James Meek, Debbie Brittain and Kaisha Dunnett from the University of Central Lancashire discuss The role of the HCA in sexual health services
The healthcare assistant (HCA) in sexual health services has a varying role, including chaperoning, sexual history-taking, clinical skills in venepuncture or swab taking and finally pregnancy testing.
The role differs from one sexual health service to another and so does the level of training and development that the HCA receives.
This article presents a review of the literature and the future training and development opportunities available to the HCA in order to progress in acareer within sexual health services.
Sexual health is an important area of public health, as most of the adult population is sexually active within England (Department of Health (DH), 2013a), which accounts for 84% of the UK's population. Providing accessible, quality sexual health services is a significant aspect of improving the health and wellbeing of individuals and populations (DH, 2013a).
The 2013 publication, Framework for Sexual Health Improvement in England (DH, 2013), clearly laid out the Government's ambitions for improving sexual health within the country.
Likewise, poor sexual health is not evenly spread throughout the population. There are significant links between deprivation and poor sexual health (DH, 2014). Recent statistics from the DH (2014) andPublic Health England (PHE) (2014) report that in 2013 there were approximately 450 000 diagnoses of sexually transmitted infections in England. Alongside this are increasing rates of abortions, teenage conceptions and sexually transmitted infections (STIs). This appears to be mostly associated with women, young adults, black and minority ethnic groups and men who have sex with men (MSM) (DH, 2013a).
The recently published 2013 abortion statistics for England and Wales reported 185 331 abortions had been performed (DH, 2014). The data also highlights the increasing numbers of women undergoing repeat abortions and their age: last year, 37% of women had previously had one or more abortions and approximately 27% of the women were aged under 25.
Women who engage in unprotected sexual intercourse not only risk unplanned pregnancy but also risk contracting blood-borne virus infections (BBVs), such as hepatitis and human immunodeficiency virus (HIV), as well as STIs (British Association for Sexual Health and HIV (BASHH), 2013; DH, 2014). However, some women are often uninformed of these added risks to their sexual health. The recent DH (2014) report acknowledges that unplanned pregnancy and repeat abortion represent major public health issues within the UK.
Chlamydia is the most commonly reported curable bacterial STI in the UK. In 2013, 1.7 million chlamydia tests were undertaken and 208 755 chlamydial infections were diagnosed (DH, 2013). The statistics report 80% of cases were diagnosed in sexually active young adults who were aged under 25 years (DH, 2013). Therefore, the highest prevalence rates are in sexually active 15-24-year-olds and are estimated at 5-10% (DH, 2013). Chlamydial infection is mostly asymptomatic in approximately 70% of women and 50% of men. It causes significant short- and long-term morbidity (BASHH, 2006). Guidance for chlamydia screening recommends that this should be undertaken annually and, for sexually active young people, on change of sexual partner (BASHH, 2006). It is mostly provided through community sexual and reproductive health (SRH) services (together with termination of pregnancy services), genitourinary medicine (GUM) clinics (PHE, 2014) and primary care, which included general practices and pharmacies (DH, 2013).
Public Health England (2014) reports the growth in the rates of gonorrhoea, which have increased by 15% between 2012 and 2013. Both young people aged under 25 years and MSM are associated with increased rates of STIs.
However PHE (2014) acknowledges that this increase is due to several factors, including increased testing of this population and unsafe sexual behaviour.
It is estimated that, in 2012, there were 98 400 (93 500-104 300) people living with HIV in the UK. The recent statistics from the PHE HIV Report (2013) cite an estimated overall prevalence of 1.5 per 1000 populations (1.0 in women and 2.1 in men) (PHE, 2013). Of concern is that approximately 21 900 people living with HIV in 2012 did not know they had HIV infection, thereby increasing the chance of HIV spread (PHE, 2013). MSM and black Africans are disproportionately affected by HIV in the UK (DH, 2013). Stigma and discrimination are commonly associated with HIV; challenges arise as some MSM and Black Africans are likely not to access services because of this (DH, 2013). PHE (2014) acknowledges the real challenges to sexual health service care and provision to address this.
It recommends sustained preventative efforts, such as providing improved coverage for STI screening and better access to contraceptive and sexual health services (CaSH). The aim is to meet the sexual health needs of those groups that have the poorest sexual health.
Integrated sexual health services Sexual health can be improved by providing alternative models of care. Integrated sexual health services provide better access, as they are normally provided under one roof, often referred to as ‘one-stop shops’.
This allows most contraceptive and sexual health needs to be met in one visit to a service. It also provides services with extended opening hours in accessible locations and is seen as an efficient use of resources.
Public Health England, in conjunction with partner agencies, has developed a national framework for commissioning HIV and sexual and reproductive health services (DH, 2013). Local authorities were mandated from 1 April 2013 to commission comprehensive open access sexual health services (DH, 2013). Public Health England suggests this approach will facilitate effective use of available staffing resources and skills mix within the available sexual health workforce.
Skill mix within sexual health The Faculty of Sexual and Reproductive Healthcare (FSRH) (2013a)'s publication, Service Standards on Workload in Sexual and Reproductive Health, acknowledges the considerable variation in sexual health service delivery within the UK. Services range from primary care/community-based contraceptive services, which are separate from genitourinary medicine (GUM) services and abortion services, to community-based services that are fully integrated (FSRH, 2013a). It ‘recommends services, but not necessarily individual clinics, should be staffed by doctors, nurses and healthcare assistants with a variety of skills and working as a clinical team’ (FSRH, 2013a:6).
Emily Bullock, Clinic Support Worker, Brook, Salford How long have you been an HCA in sexual health services? I have worked for Brook, which is a sexual health and wellbeing charity providing services for under-25s, for two and a half years as a clinic support worker. I have been mainly based in clinics across Salford and Oldham, but have also had the opportunity to take part in sexual health drop-in clinics in schools and colleges.
What is your favourite part of the role? My favourite part of the role is the constant learning curve. I see clients face to face on a daily basis and they present such a variety of questions and situations I am constantly learning new things.
I feel like I learn a lot from the clients I see; I have been in this role for almost 3 years now and I am still learning new things every day. Working with sexual health nurses has been a valuable experience, as everyone shares their knowledge and skills to make for a supportive, communicative working environment.
What training have you undertaken? During my time working at Brook, I have had the opportunity to access a variety of training, ranging from basic life support, safeguarding training to child sexual exploitation training. The training on offer is extremely valuable as I am able to apply my knowledge to my role on a daily basis. Knowledge and practice around young people and sexual health is constantly developing, so there is a vast and varied amount of training to access.
What's coming up next for you? I hope to return to university and train as a nurse alongside continuing to work as a clinic support worker (CSW) at Brook, with the aim to becoming a sexual health nurse, either in GUM or a contraception and sexual health (CaSH) setting.
The FSRH's Service Standards for Sexual and Reproductive Healthcare (2013b) supports this further, while clearly acknowledging enhanced nurse-led service provision. It also recommends developing the role of healthcare assistants/clinical support workers within sexual health.
This article will discuss some of the main roles a HCA will be involved with, although these examples are not exhaustive and may vary from service to service.
The HCA plays a pivotal role within sexual health care delivery. They are a key member of the team that provides high-quality care to patients within sexual health services and this role should be supported and developed.
“The HCA is a key member of the team that provides high-quality care to patients within sexual health services.”
The role of the HCA within sexual health care Chaperoning The HCA has frequently been involved with chaperoning within sexual health services. Patients are often required to have intimate genital examinations for obtaining samples such as swabs, or insertion of devices such as the intrauterine device. The chaperone acts as an advocate to the patient, explaining what will happen during the procedure or examination and why this is required.
The chaperone can assist in avoiding any unnecessary discomfort or pain and help to ensure dignity can be maintained for the patient. They could also assist in any misunderstanding or where false allegations may have been made against a healthcare professional (Royal College of Nursing, 2006).
The HCA should document in the medical notes that they were present at the time of examination or procedure being undertaken.
Pregnancy testing Pregnancy testing is an important role within sexual health care and many tests are undertaken each day (Kraszewski, 2007). Tests can be undertaken with blood sampling, although most commonly urine testing takes place, using commercially prepared point-of-care tests.
HCAs should ensure they have received training on how to use the test and to interpret the findings. Competency documents should be used and assessed regularly, to ensure staff in sexual health services remain competent in this skill. Recording the batch number of the test and documenting the findings in the medical notes is required.
A diagnosis of an unwanted pregnancy can be very distressing for a patient and relevant training and experience is required in order to support the patient with the result (Society of Sexual Health Advisors (SSHA), 2004).
Sexual health services should have a referral process in place to ensure timely access to termination of pregnancy, should this be required. The HCA should follow clinic protocol on management of pregnancy test results, including when to return to repeat a test.
Venepuncture Blood samples are required in sexual health services, most commonly to test for HIV and syphilis, alongside other blood-borne viruses. Obtaining blood samples is one of the most common non-invasive procedures that are undertaken in sexual health services. It was once a skill that only medical staff undertook; however, many non-registered practitioners, including HCAs, now undertake the role (Brooks, 2014).
There are no nationally recognised qualifications in venepuncture and training varies from a few hours to several days. Once a training programme has been undertaken, a clinical competency document should be completed and an appropriate mentor should be assigned to the HCA. This can assist the HCA in becoming competent in this skill.
“The HCA plays a pivotal role within sexual health care delivery.”
The HCA should be aware of any follow-up that is required for the patient, such as returning out of incubation period to repeat the blood test or management of vasovagal episodes.
Undertaking a sexual history Patients attending sexual health services commonly complete a triage form when they attend the service. This helps to ensure the patient sees the most appropriate member of staff within the service (Meek, 2013). Patients attending for repeat blood testing out of incubation periods or urine testing to rule out pregnancy, for example, may be seen by the HCA first within the clinic.
The HCA can follow clinic procedures, ensuring guidelines are followed and escalating problems or concerns to one of the registered practitioners.
HCAs can be trained to undertake sexual history taking from patients, especially those who attend services without any symptoms of infection within GUM clinics. The BASHH (2013) guidelines on sexual history taking discuss the main points of a sexual history for someone without any signs of an infection, and although BASHH does not discuss HCAs undertaking this skill, its website does offer training called ‘STIF Level 1 Competency’, which includes sexual history taking and asymptomatic screening for sexually transmitted infections (BASHH, 2014a).
The HCA completing this role can ensure effective use of resources is deployed to ensure the patient can be seen as efficiently as possible within sexual health services (Meek, 2013).
Obtaining genital samples Genital sampling for sexually transmitted infections used to be solely an invasive procedure requiring a practitioner to obtain the samples. With advances in diagnostic testing, urine and patient self-obtained vaginal, pharyngeal and rectal swabs can easily be used for patients without signs and symptoms of a sexually transmitted infection (BASHH, 2014b).
As previously discussed, HCAs are able to take a sexual history and then proceed with instructing the patient how to obtain samples. The HCA completing this role requires training such as the ‘STIF Level 1 Competency’ or in-house training to be able to fulfil this role.
The benefit to sexual health services of the HCA undertaking this is that it ensures patients with more complicated signs of infections can then be seen more promptly by the most appropriate specialist nurse or clinic doctor (Meek, 2013). It is an effective use of resources within the clinic.
Immunisation and vaccination Patients in sexual health services may require vaccination, depending on their sexual history. Most commonly, hepatitis B vaccines are offered to those at increased risk of contracting the virus (BASHH, 2012).
Another vaccine commonly given in the sexual health clinic is that for influenza, usually referred to as the ‘winter flu’ vaccine and is something offered to all patients living with HIV, due to their potentially compromised immune system. The HCA with appropriate training is well placed to be undertaking this role. The RCN (2013) has produced guidelines on HCAs vaccinating in practice and supports HCAs performing this role if they have backing from a registered practitioner and their employer.
Natasha Nellis, Healthcare Assistant, Blackpool Teaching Hospitals NHS Foundation Trust How long have you been an HCA in sexual health services? I have been working in sexual health services for just over 6 years now. I had previously been working at Blackpool Victoria Hospital on the endocrinology ward for 5 years and had always wanted to work within sexual health, so as soon as I saw the job advertised I went for it.
What's your favourite part of the role? My favourite part of the role is providing people with the correct information and knowledge about their infection and reassuring them that there is always treatment and help available. I also like the fact that I am working in an integrated service, so I get to see all different aspects of sexual health services, including blood-borne viruses and chlamydia screening.
What training have you undertaken? While working in sexual health, I have undertaken 4 modules at the University of Central Lancashire, which my department has supported me to do. I have also done some in-house training, which includes:
● Moving and handling
● Self-harming training
● Information governance
What's coming up next for you? In the next year, I am hoping to gain a secondment from my organisation to go on to do my nurse training. In the meantime, I would like to carry on studying at university to keep up my academic skills, to help me when I am ready to study nursing.
Training and development needs HCAs working in sexual health services need to ensure they receive training in order to develop personally within the service. Training can be formal courses, for example, organised by the BASHH, or informal in-house training conducted by clinical experts working in the clinic.
Occasionally, external commercial companies may provide training on new products or services that are going to be used within the service; although access to training may not always be easy.
Alternatively, academic institutes such as the University of Central Lancashire offer a full and part-time undergraduate BSc (Hons) sexual health studies degree (2014). This degree can equip HCAs with relevant knowledge and skills in the field of sexual health care to enhance their employability skills in further roles in sexual health.
Graduates have secured roles as sexual health promotion practitioner, community sexual health outreach workers and advocates for those suffering sexual violence.
NHS trusts may also second an HCA to undertake nurse training at a university (NHS Careers, 2014). HCAs have a wealth of knowledge in sexual health care and, with the appropriate training, development and support, can progress in their career.
Kaisha Dunnett, Senior Support Worker, NHS City Healthcare Partnership, Hull How long have you been a HCA in sexual health services? I have worked within sexual health as a senior support worker for just over one year. I first started on the bank, while I was completing my degree in sexual health studies. As soon as I had graduated, I started full-time hours.
What's your favourite part of the role? My favourite part of my role is the express clinic. Within this clinic, we triage patients and undertake asymptomatic screenings. I enjoy this clinic, as it allows you to help patients in a one-to-one consultation: you can gain their trust and personally help them with their issues.
What training have you undertaken? Within this role, I have undertaken all my mandatory training, such as: infection control, fire safety awareness and safeguarding adults and children. I have also trained to work on various different clinics: HIV, community gynaecology and GUM/family planning. The training for these clinics has given me a diverse range of skills that I can use in other clinics that are based at Conifer House (sexual health clinic).
What's coming up next for you? I am leaving my role as a senior support worker to train as a nurse. I am very excited to do my nurse training, as it will allow me to expand my clinical skills. I have plans to return to Conifer in the future, when I have completed my training, where I will, I hope, progress on to a dual-trained nurse: in contraception and GUM.
Future and regulation The role of an HCA has been expanded over the past 20 years to include a more hands-on approach to working, incorporating aspects of venepuncture, leading counselling sessions and carrying out invasive procedures.
HCAs have to deliver these duties in order to respond to the local need for care—often despite lack of training, assistance and regulation (McKenna et al, 2004; Brant and Leydon, 2009).
The RCN has stated that it is committed to supporting the development of mandatory training for HCAs in the interest of public safety (Royal College of Nursing, 2014). It is evident that there is a general consensus within healthcare that HCAs and assistant practitioners (APs) should be regulated (Peate, 2013), yet the continuing question is: who will be responsible for this?
Regulation is significant; it not only protects the public, but it also protects the individual, as well as driving the clarity for role definition and the development for a national training programme (Storey, 2007).
On a level where HCAs have more of a hands-on approach within their duties, it seems apparent that education, training and protection are mandatory throughout the HCA role. The recent Francis inquiry has identified important lessons to be learnt for the future of patient care, but the existing position with HCAs and APs does not provide adequate protection for patients and staff (Peate, 2013). Furthermore, Peate (2013) rightly acknowledges how regulation could provide the HCA with a much-needed set of acknowledged skills that could be transferred between employers.
There is significant disparity across UK sexual health service provision; delegation of clinical tasks for HCAs varies considerably within these services. Regulation would provide employers with a clear indication of the HCA role and be a significant step towards maintaining professional development.
This article has outlined the significant role of HCA within sexual healthcare delivery. HCAs are a key member of the team that provides high-quality care to patients within sexual health services. This role should be supported and developed.
Key points ● Sexual health is an important area of public health, as most of the adult population is sexually active
● In 2013, there were 450 000 diagnoses of sexually transmitted infections in England
● There are increasing numbers of women undergoing repeat abortions
● The healthcare assistant is a key member of the sexual health team within sexual health services
● The healthcare assistant role should be supported and developed within sexual health care
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