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CHAPTER 4: TRAINING AND DEVELOPMENT - ACCREDITED COURSES

Summary

PATH's achievements to date

4.1 The broad objectives of PATH's training and development remit are:

• To promote best practice through evidence-based training;
• To increase the quality and consistency of tobacco-related training in Scotland;
• To broaden the range and scope of tobacco-related training in order to increase the number of people trained in tobacco issues;
• To ensure that everyone who needs tobacco-related training has equal opportunities to access it;
• To enhance the professional standing of the smoking cessation specialism, through developing validation and accreditation systems.

4.2 Initial tasks for PATH were to develop a national training strategy and national training standards for smoking cessation work and to develop an approval scheme for courses that are in line with training standards. ASH Scotland published a Strategy for smoking cessation training in Scotland in September 2003, following a mapping exercise and training needs analysis ³⁸ and widespread consultation. The Standards for Smoking Cessation Training in Scotland were produced in tandem with the training strategy and published in December 2003. They are a set of criteria outlining the skills and knowledge that a participant should have on completion of a course.

4.3 PATH subsequently developed an approval scheme for courses that meet the standards. This was launched in September 2004 after a successful pilot. This element of PATH's work is discussed in Chapter 5.

4.4 The most recent phase of PATH's training and development work has been the development of accredited training modules in smoking cessation in partnership with Glasgow Caledonian University ( GCU) (specifically, with the School of Nursing, Midwifery and Community Health). These modules are designed to be delivered across Scotland by PATH's four Regional Training Officers ( RTOs), working in partnership with local trainers.

4.5 To date, three accredited smoking cessations modules are provided by PATH. These cover:

• The provision of brief advice to stop smoking;
• The provision of specialist cessation support to individuals;
• The provision of specialist cessation support for groups.

4.6 Each module runs over 15 weeks. To complete the module, students must successfully:

• Fill in a workbook;
• Attend a locally-held classroom-based learning day(s);
• Submit a learning or practice log;
• Submit a written assignment;
• Be assessed delivering the equivalent intervention in a simulated environment. ³⁹

4.7 Each course has a specific credit level. Students who hold a degree and complete all of the modules at Level 3 are awarded a Graduate Certificate in Smoking Cessation. Students who successfully complete all three modules at Level 3 but do not hold a degree receive a Certificate in Smoking Cessation. Each module currently costs £130 (and can only be offered at this price as a result of investment by the Scottish Government).

4.8 Although the courses were initially designed for use within the regional Health Boards, PATH has also developed a working partnership with the Scottish Prison Service ( SPS) and has delivered several courses for staff working in this service.

i) Brief Advice for Smoking Cessation

4.9 This module provides participants with the evidence base and skills required to deliver brief opportunistic advice to stop smoking. It is intended for anyone who may have the opportunity to bring up the issue of smoking with clients. This includes all health workers and may also include workers from other sectors, such as youth workers, teachers, drug and alcohol workers, and volunteers.

4.10 The course syllabus covers:

• Efficacy of brief advice, overview of local and national smoking rates, and cessation policy;
• Smoking and health: the common diseases and health complaints caused by active and passive smoking and the health benefits of stopping smoking;
• Communication skills: how to raise the issue of smoking appropriately, tailoring brief advice to the individual;
• Introduction to the social and behavioural aspects of smoking, the nature of nicotine addiction and withdrawal;
• Support for a quit attempt: pharmacological therapies and behavioural support;
• Information on local smoking cessation services and other resources available to support smoking cessation work.

4.11 The module offers 20 credits at Scottish Higher Education Level 1 (equivalent to the first year of an undergraduate degree). There is also an option to take the module up to Level 3 (equivalent to the third year of an undergraduate degree) to facilitate attainment of the graduate certificate.

ii) Providing Specialist Smoking Cessation Support to Individuals

4.12 This module provides participants with the evidence base and skills required to provide specialist smoking cessation support to individuals. It is intended for anyone whose role allows them to offer specialist support on an individual basis, including all health professionals. It may also be appropriate for workers from other sectors, such as community workers, youth workers, teachers, drug and alcohol workers, and volunteers. Students are expected to have covered the learning outcomes in the Brief Advice module or to be able to demonstrate that they have received training or gained experience equivalent to taking the Brief Advice module.

4.13 The course syllabus covers:

• What is specialist cessation support?
• Overview on smoking cessation services across Scotland and in-depth information on local cessation work;
• Practicalities of setting up and running a smoking cessation service;
• In-depth input on the nature of tobacco use, including physical and behavioural determinants and the nature of addiction;
• How to assess a client's tobacco use: nicotine dependence and behavioural characteristics;
• Evidence and effectiveness of various cessation therapies, and in-depth input on pharmacological therapies;
• Relapse prevention;
• Dealing with other issues that may arise when delivering support: setting boundaries and referring on;
• Working with priority groups or those facing inequalities: tailoring support and accessing information;
• Personal development issues and resources to support specialist cessation support.

4.14 The module offers 20 credits at Scottish Higher Education Level 3 (equivalent to ordinary degree level).

iii) Providing Specialist Smoking Cessation Support to Groups

4.15 This module provides participants with the evidence base and skills required to provide specialist smoking cessation support to groups. It is intended for anyone whose role allows them to offer specialist support on a group basis, including all health professionals. It may also be appropriate for workers from other sectors, such as community workers, youth workers, teachers, drug and alcohol workers, and volunteers. Students are expected to have covered the learning outcomes in the Brief Advice and Specialist Smoking Cessation Support to Individuals modules or to be able to demonstrate that they have received training or gained experience equivalent to taking the Brief Advice and Specialist Smoking Cessation Support to Individuals modules.

4.16 The course syllabus covers:

• Running a smoking cessation group: practicalities of setting up a group;
• Defining a typical smoking cessation programme;
• Group dynamics;
• Group leadership and facilitation skills;
• Decision making skills to determine appropriateness of group or 1:1 consultations.

4.17 This module offers 20 credits at Scottish Higher Education Level 3 (equivalent to ordinary degree level).

Course-related activity to date

4.18 Tables 4.1 and 4.2 summarise the numbers accessing each of these accredited training courses between December 2005 and September 2007.

Table 4.1: Numbers accessing accredited training courses by NHS Health Board

Source: ASH Scotland

Table 4.2: Access to accredited courses by date

Source: ASH Scotland

4.19 Given that the courses need to be taken sequentially, numbers taking the two specialist courses would be expected to be lower than for the brief advice module. Furthermore, the specialist courses are less likely to be appropriate for staff who do not work primarily in smoking cessation services.

4.20 Table 4.3 shows the results to date for each module in terms of the percentages of the students who pass, fail and defer. To date, approximately two-thirds of the students have passed the brief advice module and just over half have passed the specialist support modules.

Table 4.3: Results in terms of pass rates

Source: ASH Scotland

4.21 Failures generally relate to the academic requirements of the essay (e.g. insufficient discussion; incorrect referencing) rather than to knowledge levels or practitioner issues. However, a minority fail on the objective structured clinical examination ( OSCE), usually due to poor communication skills. Deferrals seem to be due to a lack of capacity to complete particular aspects of the course (the workbook and the essay are flash points). This can be due to inappropriate student expectations (i.e. they register without fully appreciating the level of work required) or because they lack time to complete the requirements due to work pressures and a lack of protected time to undertake the course requirements.

4.22 To help to address these problems, all students are now signposted to attend an effective learning session at GCU, which covers the academic requirements for the essay. There are also plans to enhance the communication elements within the learning days for each module. There will also be an in-house reflection session at the end of each semester, part of which will include proactively looking at any fails to determine why they occurred and, if themes emerge, whether any actions can be taken to prevent fails for similar reasons in the future. When comparing these courses with other similar ones, GCU felt that these modules compared well in terms of failure rates and that there were no significant causes for concern.

4.23 PATH and GCU also intend to emphasise the work commitment more in their marketing and to change the way in which the workbook is completed by splitting it into two sections. In the future only one of these sections will need to submitted, with the other part helping to build the foundations for the essay.

Current developments within PATH

4.24 PATH is currently undertaking an internal evaluation of its accredited training modules. The Kirkpatrick model of training evaluation (which was originally developed during the 1950s) has been adopted as it is widely used for evaluating training programmes. The model incorporates four levels of evaluation - reaction of student, learning, behaviour and results; the PATH evaluation is concentrating on the results level.

4.25 The specific objectives of PATH's internal evaluation are to:

• Determine the quality, structure and relevance of the course content for each accredited training module;
• Determine the quality, structure and relevance of both the Learning Day and OSCE components for each accredited training module;
• Determine the appropriateness of the depth/level of difficulty of the written assessment;
• Explore the expectations, reality and balance of time committed to complete the accredited training modules;
• Determine the quality, value and relevance of the student handbook to complement the accredited training modules;
• Explore the perceptions of the course tutors in terms of their accessibility, knowledge, skills and expertise in delivering and supporting the accredited training modules;
• Explore the relationships between the students and both GCU and ASH Scotland prior to, during and after completion of the accredited training modules;
• Explore the effectiveness of the marketing for the accredited training modules.

4.26 The PATH member of staff undertaking the evaluation is using a combination of data analysis, themed focus groups, in-depth 1:1 interviews and a marketing questionnaire. The evaluation was expected to take six months to complete. Its interim findings were published in December 2007 and include the following observations:

• There is a need to develop a 'memorandum of understanding' summarising the commitments that need to be recognised by all stakeholders to counteract miscomprehension about the modules and their requirements;
• There is a need to move towards a range of context-specific examples for the role-play and OSCE components, especially for the students from the Scottish Prison Service. ⁴⁰

4.27 Finally, a number of areas of future work are currently being developed by PATH. All of these place considerable emphasis on partnership working and include:

• Tobacco and mental health training;
• Cessation and pregnancy training;
• Cessation training for those working in the dentistry profession;
• Consulting with practitioners on developing competencies for smoking cessation work;
• Devising a marketing strategy to determine how to market PATH's training activities effectively both nationally and locally.

Feedback from stakeholders and discussion

4.28 The interviews with stakeholders were used to:

• Determine the number and characteristics of courses approved by PATH;
• Obtain feedback about the provision of these courses (e.g. numbers and backgrounds of participants; views of participants) from those responsible for their delivery;
• Explore the experiences of the modules accredited by GCU which have been or are being run (e.g. numbers and backgrounds of participants; completion rates; take-up of multiple modules; feedback from course managers and tutors; feedback - such as course evaluations - from course participants).

4.29 The feedback on the accredited courses was mixed, although the overall views were generally positive. The main points are summarised below (though this list should be read in conjunction with the findings of the internal evaluation, when finalised):

• Stakeholders welcomed the creation of accredited, evidence-based courses and thought that Scotland is leading the way in the UK;
• The course material is seen as being very comprehensive;
• The courses seemed to be especially appreciated by the smaller Health Boards that had not developed (or been able to develop) their own internal smoking cessation training programmes;
• Many respondents commented on the significant time commitments associated with the courses, not just in terms of the individual participants but also from an organisational perspective;
• Although support is available from GCU for those with limited or no recent experience of higher education, the courses seem to have been especially demanding for such participants;
• Furthermore, some participants seem to have been unaware of this additional support;
• Staff in remote areas (e.g. in the Island Health Boards) commented that it can be very difficult for them to attend Learning Days on the mainland, due not only to the time requirements but also because of the associated travel-related costs;
• Although the courses have been marketed as being suitable for those who do not specialise in smoking cessation work, the general consensus was that they were unnecessarily detailed for those professionals and volunteers who may come into contact with smokers as part of their day-to-day work and wish to provide them with brief advice only;
• Some Health Boards prefer to fly staff to England so that they can take shorter courses there (even though the course fees may be much more expensive);
• Rather than "taking a sledgehammer to crack a nut" and changing the existing accredited modules, there is a clear need for some much shorter training courses, especially relating to providing brief advice;
• PATH and GCU staff were very positive about their working relationships;
• Views varied on the accessibility of PATH staff for support and advice whilst taking the courses - some staff appeared to be easier to contact (and/or quicker to respond) than others;
• Although staff from GCU helped PATH staff develop assessment procedures for coursework and assignments, concern was expressed by some respondents that PATH staff may lack the necessary academic training and experience to deliver the accredited training modules; ⁴¹
• Initially many participants experienced problems registering with GCU, as they seemed to be unaware that they needed to register for each semester (despite this being stressed in the course materials), not just for each course - course dates have been streamlined to try to prevent such problems (which often only became apparent when a student was unable to access their results) arising in the future;
• Some respondents reported problems accessing some of the required reading for the courses; ⁴²
• Some respondents felt that the failure rate was fairly high and were surprised that some of their most experienced staff (e.g. those with up to 20 years' experience in smoking cessation work) had not passed;
• Other respondents, however, felt that it was good to challenge staff who had possibly worked in the same way for many years, so that they were aware of relevant new research and developments (e.g. different types of nicotine replacement);
• Many respondents stressed the need to develop a range of non-accredited courses with specific foci, often drawing on the lessons from the various supported projects within PATH and ASH Scotland (e.g., ways of working with young people; attracting people from the traditionally hard-to-reach client groups);
• Staff from some Health Boards would like to be able to use high quality training materials that have been developed elsewhere (e.g. by PATH), using local staff for their delivery (e.g. as part of an induction programme for all new staff);
• Other staff would like to be able to contact PATH to deliver specific courses for them as and when local needs dictate;
• There is a need for courses that are delivered in different ways, such as via CD- ROM or interactively;
• There is also considerable potential to develop training materials for specific professional groups, such as pharmacists and dentists;
• Demonstrating competencies is an important element of continuing professional development ( CPD) for staff, and there is scope for PATH to work closely with Health Boards and relevant professional bodies to help to ensure they are all actively involved in national discussions relating to the potential for developing a formal, national 'competency' framework for smoking cessation (and to identify its resultant implications for training);
• A small number of respondents felt (in some cases strongly) that ' PATH' should also explore the possibilities of building training-related alliances with others working within substance misuse services (especially regarding the use of cannabis, as this is often closely linked to tobacco use).

4.30 It is recognised that many of these issues are already being addressed within PATH, who are keen to streamline the delivery of the accredited modules and develop a portfolio of training courses to meet the various needs of the Health Boards identified above. Their internal evaluation of their accredited training modules will contribute to this process.

4.31 One final point to emerge from the interviews was the challenge for the RTOs of delivering training across the Health Boards, where local policies (e.g. relating to the health and safety of staff) may differ. It is important that the RTOs are aware of any circumstances where their advice on delivering smoking cessation may be at odds with local policies, which further emphasises the need for ongoing engagement between the RTOs and the local smoking cessation co-ordinators and managers.

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