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RCN updates travel health guidance to reflect new nursing challenges

It is six years since the RCN published its last set of travel health nursing guidance. Sandra Grieve explains how and why the guidance has been updated

It is six years since the RCN published its last set of travel health nursing guidance. Sandra Grieve explains how and why the guidance has been updated

Travel Health

Background

The Royal College of Nursing (RCN) has recognised and given a platform to nurses providing travel health services since 1994. The first guidelines and standards published in 2007 were updated in 2012. Following an audit and evaluation (RCN 2017) revised Travel Competencies have been published (RCN 2018). This revised edition retains the elements that nurses have found most useful, such as the information on pre-travel risk assessment and management but has been updated to reflect the changing nature of travel health.

Audit

Before updating the existing document (RCN 2012) an audit of use and perception was commissioned by the RCN Public Health Forum (PHF). No audit had previously been undertaken and evidence of value was purely anecdotal. A project group consisting of two original authors, the RCN Standards, Knowledge and Information Services team, supported by the RCN PHF professional lead was formed. To review the resource the team conducted a smart survey and audit. The project used a combination of qualitative and quantitative methods, using telephone interviews with a small number of expert nurses to develop a specific questionnaire for use on a wider audience of professional groups delivering travel health advice. The audience was targeted through relevant national bodies and publications. The survey was open for four weeks and the questionnaire pilot-tested before roll-out. Data was analysed using an agreed analytic framework, underpinned by themes identified in the interviews. These covered perceptions and experiences, expectations and benefits (Currie 2017).

Audit findings

Respondents were mainly registered nurses in England, delivering direct care through patient consultations. Fewer worked in the private sector but were more likely to use the document than NHS colleagues. Of concern was that 20% had not heard of the document, others had heard of it but did not use it. The risk assessment and risk management sections were viewed as the highest quality and most useful elements, the Knowledge and Skills Framework least useful, especially for nurses outside NHS settings.

Suggested additions included: visiting friends and relatives; migrant health; female genital mutilation (FGM) (RCN 2016); guidance on consultation times; clarity on vaccine charging; and availability of a printable risk assessment form.

The document was rated highly as a benchmark for minimum training requirements and for its emphasis on traveller benefits beyond immunisation. The lack of mandatory training and failure of general practice to take responsibility for travel health advice were seen as barriers.

Overall the publication was well-received, showing a continuing need for travel health guidance for nurses and other practitioners delivering relevant services. The evaluation confirmed the publication’s value, evidence of the influence on nursing practice and the need for continued guidance and updates but awareness of the document needs to increase.

Post audit

The original authors of the previous publications (RCN 2007, 2012) managed the project, maintaining the UK four-country perspective.  Survey proposals were considered, although some had already been addressed (RCN 2016).

New edition

Travel health services have changed since 2012. The 2018 edition builds on previous versions, retaining elements considered most useful and expanding information on governance, current resources and standards for best practice. How immunisation services are delivered in Scotland is undergoing review (Scottish Government 2017) and NHS England published a list of items considered unnecessary for routine prescribing in primary care (NHS 2017). The prescribing and administration of vaccines for travel in various settings is described. Funding of vaccinations for travel on the NHS or as a private provision remains complex.   

Online learning, internet access and social media have affected the delivery of travel health training and advice. Current guidelines and standards of care for travellers by appropriately registered practitioners remains focused on a registered nurse, defining standards expected for: competent nurse (level 5); experienced/proficient nurse (level 6); and senior practitioner/expert nurse (level 7).

Travel health services are mainly provided in primary care and increasingly in the private sector and pharmacies. Guidance is applicable to other qualified practitioners, including doctors and pharmacists, so the scope of practice can vary. Although the broadest spectrum is included in the descriptors and levels of practice, some elements may not be covered. Those included should provide an indication of the expected ability to function at that level.

The risk assessment section is comprehensive. Expanded information in the pre-travel consultation covers FGM, forced marriage and lesbian, gay, bisexual and trans travellers. The travel health consultation provides an opportunity to identify and support travellers in these categories. Appendices contain downloadable risk assessment/management forms, with standalone versions available online.

Appointment times

Recommended appointment times were retained, clarified, and expanded. It would be unsafe to allow only 10-15 minutes for a new travel appointment. To exercise best practice, a 20-minute minimum consultation time per person should be allowed. Travellers with complex or additional needs may require longer while those needing follow-up vaccinations could have shorter appointments.  Suggestions on managing children or groups of travellers within the consultation was added.

For Nursing and Midwifery Council revalidation, nurses are reminded of their personal responsibility in developing a portfolio of evidence of competence. Individuals can determine the scope of their current level of practice, future development needs and prepare themselves to progress into future roles within the field of travel health.

Some political and professional issues and initiatives are highlighted in the document, including an increased focus on work-based and lifelong learning and supervision, and the need for leadership in specialist nursing.

In the UK, formal training and qualifications became available in 1995. The Faculty of Travel Medicine (FTM), Royal College of Physicians and Surgeons of Glasgow (RCPSG) was established in 2006. To achieve optimum safe practice for travellers RCPSG (2014) recommendations can be used in conjunction with the RCN's new document (RCN 2018) to support all practitioners delivering travel health services. Expert nurses should aspire to be admitted to FTM through the Membership Diploma in Travel Medicine (RCPSG 2018).

The aim of FTM is to lead the way in raising standards of practice and achieving uniformity in provision of travel medicine services to protect the health of travellers.

Among survey respondents, 36% had undertaken a specific two-day travel health training course, 37% had attended a half or single day course and 2% had no training.

The FTM position paper (RCPSG 2014) acknowledged that travel medicine is not a recognised medical specialty in the UK or the Republic of Ireland. There is:  

  • A lack of structure and delivery of travel medicine services.
  • No formal training pathway to a recognised professional standard.
  • A lack of assurance of practice against defined standards.

Recommendations:

  • Mandatory formal training for health professionals offering medical advice to travellers by a suitably accredited provider.
  • Governance of travel medicine provided by FTM through its continuing professional development programme.
  • National authorities review and assurance of travel medicine providers' competence, with consideration of financial remuneration arrangements and licensing.
  • Educating the public to recognise the delivery and standard of service expected of providers.

Travel health is an expanding field of practice that is becoming more challenging. In the UK, travel health is mostly provided in primary care with pharmacists increasingly providing travel advice. Travellers cover people of all ages and ethnic backgrounds going abroad for a variety of reasons. Their needs vary and are increasingly complex. This updated guidance aims to support and meet the professional needs of nurses delivering travel services in this dynamic area of practice.

References

Currie L, Russell J, Bayliss A (2017) Executive summary: perceptions of the RCN Travel Health Competencies Document. RCN, London.

National Travel Health Network and Centre (2017) Becoming a Yellow Fever Vaccination Centre (YFVC) in England, Wales and Northern Ireland (EWNI).

NHS England (2017) Items Which Should Not Be Routinely Prescribed in Primary Care: Guidance for CCGs.

Royal College of Nursing (2007) Competencies: an Integrated Career and Competency Framework for Nurses Working in Travel Health Medicine. RCN, London.

Royal College of Nursing (2012) Travel health nursing: Career and Competence Development.

Royal College of Nursing (2016) Female Genital Mutilation: RCN Guidance for Travel Health Services.

Royal College of Nursing (2018) Competencies: Travel Health Nursing – Career and Competence Development.

Royal College of Physicians and Surgeons of Glasgow (2014) Protecting the Health of Travellers From the UK and Ireland.  

Royal College of Physicians and Surgeons of Glasgow (2018) Royal College Membership Diploma in Travel Medicine.

Scottish Government (2017) General Practice: Contract and Context. 4. Improving GP Workload. Vaccinations.


Sandra Grieve is an independent travel health adviser, Warwickshire, England

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