« Previous | Contents | Next »
Listen
NURSING For HEALTH: TWO YEARS ON
Annex A Developing Consensus for Public Health Nursing
Report from "Developing Public Health Nursing Practice"
Consensus Conferences, May/June 2002
Three consensus conferences for developing public health nursing practice were held in Renfrew, Dunfermline and Nairn in the summer of 2002. They were targeted primarily at an audience of public health nurses, their managers, directors, immediate colleagues and key stakeholders, with the emphasis on achieving a balance of participants to enable full discussion. The conferences aimed to develop a clear vision for the future of the public health nursing role and to formulate an action plan for national, regional, local and practitioner levels to achieve that vision. While the conferences encouraged discussion of the public health roles of the whole nursing workforce, the focus was mainly on the process of refocusing health visiting and school nursing towards public health nursing.
This annex reports the vision and action plan that emerged from the three conferences.
1. Setting the scene
Each conference began with four presentations that set out the national, regional and local contexts for public health nursing around Scotland. The presentations covered the following four areas:
National policy direction
The challenge for public health nursing leadership at regional (Board/Trust) level
The response to the policy changes from nurse education
Examples of practice from Argyll and Clyde, Greater Glasgow and Tayside of nurses extending their public health roles.
2. The public health nursing vision
The workshop sessions were structured and facilitated by LHCC public health practitioners. The morning sessions aimed to identify a collective vision for public health nursing. Participants were divided into groups of approximately 10, and asked the question, "What will public health nursing look like in five years time?" Results of the discussions were noted on flipcharts and post-it notes, and were collated over lunchtime in order to feed back the key points to participants to provide a starting point for the afternoon workshops, which sought to develop action plans.
The consensus vision from the three conferences is presented under the four headings of clarifying the public health nursing role, partnership working, organisational change, and training and development.
2.1 Clarifying the public health nursing role
The first step in creating the vision was to achieve clarity for the public health nursing role, and workshop notes recorded that a clear direction for public health nursing as part of a public health infrastructure is crucial. Participants believed that public health nurses should be focused on health improvement rather than disease management with addressing inequalities and life circumstances central to their role. The new public health nursing posts should be based on the best of existing health visiting and school nursing roles and on evidence of need.
The name change from health visiting and school nursing to public health nursing appeared to be generally supported by conference participants and there was also support for more emphasis on evaluating and recognising their contribution to, and impact on, health improvement. There was less consensus on whether the public health nursing role should be a specialist or a generalist role. Some participants "didn't want everyone doing everything" without the opportunity to specialise. Others felt that public health
was everyone's job, and therefore public health nursing should not "own" nurses' public health agenda. There was also no consensus on whether community based activity should be carried out in conjunction with caseload activity or regarded as a separate job.
2.2. Partnership working as the key approach
Partnership working was regarded as key to public health nursing activity. Public health nurses should work with families, communities and service users, other nursing disciplines and other agencies, local businesses, mental health teams and the voluntary sector. They should work as community-based, practitioner led multi-agency teams, as cross-agency special interest groups, in public health networks and in one-stop shops. This approach is necessary in order to break down barriers and access a variety of approaches, to develop mutual respect between medical and social models, and to achieve better communication between disciplines. Most of all, partnership working was thought to enable the provision of integrated services and integrated resources which would meet the needs of the population.
2.3 Organisational change
Participants were very clear that organisational change and support for that change were required to enable the vision for new ways of working to become a reality. In particular, strong leadership at all levels and training and development is required.
The organisational change that was regarded as needing to happen for public health nursing to carry out its objectives includes the LHCC giving higher priority to community development and community involvement along with individual focused work. There should be better integration of health improvement strategies between the NHS and local authorities as well as between different NHS structures. Within the LHCC or GP practice, different caseload models could be used and many participants favoured greater independence for public health nurses from GP practices, but without breaking their links entirely.
In order that public health nurses have the opportunity to develop creative solutions to problems, they need space and development time. Repeatedly, groups reported that they would welcome GP engagement in and support for the public health agenda. Finally, long term funding to enable sustainability is required, with devolved budgets for local developments and equity across rural and urban areas. An area where there was no consensus was that some participants favoured a lifespan approach rather than targeting groups, particularly for small communities where the stigma of being a priority grouping might have an effect on uptake of targeted services.
2.4 Training and development
As noted above, training and development is clearly required in order to establish new ways of working. Participants believed that public health nurses in the future would have greater opportunity and encouragement to develop their public health knowledge and skills. In addition, structural support for developing the new public health nursing role included the need for mentorship, a clear career pathway with appropriate rewards, training for existing staff, continuing professional development, promotion of good practice, education input that reflects community needs and common core training for different nursing disciplines.
Comment:There was broad consensus on the vision for public health nursing, which clearly reflected the vision set out in Nursing for health. There were three areas in which consensus was not achieved as follows:
1. The development of public health nursing as a specialist or generalist role. Should public health be regarded as the business of all nurses or should the health visiting and school nursing roles be singled out as specialist public health nursing roles?Or indeed can bot exist alongside one another?
2. Should community based activity of nurses be integrated as part of a caseload remit, or should it be a separate role?
3. Should public health nurses target their services on particular population groups, or should they adopt a lifespan approach?
3. Developing an action plan for public health nursing
Following the vision session, participants were asked to work again in their groups to discuss actions that could be taken at national, regional, local and practitioner levels in order to achieve the emerging vision for the future public health nursing role. Before setting out their actions they were asked to consider both the vision identified in the earlier session and the barriers for development that might exist.
3.1 Barriers to developing the new public health nursing role
Participants were asked to describe the potential barriers to development before thinking through their action plans. Three main themes emerged:
Difficulties with partnerships
Partnerships within the NHS
: Working across boundaries within the NHS was regarded as problematic for many of the groups. In particular, the GP contract, and the GP practice focus of the PMS budget were mentioned by most of the groups as presenting a barrier to public health nurses for working outside practice lists on community based activity.
Partnerships with other agencies: Problems were said to arise when partners were unable to achieve a shared vision for their work or to develop shared principles and values. A lack of understanding of different roles within a partnership was also a common problem, along with different accountability structures, different working patterns and different sets of jargon - all of which could create barriers to development.
Access to Resources
Most groups identified that a lack of transparency in the budget allocation process presented barriers to accessing resources. In addition, there was a need for joint funding with other agencies. Other essential resources that were mentioned as being scarce included:
Time, with high workloads and lack of time for training
Access to IT
Public health skills including community development and leadership,
Information - on new roles, standards for practice and funding streams
Process of change
Most groups had come across resistance to change among their colleagues, presenting a major barrier to developing the public health nursing role. Resistance to change resulted from fear of service dilution, lack of motivation and the speed and extent of change that was currently required. There was a perception of a lack of leadership at all levels and a need for staff to be better prepared for change as well as need for better management of change. Many groups felt that there was little opportunity to inform and influence decision makers.
Comment:There was high consensus on barriers to the development of public health nursing. Many participants appeared to be struggling with the ongoing process of change and were clearly requiring higher degrees of support and leadership than was available. However, the picture is not completely bleak. For example, two of the barriers cited were problems with multi-agency partnerships and with engaging GPs. However, the willingness to work in multi-agency partnerships and a reluctance to break links with GPs (albeit with greater independence required) were both evident from the visioning session suggesting that the barriers are already being addressed in order to establish the vision presented here for public health nursing.
3.2 Actions
Participants were asked to identify actions that could be taken at national, regional, local and practitioner levels in order to meet the vision that was identified for the future public health nursing role. The groups came up with quite different ideas for proposed actions at national and regional levels, resulting in little consensus. This could have been a result of there being few participants at any of the conferences who worked at national or regional levels and therefore there was less understanding within the groups of the current and planned activity at these levels. There was greater consensus on actions for locality and practitioner levels, particularly around public involvement and community led needs assessment.
None of the groups used the results of the vision session to frame their action plans but the proposed actions have been collated and set against the vision headings of achieving clarity for the public health nursing role, partnership working and support for organisational change (including education and training).
3.2.1 Clarifying the public health nursing role
National level actions | Regional level actions |
Identify a lead for public health nursing, eg Scottish Executive and/or PHIS Lead to turn priorities into action Evidence-based decision-making setting a clear direction for new public health roles Identify a consensus on practice Develop performance indicators for public health Create national public health nursing standards Provide examples of practical models of working Ensure consistency for titles, pay and information Should be more opportunity for secondment to Scottish Executive Profile of public health in primary care should be raised National level should understand the local public health agenda
| DPH should provide professional lead on national policy Raise the profile of public health roles Communicate and clarify national policies, vision and information Recognise diversity and commonality across regions Public should be informed Decision made regarding GP attachment or geographical working Clarity of public health and health promotion roles Enable change management - permission to change practice Provide explicit direction Value and develop the public health workforce Share information regarding local initiatives
|
Locality level actions | Practitioner level actions |
Leadership from LHCC executive team and key people in other local agencies Set direction, develop the vision and support cultural change Vision development in consultation with staff and key partners Define and adopt shared vision for a public health nursing role Recognition of public health nursing skills and promoting them to GPs and others Clarify role of LHCC Dissemination of information to practitioners Map current public health activity Share best practice between health and other agencies
| Be more assertive and influence decision-making processes Participate in developing a shared vision and clear framework for public health nursing Respect and explore different ways of working Develop evidence based and needs based practice.
|
3.2.2 Partnership working
National level actions | Regional level actions |
Cross-party consensus on health plans Compatibility of records Common IT infrastructure across agencies Shared budgets Shared strategic vision National strategy for public participation
| Accountable partnership structures Interaction with local authority through community planning partnership groups Shared funding, planning, goals and common language Co-ordination of expertise and skills Value different skills Public participation in regional structures
|
Locality level actions | Practitioner level actions |
Closer working between practitioners, LHCC PHPs and managers Enable practitioners to participate in planning and implementation of public health Address resistance from GPs GPs and practice managers should be more involved in the public health agenda Encourage models of multi-disciplinary working Opportunities for shared premises between different agencies Multi-agency management teams Needs assessment at locality level should include community needs and key partners Support for user involvement in LHCCs Greater understanding of community development Greater flexibility to meet local need Social workers should be in LHCCs
| Encourage and support public participation Engage with the local community Adopt community development approaches
|
3.2.3 Support for organisational change and public health training
National level actions | Regional level actions |
Public should have good access to information and awareness of health vs. illness Feedback to staff on success of new public health roles Mainstream, long-term funding rather than challenge funding Realistic timescales for new projects New money ring-fenced for public health Recruitment and retention should be addressed Consistency of access to training across the country Adequate resources allocated to training Integrated training across agencies Realistic timescales for change for education institutions Development of clear career pathways in public health
| Workforce planning Audit and research More nurse involvement at trust/Board level Identify core child health surveillance programme Service review to identify core work Move resources from acute to prevention Long-term approach Effective resourcing of multi-disciplinary training Establishing continuing professional development (CPD) and personal development plans Training should be available for existing staff such as health visitors
|
Locality level actions | Practitioner level actions |
Different models of working encouraged with evaluation and sharing examples of good practice Social model of health supported Support for change for practitioners Feedback to practitioners on progress Leadership to address low morale and remove blame culture Support for change by enabling practitioners to access education and training
| |
Comment: it will be argued that many of the actions identified above as being needed are in some areas already underway or planned. It is likely that different geographical areas have prioritised different starting points for meeting the recommendations in Nursing for Health. It is proposed therefore that the above list might be useful in identifying general principles for establishing the public health nursing vision rather than being read as an assumption that action is not being taken. For example, most groups raised the issue of communication between different levels. This might signal that participants are unaware of activity going on at different levels rather than that activity is not taking place.
4. Conclusion
The consensus conferences brought together some of the most insightful and practical thinking and around public health nursing in Scotland. They established that the ongoing vision for public health nursing practice continues to be in line with the Scottish Executive vision, which perhaps is not surprising as many of the participants would have been involved in the consultation process that established that vision for Scotland in 2000/2001.
Most importantly the conferences identified the extensive work that had been carried out in the first year following publication of
Nursing for Health, the direction of travel for the future and some very practical solutions. This conference report will contribute to the mapping of activity around the development of the public health roles of nurses in Scotland in order to set out the next steps in establishing public health nursing as a key force in improving the health of the Scottish people.
« Previous | Contents | Next »