COUNSELLING WITHIN SEXUAL HEALTH ADVISING - ETHICAL CONSIDERATIONS Ian Boss Sexual Health Adviser September 2009

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

AIMS In light of the requirements for statutory regulation for healthcare professionals. The main aims are: In light of the requirements for statutory regulation for healthcare professionals. The main aims are: 1). Check that the standards for offering counselling within Health Advising meet the national recommendations set out by the BACP for counselling within the NHS. 1). Check that the standards for offering counselling within Health Advising meet the national recommendations set out by the BACP for counselling within the NHS. This was done by an audit of the counselling elements within job descriptions that were advertised throughout This was done by an audit of the counselling elements within job descriptions that were advertised throughout Comparing these against the standards for offering counselling within the NHS. Comparing these against the standards for offering counselling within the NHS. Also reviewing these against the standards set down by the SSHA National Job Description. Also reviewing these against the standards set down by the SSHA National Job Description.

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

STATUTORY REGULATION Professional regulation becomes statutory regulation at a point where the State regards it as so important for public safety that it legislates for a ban on either using the professional title or doing certain things unless your name appears in the register. This protects the patients from the harm caused by people practising a profession which they are not fit to. It engenders public confidence by allowing members of the public and the employers of professionals to check on a person’s registration status, knowing that the information they find will be correct and up to date. The Department of Health (July 2006). The regulation of the non-medical healthcare professionals. London DH

AUDIT OF H. A. JOB DESCRIPTIONS & PERSON SPECIFICATIONS Job descriptions were collected for one year: January 2008 to January 2009 Job descriptions were collected for one year: January 2008 to January (search ‘health adviser’) (search ‘health adviser’) Number of Job Descriptions reviewed: n = 65 Number of Job Descriptions reviewed: n = 65 Aim to look at the counselling qualifications required to provide the counselling tasks. Aim to look at the counselling qualifications required to provide the counselling tasks. To check these against BACP/FHCP standards for offering counselling within the NHS. To check these against BACP/FHCP standards for offering counselling within the NHS.

CODES FOR DATA COLLECTION Job Descriptions: Tasks OC = Ongoing Counselling. OC = Ongoing Counselling. HV = Giving HIV positive results with ongoing/ or counselling. HV = Giving HIV positive results with ongoing/ or counselling. RR = Familiar with health promotion strategies, motivational change and counselling RR = Familiar with health promotion strategies, motivational change and counselling models. models.

CODES FOR DATA COLLECTION OT = Other Crisis Counselling Interventions OT = Other Crisis Counselling Interventions Initial crisis intervention, assessment and counselling e.g.: TOP, depression, sexual identity, sexual assault, substance misuse, sexual dysfunction. Initial crisis intervention, assessment and counselling e.g.: TOP, depression, sexual identity, sexual assault, substance misuse, sexual dysfunction. or = Assess psychological / emotional distress, provide containment and / or referral (assess immediate suicide risk). or = Assess psychological / emotional distress, provide containment and / or referral (assess immediate suicide risk). or = Respond to frequent situations which can be highly emotive, distressing and unpredictable. or = Respond to frequent situations which can be highly emotive, distressing and unpredictable.

BREAKDOWN OF THE DATA Number of job descriptions reviewed: n=65. Number of job descriptions reviewed: n=65. ‘Ongoing counselling’: OC = 34 (52.4%). ‘Ongoing counselling’: OC = 34 (52.4%). Post HIV positive counselling: HV = 55 (84.6%). Post HIV positive counselling: HV = 55 (84.6%). Crisis counselling interventions: OT = 56 (86.2%). Crisis counselling interventions: OT = 56 (86.2%). Risk Reduction: RR = 8 (12.3%). Risk Reduction: RR = 8 (12.3%). Psychological / Counselling support, includes all and/or any of the above: = 64 (98.5%). Psychological / Counselling support, includes all and/or any of the above: = 64 (98.5%).

QUALIFICATIONS SUMMARY TABLE 1

A): 14 (21.5%) of clinics were not asking for any counselling qualification. A): 14 (21.5%) of clinics were not asking for any counselling qualification. B): Counselling Training / Counselling Qualification, did not indicate the level. B): Counselling Training / Counselling Qualification, did not indicate the level. C): Only one clinic asked for a diploma in counselling. (This is consistent with BACP/FHCP & UKCP/CPC guidelines for offering counselling within the NHS). C): Only one clinic asked for a diploma in counselling. (This is consistent with BACP/FHCP & UKCP/CPC guidelines for offering counselling within the NHS). D): With the MSc Counselling; this was optional with other either/or qualifications. D): With the MSc Counselling; this was optional with other either/or qualifications. Nine ‘person specifications’ asked for two or more counselling qualifications. Nine ‘person specifications’ asked for two or more counselling qualifications.

EXPERIENCE SUMMARY TABLE 2

A): 24 (36.95%) of clinics were not asking for any counselling experience A): 24 (36.95%) of clinics were not asking for any counselling experience B): Request that the HA has ‘counselling skills or 1:1 counselling experience’. (Counselling comes across as something that is picked-up on the job rather than an academic qualification). B): Request that the HA has ‘counselling skills or 1:1 counselling experience’. (Counselling comes across as something that is picked-up on the job rather than an academic qualification). 18 ‘person specifications’ asked for more than two elements for counselling experience. 18 ‘person specifications’ asked for more than two elements for counselling experience.

14 CLINICS THAT DID NOT ASK FOR COUNSELLING QUALIFICATIONS TABLE 3

14 CLINICS THAT DID NOT ASK FOR COUNSELLING QUALIFICATION TABLE 3 14 (21.5%) of clinics were not asking for any counselling qualification. Equates to: 9 (13.9%) carrying out ‘ongoing counselling’ without counselling qualifications. Equates to: 9 (13.9%) carrying out ‘ongoing counselling’ without counselling qualifications. 5 (7.7%) were carrying out high level counselling with either none or little experience of having previously used counselling. 5 (7.7%) were carrying out high level counselling with either none or little experience of having previously used counselling. NB: All these clinics are in breach of SSHA, BACP & UKCP guidelines for offering counselling within the NHS.

OVERALL ASSESSMENT OF THE DATA 1). Generally fair to say that all clinics carry out some form of counselling support or ‘ongoing counselling’. 1). Generally fair to say that all clinics carry out some form of counselling support or ‘ongoing counselling’. 2). Primarily in the area of giving HIV positive results and crisis work. 2). Primarily in the area of giving HIV positive results and crisis work.

EVALUATION OF THE JOB DESCRIPTIONS (1) ‘Nursing’ Within The Job Descriptions RGN as an essential qualification was in all the job descriptions. RGN as an essential qualification was in all the job descriptions. 58% of the ‘job descriptions’ did not have any nursing task within them. 58% of the ‘job descriptions’ did not have any nursing task within them. 14% only had PDGs as the only nursing task. 14% only had PDGs as the only nursing task.

EVALUATION OF THE JOB DESCRIPTIONS (2) Two ‘job description’ from the same clinic demonstrate how the essential qualifications in general are becoming more nursing orientated. In both cases the ‘job descriptions’ remained the same. There was also very little in both of them that required you to be a nurse. FROM: Sexual Health Adviser / Nurse Practitioner Qualifications Registered Nurse 1st level/CQSW/Diploma Social Work or relevant degree e.g. psychology (E) Counselling Qualification (D) Skills Counselling skills (E) Special Knowledge: To have knowledge and understanding of clinical and psychological aspects of STI’s and related sexual health issues (E). TO: Nurse Practitioner / Health Adviser Qualifications Registered Nurse 1st level (E) Counselling Qualification (D)

EVALUATION OF THE JOB DESCRIPTIONS (3) Only one job description mentioned the BACP as a professional body and was asking for BACP Accreditation. Only one job description mentioned the BACP as a professional body and was asking for BACP Accreditation.

COUNSELLING STANDARDS WITHIN THE NHS (1) SSHA Manual for Sexual Health Advisers recommend: SSHA Manual for Sexual Health Advisers recommend: For contract based counselling – to work within BACP Ethical Framework for Good Practice in Counselling & Psychotherapy. For contract based counselling – to work within BACP Ethical Framework for Good Practice in Counselling & Psychotherapy.

COUNSELLING STANDARDS WITHIN THE NHS (2) BACP/FHCP & UKCP/CPC recommendations for qualifications for counselling with in the NHS: BACP/FHCP & UKCP/CPC recommendations for qualifications for counselling with in the NHS: ‘qualification to diploma level or equivalent, which comprises a minimum of 450 hours of, taught theory and skills’. ‘qualification to diploma level or equivalent, which comprises a minimum of 450 hours of, taught theory and skills’. A4C Band 6 or above ‘to be accredited in counselling or psychotherapy recognised by a professional body’. A4C Band 6 or above ‘to be accredited in counselling or psychotherapy recognised by a professional body’.

COUNSELLING STANDARDS WITHIN THE NHS (3) Guidance for best practice: the employment of counsellors and psychotherapist in the NHS. BACP A ‘counselling skills’ course: “do not result in a professional qualification……as counselling competency is not tested at this level and that course tutors may not be qualified counselling practitioners”. A ‘counselling skills’ course: “do not result in a professional qualification……as counselling competency is not tested at this level and that course tutors may not be qualified counselling practitioners”. A ‘certificate in counselling’: “may combine both practical and theoretical components….. successful completion of this programme usually enables the student to access the diploma in counselling”. A ‘certificate in counselling’: “may combine both practical and theoretical components….. successful completion of this programme usually enables the student to access the diploma in counselling”.

COUNSELLING STANDARDS WITHIN THE NHS (4) These are only guidelines for best practice as legally there are no statuary requirements. These are only guidelines for best practice as legally there are no statuary requirements. Statutory regulation takes place in 2 – 3 years for the BACP through the HPC. Statutory regulation takes place in 2 – 3 years for the BACP through the HPC.

REVIEW OF SSHA NATIONAL JOB DESCRIPTION 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 counselling qualification. (This would be prior to A4C and is against both SSHA & the BACP guideline for offering counselling within the NHS). A ‘counselling certificate’ is the only essential counselling qualification. (This would be prior to A4C and is against both SSHA & the BACP guideline for offering counselling within the NHS). The MSc in Counselling is optional, along with other masters qualifications. The MSc in Counselling is optional, along with other masters qualifications. The Job Summary / Main Responsibilities both state ‘ongoing counselling’. The Job Summary / Main Responsibilities both state ‘ongoing counselling’. There are no nursing elements within this job description. There are no nursing elements within this job description. This is a ‘health promotion / counselling’ Job Description and has nothing to do with nursing. This is a ‘health promotion / counselling’ Job Description and has nothing to do with nursing.

NMC MIGRATION FOR SCPHN IN SEXUAL HEALTH Application Pack 4: Migration To NMC Register as a Specialist Community Public Health Nurse (SCPHN) in Health Advising, Part 3 of the NMC Register. Application Pack 4: Migration To NMC Register as a Specialist Community Public Health Nurse (SCPHN) in Health Advising, Part 3 of the NMC Register. The NMC have seemingly taken the ‘public health’ recommendations from the DoH documents, and have created the Application Pack 4. The NMC have seemingly taken the ‘public health’ recommendations from the DoH documents, and have created the Application Pack 4. This now has become the gold standard adopted by SSHA for Sexual Health Advising, (Develping The Workforce). This now has become the gold standard adopted by SSHA for Sexual Health Advising, (Develping The Workforce). These days nationally most HA jobs are excluding non- nurses from application. These days nationally most HA jobs are excluding non- nurses from application.

MY CONCERNS ABOUT THE NMC ‘APPLICATION PACK 4’ It doesn’t adequately equip the nurse to deal with the more complex patient issues. It doesn’t adequately equip the nurse to deal with the more complex patient issues. It doesn’t ensure that the nurse is qualified to carry out the counselling task, nor doesn’t it suggest any formal counselling training for the nurse. It doesn’t ensure that the nurse is qualified to carry out the counselling task, nor doesn’t it suggest any formal counselling training for the nurse. For example; Principle 3 For example; Principle 3 1a) Critically analyse communication, teaching and counselling models theories, and their application to sexual health advising practice. 1a) Critically analyse communication, teaching and counselling models theories, and their application to sexual health advising practice. 1b) Develop self awareness and interpersonal skills to feel comfortable, responding to sexual health need or referring appropriately. 1b) Develop self awareness and interpersonal skills to feel comfortable, responding to sexual health need or referring appropriately. 2) Demonstrate skill in the application of motivational and behaviour change theories to practice. 2) Demonstrate skill in the application of motivational and behaviour change theories to practice. There is very little in this ‘Application Pack 4’ that requires you to be a nurse. The only nurse specific task is for prescribing medications under PGDs. There is very little in this ‘Application Pack 4’ that requires you to be a nurse. The only nurse specific task is for prescribing medications under PGDs.

SEXUAL HEALTH ADVISING – Developing The Workforce (London DH June 2008) This document presents as a fait accompli that the NMC set the standards for health advising. This document presents as a fait accompli that the NMC set the standards for health advising. Nurses are the only professional group valued within this document. Nurses are the only professional group valued within this document. It does not mention counsellors, counselling or the BACP as a professional body. It does not mention counsellors, counselling or the BACP as a professional body. It is also negligent in failing to acknowledge the complexity of patients presenting issues. It is also negligent in failing to acknowledge the complexity of patients presenting issues. The competencies for nurses within this document are very good for the ‘health promotion’ aspects of HAing, which could be for all HAs and not just for the nurse HAs. The competencies for nurses within this document are very good for the ‘health promotion’ aspects of HAing, which could be for all HAs and not just for the nurse HAs. My concern is that by putting nurses into a job they are not qualified or skilled enough to do, may compromise patient care, inadvertently keeping the patient psychologically maladjusted and within the ‘sick role’. My concern is that by putting nurses into a job they are not qualified or skilled enough to do, may compromise patient care, inadvertently keeping the patient psychologically maladjusted and within the ‘sick role’.

CONCLUSION / RECOMMENDATIONS (1) 1). Due to poor counselling standards within HAing over the years, many clinics are in breach of BACP/FHCP and SSHA guidelines for offering counselling within the NHS. 1). Due to poor counselling standards within HAing over the years, many clinics are in breach of BACP/FHCP and SSHA guidelines for offering counselling within the NHS. 2). Over the past 18 months with the move by SSHA to align HAing to the NMC, most clinics usually only want RGN (level 1) as the only essential qualification: 2). Over the past 18 months with the move by SSHA to align HAing to the NMC, most clinics usually only want RGN (level 1) as the only essential qualification: New tasks are also being added which exclude non-nurses from application. New tasks are also being added which exclude non-nurses from application. Job description still expect HA to carry out complex counselling task without any formal counselling qualifications. Job description still expect HA to carry out complex counselling task without any formal counselling qualifications. The majority of job descriptions (58%) don’t have any nursing tasks within them, yet some form of counselling was in 98.5% of them, including ‘ongoing counselling’ in 52.4%. The majority of job descriptions (58%) don’t have any nursing tasks within them, yet some form of counselling was in 98.5% of them, including ‘ongoing counselling’ in 52.4%.

CONCLUSION / RECOMMENDATIONS (2) 3). SSHAs ‘National Job Description’, does not have any nursing tasks within it. This leaves questions as to why SSHA is aligning HAing to the NMC for standards. 3). SSHAs ‘National Job Description’, does not have any nursing tasks within it. This leaves questions as to why SSHA is aligning HAing to the NMC for standards. 4). With statutory regulation for counselling via BACP with the HPC in 2011/2012. Many HAs and clinics that offer counselling could be in breach of these guidelines and open to prosecution, leaving the workforce unsupported and vulnerable, including their patients. 4). With statutory regulation for counselling via BACP with the HPC in 2011/2012. Many HAs and clinics that offer counselling could be in breach of these guidelines and open to prosecution, leaving the workforce unsupported and vulnerable, including their patients.

CONCLUSION / RECOMMENDATIONS (3) 5). There needs to be uniformity of counselling qualifications and standards for HAs across the UK. 5). There needs to be uniformity of counselling qualifications and standards for HAs across the UK. It needs to be in-line with BACP/FHCP recommendations and A4C for counsellors and counselling within the NHS. It needs to be in-line with BACP/FHCP recommendations and A4C for counsellors and counselling within the NHS.

CONCLUSION / RECOMMENDATIONS (4) 6). SSHA has created a split amongst HAs by not registering all HAs at the same time: 6). SSHA has created a split amongst HAs by not registering all HAs at the same time: I suggest they take this slit further and create two categories of HA. I suggest they take this slit further and create two categories of HA. 1). First being counselling HA, who are the prime HAs who work in GUM clinics. 1). First being counselling HA, who are the prime HAs who work in GUM clinics. 2). Second being SCPHN HAs who are the prime HAs in the community. 2). Second being SCPHN HAs who are the prime HAs in the community. NB: This would fit in with the recommendations by the DoH and NICE documents. NB: This would fit in with the recommendations by the DoH and NICE documents.

TO ANSWER MY INITIAL Finally, to answer the question I posed at the start of this presentation: Finally, to answer the question I posed at the start of this presentation: “In the rush towards professionalism and statutory regulation for Sexual Health Advisers are we ignoring the ethical boundaries for good counselling practice and patient care within Health Advising?” My answer is “YES”.

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