Cervical Screening: Participation and Informed Consent
Thisworkshopplan covers two topics.
Encouraging participation of women in cervical screening
Helping women understand informed consent for cervical screening.
A health literacy model for communication is introduced and used to support both topics.
Participants
Clinical staff in primary care and health promoters encouraging cervical screening are the main audience for this workshop. Management and administrative staff can also attend the workshop.
Pre-Requisite
CALD or similar Cultural competency training
Preparation
Link to the website, the video“A woman’s experience of communication”.
As per preliminary workshop; data (coverage for total population and for high needs population as available from each PHO) for practice
Length
This workshopcan be delivered in atwo hour workshop. The workshop could be split into two sessions provided a week apart.
Framework
This workshop plan is based on the Three Steps to Health Literacy Model (Ask, Build, Check).
Ask
At the start of the workshop the facilitatorwill find out what participants already know.
Build
During each workshop the facilitatorwill build new knowledge by connecting to participants’ existing knowledge.
Check
At the end of theworkshop the facilitator will check that participants have achieved the intended outcomes for the workshop. If not, the facilitatortakes responsibility for not achieving the outcomes and goes back to the Build stage to develop the necessary knowledge.
Objectives for this session
By the end of this session participants will:
understand the Three Step Model for health literacy
understand how to use the Three Step Model to encourage participation and informed consent for cervical screening.
Resources
Laptop and data show for PowerPoint.
Whiteboard and markers.
Post-it notes.
Butchers paper and pens.
BluetakCopies for each participant of:
- Three Step Model booklet or handout
- Informed consent list
- Participation statistics (current information provided by the Metro Auckland Cervical Screening Project and available on the website
- Scripts showing possible questions and answers about cervical screening
- Audio recordings of questions and answers on website
- Following the training, an email with useful questions generated by the group, simple explanations, etc.
Time / Activity / Resources
5 mins / Welcome and housekeeping
Welcome all participants. Round of Introductions
Give housekeeping information.
Show Purpose of training session on PowerPoint.
Explain purpose of the workshop is to provide a model for discussing participation in screening, particularly with priority populations, and informed consent for cervical screening.
This will build on the knowledge the participants already have of cervical screening.
This workshop is focused on how to have good discussions with women (coming into your practices for other matters) about being screened and ensuring informed consent with those are willing to consider it.
Explain it is a two hour session.
Encourage participants to ask questions throughout session.
Explain there is another workshop looking at how the wider team can engage with eligible women and make the most of opportunities to invite for tests. Workshop One can be facilitated with a whole team at the surgery. This can be provided through a PHO nurse liaison or through a member of the team. / Slide 1
Slide2
5 mins / Introduction to health literacy
Ask participants what they think health literacy is
Write responses on white board – separate out points related to health professionals and complexity from those related to consumer skills/competency
READ slide definitions to explain HL and note the importance of looking at it from both sides (how information and support is provided and how it is received)
Explain that over half of the population has low levels of HL. (every second person - the majority reflect the majority population)
Ask which people tend to have lower Health Literacy and Why
Some groups have lower/poorer HL and why – older (due to not using literacy skills as regularly), unemployed (due to lower education levels), younger (due to less health sector experience) and rural (less clear – maybe less interaction with health sector).
Ask if they think the level of Health Literacy for a particular person remains static. If not, why not?
Explain HL is not fixed/static – the skills and knowledge we need depend on the situations (HL demands) we face and these change over time.
Ask: What affects Health Literacy?
Read slide 7
All NZ statistics are from Korero Marama (2010) Ministry of Health.
The raw data is from the OECD International Adult Literacy Survey 2006.
Health Literacy A prescription to end confusion (2004) Institute of Medicine (the other second definition on slide 3)healthliteracy8-27-08.ppt / Slide 3
Slide 4
Slide 5
Slide 6
Slide 7
5 mins / Introduction to schema theory
Ask if participants have heard of schema theory.
Schema theory is a learning theory – about how we learn and retain knowledge. It’s about connecting new information to existing knowledge to help it ‘stick’ or change the mental picture and connections people use to store knowledge.
Use slide to show an Initial schema (like leaves on tree) and how these connect to new ideas to grow a more developed schema.
You need to start where people are at (with what they know) otherwise you are explaining things they already know; talking about things that make no sense to them because they assume prior knowledge they don’t have; or are at odds with what they already know (believe to be true) without addressing the conflicts. This means new information is dismissed or forgotten. THIS IS HOW NEW KNOWLEDGE AND SKILLS (also known as HEALTH LITERACY) ARE BUILT
Schema theorywasdeveloped by Jean Piaget andis a cognitivist learningtheory. Many explanations are available: / Slides 8, 9,10
5 mins / Using a health literacy communication model today – called the Three Steps Model for Health Literacy
Three Step Model: ASK, BUILD, CHECK
Give people a handout/ with Three Step Model to Health Literacy.
Ask participants if they have heard of these steps or been trained in these steps.
Go through each step quickly.
Ask – find out what woman/family already know and feel about cervical screening. Acknowledge what is known and felt.
Build – based on what woman/family knows and feels, build an accurate understanding of screening. Discuss the how and the whyof screening. (WHERE SCHEMA THEORY IS IMPORTANT)
Check – at the end check what a woman/family and you plan to do.
Explain you will be demonstrating this by using it as a framework for the training - as well as helping them to use it.
Ask
Before each topic I’ll be asking questions to find out what you already know. This is a chance to acknowledge the good things you are already doing and share these with your colleagues.Build
During each topic, I’ll build new knowledge with you by connecting to your existing knowledge and extending it.This is based on schema theory.
Check
At the end of each topic or part of the workshop, I’ll check that you’ve achieved the intended outcomes for that topic. If not, I’ll take responsibility for that and go back to the Build stage to develop the necessary knowledge.Acknowledge that participants will have developed their own ways of communicating with women which draw on their skills and experience. It can be challenging to think about new ways of working and it is always easier to keep on doing what has worked before. The approach used in this workshop is based on evidence and will add to your repertoire in a way that ensures you build on the knowledge and beliefs of each woman, asking and listening first of all. Then you will tailor your explanations, and then you will check for understanding.
Acknowledge that limited time often puts a strain on the communication process. Where possible provide a testimonial from a smear taker who has worked in this way.
Health Quality Safety Commission / Slide 11
Three Step booklet or handout
(Booklet copies can be requested from the HQSC)
10 mins / Reaching priority populations
At this stage of the session the facilitators are modelling Step 1
Ask:Who are your priority populations for cervical screening?
Ask: What are the screening rates like in your practice for these women?
Ask: When do you see these women?
Ask: When do you encourage cervical screening? (refer back to work done in preliminary training session if appropriate)
Ask: How do you meet language and cultural needs?
Acknowledge the range of things that are working well.
ACTIVITY:
Ask: How do you explain the technical concepts such as
a) cervical smear,
b) abnormal cells, and
c)cervicalscreening programme?
Invite participants to get into pairs with post it stickers. Give each pair one of these three concepts. Tell participants they will record their partner’s explanation on post it stickers and report back to the group.Stick post its on the large sheet of paper under the appropriate section.
Suggest the simple explanations can be circulated. Use post it stickers to capture the simple explanations. If they are simple they should be able to get them on to a sticker! / Capture good ideas on the Whiteboard
Large sheet of paper on the wall divided into 3 sections.
Then circulate via email later
20 mins / Step 1: Ask questions to find worries, queries and barriers
Ask:How do you talk to a woman, from a priority population that is overdue for a cervical smear?
(Note that the responses should identify where and when participants are talking to women as well as the priority group)
Ask (if the answer has not been provided by responses to the previous question):What questions do you ask her at this point to get a picture of what she already knows and feels?
Ask (if it has not already emerged) for any differences between effective questions for Māori, Pacific and Asian women.
Make a list of good questions on the whiteboard.
NOTE that this is the ASK / STEP 1 part of the model.
E.g. What worries or concerns do you have about having a smear?
Use the Three Step Model Handout to prompt more examples
ACTIVITY
Ask : What are the worries and concerns that stop these women from being screened
Work either in pairs or as a small group.
Develop a collective list for whiteboard by each pair giving two worries/barriers until there are no more suggestions..
Acknowledge the suggestions already made. “Let’s see if there is anything else that we can add:”
The group is likely to have identified more than is on the list below. Acknowledge that.
Check and add to the board anything that has not already been mentioned.
- Never discussed with a health professional
- Haven’t received reminders
- Don’t know what smear, cervical cancer are (or it seems rare/unlikely – not a priority)
- Embarrassment
- Pain or discomfort
- Thought unnecessary (such as not sexually active, post-menopause, lesbian, hysterectomy, pregnant, been vaccinated, had STI check)
- Health concerns (such as impact on fertility)
- Cost (fees, transport, childcare and time off work)
- Time (such as inconvenient GP hours, too busy, not a priority)
- Fatalism (it might be my fate)
- Worry about getting bad news (I’d rather not know)
- Husband/family against it (or suspicious)
- Don’t believe in screening (I’ll know if I’m sick)
Whiteboard to record questions (circulate to group as follow-up)
Whiteboard
Copy 3-4 barriers to each of the large sheets of paper that will be used in the next activity.
20 mins / Step 2 Building understanding (responding to Step 1)
At this stage of the session the facilitators are modelling Step 2
ACTIVITY
Invite participants to work in smallgroups and allocate three or four worries/barriers to each group. Provide each group with a large sheet of paper.
Ask them to come up with responses toeach of the 3-4 worries/barriers. (Slide 14 has some techniques they could use). Use the large sheets.
Groups come back and to share their responses.
Acknowledge‘responses’ that show empathy, relationship building, acknowledgement; THIS MAY BE ENOUGH to help a woman decide to be screened – new knowledge is not always needed. At other times, new knowledge is also needed.
LISTENING. In Step One it is the health professional doing the listening – Slide 15. In Step Two it is the woman listening – Slide 16.
Where information is connecting to existing knowledge this helps it ‘stick’ or change amental picture. You need to start where people are
at (with what they know) otherwise you are explaining things they already know; talking about things that make no sense to them because they assume prior knowledge they don’t have; or are at odds with what they already know (believe to be true) without addressing the conflicts. This means new information is dismissed or forgotten.
Workbase have developed a resource – a list of frequently asked questions and plain English explanations as examples. This is a handout in your folder.
Discuss building understanding of new vocab/words. Need to hear and see a new word many times so don’t be afraid to repeat and explain new words.
Ask: as per slide 17 / Refer to list on Whiteboard
Slide 13
Large sheets of paper
Slide 14
Circulate responses later
Slide 15
Slide 16
Slide 17
10 mins / Step 3: Check
Discuss limitations of asking “Do you have any questions?” This puts pressure on a woman; and the easiest answer is “no”.Sometimes there is so much new jargon and information it’s hard to formulate questions.
Use a slide to ask participants:
ACTIVITY
Distribute post-it notes. Use different colour post it notes for the two questions.
This is an individual exercise.
1. Ask: What questions could you ask to check a woman has the information she needs?
2. Ask: What questions could you ask a woman to check whether she is willing to have a smear?
Invite participants to share their ideas. First the ideas for question 1, then round again for question 2. Gather in the Post it Notes / Slide 18
Post-it notes
Large Sheet of Paper (with the 2 questions) on wall to collect post it notes.
Ideas can be sent out later
5 mins / Recap
At this stage of the session the facilitators are modelling Step 3
Check: Did you all identify key points in relation to the 3 steps?
Asking – questions about concerns re screening – need to understand unique needs of a woman and start there.
Building – acknowledge responses and build on these to add new information.
Checking – that there is a plan/understanding achieved.
ACTIVITY
Ask participants to reflect individually on how they could use each of the three steps to encourage women to be screened, then share with neighbour.
10 min / Informed consent
DistributeStandard 405 and a list of the things covered during informed consent discussion for new entrants (the list is an interpretation of how to implement Standard 405).
Discuss the list.
Ask:Which of these are usually discussed with women who are new to cervical screening? What written information are you using?How do you confirm understanding and consent? / Slide 19
Copies of Standard 405 and list (appended to the session plan)
20 min / Apply three steps to informed consent
ACTIVITY
Break the group smaller groups. Provide large sheets of paper and pens.
Allocate each group two points from the list.
Ask groups to discuss how they could work though these points with women who are new to cervical screening.
Display the slide with instructions:
What could you say about these points with women who are new to cervical screening?
- Using Ask, Build, Check
- Using plain language
- Using pictures or models where possible
Ask the pairs to report back to the group. Ask the rest of the group to offer comments or other things that could be said or asked.
Note that this exercise is an example of ‘checking’ as they have already demonstrated their understanding of Ask, Build, Check
Ask: If women who are already engaged and informed are ready to have their smear, they might not want to go through all the informed consent information. How do you manage this? / List (as above)
Slide20
Large sheets of paper each with two points from list
Record the reusable questions and explanations from the report back and discussion (and use notes from butchers paper)
5min / Wrap up
We have been through two important conversations - encouraging screening with women from priority groups, and ensuring understanding of informed consent.
Ask: What is one thing from today will you try or change when you go back to work? Write them inside the Three Step books.
For further information on the three steps visit the HQSC website
For further information on cervical screening visit:
Thank participants for their time and contributions. / Slide21
Slide 22
Scribe to take notes of commitments
Slide 23
Informed consent