To provide a framework for clinical nurses and doctors working in sexual health wishing or required to undertake a process of clinical accreditation and competency assessment within their service, with the aim of providing a supportive learning environment while maintaining a high standard of client care.
The accreditation process provides a contract between a senior nurse or doctor accredited to assess clinical skills and the nurse or doctor new to the clinical setting.
It is recognised that competency develops over time and that clinical learning will continue both before and after clinical accreditation. The nurse will continue to practise under the Nursing and Midwifery Board of Australia and Australasian Sexual Health & HIV Nurses Association codes of conduct. The doctor will continue to operate under the Australian Medical Association (AMA) Code of ethics and should already be competent in a range of activities as determined in the Australian Curriculum Framework for Junior Doctors.
Where a doctor or nurse has previously completed a sexual health accreditation competency process, there should be a local process in place for considering prior learning and experience.
Registered nurses who successfully complete the clinical accreditation process will be deemed competent to undertake a scope of practice as outlined in Delegation of clinical practice.
The accreditation process is based on adult learning principles1 and experiential learning. Adults learn by:
- knowing why they should learn something and considering it important to acquire the new skill, knowledge or attitude
- being self-directing and deciding for themselves what they want to learn
- having had far more experience than young people and different kinds of experiences, so that connecting the learning experiences to past experiences can make the learning experience more meaningful and assist them to acquire new knowledge
- becoming ready to learn when they experience a life situation where they need to know
- entering the learning process with a task-centred orientation to learning
- having both extrinsic and intrinsic motivation to learn.
The process of clinical competency accreditation has three distinct stages:
- Clinical skills accreditation and formative review
- Summative review.
At each of these stages the clinical teacher and the learner undertaking accreditation have objectives and outcomes that need to be met.
Clinical teacher Learner
- Establish recognition of prior experience
- Orient learner to clinical areas, client files, clinic forms and appointment system
- Demonstrate clinical skills and clinical decision making with reference to clinic-based guidelines and the standard operating procedure
- Provide information on evidence-based resources for use in the clinic setting and for self-directed learning
- Observe client consultations
- Commence supervised clinical skills
- Engage in reflective practice during and after client consultation
Clinical skills and formative review
Clinical teacher Learner
- Base skill review on clinical practice wherever possible
- Observe client consultations to ensure skills are performed in the clinic context and continuity of care is maintained
- Provide specific, timely and constructive feedback based on observations
- Refer to clinic-based guidelines and the standard operating procedure when teaching
- Meet with learner regularly to review file documentation and participate in reflective practice and planning for skill development
- Provide opportunities to role play skills and attributes
- Perform client consultations with observation
- Provide rationale for any variations in client consultation
- Perform client consultations independently once accredited for each skill
- Continue to observe client consultations and actively reflect on attitudes, knowledge and skills demonstrated
- Follow clinic-based guidelines and the standard operating procedure
- Ensure a safe client environment by working within own scope of practice
Clinical teacher Learner
- Provide feedback on clinical skills accreditation and clinical practice
- Develop action plan for skills not yet accredited
- Review after three months with line manager
- Undertake a clinical session with a senior clinician utilising feedback and reflection skills
- Demonstrate ability to apply knowledge within the context of sexual health clinic practice
- Demonstrate critical thinking and clinical decision-making skills appropriate to the speciality and scope of practice
- Perform client consultations independently for accredited skills
- Within multidisciplinary framework consult with senior colleagues in accordance with delegation of clinical practice
- Commence medications package for standing order accreditation
- Continue clinical supervision and skills accreditation as negotiated with line manager
Clinical teaching skills
Feedback is a means of communicating thoughts and feelings about the performance and competence of another person. It is central to sharing ideas, information and skills, as well as being vital for establishing and building relationships.
Helpful feedback makes a conscious distinction between the person—who is always valued—and particular acts or specific work—which may be subject to critical comment. The most important characteristic of constructive feedback is the way it is given. The tone, the style and the content should be consistent and provide the message that the person is valued.2
Skills for giving and receiving feedback are learnt. They are an essential element of lifelong learning. Feedback provides information that the learner can use to make changes to their practice.
Guide to helpful feedback (based on Boud2):
- Be realistic—direct comments towards things that the person can act on
- Be specific—base your comments on concrete observable behaviour
- Be sensitive to the goals of the person—link your comments to their intentions
- Be timely—select a time appropriate to timing of the event you are giving feedback on
- Be descriptive—describe your own views; it is up to the person to accept or reject them
- Be consciously non-judgmental—offer your personal view
- Don’t compare—treat each person’s work as their own
- Be direct—say what you mean
- Be positive—say what you appreciate
- Be aware of your own emotional state and focus on the other person.
Reflection is an intentional process of examining experience to help people understand the action and the reasoning behind their thoughts and actions.
There are two main types of reflection: reflection in action (during the event) and reflection on action (after the event). The retrospective action of reflecting on a prior experience or action aims to promote one’s thoughts and judgments, attitudes and actions in the context of a particular experience. The knowledge gained cannot affect the past event but it can be used in future events.
David Kolb articulates the experiential learning cycle that shows how the learner plans, acts, observes and, through understanding, plans for the next encounter.3
Through reflection, it is possible for the learner and teacher to accumulate knowledge about and become familiar with sexual health practice. The result is that the learner not only changes their practice (learns from experience) but the teacher can also impact in a co-participatory way on the learner’s practice.
During the reflective process the clinical teacher will use listening techniques:
- recognising areas that need further reflection
- using questioning techniques to guide the learner’s reflection
- sharing both experience and reflective insight
- supporting the learner’s reflective practice
- guiding and supervising the learner’s journal writings.
It is the responsibility of the clinician to maintain and update their professional knowledge relating to sexual health in order to provide a high-quality service for clients and to develop case-related experience. Time may be allocated within the roster for self-directed learning. There are also many online learning packages with topics on HIV, sexual health, history taking, and women’s and men’s health.
In relation to nursing, the clinical competency assessment tools are based on the scope of practice as outlined in the Delegation of Clinical Practice.
The Mini-clinical evaluation exercise from the Royal Australasian College of Physicians is a useful tool.
Professional relationship issues
If the learner experiences difficulty in their relationship with the clinical teacher, all possible attempts should be made to ensure that a professional, constructive and supportive relationship is maintained. If this cannot be managed on an individual level, consultation with the line manager to develop a plan is recommended.
To finalise the accreditation for each skill competency or practical procedure, the competency accreditation record (Appendix 7.1 ) must be completed. This is often completed as reflection on action at a separate meeting time from the clinic session.
Once complete, all documentation is kept in the personnel file by the line manager.
For self-directed learning, or to guide the clinical teaching process, a clinical action and reflection plan can be used by both the learner and the clinical teacher setting out the learner’s weekly goals and achievements.
References and further reading
- Knowles M and associates. Andragogy in action: applying modern principles of adult education. San Francisco (CA): Jossey Bass; 1984.
- Boud D. Implementing student self-assessment. HERDSA Green Guide. No. 5. 2nd ed. Sydney: Higher Education Research and Development Society of Australasia; 1991.
- Smith MK. David A. Kolb on experiential learning. In: Encyclopedia of informal education. London: YMCA George Williams College; 2010. Available at: http://infed.org/mobi/david-a-kolb-on-experiential-learning/
- Nursing and Midwifery Board of Australia. Registered nurse standards for practice. Melbourne: NMBA. Available at: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx
- Australasian Sexual Health and HIV Nurses Association. ASHHNA competency standards for sexual and reproductive health and HIV nurses. 2nd ed. Ashfield (NSW): ASHHNA; 2011. Available at: http://ashhna.org.au/resources/#standards