Report from the UK and Eire Association of Genetic Nurses and Counsellors (AGNC) supervision working group on genetic counselling supervision

Making the 'genetic counsellor' in the UK, 1980-1995

The professional identity of the 'genetic counsellor' first took shape in the UK in the early 1990s, when the University of Manchester established the country's first masters-level training course. Postwar, genetic counselling had been carried out by (male) clinical geneticists, who, alongside their research, clinical and field-building activities, met patients and families to discuss inherited conditions and risk estimates, and who sometimes advised parents whether to attempt or continue pregnancies. By contrast, the new cohort of students in Manchester in the 1990s were not medically trained, were mostly women, and were schooled in the psychological and social consequences of genetic testing and diagnosis, as well as methods for the care, support and emotional management of patients and families. This was a significant change both in the practices of 'genetic counselling' and who was expected to practise it. Focusing on a small section of this history, between 1980 and 1995, this paper describes some of the historical threads that contributed to this change. It charts the early work of genetic nurses and social workers, who in the 1980s carved out distinctive roles within National Health Service genetics centres. It describes the separate, specialist provision developed by sickle cell and thalassaemia counsellors, who developed new approaches in dialogue with racialised and underserved patient communities. It examines growing interest in the late 1980s and early 1990s in the tacit social and cultural conditions of genetic counselling encounters, and how this cohered with attention from disability scholars, psychologists and social scientists. By describing these historical contributions, this paper explores how the intersecting gendered, racialised and disciplinary politics of clinical genetics shaped the new professional role of the 'genetic counsellor'.

An European overview of genetic counselling supervision provision

Genetic testing is becoming more commonplace in general and specialist health care, and should always be accompanied by genetic counselling, according to legislation in many European countries and recommendations by professional bodies. Personal and professional competence is necessary to provide safe and effective genetic counselling. Clinical and counselling supervision of genetics healthcare practitioners plays a key role in quality assurance, providing a safe environment not only for patients but for professionals too. However, in many European countries, genetic counsellors are still an emerging professional group and counselling supervision is not routinely offered and there are no enough evidences on the impact of these insufficiencies. This study aimed to explore the current status of genetic counselling supervision provision across Europe and to ascertain factors that might be relevant for the successful implementation of counselling supervision. A total of 100 practitioners responded to an online survey; respondents were from 18 countries, with the majority working in France (27%) and Spain (17%). Only 34 participants reported having access to genetic counselling supervision. Country of origin, the existence of a regulation system and years of experience were factors identified as relevant, influencing access and characteristics of counselling supervision. Although there is a growing number of genetic counsellors trained at European level, just a few countries have implemented and required as mandatory the access to genetic counselling supervision. Nevertheless, this is essential to ensure a safe and effective genetic counselling and should be regulated at the European genetic healthcare services.

Genetic counseling globally: Where are we now?

The genetic counseling profession is continuing to develop globally, with countries in various stages of development. In some, the profession has been in existence for decades and is increasingly recognized as an important provider of allied health, while in others it is just beginning. In this article, we describe the current global landscape of the genetic counseling specialty field's professional development. Using examples of the United States, United Kingdom, Canada, Australia, South Africa, and various countries in Asia, we highlight the following: (a) status of genetic counseling training programs, (b) availability of credentialing through government and professional bodies (certification, registration, and licensure), and potential for international reciprocity, (c) scope of clinical practice, and (d) health‐care system disparities and cultural differences impacting on practice. The successful global implementation of precision medicine will require both an increased awareness of the importance of the profession of “genetic counselor” and flexibility in how genetic counselors are incorporated into each country's health‐care market. In turn, this will require more collaboration within and across nations, along with continuing engagement of existing genetic counseling professional societies.

Challenges for providing genetic counselling in Colombian genetic clinics: the viewpoint of the physicians providing genetic consultations

This study explores the provision of clinical genetic services in Colombia, in order to promote improvements in these services. We carried out semi-structured interviews with 20 doctors working in genetic clinics, and we report the challenges in providing genetic counselling that they have identified. Education and training in genetics in Colombian medical schools were described as inadequate, and interviewees found that many of their medical colleagues knew too little to be able to refer appropriately to a genetics service. The doctors interviewed recognised their own limitations, including lack of knowledge, absence of training in communication skills and the strong influence of religious beliefs on the consultations of some colleagues. There may also be communication problems during the consultation: patients may fail to understand the explanations given or to accept the incurable nature of genetic conditions. There are also problems with access, because genetic services are not covered by the health insurance system in Colombia. More training in genetics is required at medical schools in Colombia, at the undergraduate and postgraduate level. There was a consensus that most medical specialities are limited in their knowledge, awareness and understanding of genetics. Furthermore, many medical geneticists did not believe that other health professionals should work as genetic counsellors. These findings may assist in the development of improved genetic counselling services in Colombia and in the establishment of an enhanced academic curriculum of basic and clinical genetics at Colombian universities.

Quality issues concerning genetic counselling for presymptomatic testing: a European Delphi study

Genetic counselling for presymptomatic testing is complex, bringing both ethical and practical questions. There are protocols for counselling but a scarcity of literature regarding quality assessment of such counselling practice. Generic quality assessment tools for genetic services are not specific to presymptomatic testing (PST). Therefore, the aim of this study was to identify aspects of effective counselling practice in PST for late-onset neurological disorders. We used the Delphi method to ascertain the views of relevant European experts in genetic counselling practice, ascertained via published literature and nomination by practitioners. Ethical approval was obtained. Questionnaires were sent electronically to a list of 45 experts, (Medical Doctors, Geneticists, Genetic Counsellors and Genetic Nurses), who each contributed to one to three rounds. In the first round, we provided a list of relevant indicators of quality of practice from a literature review. Experts were requested to evaluate topics in four domains: (a) professional standards; (b) service standards; (c) the consultant's perspective; and (d) protocol standards. We then removed items receiving less than 65% approval and added new issues suggested by experts. The second round was performed for the refinement of issues and the last round was aimed at achieving final consensus on high-standard indicators of quality, for inclusion in the assessment tool. The most relevant indicators were related to (1) consultant-centred practice and (2) advanced counselling and interpersonal skills of professionals. Defined high-standard indicators can be used for the development of a new tool for quality assessment of PST counselling practice.

From constraints to opportunities? Provision of psychosocial support in portuguese oncogenetic counseling services

Although available guidelines for familial cancer risk counseling clearly state the need to provide adequate psychosocial assessments and support, this feature of care is only available in part for individuals and families in oncogenetic counseling protocols in Portugal. The purpose of this study was to examine the psychosocial aspects of oncogenetic counseling provided by a sample of Portuguese genetics professionals. We sought to ascertain perceived need for the provision of psychosocial services and ways to enhance the psychosocial focus in service delivery. A qualitative study was designed; semi-structured focus groups and individual interviews were performed with 30 professionals from Portuguese healthcare institutions where oncogenetic counseling is offered. Findings suggest: current practice is aligned with the teaching model, with a mainly information-based focus; use of psychosocial counseling techniques and psychosocial support is limited throughout the genetic counseling timeline; there is a limited workforce of adequately trained psychosocial professionals, who are disadvantaged by structural and organizational constraints. These factors are considered to be serious barriers for psychosocial delivery. Development of multidisciplinary teams working in oncogenetics, and need for further counselling skills and training for genetics healthcare professionals were identified as priorities. Implications for practice and policy are discussed. Portuguese genetic counselors who have recently completed their training, may therefore contribute to enhanced psychosocial services delivery.

A model of professional development for practicing genetic counselors: adaptation of communication skills training in oncology

Ongoing professional development for practicing genetic counselors is critical in maintaining best practice. Communication skills training (CST) workshops for doctors in oncology, utilizing trained actors in role plays, have been implemented for many years to improve patient-centred communication. This model was adapted to provide professional development in counseling skills for practicing genetic counselors, already highly trained in counseling skills. Detailed evidence based scenarios were developed. Evaluation of participants' experience and perceived outcomes on practice included surveys immediately post workshops (2002, 2004, 2005, 2008 (×2); n = 88/97), 2-5 years later (2007; n = 21/38) and a focus group (2007; n = 7). All rated workshops as effective training. Aspects highly valued included facilitator feedback, actors rather than role-playing with peers and being able to stop and try doing things differently. Perceived outcomes included the opportunity to reflect on practice; bring focus to communication; motivation and confidence. The high level of satisfaction is a strong endorsement for ongoing communication skills training in this format as part of professional development.

Clinical geneticists' and genetic counselors' views on the communication of genetic risks: a qualitative study

OBJECTIVE

In genetic counseling, counselees' understanding of risk information is considered crucial for informed decision-making. The counselors' task is to convey risks in a format that is understandable. It is therefore important to know how and why counselors say they communicate risks in different formats, and to identify any perceived training needs. By investigating counselors' perspectives, training can be more tailored to their needs.

METHODS

Interviews were held with 18 counselors in 4 of the 8 clinical genetic centres in The Netherlands.

RESULTS

Counselors reported using different formats, but seemed to prefer a numerical format (e.g. percentages). Methods varied between counselors and depended on their training, their own abilities, experiences they have had with counselees, but rarely because of information they have gathered from the literature on risk communication. Counselors reported assessing comprehension most often from counselees' non-verbal responses, and reported tailoring their approaches to their clients' needs. Although some counselors are eager to know if their way of risk communication is 'right', overall the counselors did not report a need to be trained in risk communication.

CONCLUSION

Counselors appear to have clear ideas about how to present risks, although evidence for their methods is often lacking.

PRACTICE IMPLICATIONS

Training in general communication skills and evidence-based risk communication could be of benefit to counselors and, consequently, to their counselees.

An investigation of genetic counselor experiences in peer group supervision

Peer supervision groups have been studied in counseling fields including psychotherapy and social work. However, limited research exists regarding genetic counselor peer supervision groups. In the present study five major research questions were investigated: (1) How prevalent is peer group supervision among genetic counselors? (2) What motivates genetic counselors to join and continue to seek peer group supervision? (3) What comprises the content, agenda, and structure of group meetings? (4) What are participants' perceptions of group dynamics, including conflicts, cohesion, and leadership? and (5) What are the perceived benefits and limitations of participating in peer group supervision? A total of 214 genetic counselors completed an online survey, and 70 (34.8%) reported being involved currently in peer group supervision. Fifteen of these 70 respondents were interviewed regarding their experiences in peer group supervision. Inductive analysis of their responses yielded 11 domains and 37 categories. Practice implications and research recommendations are discussed.