Competencies: Travel health nursing: career and competence development - CLINICAL PROFESSIONAL RESOURCE - Royal College of Nursing
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Competencies:
Travel health nursing:
career and competence development
CLINICAL PROFESSIONAL RESOURCE
NaTHNaCTRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT
Acknowledgements
We would like to thank all those who supported This document was supported by the
the development of this document, especially RCN Public Health Forum.
the travel health nurse specialists who have
updated this document and also authored the
The following bodies have endorsed this
original and revised documents (RCN 2007;
document
RCN 2012). They are all current members of the
RCN Public Health Forum and Fellows of the The Faculty of Travel Medicine of the Royal
Faculty of Travel Medicine of the Royal College College of Physicians and Surgeons of Glasgow
of Physicians and Surgeons of Glasgow. Health Protection Scotland
The National Travel Health Network and Centre.
Lorna Boyne
Nurse Consultant Travel and International Health, Statement of interest: Jane Chiodini is Founder
Travel and International Health Team, Health and Director of Travel Health Training Ltd.
Protection Scotland
Jane Chiodini
Travel Health Specialist Nurse. Dean Elect,
Faculty of Travel Medicine, Royal College of
Physicians and Surgeons of Glasgow
Sandra Grieve
Travel Health Specialist Nurse, Lead Nurse Travel
Health for the RCN
Alexandra Stillwell
Specialist Nurse (Travel Health), National Travel
Health Network and Centre (NaTHNaC)
This publication is due for review in December 2021. To provide feedback on its contents or on
your experience of using the publication, please email publications.feedback@rcn.org.uk
Publication RCN Legal Disclaimer
This is a RCN competence knowledge and skills framework to This publication contains information, advice and guidance to
support personal development and career progression. help members of the RCN. It is intended for use within the UK
but readers are advised that practices may vary in each country
Description and outside the UK. The information in this booklet has been
This framework defines the standards of care expected for a compiled from professional sources, but its accuracy is not
competent registered nurse, experienced/proficient nurse and a guaranteed. Whilst every effort has been made to ensure the
senior practitioner/expert nurse delivering travel health services. RCN provides accurate and expert information and guidance, it
Publication date: May 2018 is impossible to predict all the circumstances in which it may be
used. Accordingly, the RCN shall not be liable to any person or
Review date: December 2021 entity with respect to any loss or damage caused or alleged to be
The Nine Quality Standards caused directly or indirectly by what is contained in or left out of
this website information and guidance.
This publication has met the nine quality standards of the quality
framework for RCN professional publications. For more Published by the Royal College of Nursing, 20 Cavendish Square,
information, or to request further details on how the nine London, W1G 0RN
quality standards have been met in relation to this © 2018 Royal College of Nursing. All rights reserved. No part of
particular professional publication, please contact this publication may be reproduced, stored in a retrieval system,
publications.feedback@rcn.org.uk or transmitted in any form or by any means electronic,
mechanical, photocopying, recording or otherwise, without prior
Evaluation permission of the Publishers. This publication may not be lent,
The authors would value any feedback you have about this resold, hired out or otherwise disposed of by ways of trade in any
publication. Please contact publications.feedback@rcn.org.uk form of binding or cover other than that in which it is published,
clearly stating which publication you are commenting on. without the prior consent of the Publishers.
2ROYAL COLLEGE OF NURSING
Contents
Foreword and Introduction 4 • Purpose of trip and planned activities 16
• Quality of accommodation 17
1. How to use the Competency Framework 6
• Financial budget 17
Producing evidence – Revalidation 6 • Health care standards at destination 18
2. Travel medicine services in the UK 7 Performing risk assessments 18
Introduction 7 • Appointment guidance 18
Education and professional support – a • How to conduct a risk assessment 18
historical overview to current day practice 7 • Steps to follow after a risk assessment 19
Travel medicine services 8 • Documentation to accompany the travel
• Financial provision 8 consultation20
• Governance within the travel health setting 9 Conclusion 20
• Prescribing travel vaccines 10 4. The competency framework for travel
health nurses 21
• Administration of travel vaccines 10
Core competency 1: General standards
3. Pre-travel risk assessment and
expected of all nurses working in
management11
travel health 21
Introduction11 Core competency 2: Travel health
What is pre-travel risk assessment? 11 consultations22
• Information about the traveller 11 Core competency 3: Professional
responsibilities for nurses working in
• Information about the traveller’s itinerary 11 travel health 23
Reasons for asking questions 12 5. References 24
• Age and sex 12 6. Appendices 28
• Medical history 13
Appendix 1:
• Previous travelling experience 14 Sample travel risk assessment form 28
• Current knowledge and interest in Sample travel risk management form 30
health risks 14
Appendix 2: Summary of travel health-related
• Travellers visiting friends and relatives 14 information sources 32
• Previous vaccination history 15 – essential guidance documents 32
• Additional needs 15 – telephone advice lines and databases 32
• Destinations 15 – useful websites 33
• Departure date 16 – travel-related organisations 33
• Length of stay 16 – travel health training and education 33
• Transport mode 16
3TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT
Foreword and Introduction
Travel health is an expanding specialist field of and competence development, RCN guidance
practice which is becoming more challenging. (RCN 2012). This edition has been updated in
In the UK, travel health services are mainly response to an audit and evaluation; Perceptions
delivered by nurses, mostly in a primary care and expectations of the RCN Travel Health
setting. Pharmacists are increasingly providing Competencies Document (Currie, et al., 2017). The
advice for travellers. There is no “one size fits survey demonstrated that the document remains
all”, travellers include people of all ages and useful to practitioners who used it, but awareness
ethnic backgrounds going abroad for a variety of of the resource should be increased. In this revised
reasons. Their needs vary and are increasingly edition we have retained the elements that nurses
complex. find most useful, such as the information on
the pre-travel risk assessment and management
Despite natural disasters, disease outbreaks which underpin the travel health consultation. A
and terrorism threats, the number of travellers
detailed description of the concept was included
from the UK continues to rise. Mass migration
in the previous edition but to reflect the changing
across Europe by displaced people from war-
nature of travel health issues further relevant items
torn countries has affected tourism in countries
have been added. As Agenda for Change (AfC)
previously frequented by visitors from Britain.
information was seen as least useful, especially for
Travellers are now more likely to research
nurses working in travel health outwith the NHS,
options and choose destinations deemed to be
this has been removed. The information on travel
“safer”. Cruising, travelling solo and seeking
medicine services in the UK has been updated to
adventure and new experiences in exotic and
reflect recent changes and also to signpost changes
remote destinations remain popular. The UK
that are likely to come.
is a multicultural society with many settled
migrants returning to their country of origin to Undertaking the delivery of travel health services
visit friends and relatives (VFRs). They may not requires competence, defined as: “The state
present for pre-travel advice but as the rate of of having the knowledge, judgement, skills,
imported disease can be higher in this group, it’s energy, experience and motivation required
important to reach out to them. to respond adequately to the demands of one’s
There is now more directional guidance professional responsibilities.” (Roach, 1992). As
and increasing resources available to both the competency framework tables are useful for
practitioners and the public. Practitioners nurses to identify what level they are currently
are reminded to refer to the national websites working at, and how they may progress to the
TRAVAX and NaTHNaC for current evidence- level that they aspire to reach, these have been
based information. Technology and social media retained. As individuals progress through each
use has changed the way advice is delivered. level of competence they build on the previous
Nurses can access training through e-learning set of skills and knowledge, therefore an expert
portals and with internet connections and nurse would be able to function across the entire
instant communication increasingly available range of descriptors of practice.
in remote locations travellers can stay informed Information on current guidelines and standards
when abroad. This updated publication reflects for the care of travellers by appropriately
these changes.
registered practitioners has been revised and
The RCN Public Health Forum resources are updated. The focus remains on the work of a
available through the travel health pages on the registered nurse and defines the standards that
website. These pages are regularly updated, would be expected for:
related to all four UK countries and linked to • competent nurse (level 5)
further resources through the RCN Library.
• experienced/proficient nurse (level 6)
The first published guidelines and standards in the
• senior practitioner/expert nurse (level 7).
field of travel health medicine, Competencies: an
integrated career and competency framework for The information is equally applicable to other
nurses working in travel health medicine (RCN qualified practitioners providing travel health
2007), were published in 2007, followed in 2012 by services, including doctors and pharmacists. We
an expanded version, Travel health Nursing: career recognise that there are now nurses working in
4ROYAL COLLEGE OF NURSING
travel health at nurse consultant level, but as
these roles are rare, they have not been captured
within this framework beyond the described
competency descriptors.
A number of political and professional issues and
initiatives are addressed, including:
• need for leadership in specialist nursing
• need for development of standards relevant to
all four UK countries
• increased focus on work-based and lifelong
learning and supervision
• changing focus towards professional rather
than academic accreditation.
Nurses continue to contribute to the travel
health agenda through several national and
international bodies. Formal training and
qualifications in travel medicine have been
available in the UK since 1995. The Faculty of
Travel Medicine (FTM) at the Royal College
of Physicians and Surgeons of Glasgow
(RCPSG), was established in 2006. The FTM
publication Recommendations for the Practice
of Travel Medicine (Chiodini, et. al, 2012) is
complementary and can be used in conjunction
with this document to support nurses, doctors
and pharmacists delivering travel health services
to achieve optimum safe practice for travellers.
The Membership Diploma in Travel Medicine is
conducted by the RCPSG. It is anticipated that
expert nurses, as described in this document,
should have the qualifications and experience
sufficient to aspire to be admitted to the Faculty.
With the process of revalidation now in place,
this updated integrated career and competency
framework remains important for travel health
practitioners. We hope that this document
continues to support and meet the needs of
practitioners delivering travel health services in
this dynamic area of practice.
Jason Warriner
Chair, RCN Public Health Forum
Sandra Grieve
Travel health committee member, RCN Public
Health Forum
See References and Appendix 2 for further
details on the papers mentioned here.
5TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT
1. How to use the Competency
Framework
Nurses working in the field of travel health While this framework provides comprehensive
practice work in a variety of settings, including guidance for nurses working in travel health, it
primary care, occupational health, NHS clinics should be used flexibly and within the context
in secondary care, private travel clinics, armed of meeting revalidation requirements. It can
services, universities and schools. The scope help individuals to determine the scope of their
of practice depends on a variety of factors, current level of practice, determine current and
which vary between settings and the different future development needs and can help prepare
requirements for the NHS or the private sector, individuals to progress into roles in line with
for example. Therefore, while the broadest changing needs in the field of travel health.
spectrum of practice has been included in the
descriptors and levels of practice, some elements
may not be covered. The descriptors and levels
do however provide an indication of the expected
ability to function at that level.
Producing evidence –
revalidation
Health care professionals are responsible for
producing their own portfolios of evidence of
competence. Revalidation came into effect in
April 2016 and is the new process that nurses
and midwives in the UK need to follow in order
to maintain their professional registration with
the Nursing and Midwifery Council (NMC)
(NMC, 2017).
Every three years, in order to renew NMC
registration, nurses must produce or maintain a
revalidation portfolio that demonstrates:
• 450 practice hours, or 900 if renewing as both
a nurse and midwife
• 35 hours of CPD including 20 hours of
participatory learning
• five pieces of practice-related feedback
• five written reflective accounts
• reflective discussion
• health and character declaration
• professional indemnity arrangement.
On completion, a confirmation declaration is
signed and submitted online to the NMC.
For more information on revalidation:
http://revalidation.nmc.org.uk/
6ROYAL COLLEGE OF NURSING
2. Travel medicine services
in the UK
that international tourist arrivals will increase to
Introduction 1.8 billion by 2030 (UNWTO, 2011).
While travel advice is mostly given in primary The International Air Transport Association (IATA)
care settings, it is increasingly taking place in expects 7.2 billion passengers to travel in 2035, a
private travel clinics, the occupational health near doubling of the 3.8 billion air travellers in 2016
sector, military settings, universities and schools. (IATA Press Release, October 2016).
Recently large pharmacy chain outlets have also
become involved, offering out-of-hours provision Travel for holidays, recreation and other forms
that is more acceptable to an increasingly of leisure accounted for just over half of all
demand-led service. international tourist arrivals in 2016 (53% or
657 million). Some 13% of all international
In 2017, international tourist arrivals grew tourists reported travelling for business and
to 1,322 million, the highest in seven years, professional purposes, and another 27% travelled
with continued growth expected. Led by for other reasons such as visiting friends and
Mediterranean destinations, Europe recorded relatives, religious reasons and pilgrimages,
671 million arrivals (+8%) and Africa 62 million health treatment, etc. The purpose of visit for
(+8%). Both North Africa and Sub-Saharan Africa the remaining 7% of arrivals was not specified.
arrivals increased. Asia and the Pacific recorded (UNWTO, 2017). According to UNWTO forecasts,
324 million arrivals (+6%). South Asia, South-East trends will remain largely stable into 2030, when
Asia, Oceania and North-East Asia all saw growth. it is projected that leisure, recreation and holidays
In the Americas there were 207 million arrivals will represent 54%, business and professional
(+3%) with growth in South America, Central travel 15%, and VFR, health, religion and other
America and the Caribbean and North America. purposes 31% of all international arrivals
The Middle East received 58 million international (UNWTO, 2011).
tourist arrivals (+5%) (UNWTO, 2018).
While some travellers seek travel health advice
People travel abroad for a variety of reasons, before they leave the UK, surveys indicate that a
including business trips, holidays and visits to significant number still do not see a health care
friends and relatives. During the first decade of professional before departure, with figures as high
the new millennium the number of visits overseas as 60% in some studies (LaRocque et al., 2010;
made by UK residents peaked at nearly 70 million. Schlagenhauf et al., 2015).
There were 70.8 million visits overseas by UK
residents in 2016, an increase of 8% compared
with 2015. This is a record figure, and the first Education and professional
time that visits have surpassed the 2006 figure
of 69.5 million. Overall 75% of visits were to EU
support – a historic overview
countries, mainly Spain, France and Italy. Poland to current day practice
entered the top 10 most visited countries, many
visits made by Polish nationals living in the UK Formal education in travel medicine commenced in
(ONS, 2016). 1995 when Dr Cameron Lockie, a GP from Stratford-
upon-Avon, researched the concept of a training
The most common reason for travelling abroad was course which was then developed by the Public
for holidays, with visiting friends and relatives (VFRs) Health Department of the University of Glasgow
as the second most popular reason. The underlying with support from a team at the Scottish Centre for
trend for business and miscellaneous purposes for Infection and Environmental Health (now Health
travel is fairly flat but numbers are increasing for Protection Scotland). Shortly after the development
holidays and VFR travel. For example, there were of the Diploma a shorter Foundation course was
26.8 million holiday visits and 5.5 million VFR visits developed and an MSc was also established through
in 1996 compared with 45.0 million and 16.6 million the University of Glasgow.
respectively in 2016 (ONS, 2017).
In 2003, Health Protection Scotland (HPS) took
The UN World Tourism Organization forecasts full managerial and administrative control of
7TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT
the courses from the University of Glasgow, in amongst the first bodies to recognise travel health
conjunction with the Royal College of Physicians nursing as a specialist area of practice. In 1994, the
and Surgeons of Glasgow (RCPSG) which RCN Travel Health Group – which subsequently
conducted exams and awarded the Diploma. became a special interest group and then a forum
During this period other courses were developed from 2000, began to produce newsletters and
through other academic institutes, but these have hold conferences for nurses working in the field.
not continued. The MSc also discontinued after Membership of the group exceeded over 5,000 at
a number of years as the number of students its height, and was highly active in the support of
wishing to study travel medicine at this level education and standards for nurses working in the
diminished and the course was no longer viable. field. In 2010 the Travel Health Forum was merged
into the RCN’s Public Health Forum.
In 2011 RCPSG took over the responsibility for
providing the Foundation and Diploma courses
which continued to be popular. Other short Travel medicine service
courses became quite widely available around factors
the UK (see National Travel Health Network and
Centre (NaTHNaC), TRAVAX and the RCN Travel Financial provision
Health pages for the most up to date information),
but the Diploma course remained the only Funding of travel vaccinations both on the NHS
registered qualification throughout this time. and as a private provision has been a complex
issue for many years and description of such
In 2006 the Faculty of Travel Medicine (FTM) has been included in the previous version of this
was formed in RCPSG. The aim of the Faculty is document. This detail has now been removed but
to lead the way in raising standards of practice could be obtained by contacting one of the authors
and achieving uniformity in provision of travel via NaTHNaC or TRAVAX or reviewing the
medicine services to protect the health of information here.
travellers. This was the first time that nurses
and pharmacists were eligible to become At the time of review of this publication the way that
Associates, Members and Fellows of the RCPSG immunisation services as a whole are delivered in
through the FTM, depending on qualifications Scotland is undergoing significant review. Scottish
and experience. The Membership of Faculty Government (SG) conducted a comprehensive
of Travel Medicine examination (MFTM) was consultation with representatives from general
developed by FTM so that practitioners could practice and the regional health-boards across
take the membership examination (with or Scotland and this showed that general practice
without undertaking the Diploma course) and no longer wanted to be responsible for delivery
successful candidates were eligible to join the of the National Immunisation Programme
Faculty as members. (NIP). In response to this, SG agreed to carry
out a Vaccination Transformation Programme,
During 2016 the FTM took the decision to whereby each of the individual health-boards
completely redevelop the Diploma in Travel could determine how the National Immunisation
Medicine course to bring it in line with modern programme should be delivered in accordance
education delivery, to incorporate some RCPSG to local needs. (Scottish Government, 2017 ) The
membership benefits and culminating with the Vaccine Transformation Programme will commence
MFTM examination. The result is the Royal in 2018 and is expected to take three years.
College Membership Diploma in Travel Medicine
(MDTM), the first of its kind in the world. In July 2017, NHS England launched an action
During 2017, the Foundation course was also plan to drive out wasteful and ineffective
redeveloped to incorporate modern, blended drug prescriptions, saving the NHS over £190
eLearning delivery in line with the MDTM. million a year. A consultation document was
subsequently published detailing a list of
Nurse specific contribution to UK items considered unnecessary to be routinely
travel health prescribed in primary care. The outcome of this
consultation was that the following vaccines
Nurses have been at the forefront of travel health care should not be prescribed on the NHS exclusively
in the UK since the early 1990s and the RCN was for the purposes of travel (in England):
8ROYAL COLLEGE OF NURSING
• Hepatitis B • Under the International Health Regulations
• Japanese encephalitis (IHRs) the state party for England, Wales
and Northern Ireland (EWNI) is the
• Meningitis ACWY
National Travel Health Network and Centre
• Yellow Fever (NaTHNaC) which has responsibility for
• Tick-borne encephalitis administering Yellow Fever Vaccination
• Rabies Centres (YFVCs) https://nathnacyfzone.org.
• BCG. uk/managing-your-yfvc
• Under the International Health Regulations
These vaccines should continue to be
(IHRs) the state party for Scotland, Health
recommended for travel but the individual
Protection Scotland (HPS) is responsible for
traveller will need to bear the cost of the
administering YFVCs http://www.hps.scot.
vaccination. (NHS England 2017). A patient
nhs.uk/yellowfever/index.aspx
leaflet has been produced providing the
current provision of travel vaccines – see www. In the rationale of the NaTHNaC training for
prescqipp.info/component/jdownloads/ YFVCs it is expected that their efforts to improve
send/414-items-which-should-not-routinely- yellow fever vaccine administration will lead to
be-prescribed-in-primary-care-patient- an improvement in the overall practice of travel
leaflets/3790-patient-information-changes- medicine. (NaTHNaC, 2017a) This theme has
to-travel-vaccines-prescribing. been voiced in an editorial: “There is no linkage of
licensure with providing a higher quality of travel
At the same time, NHS England asked Public
medicine care, but there ought to be… Having
Health England to conduct a review of travel
a YF vaccination license must carry with it the
vaccines currently available on the NHS to assess
weight of a higher standard of care, a higher level
their appropriateness for future NHS prescribing
of training, and the responsibility to protect the
– these are cholera, diphtheria/tetanus/polio,
traveller from other health threats” (Spira, 2005).
hepatitis A and typhoid. This evaluation is currently
Whilst the undertaking of YF training is not
being undertaken but at the time of publication no
mandatory for all individuals administering the
outcome is known. However, when the information
vaccine, NaTHNaC and HPS yellow fever training
becomes available, the electronic version of this
(either online or classroom) is required of at least
guidance will be updated accordingly.
one health professional, working at the YFVC or
Governance within travel health multiple YFVCs, every two years. However, they
settings recommend (i.e. this is preferred but optional) all
those responsible for administering the vaccine to
• In England GP surgeries and private travel complete training for their own accountability and
clinics must be registered under the Care good practice (HPS, 2018; NaTHNaC, 2017b).
Quality Commission (CQC) www.cqc.org.uk,
however pharmacy led private travel clinics In a position paper of the Faculty of Travel
are currently registered under the General Medicine (RCPSG, 2014), published by the Royal
Pharmaceutical Council (GPhC). www. College of Physicians and Surgeons of Glasgow
pharmacyregulation.org/registration in 2014, the authors acknowledged that Travel
Medicine is not currently a recognised medical
• The situation is similar in Scotland where
specialty in the UK or the Republic of Ireland
private clinics are registered with Healthcare
and that within the UK and Ireland there is a
Improvement Scotland (HIS) www.
lack of structure and delivery of travel medicine
healthcareimprovementscotland.org
services, absence of a formal training pathway to
• In Wales private clinics are registered with the a recognised professional standard, and lack of
Healthcare Inspectorate Wales (HIW) as private assurance of practice against defined standards.
health care providers. www.hiw.org.uk
• The Regulation and Quality Improvement They recommended the following:
Authority (RQIA) is the regulator for private • the standards of medical care given to travellers
clinics in Northern Ireland although they before, during and after travel should be as
currently appear to have no private travel high as those practised in every other field of
clinics registered. www.rqia.org.uk medicine
9TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT
• standards of best practice should be outlined a prescriber as previously described, then he/
and national guidelines adopted where she can operate independently.
appropriate • Travel vaccines given within Occupational
• formal training by a suitably accredited provider Health Schemes (OHS) are exempt from this
should be mandatory for all health professionals regulation but must operate under their own
offering medical advice to travellers Written Instruction (BMA, 2017). https://
• the governance of travel medicine should be www.bma.org.uk/advice/employment/
provided by the Faculty of Travel Medicine occupational-health/the-occupational-
by means of its continuing professional physician Nice Guidance Patient Group
development programme Directions (PGD) 2013 recommends that
PGDs are not used when exemptions in
• assurance of the competence of travel medicine legislation allow medicine supply and/or
providers should be reviewed by national administration without the need for a PGD.
authorities, with consideration given to the The scope of this exemption in legislation is
financial remuneration arrangements and much broader than the use of PGDs (NHS
licensing Specialist Pharmacy Services – England)
• the travelling public should be educated to https://www.sps.nhs.uk/wp-content/
recognise the standard of service that should be uploads/2017/11/To-PGD-v9.5-Jan-2018.
expected of providers, and how this is delivered. pdf The BMA guidance for OH physicians
Much work is still needed to achieve these provides an example template for a “Specimen
recommendations but this RCN document has operating policy/written instruction” Also
see: https://www.rcn.org.uk/clinical-
been a forerunner in outlining best practice for
topics/public-health/specialist-areas/
travel medicine practice and awareness of its
occupational-health/occupational-health-
existence should be promoted as fully as possible.
nursing-skills-and-role-development
Prescribing travel vaccines Administration of travel vaccines
The prescribing of travel vaccines is an area of great
Registered nurses who are fully trained and
confusion. The following information provides a
competent can administer travel vaccines.
basic outline, but further reading is recommended
(see Resources section of this document). They should be familiar with the Public Health
• In an NHS setting travel vaccines can be England National Minimum Standards and
prescribed either under a Patient Group Core Curriculum for Immunisation Training for
Direction (PGD) for the NHS travel vaccines or Registered Healthcare Practitioners (PHE, 2018).
a Patient Specific Direction (PSD), or prescribed The aim of the national standards is to describe the
by a doctor, nurse independent/supplementary training that should be given to all practitioners
prescriber (NMC, 2006) or pharmacist engaging in any aspect of immunisation so that
independent prescriber (GPhC, 2006). they are able to confidently, competently and
• In the Human Medicines Regulations 2012 effectively promote and administer vaccinations.
an exemption was made for the provision National Minimum Standards and Core
of prescribing within private practice. A GP Curriculum for Immunisation Training of
practice can now, in law, develop their own Healthcare Support Workers (HCSWs) was
PGDs for use in their private practice (non published by the PHE for the administration of
NHS work), for example for the administration influenza and pneumococcal vaccines. It is not
of travel vaccines (such as yellow fever, current practice for HCSWs to administer childhood,
rabies, tick borne encephalitis and Japanese travel or other vaccines in the UK (PHE, 2015).
encephalitis) (Chiodini J, 2015). If they choose
not to do so, then these vaccines can be
administered under a PSD or prescribed by a
medical or non-medical prescriber.
• Private travel clinics can operate under
Patient Group Directions for all vaccines.
Alternatively if the health care professional is
10ROYAL COLLEGE OF NURSING
3. Pre-travel risk assessment and
risk management
Introduction What is pre-travel risk
This section introduces the concept of pre-travel assessment?
risk assessment, its importance in the task of
evaluating and managing the advice required to A pre-travel risk assessment entails collection
minimise the traveller’s risk, the structure and of information regarding the traveller and the
reasons for performing assessments, and the nature of the trip (see below). You will find
practical aspects of essential documentation. sample pre-travel risk assessment and pre risk
travel management forms in Appendix 1 that
National online websites should always be you can adapt as necessary. Both these forms
consulted for the latest information on the country will also be available to download as separate
specific risks – to help inform recommended documents online (see Resources section).
vaccines and additional information, for example
disease outbreaks. There are two main resources Information about the traveller:
in the UK: TRAVAX produced and maintained
by Health Protection Scotland (www.travax. • age and sex
nhs.uk) and TravelHealthPro from NaTHNaC
(https://travelhealthpro.org.uk). Both • medical history – past and present
resources are reliable and up to date and produced • relevant family history
by National Centres of excellence. All practitioners
should also have access to the latest online • current health status
versions of Immunisation against infectious • for women only, pregnancy status, actual or
disease, also known as The Green Book (PHE, planned, has FGM been performed
2013) and Guidelines for malaria prevention in
travellers from the UK (Chiodini et al., 2017) • disability
• mental health status
The learning objectives of this section
are: • any other special needs
• medication
• understand what pre-travel risk assessment is
and its importance for the care of a traveller • any known allergies
• understand the contents and reasoning of a • previous vaccine history
pre-travel risk assessment
• previous experience travelling
• be aware of the appropriate use of information
collected during the assessment to decide • current knowledge and interest in health risks.
travel risk management advice required,
Information about the traveller’s itinerary:
including relevant travel immunisations and
malaria prevention advice • destination(s)
• have greater insight into the practical aspects • departure date
of pre-travel risk assessment, including
documentation of the process • length of stay
• understand the importance of using the • mode of transport
latest versions of national guidance, online • purpose of trip and planned activities
websites, the Green Book and the UK Malaria
Guidelines (see resources in Appendix 2) • quality of accommodation
• have the ability to evaluate the sources of • financial budget
travel information and use other appropriate
• health care standards at destination
up-to-date resources in the travel health
consultation. • relevant comprehensive insurance provision.
11TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT
Older travellers:
Reasons for asking
• immune systems reduced, at greater risk of
questions infection and serious sequelae
It is essential to ask a traveller questions on the • immune response to immunisation may
topics detailed above. Responses will influence diminish with advancing age
many things, some of which are detailed below.
This knowledge will help you to assess the risk • senses reduced, at greater risk of accidents
factors and then manage that risk by selecting • pre-existing medical conditions such as diabetes,
appropriate health advice, vaccinations, malaria coronary heart disease often lead to complications
prevention measures and advice. The following
section looks at some examples of what you • primary immunisation may not have been
should consider in a pre-travel risk assessment. administered if born prior to implementation
of national programmes
Please note, resources for many links to the
topics below are included in Appendix 2. • evidence of increasing risk of sexually
In addition, many links will be found on specific transmitted diseases in the over 50-year-old
subject topics on the recommended websites e.g. age group (DH, 2015)
TRAVAX and TravelHealthPro and the latest • increased risk of serious adverse events
edition of Public Health England Guidelines for following a first dose of yellow fever vaccine
malaria prevention in travellers from the UK. in those over 60 years (Gershman MD and
For this reason the following section has not been Staples JE, 2018)
overly referenced.
• in travellers from the UK, mortality from
malaria increases with age. Elderly travellers
Age and sex need to be targeted for pre-travel advice
Young travellers: (Checkley, et al., 2012).
(This relates particularly to children under five Female travellers:
years old, but includes other age groups)
• security risk possibly increased if travelling
• road traffic accidents and drowning incidents alone
are the leading causes of death in child
• need to be culturally sensitive in personal
travellers (WHO, 2015; WHO, 2012)
dress
• risk of illness such as malaria, or travellers’
diarrhoea, which can be more severe • sexual health issues should be considered
• small, mobile and inquisitive toddlers, who • if of child bearing age, need to determine that
have limited hygiene awareness – put fingers there is no possibility of being pregnant at
in mouths, touch everything – which leads time of travel and establish if currently trying
to increased risk of faecal orally transmitted to conceive
illnesses and dehydration • consideration of issues when administering
• children are more vulnerable than adults to travel vaccines in pregnancy
the exposure of rabies (Warrell, 2012) • appropriate Zika prevention advice if
• increased risk of other hazards such travelling when pregnant or planning to
as sunburn and heat exposure; careful conceive
supervision is needed • problems associated with contraception;
• restrictions on some choices for travel travelling while managing menstruation
vaccines and malaria chemoprophylaxis (FSRH, 2012)
• risk of being subjected to female genital • risk of being subjected to female genital
mutilation (FGM) for young female travellers. mutilation (FGM)
• risk of being taken abroad for the purpose of • risk of being taken abroad for the purpose of
forced marriage. forced marriage.
12ROYAL COLLEGE OF NURSING
Male travellers: attention that may be of variable quality.
People with epilepsy have reduced choice of
• risk of accidents higher in males 20 to 29
chemoprophylaxis for malaria endemic regions
years old. From a young age, males are more
likely to be involved in road traffic crashes • people with a family history of relevant
than females. About three quarters (73%) of illness; for example, the condition of epilepsy
all road traffic deaths occur among young in a first degree relative may influence the
males under the age of 25 years who are choice of the malarial chemoprophylactic
almost 3 times as likely to be killed in a road drug selected
traffic crash as young females. (WHO, 2017) • recent surgery or long term medical problem
• sexual health issues should be considered such as respiratory disease may impact on
travel and a fitness to fly examination may be
• appropriate Zika prevention advice if required (CAA, 2017)
travelling when partner is pregnant or the
couple have plans to conceive. • physical disability may impact on type of trip,
limit activities, and have an increased need for
Lesbian, gay, bisexual and transgender medical care, which may be of variable quality
(LGBT) travellers: • HIV-infected people may be denied entry into
• attitudes towards LGBT travellers varies some countries (The Global Database); if they
greatly around the world; in seven countries are not denied entry, their immune status will
homosexuality is punishable by death and a need to be known prior to administration of
further seventy countries imprison people some vaccines and for the purpose of tailoring
because of their sexual orientation (Foreign and advice. Practitioners should be aware of the
Commonwealth Office. Lesbian, gay, bisexual British HIV Association (BHIVA) guidelines
and transgender foreign travel advice) on the use of vaccines in HIV positive adults
(BHIVA, 2015)
• LGBT travellers are advised to carefully
research acceptance of LGBT in the culture/ • psychiatric history and state of mental
country to be visited health may have impact on long-term
travel or expatriate lifestyle (Patel, 2011);
• see resources for links to more information. and for example, mefloquine for malaria
chemoprophylaxis is contraindicated for
Medical history certain psychiatric or mental health conditions
Past and present medical history and • pregnancy increases risk from malaria; if
current health status: complications occur in the pregnancy medical
intervention may be required but reliable medical
• previous medical history may have impact care may not be available at the destination;
on choice of trip; for example, a person who Venous thromboembolism (VTE) (deep vein
has had their spleen removed would be at thrombosis or pulmonary embolism) following
increased risk of severe illness if travelling a long haul flight is a greater risk in pregnancy;
to a destination where malaria, particularly the early scan should be performed ideally before
P. falciparum, is endemic travel ; antenatal records should always be taken
• those with ongoing medical problems may on the trip; tour operators will set individual
require specialist advice; for example, those restrictions on a pregnant woman flying in the
with severe renal or liver disease would need third trimester of the pregnancy (CAA, 2017)
advice regarding malaria chemoprophylaxis. • breastfeeding presents some restrictions on
For people who are immuno-suppressed; some choice of malaria chemoprophylaxis, some
live vaccines may be contra-indicated and other precautions regarding administration of live
vaccines may be less effective (PHE, 2013a) vaccines need to be assessed
• people with pre-existing conditions such as • determine wellbeing at the time of
diabetes and coronary heart disease may have vaccination, afebrile, feeling well and fit
higher risk if illness occurs at destination, to receive vaccinations, no possibility of
increasing their risk of needing medical pregnancy as mentioned above.
13TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT
Medication: • provide specific advice to minimise problems
to severe reactions to insect bites
• some prescribed medication could
contraindicate malaria chemoprophylaxis or • establish previous severe adverse reactions/
live vaccines events to malaria chemoprophylaxis
• a woman on the oral contraceptive pill could • consider arrangements for the traveller to
lose contraceptive efficacy if she suffers carry with them a supply of epinephrine
travellers’ diarrhoea (adrenaline) for emergency use where there is
a history of severe allergic reaction to an agent
• specialist advice is required for those on
medication such as insulin • to establish a history of, or the possibility
of fainting, enquire before administering
• safe storage of drugs in transit, particularly
vaccines. Fainting is more common than
for drugs that need refrigeration
anaphylaxis and practitioners need to know
• generally taking sufficient supplies of the difference between the two.
medication for an entire trip is recommended
due to problems of counterfeit medicines found Previous travelling experience:
abroad. It is advisable to take medication in its • establish previous travel experience to
original pharmacy packaging. identify any problems in the past; for
• problems can occur when taking drugs into example, difficulty in compliance with any
other countries, the legal status of some drugs malaria chemoprophylaxis, whether more
in other countries may be different to the prone to travellers’ diarrhoea, insect bites
UK and restrictions are in place regarding • deliver advice in an appropriate way so that it
controlled drugs; correct paperwork, is more likely to be accepted by traveller.
including a doctor’s letter or prescription and
any relevant licence can be helpful at the point Current knowledge and interest in
of entry to a country https://www.gov.uk/ health risks:
travelling-controlled-drugs • establish the level of knowledge and concept
• elderly people on regular medication need of health risks of the traveller so that
to be aware of the importance of continuing appropriate travel health advice can be given
regular administration despite crossing • consider traveller’s attitude – for example, a
time zones, inconvenience of diuretics and risk taker or risk averse
resulting diuresis
• establish general interest and response to
• be aware of restrictions for carrying advice that may be given to encourage self-
medication and medical equipment learning; for example, suggest well regarded
through airport security, on aircraft and at internet sites to increase knowledge further.
immigration (such as fluids over 100mls,
needles etc.) see information www.gov. Travellers visiting friends and relatives
uk/hand-luggage-restrictions/essential- (VFRs):
medicines-and-medical-equipment
• VFR travellers have a different risk profile to
other types of travellers – tending to travel
Allergies to drugs or food/reaction to
for longer, live as part of the local community,
vaccination:
may not seek advice prior to travel,
• establish if there was a true anaphylactic underestimate their health risks
reaction to vaccines previously administered
• data suggests that VFR travellers are less likely
to avoid similar event – it should be noted
than other travellers visiting Africa to take anti-
that anaphylactic reaction to vaccines is
malarial prophylaxis; this is possibly because
extremely rare (PHE, 2013b)
they underestimate the risk of acquiring
• allergy to foods, any specific drugs or latex; malaria, and do not appreciate that natural
for example, establish if there is a true immunity will wane after migrating to the UK;
anaphylactic reaction to eggs in which some of second generation family members will have no
the vaccines are manufactured clinically relevant immunity to malaria
14ROYAL COLLEGE OF NURSING
• those VFRs in countries with endemic malaria • travellers should be advised to safely keep
make up the majority of cases of falciparum documentation of their own vaccination
malaria in the UK, but the risks of this group record cards, particularly if they get vaccines
dying from malaria are much smaller than for from different sources, such as GPs and
other travellers, with most deaths occurring in private travel clinics. Apps are now available
tourists (Checkley, et al., 2012) to record data on a mobile device.
• consultation with VFRs should explore their
Additional needs:
values and beliefs and the practitioner should
deliver advice accordingly; the importance • identify any specific needs so that plans can
of health risks should be stressed such be made to ensure travel arrangements are as
as how essential it is to take appropriate smooth and convenient as possible
chemoprophylaxis when travelling to areas
where malaria is endemic. • identify groups and associations that will
inform and protect travellers with additional
FGM and Forced Marriage: needs, such as travellers with a disability.
• migrants from countries with high rates of Destinations:
female genital mutilation (FGM) may return to
visit friends and relatives intending their children • establish the exact destination location to
to undergo FGM; it is illegal to take girls who are determine the disease risks; for example,
British nationals or permanent residents of the yellow fever virus is endemic in tropical areas
UK abroad for FGM whether or not it is lawful in of Africa and Central and South America.
that country (DH 2017a). Many useful resources (WHO, 2018)
are available on this subject from the Department
• establish a specific location in a country; for
of Health (DH 2017b) Travel health practitioners
example, malaria is rarely present in Nairobi
should be aware of the potential for a girl to be
in Kenya, but it is a high risk in other parts of
taken to another country for this purpose, be
the country, for example Mombasa
prepared to ask the question directly, and where
appropriate initiate safeguarding procedures • record stopovers in case the destination may
or refer for further care (RCN, 2016a) The RCN have impact on the risk assessment regarding
has published specific guidance for travel health immigration requirements
services (RCN, 2016b)
• rural areas may be of greater risk than urban,
• forced marriage is an abuse of human rights, particularly for diseases such as malaria
a form of violence against women and men, and Japanese encephalitis; in an emergency
where it affects children, child abuse and situation, especially in more remote areas, it
where it affects those with disabilities abuse may be difficult to reach medical help e.g. in
of vulnerable people. (FCO & Home Office the event of a potentially rabid wound
2013). Guidance Forced Marriage: Survivors
Handbook, published by the Foreign and • location may also impact on other risks such
Commonwealth Office is an invaluable as road accidents; developing countries may
resource to be aware of. Such activity needs to have inadequately constructed roads, limited
be considered in a travel consultation setting. road safety rules and poorly maintained
vehicles
Previous vaccination history:
• accidents may be a greater risk and poor
• having accurate information of previous vaccine standards in health care facilities may mean
history status will ensure previous vaccination an inadequate provision of care and an
is not duplicated unnecessarily and makes it inability to cope with injuries
possible to plan appropriate schedules within • consider the political and cultural issues at
the time limit prior to departure the destination and observe any UK Foreign
• gather information about primary Office travel restrictions (see the Foreign &
immunisation status to ensure complete Commonwealth Office) https://www.gov.uk/
courses were given foreign-travel-advice
15TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT
• areas at high altitude may have unknown pregnancy and gastro-intestinal surgery. (IATA
unpredictable effects on travellers, for Medical Manual, 2018). Individual airlines may
example acute mountain sickness. vary on required intervals. Further information
is also available from the Civil Aviation Authority
Departure date: (CAA) at https://www.caa.co.uk/Passengers/
• departure date will affect the time for giving Before-you-fly/Am-I-fit-to-fly-/
advice and the timing of vaccine schedules • cruise ship travel is increasingly popular,
• seasonality of certain diseases will affect particularly with older people; issues for
advice to travellers. Examples of diseases with consideration could include: risk of yellow fever
seasonal risk in some parts of the world include and/or the requirement for a certificate under
JE, influenza and malaria IHR for entry into some countries; risk of disease
outbreaks such as influenza and norovirus; and
• travellers who attend a travel advice
physical problems such as sea sickness.
consultation very late may not have time
to receive optimum pre-travel advice or Purpose of trip and planned activities:
protection; however, it is never too late
to commence some vaccine protection or • people travel for many reasons and it is
provide malaria chemoprophylaxis and important to establish the reason because this
receive appropriate advice to take additional impacts on the risks and type of pre-travel health
precautions – for example, food, water and advice given
personal hygiene advice. • holiday makers may take risks that they would
Length of stay: not at home because they are relaxed and want to
enjoy the experience without always considering
• generally, the longer the duration of stay, the the risks involved; package tours generally provide
greater the likelihood of exposure to travel a reasonable amount of security, and that can lead
related health hazards to excessive complacency or over indulgence; this
is particularly true for all-inclusive holidays that
• longer stays may run into seasons where risk is
are aimed at younger age groups where limitless
either higher or lower for certain diseases
alcohol could be available for consumption
• travellers are sometimes less cautious on a long (SHAPP, 2014)
stay, and this may increase the personal health
• backpackers and people undertaking more
risk; for example, relaxing adherence to malaria
adventurous travel or expeditions may travel for
chemoprophylaxis
longer periods of time and venture to areas where
• advice on the use of malaria chemoprophylaxis tourism is less well-developed; they may undertake
is different for long-stay travellers and the risky activities such as camping in areas where
practitioner may need specialist knowledge. malaria is a high risk, and where other mosquito-
borne diseases are transmitted in the daytime such
Transport mode: as yellow fever, dengue and Zika; they also often
take part in activities that can be hazardous such as
• long haul travel is most commonly by air, but
scuba diving, water sports like white water rafting,
travel by sea and overland journeys should also
bungee jumping, and trekking; facilities may not be
be taken into account when assessing individual
designed to the same standards as those in the UK,
risk
and the quality of equipment and supervision may
• risk of travel-associated complications due not be adequate
to prolonged periods of immobility while
• those travelling for the purpose of a pilgrimage,
travelling, such as VTE should be considered for
for example – Umrah and Hajj, are at greater
travellers who have any pre-disposing factors
risk of diseases resulting from close association
• any pre-existing medical condition or situation such as respiratory disease and meningococcal
may raise concerns about fitness to travel, meningitis; proof of vaccination for ACW135Y will
and an examination prior to the trip may be required by these pilgrims to obtain a country
be necessary; for example, respiratory or entry visa www.hajinformation.com/main/
cardiovascular disorders, psychiatric illness, p10.htm Travellers should be made aware of the
16ROYAL COLLEGE OF NURSING
annual advice given by the Kingdom of Saudi Medical tourism
Arabia Ministry of Health for those travellers in
the more vulnerable groups www.moh.gov.sa/ A growth area in recent years, with people travelling
en/hajj/pages/healthregulations.aspx for many types of surgery including dental
treatment, cosmetic surgery, elective surgery and
• people working abroad face special risks infertility treatment; the most common problems
depending on their type of work; for example, travellers experience when travelling abroad for
medical personnel working in disaster areas, or treatment result from undertaking limited initial
security workers going to war zones will be at research, booking treatment without a proper
greater risk of diseases of close association and consultation, aftercare, travel risks (for example,
blood borne infections VTE), lack of insurance, and poor communication
• business travellers under great pressure, and language difficulties (NHS, 2015); guidance is
making frequent short term and/or long haul available from NHS Choices.
trips can experience loneliness, isolation, and a
cultural divide; this group of travellers can be at Quality of accommodation:
risk from excessive alcohol use and casual sex • good quality air-conditioned hotels can reduce
(Patel, 2011) some health risks, but travellers should be
• expatriate travellers can also have similar advised not to be complacent about hygiene
experiences; they miss family, have difficulties standards especially for food preparation
with language barriers and suffer psychological • screened accommodation gives better protection
stress (Patel, 2011) in an area with malaria, but travellers should
• people travelling to visit friends and relatives are be advised about other personal protection and
at greatest risk from diseases such as malaria bite prevention measures for night-time and
because they may not fully understand the daytime
risks; they could have incorrect, pre-conceived • camping and living rough will increase travel
ideas that they have natural protection against health risks.
the disease, and may stay longer at hazardous
locations such as rural areas Financial budget:
• travellers are more adventurous today and • budget often dictates the quality of eating places,
advice must emphasise and focus on, for but food hygiene is not always guaranteed in an
example, risk of accidents, environmental expensive venue
hazards
• generally, travellers should be advised not to eat
• the risk of sexually transmitted infections and food from street vendors because of potentially
sexual health in general needs to be considered poor (or risky) hygiene standards and the quality
for all travellers but there is also a recognition and storage of the food used; however, sometimes
that some travellers may be at particular risk if the reverse is true if it is possible to observe
travelling with the purpose of sexual encounters the thorough cooking of fresh food at high
temperatures
• social media has significant impact on
traveller activity today. The Department of • backpackers often have to manage their trip
Education together with the Home Office within a tight budget and need to be aware of
have published guidance concerning the use the increased risk of using cheaper forms of
of social media for online radicalisation (GOV. transport, living in poorer accommodation, and
UK, 2015) Individuals need to be aware of having less money for medical help
the increased risk and danger when meeting • all travellers should make it a priority to buy
people through actions such as dating comprehensive travel insurance which includes
apps (NCA, 2016). Travellers using dating medical repatriation before travelling, and
apps could potentially be very vulnerable always carry details of policy documents with
when using them in another country where them or be able to access these electronically;
strange surroundings, cultures, customs and special attention should be given to the pregnant
communication issues add to the risk. traveller’s insurance including cover of the foetus
17You can also read
