Introduction to an integrated competence framework for health-care support workers and nurses working in menopause

As part of a multidisciplinary team, the role of the menopause nurse has evolved over 20 years into an essential element of expert clinical care. It has also been important in contributing to the education of women themselves as well as to other health-care professionals. Menopause nurses work in a variety of different settings including specialist menopause clinics that may include tertiary referral centres and clinics for patients requiring long-term follow-up with regard to hormone replacement therapy (HRT), for example, those with premature menopause, Turner's syndrome and also those who have had treatment for cancer in their younger years. Menopause nurses also work in gynaecology outpatients, ward areas and primary care, with roles that vary according to service provision and patient need.

The integrated competence framework has been developed to provide guidance for nurses working in the field of menopause and attempts to ensure consistency in standards of care for women experiencing the menopause. It can be used to ensure practice is safe, effective and accountable. Using the competences nurses may identify their own level of practice and career plan in a more structured way and pinpoint education and development needs, while increasing the effectiveness of service provision. In addition, it enables standards of competence to be set, which should be transparent across all working environments involving menopause, thus improving accountability within the profession.

Agenda for Change, the NHS Knowledge and Skills Framework and the Development Review Process, and the NHS Plan are all key drivers for expanding the role of nurses, who are increasingly responsible for seeing and advising women at the time of menopause and promoting health into the years beyond. ^1–3 The Department of Health publication, Modernising Nursing Careers: Setting the Direction, ⁴ proposed career development for nurses built around patient pathways. Competences allow greater flexibility and transferability across traditional organizational and career boundaries. Other documents stressing the need for skills, knowledge and competency frameworks to improve quality of care include High Quality for All ⁵ , A High Quality Workforce, ⁶ and Framing the Nursing Contribution: Driving up the quality of care. ⁷

Competence is defined by Roach ⁸ as ‘the state of having knowledge, judgement, skills, energy, experience and motivation required to respond adequately to the demands of one's professional responsibilities’. The Nursing and Midwifery Council Code ⁹ on standards of conduct, performance and ethics states that in order to provide a high standard of practice and care at all times, nurses must have knowledge and skills for safe and effective practice and must recognize and work within their own level of competence. Nurses must also take part in appropriate learning and practice activities that maintain and develop competence and performance. ¹⁰

The Royal College of Obstetricians and Gynaecologists (RCOG) ¹¹ established standards of care within the field of menopause. These standards support the role of the nurse in the promotion of a multidisciplinary team approach to ensure holistic care and also with the encouragement of evidence-based practice in specialist nurse-led clinics. Nowadays, independent prescribing is an accepted extension of the nursing role with increasing numbers prescribing HRT. ¹² Stenner and Courtenay, ¹³ following a survey of nurse prescribers, highlighted a need for additional education specific to assessment and diagnosis. A nurse-led competence framework is clearly required if the challenges of expanding roles are to be met and services to women improved.

A subgroup of the Royal College of Nursing (RCN) Women's Health Forum, the RCN UK National Menopause Nurse Group was established in 2003 with the objectives of:

driving professional nursing practice within the field of menopausal health, and offering clinical leadership for nurses during periods of change

promoting education to all nurses on issues relating to menopause

encouraging a multidisciplinary approach to menopause care

promoting issues relating to menopause across all RCN forums.

Previous publications from this group have included Women's Health & the Menopause ¹⁴ and Complementary Approaches to Menopausal Symptoms. ¹⁵

The menopause framework development process began when the RCN group conducted a clarification exercise designed to articulate the values and beliefs of menopause nurses and to flag issues/concerns of women experiencing the menopause. The themes that were generated formed the basis for the framework. Recognition of the need for a unique and specific framework that enables menopause nurses to describe their competence in this complex nursing specialty was the catalyst for progress. All levels of nursing needed to be included, from health-care support worker, competent nurse, experienced proficient nurse, senior/advanced practitioner through to nurse consultants, who are increasingly active in menopause care. Much redefining and refocusing was needed as a wide range of views were sought. RCN Menopause group members, external reviewers–professionals in field and client group representatives all contributed from around the UK. RCN advisers also made a significant contribution. Accreditation was finally achieved in March 2009 from the RCN.

The menopause framework is centred on the patient experience with the identification of four overarching areas of competence as below:

Caring for women:

Experiencing the menopause

Requiring specific interventions:

 HRT

 Non-hormonal therapies

 Hormone implants

Maintaining health and wellbeing for women experiencing menopause

Enable learning to promote care of women at time of menopause.

Each of the overarching areas of competence is described across all individual levels of practice within nursing. Levels refer to the relevant Agenda for Change criteria, e.g. level 2/3/4 – health-care support worker, level 5 – competent nurse, level 6 – experienced proficient nurse, level 7/8 – senior/advanced nurse and level 8 – nurse consultant. Attached to each area are specific competences. Each individual competence is matched to the related dimensions in the Knowledge and Skills framework with which nurses in secondary care are familiar. Performance criteria, that is, how the required competence should be performed is detailed and measurable. The necessary underpinning knowledge and understanding and also contextual factors that include useful resources are all outlined in detail. These include the British Menopause Society (BMS) handbook on menopause management and Skills for Health resources. ^16,17 Specific attitudes and behaviours when communicating with women are suggested, e.g. sensitivity and understanding.

The development of knowledge, skill and expertise as described by Hale ¹⁸ suggests competence is incremental in nature. Building on existing competence, acquiring new knowledge and skills alongside experiential learning encourage broadening of the sphere of competence. The framework is not designed to be prescriptive, but rather to act as a template that can be used to suit local needs. It is anticipated that competence will be assessed at a local level in partnership with medical and allied health professional colleagues. Those performing assessment of competence should have expertise in such assessments. There are many forms of evidence, with which nurses will be familiar, that can contribute to evidence that a specific competence has been met including reflection on management of patient care that is appropriate for the individual's level of expertise.

Sadly, in practice today some women still comment that they were treated as though menopause was inevitable, given HRT as a foregone conclusion and sent on their way without further discussion. Many say they wished that their individual needs, choices and risks were discussed. Women are also keen for ongoing monitoring and support with an acknowledgement of the psychological impact of the menopause. There is an appreciation for specialist clinic information, advice and education on menopause designed to help manage health effectively in the future. These are not unrealistic expectations and nurses, if competent, can play an active role alongside medical and other colleagues in providing such a service.

The menopause competence framework, from the Royal College of Nursing, will increase individual effectiveness as nurses identify their level of practice and define personal education and developmental needs and are enabled to career plan. This combined with interdisciplinary team effectiveness can only improve standards of holistic care for women across all settings. The framework is a dynamic document that will hopefully continuously evolve as it is used. Comments and suggestions are welcome to ensure that the framework remains current and relevant to nurses involved in care of women experiencing menopause. Evaluation will be required to identify issues such as gaps in information and ease of use. Annual update is required for the framework to remain on the RCN publication register for three years. The full document is available at www.rcn.org.uk/publications. UK wide workshops for nurses, to disseminate how competences can apply to clinical practice, are planned for 2010.

Competing interests

None declared.