Widening the entry gates to HV training

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Widening the entry gates to HV training Prof
Sarah Cowley Professor of Community Practice
Development Kings College London, Florence
Nightingale School of Nursing and Midwifery
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Widening the entry gate to health visitor
education
Sarah Cowley 15th October 2009
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Health visitor education and regulation

• 1892 first formal education programme for
  health visitors
• 1929 regulated profession in statute 2 years
  training, or 6 months for qualified
  nurses/midwives, graduates, teachers
• 1965 51 weeks training entry restricted to
  general nurses with midwifery training only
  midwifery requirement gradually reduced to
  obstetric experience, then removed
• 1995 minimum 32 weeks training nurses accepted
  from any part of the register
• 2000 registered nurses or midwives accepted
• 2001 health visiting removed from statute
• 2004 45 programmed weeks training entry
  restricted to registered nurses or midwives
• 2004 - health visiting register closed

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Widening the entry gate

• Why is change necessary?
• Improve educational standards and fitness for
  purpose
• Workforce crisis most immediate and significant
  
• Improve equity and diversity in workforce
• What are the barriers?
• Myths and misconceptions
• Resistance to change
• Professional protectionism
• What is the way forward?

Cowley 2009
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Educational needs and standards

• Since 1995, educational standards have been
  concerned with issues other than health visiting
• Current standards written to establish a generic
  register for community public health nurses, not
  to meet the educational needs of health visitors
• Of the four years spent in education, less than
  one is specifically concerned with health
  visiting
• There is no consensus about the importance of
  pre-registration nursing education, or about
  which elements are relevant to health visiting

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Post-registration nursing system

• Two major concerns cited by programme leaders
• Viability of programmes, as too few students
• Lack of time for essential content within
  programme
• Health visiting qualification bound up with
  SCPHN, so generic content is standardised
• Limited flexibility to update/vary content
• Prevents improvements/developments in health
  visitor education
• In law (e.g. for purposes of regulation) health
  visiting is a post-registration nursing
  qualification

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System problems

• Career framework
• Starts at wrong place for Modernizing Nursing
  Careers
• Skillmix issue substitution and capability
• Limited funding for student places on full time
  programmes cited as a problem BUT
• Post-registration nursing qualifications are
  obtainedon-the-job in all other specialisms,
  SO
• Cost of health visitor education regarded as
  excessive
• Secondment/sponsorship and backfill regarded as
  luxuries and unlikely to last

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Question
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Whole Time Equivalent (WTE) Health Visitors
1988-2008
DH workforce stats
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Health visitors above retirement age
DH workforce stats
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Health visiting register 1989 2004SCPHN
register (HV) Aug. 2004 2008
Missing data 1999,2000, 2001
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Workforce crisis

• Health visitors are the NHS group that tops the
  league of numbers retiring
• Falling workforce numbers reflect cuts in posts,
  but also difficulties in recruiting qualified
  health visitors
• Falling student numbers reflect reduced funding,
  and also difficulties in recruiting students of
  suitable calibre
• Health visiting is no longer regarded as an
  attractive career option by nurses and midwives

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Equity and diversity in the workplace
government policy

• Extending employment through Sure Start Local
  Programmes 1999?
• NHS Modernisation ? improved flexibility
  including health service of all the talents
  2000
• 2003 Integrated working across childrens
  workforce
• Opportunity in the workplace

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Equity and diversity who do health visitors
delegate to?
D-SCOVOR survey, Cowley et al 2007
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Who provides core service?
80 70 60 50 40 30 20 1 0
79
49
29
25
21
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HV others
other profs
RGN
Clinic assistant
NN
HVonly
-----HV team-----
D-SCOVOR survey, Cowley et al 2007
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Who helps extend service?
More
Less
Health visitor only providing core service
fewest groups and community Health visitor
RN no increasein specific areas of work More
skillmix fewer home visits

• Health visitors others in team More of all
  groups/community
• Health visitors Nursery nurse More sleep and
  behaviour, baby massage
• Health visitors Clinic assistants More
  parenting support

D-SCOVOR survey, Cowley et al 2007
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Equity and diversity in health visiting
government policy

• 2003 DH rejected NMC consultation (agreed by
  80 at consultation) to establish direct entry
  education for third part of register
• Restrictive entry gate denies career pathways to
  majority of health visiting team members, as well
  as other potentially suitable recruits
• Unemployment, especially graduates and young
  people, is currently very high

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Myths and misconceptions

• Opening entry gates will encourage young entrants
  
• Mothers would not like young health visitors
• Changing the training would mean losing all
  content currently obtained through nurse
  education
• Direct entry means removing the nursing
  pre-requisite without changing the training
• The public trust health visitors because they are
  nurses (even if they dont know they are nurses!)
• Health visitors wouldnt like it

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Workforce development

• Length for direct entry training (if law changed)
  
• 18 2 years 34 3 years, 13 4 years
• 29 think it should not happen
• Potential recruits (as well as nurses)
• Graduates from suitable degrees 65
• Other health professionals 43
• Nursery nurses 30
• Social workers 19
• Sure start workers 13

D-SCOVOR survey, Cowley et al 2007
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Resistance to change

• Especially by those who
• Value nursing, but not health visiting
• Want health visitors to carry out nursing
  functions, not health visiting ones
• Believe the way they were educated is the only
  way of learning
• Have limited understanding of how both nursing
  education, and other forms of education have
  changed
• Have limited understanding of how career patterns
  are changing across age groups

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Professional protectionism

• Perception that unity and singularity (not
  diversity) are central to developing nursing as
  a profession
• Perception that nursing is the only occupation
  that counts, and nurses know everything
• Perception that nursing knowledge can only be
  gained through three year pre-registration
  programme
• Perceptions that to change the entry gates will
  harm nursing
• Perception that nursing and health visiting are
  the same

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How closely does health visiting relate to
nursing?
same/somewhatsimilar
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completely/somewhatdifferent
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D-SCOVOR survey, Cowley et al 2007
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Dual and single qualification options needed

• Dual qualification options,
• i.e., nursing/midwifery AND health visiting
• Develop shortened and fast-track options
• Consider pre-registration public health nursing
• Single qualification routes to be developed
• i.e., health visiting qualification only through
  
• Baseline health visiting degree
• Develop shortened Masters route for suitable
  graduates

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Dual qualification options

• Professional entry programme, for qualified
  nurses and midwives (RNHV or RM HV)
• Could this encompass other health professionals
• Allied health professionals?
• Registered complementary therapists?
• Social workers? Graduate mental health workers?
• Length of programme? 45 weeks is too short
• Dual qualification 4-year programme
• Shortened graduate-entry nursing programmes
  followed immediately by health visiting programme

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Single qualification nursing route

• Develop public health nursing options
• Pre-registration public health nursing
  qualification
• Could be feeder for SCPHN register would need
  to encompass all routes (i.e., SN, OHN, sexual
  health, health protection etc)
• Might suit nursing hierarchy
• Not another branch as most of CFP (year 1) is
  about clinical skills applied to caring for sick
  people
• Would probably need to derogate from EU
  regulations for nursing qualifications
• Would hasten loss of health visiting title

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Single qualification health visiting route

• A base-line three year health visiting degree
  programme
• Students to reach standards agreed by the
  profession
• Programme to include
• competences to be approved by regulator ?NMC
• agreed elements of nursing and midwifery
• other aspects considered important?
• Would require health visiting leadership

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Expanding entry and developing standards

• A two-year full time Masters programme to attract
  graduates from a range of suitable degree
  programmes
• Public health
• Early years studies
• Community studies
• Health promotion
• Psychology
• Sociology
• Social policy
• Biomedical sciences
• Nutrition
• Others?
• Standards based on agreed three year baseline
  degree

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The way forward

• Identify what is needed
• Forms of education content
• Relevance from nursing so that is not lost
• Funding of student programmes
• Changes to legislation to allow developments
• Explode myths and misconceptions
• Involve consumers FPI, Netmums
• Involve Unite-CPHVA??

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References

• Cowley S, Caan, W, Dowling S, Weir, H (2007) What
  do health visitors do? A national survey of
  activities and service organisation. Public
  Health. 121., (11) 869-879
• Cowley S, Bidmead C (2009) Controversial
  questions (part two) Should there be a direct
  entry route to health visitor education?
  Community Practitioner, 82 (7) 24-28
• NHS Information Centre for Heath and Social Care.
  2009. NHS Hospital and Community Health Services
  Non-Medical Workforce Census, Detailed Results
  2008. The NHS Information Centre for Heath and
  Social Care. London

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