Publication
Devising methods to assess training needs of health promoters in Scottish area health boards
3. Stage 2 of the Study
3.2 Overall conclusions and recommendations
INTRODUCTION
In this final chapter the overall conclusions of the study will be described including those from the first part of the study. During the investigation our interpretation of our results, even those of the interim study, has been changing and, we believe, maturing.
The first part of the chapter will describe what we see as the problem of TNA and more generally of training for health promoters drawing on our review of the literature, our interviews and the conference which was held. The second section of the chapter will explore the approach which we adopted to address these problems. We will attempt to assess how successful we were in this venture. The third part of the chapter will develop an action plan drawing on our analysis of the problems and on our estimate of the effectiveness of our case study approach.
1. THE PROBLEM OF TNA AND OF TRAINING FOR HEALTH PROMOTERS
1.1 Background
While there was considerable evidence of good practice in the field of TNA for health promoters in Scotland the overwhelming impression of our review of the literature, of our interviews with, inter alia, Directors of Nursing, of Education, of Social Work and of Community Education, was that TNA and the training of health promoters generally faced a number of serious problems.
This was also true of all other areas of training whether in professions or in business. Striking features were the limited success of staff training generally and the absence of generalisable TNA strategies. Two principal explanations were advanced for this situation. First was the range of interests which had to be met for satisfactory TNA and training to be established, viz management, staff and clients. Second, and of special relevance to health promotion, were the difficulties posed by the varying contexts in which TNA and training had to be developed.
The interviews and the subsequent conference reinforced this picture with regard to health promotion.
1.2 Health Promotion in Practice
Attempts to develop systematic TNA and training for health promoters were uneven in Scottish Area Health Boards. Within the education sector virtually no TNA policy for those teachers concerned with health promotion appeared to be used. Where it exists TNA for teachers is generally conducted through appraisal. It tends to be individualistic, confidential and school based. TNA involving groups of specialist teachers is very rare. There was more evidence of a well defined strategy for TNA and for training in Social Work and in Community Education but the training policies were framed for the overall work of the staff and it was not clear how far the specific needs of health promotion were actually being met. In the case of NHS Trusts it appeared that in some areas well developed strategies for TNA, which included health promotion, were in place but that the incidence was somewhat sporadic. This unevenness was also evident in how the TNA policy was implemented in the different sectors which were investigated. In Social Work, Community Education and in some NHS Trusts management appeared to take the lead. Elsewhere, in at least one College of Nursing and in some NHS Trusts, the diagnosis of staff training needs seemed to be the main driving force in determining training policy with management playing a subsidiary role. Finally in one case, an NHS Trust, the whole policy was very largely and apparently successfully determined by client needs.
There were some general factors identified by our interviewees as of central relevance to the future development of training policy. General concern was expressed about the tendency to see health promotion and its related training as of marginal importance when overall institutional or area policy was being determined. This had inevitable consequences for the allocation of resources to health promotion and any activities connected with it. Of equal significance were the reservations expressed about the ability of staff to carry out health promotion. In particular a number of informants felt that teachers and health professionals adopted an over didactic, information-based approach to health promotion, failing to appreciate the client's situation and reasons for adopting a particular life style.
1.3 The Position of Health Promotion Departments
A further problem area which the conference brought into sharper focus was the difficult position of Health Promotion Departments in relation to TNA and training policy for health promoters. The most serious problem which Health Promotion Departments encountered appears to be that they are trying to influence training in institutions which are outside their control. To initiate a training policy or to employ a TNA strategy a Health Promotion Department has to convince management, for example in an NHS Trust or a school, of the importance of health promotion and of the need to adopt an effective policy. It is very difficult to operate in this way outside the institution which you are trying to influence. It was also evident that some areas were particularly hard to influence, education being especially mentioned in this connection. School policy and the resources to support it are now largely devolved to school level creating a large number of individual headteachers and their staffs who have to be convinced of the wisdom of a policy before it can be applied. In addition, in the case of schools, and of Social Work and to a lesser extent Community Education their managers are likely to see other priorities as ahead of health promotion when they are determining their overall policies.
Behind these problems and complicating them seriously, is the view expressed especially by members of Health Promotion Departments, that health promotion strategies are still a contested field in which an agreed general strategy among health promoters has yet to emerge.
2. EVALUATION OF THE CASE STUDY STRATEGY
In developing a strategy to address the problems identified in the first half of the investigation we were very much aware of the extent and range of the difficulties we faced. We were also conscious that similar difficulties are being encountered in staff training generally in fields outside health promotion.
It is not necessary to rehearse all the arguments which we have outlined earlier in this report for developing the strategy which we eventually adopted with the help of HEBS. We considered that it was vital to concentrate on evaluating certain very promising initiatives in TNA, identified in the first part of the study. They were selected to enable us to investigate initiatives in different geographical and professional settings in Scotland. In addition each of the initiatives was adopting a different approach to TNA and to training.
The detailed results of our study of these four approaches to TNA have already been described in Chapter Eight. At this stage we will confine ourselves to the main conclusions which can be advanced as a result of our four separate studies.
2.1 Success at Case Study Level
Initially it is important to consider how successful the different initiatives were in the opinion of those we interviewed. There seems little doubt from our interviews that the initiatives in Highland, involving the Macmillan Profile, and in Lanarkshire based on client needs were very successful. The verdict on the TNA strategy adopted in Central Region's Social Work Department was far more qualified. While the intentions of the policy were recognised as worthwhile its implementation at staff level, and the degree to which staff accepted it, was limited at least in the difficult circumstances immediately prior to local government reorganisation.
A summative assessment in the case of the initiative adopted by the Borders Health Promotion Department is more difficult. Clearly a very innovative approach is being attempted which has won the cooperation of key figures in the local management of health and education. But our evaluation was in a sense incomplete because we could not estimate how successful the policy is among other staff: it is only just being implemented at that level. Also we were not able to illuminate fully how the success had been gained at managerial level. The Health Promotion Department quite naturally, had reservations about our interviewing the managers concerned because negotiations had only just been completed and the situation was still delicate. However, an extensive interview with four members of the Borders Health Promotion Department was conducted and an interview with one of the managers concerned had been carried out in the first part of the investigation in which he described the cooperation between his institution and the Health Promotion Department. These interviews are enough to suggest that the Borders Health Promotion Department has made significant strides in winning the cooperation of key managers in their area.
In reviewing our data on these four initiatives we are struck by one overwhelming conclusion. Where success was reported it was because either the staff or managers considered that they had something substantial to gain by agreeing to the TNA initiative or training policy that was being proposed.
2.2 Success at staff level
This is particularly the case with the Macmillan profile. The staff, mostly Enrolled Nurses, were gaining a great deal from the strategy of which the Profile was a part. Unexpectedly in the light of their employment history, they were being given the opportunity to qualify as Registered Nurses with all the benefits of increased status and a more satisfying professional future. Some had even proceeded further to a Diploma in Teaching and Learning. It is evident that they found the Profile professionally beneficial since most of them were still using it even after qualification. In this respect they clearly valued its emphasis on their personal and work experience with their own background being of crucial significance in determining their training needs. Their experience was being respected and used as a basis for their development, thereby recognising their importance as individuals. The Profile seems to have had the same effect on them as the type of appraisal which is sensitive to staff needs and could well be uncoupled from a qualification and employed more generally in staff TNA.
The qualified success of the initiative in the Central Region reveals the importance of winning the cooperation of staff by ensuring that they see themselves as gaining from the process. From the staff point of view the initiative was unsatisfactory in a number of ways. The staff were not sufficiently involved in the identification of the needs and skills which underlay the TNA instrument. In the case of the skills only a few were derived as a result of dialogue with staff. Where skills were identified by management and staff, priorities were rather different and the differences were not reconciled. The list of skills that was eventually established appeared more appropriate to the training of new rather than experienced staff. Finally in two out of the three staff divisions investigated in Central Region's Social Work Department the staff reverted to their old pattern of staff training effectively ignoring the new TNA strategy.
The evidence from our investigation of the Lanarkshire initiative enriches our picture of staff involvement. It is clear that the staff involved in this approach endorsed with some enthusiasm the TNA that was employed and the training strategy generally. They did this even though they were incorporated in the strategy as the result of a successful research project in which they had not initially participated. Also they appear to have been enthusiastic despite not receiving benefits such as improved status and working conditions. It was clearly sufficient that they were consulted about their training requirements, that the training programme was flexible enough to accommodate their increased needs and that their involvement in the implementation of the research project gave them the feeling that they were doing a better job with their clients.
Emphasis on the needs of staff are only part of the picture, equally important are the interests of management and the context in which an institution is operating. These problems may come to a head when the issue of resources is being considered.
Management as well as staff need to gain out of any TNA or training policy. Our investigation of these four initiatives reinforces this view.
2.3 Success at management level
It is especially clear in the case of the Borders initiative. At the conference the head of the Borders Health Promotion Department described how initial success was achieved. The breakthrough in negotiations with the local Director of Nursing occurred when the purchaser/provider table was removed from the negotiations and a common interest was established in addressing the problems of the population in an area of deprivation in the Borders.
The support of management was also evident in Lanarkshire project. It was of crucial importance that the leader of the initiative was herself one of the senior managers in the trust where it was sited. The other nurse managers found it easy to encourage the project because it was not costly. Funding for the initiative came from outside the trust which ensured that it was very competently managed. The health promotion course that was central to the project only lasted 5½days so managers did not find it difficult to release staff for training. The new skills acquired by the health visitors did not involve extra expense because they simply led to an extension of their role. At the same time managers received very gratifying feedback from staff reinvigorated by the project. Thus the managers gained advantages from enhanced staff morale and skills at very little cost.
The relatively disappointing result from the response of management to the TNA initiative in Central Region Social Work Department also throws light on the importance of management seeing themselves as gaining from an initiative. The TNA policy was implemented by the Region's training department and clearly appeared not to appeal to managers. Senior managers described the initiative as too directive. Line managers were unconvinced that the process represented an advance on existing provision. In two out of the three sectors of the Social Work Department it was tacitly abandoned by them probably influenced by the impending reorganisation of council services.
The attitude of management in the local NHS trusts to the use of the Macmillan Profile by Highland College is less clear. No attempt was made in our investigation to assess their response because it is a strategy being pursued by the college and therefore is not of direct concern to the local Directors of Nursing at this stage. However it is evident that the initiative will soon impinge on management in the local trusts and that will be a very significant stage in the process of this innovation. There are two areas in which this influence is noticeable.
First newly Registered Nurses are being created from among Enrolled Nurses - a group who until recently have not been viewed as generally capable of such promotion. The Macmillan Profile with its use of an individual's understanding of their personal and professional background as a springboard for the course is central to this initiative. Local trust managers are, as a consequence, seeing a new pattern of recruitment of Registered Nurses emerging.
Secondly these newly qualified nurses have been trained in-service with an innovative use of their current and past experience to help them to merge theory and practice. There is evidence from the projects completed by these students that their course is having an unusual influence on current practice which is unexpected for nurses in training. Again this will have an impact on managers with new approaches to practice being pioneered by nurses in training.
The relationship between staff and managers gaining from an innovation like TNA and their acceptance of an initiative will be used as a springboard for the action plan.
3. ACTION PLAN
3.1 Aim of the Plan
Given that we are not directly involved in health promotion it is inevitable that we should be somewhat tentative in suggesting an action plan as a result of our investigation. However we are confident that we can make a range of suggestions providing a basis for fruitful discussion out of which an action plan should emerge.
The basic issues seem to be: TNA is relatively underdeveloped in the health area generally; even in the instances where TNA is used, health promotion does not necessarily feature prominently. At the risk of redundancy, the basic questions which then follow are:
- how are training needs to be assessed and met?
- how is health promotion to be established as an important element of the work of a wide variety of professionals?
In practice, this would seem to be a question of how health promotion professionals (either as HEBS or Health Promotion Officers) can influence the thinking and practice of non-specialist health promoters. Given that neither has the economic (or political) resources to conduct TNA in a variety of occupational contexts the outcome from this research would appear to be recommendations for an approach to TNA which HEBS can disseminate.
As has been suggested, these recommendations could take the form of a tool box, or tool kit, which, perhaps with accompanying training, could be recommended as good practice to a target audience of Health Boards and Trusts and Education Authorities. However, our research suggests the absence of any widely used instrument which could be recommended. It also questions whether such a `one size fits all' approach is appropriate. Even without these reservations it is not inevitable that TNA would - in itself - advance the cause of health promotion.
An alternative form of such recommendations would be to identify the characteristics of `successful' TNA approaches which HEBS could disseminate. The audience for this would be Health Promotion Officers. An essential element in this approach would be the identification of a strategy for health promoters which would enable them to exert influence in establishing training needs in a range of contexts. The use of managerial targets and the strategic approach of the Borders Health Promotion Department suggest how this might be accomplished. The existing HEBS network of Health Promotion Officers could be important in this initially as the audience and then as the developers.
We would recommend this latter approach. It is more focused on HEBS core concerns: the health promotion aspect of training needs, and more fundamentally, the fostering of the importance of health promotion itself. It offers a possibility of intervening in the TNA process. It is difficult to see how this would be accomplished by the first approach suggested above. Neither HEBS, nor Health Promotion Officers, are able to appropriate the role of training and development in a large number of organisations. Whatever the circumstances of TNA, the question to be answered seems to remain the same. If organisations already conduct a TNA why involve Health Promotion Officers or HEBS? If they don't conduct a TNA why involve the Health Promotion Officers or HEBS? To be useful any set of recommendations must address this issue strategically.
Our action plan will therefore comprise a range of suggestions to reorientate health promotion primarily through more effective training which HEBS with the help of Health Promotion Officers is best placed to implement. The approaches that we are recommending can be implemented individually or together, at staff or managerial levels.
3.2 TNA Methods
We have reached the conclusion that one fruitful strategy for developing TNA for health promotion is to follow the approach adopted in the Macmillan Profile. We recognise that the Macmillan Profile was devised for a particular set of circumstances and that it could not be employed as it stands but we consider that the thinking behind the Profile is of the utmost importance. It is significant because it makes the member of staff's personal and professional experience the starting point for any assessment of training needs. The enthusiastic acceptance of this strategy by staff in Highland as a basis for training reveals what a valuable starting point such an approach provides. It may be initially costly in time and resources but it does seem to provide staff with a long term plan for further development. In short it wins staff over to the idea of training. Perhaps most important it is consistent with modern views of how staff appraisal should be conducted and how staff should be managed.
Its principles of autonomy and respecting people's personal and professional experience would appear to be consistent with the approach to health promotion encouraged by HEBS and Health Promotion Officers. Our investigation has shown that at least two of the main professional groups responsible for health promotion in Scotland adopt a didactic approach when a more client-based strategy could be more effective. It also revealed that among other professional groups health promotion appears to be seen as a marginal activity. An instrument like the Macmillan Profile with its emphasis on personal and professional experience would maximise the chances of persuading staff to reconsider their approach to health promotion while modelling good practice relevant to health promotion. What is needed is for staff to review their current practice against a template of searching questions as a springboard for developing autonomy and rethinking goals and this would be provided by an instrument developed on the model of the Macmillan Profile. However such a model would have to be interpreted rather than simply applied. It would have to be sensitive to individual professional cultures. Its development would have to be undertaken by the Health Promotion Departments who in turn would initiate the process by working with groups of health promoters.
3.3 Meeting Client Needs
We have established that client needs play an important part in motivating staff dealing with health promotion. In the case of the Lanarkshire project meeting client needs was central to the success of the initiative. It also played a significant part in the outcome of the programme completed by staff in Highland with their course projects being of significant benefit to clients.
This is an important finding. Meeting client needs seems to be a potent factor. In the Lanarkshire project it was the only factor motivating staff. The training course which staff attended which concentrated solely on meeting client needs appears to have had multiple effects on them. It increased their confidence. Managers reported that they came away from the course eager to try out the new strategies recommended in training. They were prepared to approach women on their caseload about their drinking habits despite the sensitivity of the issue involved. Having established that they could handle this topic with well women they appear to be wanting to extend the initiative to other groups. Some of them have also begun to consider how other health topics could be addressed in the same way. In short they have extended their roles as health visitors.
Managers also considered that the Lanarkshire initiative could easily be adopted in other areas. The initial costs were not high since the course was very short. Yet the impact on staff and clients appears to have been very considerable. In the managers' opinion this has been achieved by the blend of new knowledge and methodology in the course which has aroused the interest of the staff and empowered them. Once the initiative has been established it is also cheap to operate because it only involves an extension of the daily work of the health visitor. Also the project is encouraging developments which have been on the agenda of health visitors for some time, for example the need to extend their roles to the health of the whole population.
Meeting client needs then offers Health Promotion Departments an excellent opportunity to enhance the performance of health promoters in Scotland. It is based on expert knowledge of health promotion which Health Promotion Departments are ideally equipped to provide. It should be relatively easy to persuade managers to cooperate because the apparent costs of such initiatives are low and because it should help management to meet national health targets. We will return to the issue of meeting targets in the final section of this chapter.
3.4 SCOTCAT and Health Promotion
Our emphasis on the importance of staff gaining from any recommended strategy for TNA in health promotion and from training generally allows us, however, to take a wider look at staff needs than simply concentrating on a TNA instrument.
In our investigation, especially in our interviews with Health Promotion Staff and contact with them at the conference, we were struck by how uncoordinated and piecemeal training for health promoters appears to be in Scotland. A lot of effort is being made by individuals but without the benefit of working within an overall strategy. This is a worrying conclusion when we have discovered that the approach to health promotion needs to be reconsidered across a range of professional contexts in Scotland.
We recommend that all courses offered by Health Promotion Departments should be integrated into the SCOTCAT scheme. SCOTCAT is a national scheme for the award of credits at different levels:
- certificate, diploma and degree
- undergraduate and postgraduate
- pre and post experience
Students are able to gain credit for courses across a range of Scottish institutions and gradually build up to the qualification of their choice. Were the courses which are currently offered by Health Promotion Departments recognised within the SCOTCAT system, management and staff, for example in trusts and schools, would be much more ready to accept training proposals from the Departments. They would be working within a system providing their training with coherence. At the same time Health Promotion Departments would be encouraged to cooperate amongst themselves to move towards a national structure of courses in health promotion. We consider that this structure could be established without removing local flexibility of courses.
There are other advantages for staff and management in institutions responsible for health promotion.
The SCOTCAT scheme awards credit for previous professional experience as well as for courses that have been successfully completed. In the case of an award for previous professional experience the candidate is expected to provide evidence of what they have learnt from the experience for which they want credit. Thus a member of staff might have been responsible for a development or for a particular activity at work and have written a report on its operation. Such a member of staff would be in a good position to claim credit when applying to register for a course. This approach to the award which includes the recognition of previous experience is a considerable incentive for staff to be involved in training. It helps them to make sense of their past experience. This takes us full circle back to TNA. Any institution awarding this type of credit has to discuss the student's experience with them and relate it to a future course - this is a form of TNA carried out by the institution awarding the credit which will be of significance in helping the student to orientate their training successfully.
It is equally important that courses which recognise SCOTCAT allow students to learn by integrating theory and practice during a course, referred to as `experiential learning' in SCOTCAT documents. Thus a course of this type will begin with three or four sessions discussing the theory relevant to the theme of the course, then the students select an issue in their practice that relates to the course and reports back at the end of the course. This is very important because students are encouraged to review the effectiveness of their day to day practice in the light of related theory. Such an approach is very well suited to staff who need to reconsider their practice which seems to be the case with many health promoters. Courses of this type avoid the danger in so much in-service training of students enjoying a course but not applying it on their return to work.
We recognise that some training officers and some Health Promotion Officers will already be exploiting the opportunities provided by SCOTCAT but it was clear from the our investigation that many were not and were still working in isolation.
SCOTCAT will help break down this isolation. Courses offered by different training and Health Promotion Departments could with some coordination become part of a national framework. Inevitably certain institutions of higher education will become centres for validating these courses which will increase the expertise available to those developing them and encouraging cooperation amongst them. The recent integration of Colleges of Nursing into universities will greatly assist this process.
This strategy even if developed piecemeal should help to win over staff and management in institutions responsible for health promotion to the advantages of TNA and training generally. A national strategy with a range of validated course, many of them integrating theory and practice, should be very attractive to both staff and management. Resources for training are limited and health promotion currently has a low profile especially with management. A coordinated approach to training in health promotion should start to redress that balance by making the advantages of training more obvious to managers responsible for resource allocation.
3.5 Suggestions of special relevance to management
While we consider that the adaptation of the Macmillan Profile, the use of client needs and of SCOTCAT are essential starting points in developing a policy for training health promoters we are also aware that our investigation has highlighted other approaches which could be of equal importance, especially at managerial level.
Since these approaches have been considered in detail in the second part of this chapter we will only summarise them at this point to avoid undue repetition. Three themes are of particular importance with regard to management.
First all managers, for example in trusts and Area Health Boards, are responsible for meeting certain health targets for the populations in their areas. This gives those responsible for health promotion and its related training an important opportunity to persuade management to give priority to health promotion. As has been mentioned earlier a number of Directors of Nursing made this point when being interviewed.
Second the success of the Lanarkshire initiative sprang to a large extent from the success of the research project of which it was part. External funding and prestige was provided which created prestige for the trust in which it was situated. Interestingly, as has already been mentioned, the research arose out of an extensive study of the literature and the realisation that success in health promotion can often come from limited intervention. Two factors are important here - expert knowledge and external funding. Both should be available at least to some Health Promotion Departments. They already possess the expertise and funding is available from national and local sources to capitalise on the expert knowledge. We are not of course suggesting that every Health Promotion Department will be successful in gaining funding and in following the example of Lanarkshire but it is one promising avenue that some departments can exploit.
Third is a more nebulous factor. The initiative in the Borders has got off to a good start because the Head of the Health Promotion Department established a shared understanding with the local Director of Nursing on the need to tackle deprivation in the Borders. It is difficult to forecast in what circumstances such agreements will emerge. They can be based on shared values, interests, or even compatible personalities but any action plan must take them into account because they can be so important in bringing about a changed attitude to health promotion and related training. The general principle behind them is of course the importance of establishing a situation in which both the Health Promotion Department and the managers responsible for health promotion gain from the relationship. We have outlined in this chapter circumstances in which this has, or may arise, but there are clearly other situations when cooperation is possible which we have not envisaged.
In conclusion we would like to reiterate that in suggesting the different approaches to developing TNA and training for health promotion that arise out of our investigation we are not being prescriptive. We recognise that if a successful strategy is to be established our role can only be as the initiators of discussions in which HEBS will be the leaders.
3.1 Case study results
1. HIGHLAND COLLEGE OF NURSING
The in-depth study of the Macmillan Profile as a means of assessing training needs and personal goal setting in the continuing professional education of nurses was based on the following personal interviews carried out over a two-day visit to the college:
- Duncan Macdonald, manager and tutor-counsellor
- Practice supervisor, A
- Student, B, and ex-student, now practice supervisor, C
- Ex-student, now practice supervisor, D
- Tutor-counsellor E
- Tutor-counsellor F.
A picture emerged of a system which was student-centred, was highly valued by participants in all three roles investigated, and had produced an impressive range of outcomes. The Profile was more than an instrument of training needs assessment; it was a pedagogic approach which enabled participants to incorporate experiential learning into their continuing professional education. It stood in sharp contrast to previous post-experience teaching methodology based on lecturing with little or no interaction. As recently as the early 1980s, nurses attending such courses sat `regimented' in full uniform absorbing information from their lecturers. A nurse-teacher who had taught in both systems expressed enthusiasm for the difference the Profile had made to students' image of themselves as learners and professionals: `they suddenly saw themselves as having something to offer'. A number of successful students had gone on to complete the demanding Diploma in Teaching and Learning in Practice.
The Macmillan Open Learning Profile Pack (James and Harper, Macmillan Magazines 1993), consisted of a ring-binder organised into sections, a package of original sheets for photo-copying and completion and a workbook explaining and introducing the task of compiling a profile stage by stage. It was dauntingly unfamiliar to students at first. Students thought it looked frightening, asking `where do I start?' In spite of the `threatening' presentation, however, it was `an opportunity to think about me'; and although it was hard at first to be honest with oneself, students gradually realised over time that they had become more skilled at the tasks of self-review and goal-setting. They overcame the tendency, noted by students and tutors, to underrate themselves. The profile provided a baseline which they could revisit, and led students to identify learning from life experiences such as parenthood rather than focus on the private experiences as such.
A tutor commented that students had invariably been traditionally taught throughout their school and earlier professional lives; learner autonomy was a completely new concept. The sequence in which the Profile was organised was very well designed, with the less threatening working life reviewed before the possibly difficult personal section, and reflection on values and on themselves as learners before the key skills review. Only after all these stages did the student turn to setting goals for self development.
In addition to working one to one or in small groups with tutors, each student had a practice supervisor within their own ward or other work setting. Initially, the supervisors were as unfamiliar with the Profile as the new students and a number of supervision arrangements had broken down, with senior staff unsympathetic to the scheme. Informant B felt herself fortunate; her supervisor was `willing to learn along with me' and saw her role as a kind of mentorship. Student C's supervisor had accepted the nature of the new course rather than becoming involved; as the student had a strong teaching relationship with the tutor this had been reasonably satisfactory. The present intake arranged their own supervisors; the charge nurse in the student's own ward might have a limited formal role while active supervision was undertaken by another suitable person. The two former students who were now themselves supervising nurses on the course were enthusiastic about assisting a colleague through the process. One spoke of the necessity of allowing the student time to work through the stages of the Profile, and resisting the temptation to hurry them into goal-setting.
The individual projects which were part of the course assessment demonstrated students' enhanced skills, in many cases related to health promotion which forms a requirement (`Rule 18') within the present UKCCN list of competences. More than half of 73 project titles from the 1995 class list appeared to focus upon `well-being' rather than `medical' models. These included 11 out of the 12 projects from nurses on the mental nursing register. (A selection of `health promotion' project titles are listed in Appendix E). These projects had involved extensive library research by nurses who had never undertaken such tasks, and also developed the more personal learning fostered by the Profile such as questioning existing practice in the light of their own observations. This could entail persisting in the face of colleagues` scepticism and testing out new practices, for example, in a project which studied and developed better practice in foot care of elderly demented patients. Adopting the measures developed by the student had diminished the incidence of difficult behaviour and in at least one case re-established continence among these patients.
Other examples of projects leading to changes in practice and wider dissemination were a booklet on preventing and managing leg ulcers, now produced and distributed to patients at home, and a system of intervention to improve rehabilitation after heart attacks. Booklets and a video were already in use but the student piloted and researched a programme for patients and their partners consisting of 20-minute teaching and discussion sessions with a nurse for seven days while they were in hospital. Several projects had been presented at national and regional conferences.
It was not possible to attribute all of the project outcomes to the investigation of training needs by means of the Profile; other course teaching no doubt played a part. However, one tutor had `never seen such changes in people over thirty years of teaching: [students] are in the library for reference, there is more dissemination of knowledge, they take on responsibility and challenge practice', for example, in gaining the right of diabetic patients to continue to manage their own insulin injections while in hospital. A supervisor spoke of observing `dramatic change at a deep level'. These benefits were not automatic: `you get out what you put in'(C); one tutor acknowledged being conscious on occasion of someone practising avoidance, with the private activities omitted or done superficially. Such disengagement was rare, however. For the student who was committed to the process,it `raises the goals you aim at and gives you knowledge of how to move towards them (B)'.
Informants coming from different Hospital Trusts found contrasting attitudes to continuing professional education; the strong support in some places was missing elsewhere. In such cases, growth in confidence and assertiveness of staff could be perceived as a threat by management. Nevertheless, `if they want a high standard there has to be benefit both ways: we get knowledge, they get service'. Changes at national level made this a live issue: a Post-registration Profile (PREP) was now a requirement for all nursing staff. Five study days or 40 hours of courses or library study had to be included for every three years of service; some Trusts had no training budget so that the extra study had to be completed at staff's own time and expense. The successful students from the course using the Macmillan Profile found that their experience of compiling a profile was in demand among colleagues, some of whom found the compulsory PREP system frightening and demotivating. Fears had been expressed that it was a way of trying to drive older nurses out of the system; `a lot of PR work' was needed to establish it. The former students `know their capabilities and want to help'; but at least one had found herself putting on study afternoons at no expense to the Trust; if they were made use of as cheap teachers, it was wrong. They themselves wanted to continue keeping their own Profiles because they found it to be of positive benefit. The Macmillan Profile was aimed at enhancing the individual's learning, but had the potential to improve the service provided local management could take it on board.
2. CENTRAL REGION SOCIAL WORK TNAT
Study of the Training Needs Assessment Tool (TNAT) introduced in the Social Work Department of the former Central Regional Council was limited by local government re-organisation and the desegregation of the service among three new unitary councils. The system was newly designed and only partly implemented during the last year before reorganisation. Single and group interviews were held with three senior managers, two line managers and three staff members involving three sections of social work services: welfare benefits, child care and criminal justice (covering community service and young offenders).
A very different picture emerged from that at Highland College, where TNA in the form we studied had been running since 1993. The Central Region TNAT was seen as service-led, with benefits to the individual perceived by line managers and staff as incidental to the process (and more likely to be developed by existing general supervision). Two of the three senior managers were more positive, seeing it as a new attempt to achieve worthwhile ends, somewhat hastily tried, which had been overtaken by reorganisation and might be tried in the new council services with prospects of overcoming the problems encountered over the past year.
Senior managers were introduced to the TNAT as part of a five-day Change Management course. The course itself was described as directive, with two days of `heavy' financial material to absorb before the TNAT session. There was no opportunity for senior managers who reported directly to top management to undergo the process themselves. It was developed by the Training Department with two focal points for dialogue between manager and staff member: identifying and rating the skills required for each job, and the self-rating of the individual in each skill area. In one section of Social Work Services, where implementation appeared to have been carried further than in the other two, the TNAT had been modified. Using a competence document produced by the Scottish Office and based on Edinburgh University research, a working party drew up and completed an essential skills list, leaving only a few blank boxes for skills to be identified by means of dialogue with individual staff members. This system had been carried out by line managers with their qualified staff and the results analysed to compile a training needs overview. The long-term aim of the Training department, that TNAT would be used at all levels, remained to be achieved.
The advantage of this modification, however, was apparent in comparison with another area of social work. Trying out the process with line managers, the senior manager found that identifying and prioritising the skills and knowledge needed in post was far from straightforward. A planned `change management day' for the section to discuss principles unfortunately had to be cancelled. The group of staff decided to get together and produce a joint list. Whereas the range of skills identified was broadly in agreement with those of the senior manager, relative priorities were seen differently, and the gap was not resolved: efforts at reassurance did not overcome misunderstandings, with staff `feeling that they were under the microscope'. After a number of discussion sessions, with line managers `relatively cynical' about the value of the TNAT, staff became anxious that desirable training courses were filling up, and pressed to revert to the previous system of putting forward their own choices for further training courses and leaving the senior manager to make the decisions.
Still less had been accomplished in the third section of the service. Managers `went along with the idea' but were unconvinced that it offered a worthwhile return on the necessary investment of time. Staff did not anticipate any actual benefit and pressure of work seen by all concerned as genuinely essential meant that TNAT `never really got on to the agenda'.
Cautiously positive reactions were expressed by one of the three unpromoted staff taking part in a group interview in the section where implementation had gone furthest. Although the format was related more to the post than to the individual, it `made you take a look at your skills and think about them'. Doing the exercise as originally designed, taking half a day to draw up your own list of skills, would be time-consuming but might be more worthwhile. Another member was critical of the lack of scope for considering individual needs, especially in relation to the possibilities for future career development such as management training which did not relate directly to the current post. The listed skills on the modified form were already basic requirements for the posts members occupied. If their skills in these areas were not at least average they would not hold down their jobs; a newly qualifying student had to fulfil this set of skills. Nevertheless, new methods and new knowledge were accumulating every year, together with legislation bringing in new demands. TNAT might have the potential to get people into training that would cover these developments. It might be most useful for newly qualified staff.
The line managers who had carried out the TNAT sessions with these staff members had considerable reservations about the system. Some managers had felt `a bit embarrassed at the phraseology' describing levels of skill in relation to qualified and experienced staff. With a diverse group (such as Community Care staff) ranging from those with minimal entry qualifications it might be more appropriate. It could be a useful pointer to a new worker coming in, or to someone who did not have a realistic idea of their own skills. However, the TNAT contained something potentially of value. The existence of the agreed list based on research and national standards in the modified TNAT was useful; how the department worked with it for added value was up to themselves. It formalised previous decision-making about allocating staff to courses; equity was a key principle, so that it could be seen that all staff had comparable opportunities.
The links between the TNAT and regular supervision of staff was important; TNAT did not stand alone. The managers' introductory days had made clear that TNAT was not intended or expected to cover personal development and this was still dependent on flexible discussion between managers and individual staff. The informants were asked about appraisal, seeing that the documents (and the presentation of the TNAT at the HEBS Stirling conference) had emphasised that TNAT was not to be confused with appraisal. It emerged from all of the services involved in the Phase 2 interviews that no systematic appraisal had been implemented although `some sort of expectation' that it would take place had been `around' in Social Work and other Council services. This gap between official rhetoric and reality might explain some of the suspicion of TNAT that was reported. The group were unsure of what had happened to appraisal, suggesting that it may have fallen foul of the unions. One respondent contrasted the experience of a relative who had been involved in the staff appraisal scheme used by Scottish Amicable: the possibility of promotion and a 7% pay rise had resulted from a successful appraisal. No such incentives were likely to be on offer in social work services.
In the section where training needs had actually been collated as a result of the TNAT exercise, satisfaction was expressed at senior level. The system was seen as a way of handling current financial management, with training plans required to reflect service plans, and money spent on training beyond the essential demands of current jobs was regarded by auditors as a luxury. The pack gave coherence; it represented, in this senior manager's view a clear improvement on the previous lack of a system. An evaluation exercise before the next round of TNAT took place would undoubtedly reveal opportunities to improve it.
3. LANARKSHIRE HEALTHCARE TRUST
This in-depth look at the client needs-led training of health visitors to take part in an alcohol minimal intervention programme with women on their caseload is based on the following interviews which took place on different days at the Strathclyde and Udston hospitals :
- Helen Scott, Director of Nursing and Quality and project supervisor
- Eight of the twelve health visitors who implemented the study
- Three divisional nurse managers
This particular project, funded by the Scottish Office as part of an initiative to set up innovative services for alcohol-related problems, challenged the perception of the health visitor's role as one restricted to the monitoring of children's development in the 0-5 age group and of uptake of recommended health measures by families on their caseload. It focused on the health visitor's wider remit to search out health needs, in this particular case, of women in the 18-45 age group with family responsibilities who might have an alcohol-related problem.
The success of the initiative was apparent in many ways - the existence of such problems among the target group was correctly hypothesised and the minimal intervention strategies set up to deal with them had the effect of significantly reducing alcohol intake among the sample group to safe levels. The development of new skills and a deeper knowledge through involvement in the research and the special training programme, gave the health visitors concerned a boost to morale and confidence which has carried through to other aspects of their work with clients, not least the development of a health screening tool to enable health visitors to identify and record the health concerns of women on their caseload. Finally, the external evaluators at the Centre for Alcohol and Drug Studies at the University of Paisley described the project as having performed very favourably, consistently out-performing the other nine projects taking part in the Scottish Office initiative (Holttum,1996).
Among the key factors which contributed to the success of the project were the client needs-led approach, the research funding and the leadership of the project all of which engendered a strong sense of ownership by the health visitors taking part. The client need had originally been surmised through the personal commitment and experience of Helen Scott in her role as a health visitor and then extensively researched by her through an international literature review. In setting up the minimal intervention strategy in parts of Lanarkshire, Helen Scott was not testing a hypothesis about whether such strategies worked but whether or not they would work in the particular context of the local population. Equally, the literature review had uncovered clear trends in the patterns of women's consumption of alcohol which led directly to the choice of women in the 18-45 age group for the purposes of the Lanarkshire study.
In their focus group interview, the health visitors reported the impact of the road-show presentation which Helen Scott had mounted in order to recruit health visitors for the project; they had been convinced by her evidence and arguments and motivated by the prospect of a new challenge which they felt would raise the profile of health visitors as well as their own morale while offering a new service to the women on their caseload. Nurse managers reported that involvement in the project had indeed enthused the health visitors and led to a greater confidence in carrying out and extending their role.
A total of 15 health visitors took part in an individual interview with the project supervisor, Helen Scott, before final acceptance on to the project. This was necessary in order to screen out health visitors who, for example, might hold strong views about alcohol and might consequently undermine or damage the relationship with their women clients Twelve health visitors went forward into the project (twice as many as originally anticipated) once clearance had been gained from the GPs to whose surgeries they were attached. It was felt their support was vital in the event of a client with a drink-related problem coming forward for help. Support from the GPs was readily given, possibly because the timing of the project coincided with new contracts which required GPs to target and screen their patients for a number of indicators, one of which had to do with alcohol.
Concern for the clients also led to an emphasis on confidentiality. When feeding back results from the first data collection, for example, health visitors did not mention the individual client's weekly unit consumption of alcohol, only whether or not the client had been recommended to take part in level 1 intervention. The health visitors reported little conflict between the needs of the client and the requirements of the research aspect of the project. The first contact with clients in connection with the alcohol minimal intervention was scripted and timed to last ten minutes so that all twelve health visitors adopted a uniform approach. Any artificiality of these procedures was accepted as necessary for the research but also useful to the health visitors themselves as they started out on uncharted waters. In their subsequent practice such processes had become internalised and an accepted part of their interaction with clients.
The project supervisor had to make one major intervention in the interests of the confidentiality and integrity of women in the sample group when she and the health visitor team rejected a questionnaire, designed by the external evaluators to cover all those taking part in the ten alcohol related projects across the country. Several of the questions were considered not only inappropriate for well women but also potentially offensive to the particular client group in the Lanarkshire project. Through their own work on the construction and piloting of questionnaires and drink diaries for use with their clients during the six month planning phase, the health visitor team were very conscious of the need for a sensitive and constructive approach. As a compromise, the project team negotiated and produced an adapted version of the external evaluation questionnaire and used this with their clients.
The six month planning phase had seen a steep learning curve and an increasing sense of ownership of the project by the health visitors. During the focus group interview, individual health visitors commented that prior to their involvement in the project they had dealt with alcohol related problems among their clients on a crisis basis only; a lack of confidence and a feeling of being `unqualified' meant that such problems had generally been skirted over or shied away from during clinics and home visits. A tailored-made training programme was designed to overcome this and was staged to prepare health visitors for the different levels of intervention. Of the eight health visitors interviewed, all engaged in level 1 intervention, two went to level 2 and two to level 3. The external evaluators assessed the views of the health visitors on the training they had received by looking at three factors - task clarity, role adequacy and role legitimacy and found that by the end of the two years the health visitors scored 97% on task clarity, 95% on role adequacy and 71% on role legitimacy (Holttum, 1996).
The training of the health visitors to fulfil their role on the project was planned in consultation with the health visitors themselves and extended at their request to address areas of common interest or concern. Initially, the health visitors wanted more detail on the health aspects of the effects of alcohol and details of the unit values of specific drinks. Trips to local retailers to list the kind of alcoholic drinks on sale in particular areas and the calculation of their unit values were part of this process. The health visitors were concerned about setting up barriers with their clients and finding ways of encouraging dialogue or handling any confrontation. As a result, one of the training days was devoted to motivational interviewing which was needed for the second level of intervention. Helen Scott invited a member of the Health Promotion Department of the local health board to lead this part of the training which included role playing. When asked directly as part of their focus group interview, the health visitors all said they would not have identified any of these training needs prior to their involvement in the project.
In addition to the five and a half days training, there was individual and small group support from the project coordinator and other members of the health visitor team as part of the regular programme of meetings. Each health visitor met the project coordinator once a week and there was a monthly meeting of the whole team, the minutes of which were routinely fed back to the nurse managers. This group, the immediate line managers of the health visitors, had been approached by Helen Scott prior to and regularly throughout the project. Their support was deemed essential and had to be won over, particularly since their training priorities might not have included alcohol minimal intervention. A case had to be made for the potential long run benefits of the project in terms of saving staff time. In their interview, nurse managers made the point that the whole project had been very cost-effective - the few days training had created a reorientation that was quite dramatic in its effects.
During their focus group interview, health visitors reported some scepticism among their nurse managers and, to a lesser extent their other colleagues, about the project, particularly about the honesty of the women clients in their claims to have reduced their alcohol intake. One divisional nurse manager felt that it might have been appropriate to follow-up the sample group of women clients six months after the project had ended to establish whether or not the reduced drinking levels had been maintained.
Two additional factors contributed to the overall success of the Lanarkshire project, the first of which concerned the use of the external research funding to appoint a full-time research secretary and a paid research coordinator, the latter from within the health visitor project team. The research secretary kept to a minimum the administrative burden on the health visitors and was central to maintaining the system of support and communication which characterised the whole project. The research coordinator took on a mentorship role for her colleagues and gradually assumed responsibility for the day to day running of the project. The second factor was the leadership shown by Helen Scott herself both as a result of her personal commitment to the needs of women and to a research approach and also of the way she used her position as Director of Nursing and Quality to set up the project and negotiate its acceptance among colleagues at all levels. In their focus group interview, the health visitors said that Helen's ability to ensure management commitment to the project had been crucial. For their part, the divisional nurse managers confirmed the positive impact of Helen's enthusiasm and management style and commended her in particular for the appointment of good research staff to coordinate the project.
The impact of the project within the Lanarkshire Healthcare Trust itself can be seen at various levels. The training programme for alcohol minimal intervention has now been extended to all 145 health visitors within the Trust. The original team of twelve health visitors is currently working on the development of a health screening tool, an idea which arose directly from contacts with women on their caseload who welcomed concern for their health and who wanted to see the approach extended to cover non-alcohol related problems. The health visitors mentioned sexual health, diet, smoking, depression and coping with stress as issues raised by the women themselves which were being incorporated into the health screening tool. The health visitors said they were already handling some of these issues with their women clients using their skills in motivational interviewing.
A business plan to extend the project to cover other groups and other health professionals has been accepted by the Scottish Office for funding. Alcohol minimal intervention is being considered for children and young people, men and women over the age of 45 and in the 65+ age group. Knowing the client group, its needs and its place on the motivational cycle are seen as the keys to introducing a behavioural change model and appropriate methods for gaining access to such information through direct involvement with the client groups are being researched.
4. BORDERS HEALTH PROMOTION DEPARTMENT
During the first phase interview study, representatives from Community Education and the Schools Advisory service in Borders spoke positively of liaison and collaboration with local health promotion specialists particularly in connection with services for young people. The Director of Nursing and Quality at the Borders Community Trust highlighted a TNA initiative with health visitors, organised by the Health Promotion Department, which he felt had addressed professional priorities, the needs of the local communities and national targets. He also welcomed the assessment of needs in different communities within Borders which included data on referrals to the acute services and took account of the perceptions of the primary care team.
It seemed, therefore, that the Health Promotion Department in Borders was succeeding in its approach to TNA among a range of potential health promoters and that the second phase of the study might usefully look at the processes which had helped them gain trust and credibility for their work in general. The following analysis is based on a group interview with four members of the health promotion team which took place at Borders General Hospital in early April.
Borders Health Promotion was a relatively young department and the current team had been together for three years. Members of the team came from very different backgrounds and those interviewed felt that it had taken this length of time to evolve a shared understanding of the principles of health promotion and to transmit a common message through what was described as a `synergy of different approaches'. An infrastructure to underpin this common concept was now coming into place. For example, at the strategic level, priorities were identified which were then translated into setting objectives for individual officers and any overlap was used to set further joint objectives.
Discussion in the group interview looked back to earlier attempts to gain credibility, both for themselves as individual officers and for their work. Sometimes this had been achieved through listening to professional groups, offering them the training they requested and making a good job of it. Another strategy involved the long process of `internal marketing' -talking to people at all levels of any organisation or system informally and in scheduled meetings. Members of the health promotion team seemed to actively, or maybe instinctively, seek out common ground between themselves and such individuals, whether on a personal or a professional level, and gradually overcome misunderstandings about their role and the role of health promotion generally. One of the interviewed team members described it as `creating the culture, creating the environment in which change can take place at that level -it's a very subtle process'. The team looked forward to the time when their work would depend less on a web of personal relationships which could so easily be broken when individuals, health promotion advocates among them, moved on from their posts. There was some optimism that commitment to health promotion was beginning to take root at the organisational level in some cases.
Although many of the processes which were described in the course of the group interview are not context-specific some conditioning factors had obviously coloured choices and approaches. Communities in the Borders were not accustomed to being asked about their needs nor indeed to expressing them openly. Local culture tended to be very hierarchical and paternalistic and individuals felt able to speak for whole groups without consulting those they claimed to represent. The population was dispersed over a wide geographical area and communities were very mixed so that postcodes were not a useful device for identifying pockets of ill-health or need. Furthermore, the small size of the population and relatively few organisations and agencies serving it meant working with all concerned, not just opting to work with sympathetic associates.
The approach which the health promotion team had evolved to address the above factors was to engage with people in a way that made them feel partners in the process, trying to work with the culture rather than alongside it. Under the circumstances, an over-zealous or radical approach would have met with hostility. A long-term view was required and a willingness in the meantime to be pragmatic and start where people were, even if this occasionally meant having to work in ways that fell short of their ideal. For example, a colleague had been asked to distribute leaflets and speak to people in a supermarket as part of a national campaign about mental health and depression. She had discussed this carefully with colleagues and gained their support before agreeing to take part. The health promotion team accepted the need to be visible in this way but would not engage in any form of health propaganda and monitored such promotional material very closely.
Identifying client need and feeding this information back to potential health promoters and their managers were key elements of the team's strategy. This was done partly through the usual channels of cultivating personal contacts, engaging in training and various promotional activities and collaborating with other agencies and, in a more novel way, through the commissioning or carrying out of various types of research work within the Borders communities. The findings from such projects could be used by the health promotion team to articulate health needs of the local communities to organisations whose staff had a health promotion role and invite managers to consider the training implications of their findings.
Two current projects in the Burnfoot area of Hawick and Eyemouth were cases in point, where local people had been recruited and commissioned to carry out a community needs assessment and produce a final report. Such initiatives had to be carefully planned, however, and the terms of reference and their limitations clearly understood by those involved. Steering committees were appointed from within and, as representative as possible of the community, and local researchers were trained for their role in the data gathering processes. Everything was done to foster a sense of ownership of the project and, ultimately of its findings, among the participating communities.
Such projects were taking two years or more to report and understanding for such a long-term approach had to be sought from executive members of the Health Board. The community studies did, however, throw up issues of immediate concern that could be acted upon by the Health Promotion Department. One such example, was the lack of a pharmacy in a very large housing scheme. Alerted to this, the health promotion team set up a meeting between a group of purchasers and providers and local people with the result that one or two pharmacies in the nearby town were now interested in setting up a satellite service.
It is in the nature of empowering communities, that such interventions cannot be openly acknowledged and credit given, but as member of the health promotion team saw it: `we're marketing what the Department can do, what our role is and where it stops and starts. We can feed back on the progress that they've made to our paymasters'.
SUMMARY OF THE MAIN LEARNING POINTS FROM EACH CASE STUDY
1. HIGHLAND COLLEGE OF NURSING
· developing awareness of prior experiential learning releases ability and creativity
· managers need to be ready to respond to positive ideas brought forward by `empowered' staff
2. CENTRAL REGION SOCIAL WORK DEPARTMENT
- the need to involve team managers as well as service managers in TNA
- training needs of staff who are already expert at current level should be incorporated into the TNA system (moving up skill levels)
3. LANARKSHIRE HEALTHCARE TRUST
- client need as a central focus for health promotion extends the role and increases the morale and knowledge-base of the health visitor
- external funding and a research-led approach to TNA increases a sense of ownership among the health promoters concerned
- commitment, enthusiasm and the ability to gain management support for TNA and training for health promoters are necessary in the leadership of such projects
4. BORDERS HEALTH PROMOTION DEPARTMENT
- a shared understanding of the principles of health promotion and an infrastructure to underpin this have to be developed within a team of HP specialists
- the needs of local communities can form a useful basis for dialogue with health promoters and their managers and with members of the local communities themselves
- a short-term pragmatic approach which meets the immediate needs of health promoters is required as well as a longer term strategy for client needs-led health promotion