ in 52.4%.of them, including ‘ongoing counselling’ in 52.4%.


3). SSHAs ‘National Job Description’, does 3). SSHAs ‘National Job Description’, does not have any nursing tasks within it. This not have any nursing tasks within it. This leaves questions as to why SSHA is aligning leaves questions as to why SSHA is aligning HAing to the NMC for standards.HAing to the NMC for standards.

4). With statutory regulation for counselling 4). With statutory regulation for counselling via BACP with the HPC in 2011/2012. Many via BACP with the HPC in 2011/2012. Many HAs and clinics that offer counselling could HAs and clinics that offer counselling could be in breach of these guidelines and open to be in breach of these guidelines and open to prosecution, leaving the workforce prosecution, leaving the workforce unsupported and vulnerable, including their unsupported and vulnerable, including their patients. patients.


5). There needs to be uniformity of 5). There needs to be uniformity of counselling qualifications and standards counselling qualifications and standards for HAs across the UK.for HAs across the UK. It needs to be in-line with BACP/FHCP It needs to be in-line with BACP/FHCP

recommendations and A4C for counsellors and recommendations and A4C for counsellors and counselling within the NHS.counselling within the NHS.


6). SSHA has created a split amongst 6). SSHA has created a split amongst HAs by not registering all HAs at the HAs by not registering all HAs at the same time:same time: I suggest they take this slit further and create two I suggest they take this slit further and create two

categories of HA.categories of HA. 1). First being counselling HA, who are the prime 1). First being counselling HA, who are the prime

HAs who work in GUM clinics.HAs who work in GUM clinics. 2). Second being SCPHN HAs who are the prime 2). Second being SCPHN HAs who are the prime

HAs in the community.HAs in the community. NB: This would fit in with the NB: This would fit in with the

recommendations by the DoH and NICE recommendations by the DoH and NICE documents.documents.

TO ANSWER MY INITIALTO ANSWER MY INITIAL

Finally, to answer the question I posed at Finally, to answer the question I posed at the start of this presentation:the start of this presentation: ““In the rush towards professionalism and In the rush towards professionalism and

statutory regulation for Sexual Health statutory regulation for Sexual Health Advisers are we ignoring the ethical Advisers are we ignoring the ethical

boundaries for good counselling practice boundaries for good counselling practice and patient care within Health Advising?”and patient care within Health Advising?”

My answer is “My answer is “YESYES”.”.

THANK-YOU FOR YOUR THANK-YOU FOR YOUR TIMETIME

I can be contacted via I can be contacted via email:email:

[email protected]@orh.nhs.uk

COUNSELLING WITHIN SEXUAL HEALTH ADVISING - ETHICAL CONSIDERATIONS Ian Boss Sexual Health Adviser...

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