The Scottish Government

Main Findings

• The 40 week degree-level course designed to prepare the FHNs was completed by a total of 31 students (11 in the first cohort in 2001; 20 in the second cohort in 2002). Most of these students were experienced local community nurses with a midwifery qualification.
• Evaluation of the educational course showed it to be very focused on its speciality. It was theoretically grounded in an ideology of nursing which combined elements of Family Nursing from North America with the promotional ideas from WHO Europe.
• There were some persistent problems with the scheme for Accreditation of Prior Learning and with practice placement supervision. However the course was strong in teaching communication and family health assessment skills and used innovative IT approaches.
• The educational programme is distinctively different from other specialist community nursing programmes and has growth potential. In this regard a number of suggestions for further curriculum development are made within the main report.
• Evaluation of the first year of practice focused on ten sites where FHNs were working. Four distinct patterns of context, process and outcome were evident within the typology of practice that emerged. These were: Slow/No go; High scope-slow build; Slow build-key ally and Bold build.
• The FHN role was typically developed in a limited way on top of a district nursing caseload and within pre-existing resources. This involved the supplementation, rather than the supplanting, of "normal" community nursing activities.
• The presence of at least one of the following two factors appeared to be a necessary condition for family health nursing practice to progress: (i) the perceived scope/space to encourage implementing this new approach (ii) the local presence of at least one active supporter who changed their own practice.
• Programmes of active facilitation at local level are required if the FHN role is to be successfully developed within remote and rural Scotland. The possible introduction of the role within more urban areas requires careful consideration and in this regard a number of suggestions are made within the main report.

Background

Within Europe, Scotland has been the first country to enact the new Family Health Nurse concept through a pilot project. As such this independent evaluation represents the first systematic study of this new role. The evaluation studied the first two years of the educational course and the first year of the role in practice. The objectives were:

1. To evaluate the education programme curriculum and consider how well it fits into the Scottish context.

2. To evaluate the learning experience and preparation of FHNs and the support provided to them in placements, focusing in particular on the role of mentors.

3. To compare the coverage and extent of service provided by current primary health care nursing services and the subsequent coverage of service provided by the FHN.

4. To explore the operation of the FHN model, focusing on the nature of the services provided and drawing comparisons between the pilot sites.

5. To identify relevant stakeholders' perceptions of the FHN model.

6. To draw out implications from the study's findings for the future provision of education for FHNs and for the extension of service provision to other areas of Scotland, including urban areas.

The Educational Programme

A Scottish University was commissioned to provide the educational programme. The course award was Bachelor of Nursing in Community Studies (Family Health Nursing). The course was designed to be compatible with a curriculum suggested by WHO Europe, and with the Nursing and Midwifery Council (NMC; formerly UKCC) framework for nursing specialist practice qualifications. Students attended full-time and undertook a fixed sequence of modules. During the first year of the course a number of major curricular modifications took place.

The students were typically middle-aged females with considerable experience of community nursing in their particular remote and rural location. Two thirds were midwives and two thirds had no specific community specialist nurse qualification.

The educational programme was found to be distinctively different from other specialist community nursing programmes available in Scotland. It was much more focused on its speciality and was theoretically grounded in an ideology of nursing which combined elements of Family Nursing from North America with the promotional ideas from WHO Europe. It did not share core modular content with other community education courses and was less flexible in terms of negotiating learning outcomes. The course was also distinctive in having no modules dedicated to quality issues, teaching and supervision, management or leadership. This differed from WHO Europe's suggested curriculum. The combination of generic and specialist content was not always congruent with assessment processes.

Eleven of the twenty students in the second cohort obtained some exemption under the scheme for Accreditation of Prior Learning (APL). This meant that they did not have to attend campus during their "APL weeks", but most had to return to their jobs, and all still had to complete the modular assessments. This was an unsatisfactory practice from the perspective of students, teachers and by any contemporary understanding of APL processes.

Practice placement supervisors were typically District Nurses or Health Visitors. Problems with the selection, preparation and support for supervisors were marked during the first eight months of the course. Most difficulties were resolved thereafter.

Students identified newly learned family health assessment/promotion skills as being particularly valuable and these were seen as central to their emergent professional identity. Communication and IT skills were also highly valued, as was an innovative web-based facility developed for the course. The course was very much tailored to a specific market context and the balance between campus attendance and distance learning emerged as being a real strength.

One of the persistent difficulties for students, supervisors and educators was the simple fact that until 2002 the FHN role was hypothetical. In effect the course was tied to the concurrent development of policy and practice, and necessarily led practice. In doing so the course provided these experienced nurses with personal and professional development, encouraging a "graduateness" whereby they learned to reflect on and analyse situations.

The course has growth potential. In this regard a number of suggestions for further curriculum development are made within the main report. In developing a distinctively different approach, the Family Health Nurse course provides a precedent for other educational providers to reconsider their approach to specialist practice degree level education.

Family Health Nursing Practice

During 2002 family health nursing practice at ten sites was studied. The typology of practice which emerged identified four distinctive patterns relating to the context of the development, the process of engagement and the outcome of practice. These were: Slow/No go; High scope-slow build; Slow build-key ally and Bold build. The first three patterns involved the FHN role being super-imposed on pre-existing district nursing caseloads. The latter involved more autonomous role development.

It was found that the role can be developed in a limited way on top of a district nursing caseload and within pre-existing resources. This typically involved the supplementation, rather than the supplanting, of "normal" community nursing activities. The Bold build approach also supplemented pre-existing services by expansion into gaps, but characteristically delivered more sustained, in-depth care programmes. This presents a different type of role that has more potential resource implications if replication were to be pursued in the absence of re-appraisal of existing Primary Health Care Team (PHCT) roles.

Generally speaking, the presence of at least one of the following two factors appeared to be a necessary condition for FHN practice to progress: (i) the perceived scope/space to encourage implementing this new approach (ii) the local presence of at least one active supporter who changes their own practice.

All the new FHNs tried to operationalise the in-depth family assessments within their everyday practice. These assessments tended to be time consuming and difficult to orchestrate, but were generally well received by family members.

Few professional colleagues were active in referring families to the service and even where the role was legitimised through referrals it could not necessarily be prioritised by the FHNs as there was a "bottom line" expectation that the pre-existing level of community nursing service must be maintained.

During the first year of practice FHNs usually operated alone and their activities were often not well understood by colleagues. This made integration problematic. There is a need for much stronger local programmes of support and facilitation if the role is to be developed and sustained. This should be part of wider review and development of PHCT working practices and should include review of caseload management and staff skill mix.

The Wider Scottish Context

In order to inform judgements about the applicability of a family health approach to community-based nursing in the wider Scottish context, we interviewed 19 key informants. Findings suggest that overall community nursing services are adapting to the policy changes which have been advocated and that current educational provision is generally perceived as good. However there were concerns about duplication of effort, territorialism and recruitment. Perceptions of family health nursing varied widely.

Implications For Role Development

We suggest that there are three areas where active facilitation is required in order that the role of those Family Health Nurses currently in post can be developed further:

• Enabling the FHN role to merge with current service provision in a meaningful way
• Developing the core PHCT in order that they can incorporate a more systematic focus on family and health into existing services and care practices.
• Involving patients and the wider community to expect, accept and value a different approach to nursing care in particular and health care in general.

Furthermore we suggest that prior to introducing family health nursing as a new role service providers conduct a comprehensive analysis to plan, facilitate and sustain the development. This should include situational analysis (e.g. why is the role needed?); role analysis (e.g. what work will be done in the new role); cultural analysis (e.g. how will it fit with current practices and understandings); and business analysis (e.g. what resources are available to support and sustain the new role). As such, any development of the FHN role should be considered as part of wider service review and redesign. The latter processes would be relevant to urban applications and would also enhance the potential of the FHN role to be a solution to the particular problems of recruitment, development and retention of nursing staff in remote and rural areas.

It seems likely that in the short term in Scotland there will be inherent ongoing tension between the distinctive family focus of the role and the demand within the system for generalist activities prioritised around individuals' needs. Whether this tension proves dysfunctional or not will depend on the extent to which the role can be facilitated and the extent to which PHCTs are willing to engage in practice review and service redesign. If the latter activities are successful it is possible to envisage the Slow build types, and the Slow/No go types, developing significantly as part of more integrated, family orientated services. In turn this would lead towards a critical mass being achieved that would present a stronger argument to inform debate about changing the present UK system of community specialist practitioner roles.

This evaluation has studied the formative stages of the Family Health Nurse role. In attempting to simultaneously develop national policy, education and service delivery, the FHN initiative in Scotland has achieved much in a short space of time, but so far the scope of the necessary change process has been underestimated. In order to capitalise on the achievements to date we suggest that:

• Planned development is facilitated with those PHCTs that include a Family Health Nurse in order that the role can be understood and developed further.
• The critical mass of FHNs is helped to grow in the remote and rural areas.
• The educational programme is further developed.
• The evaluation is disseminated widely to foster debate and critical thinking about the nature of community nursing services and educational preparation.

Research Methods

The evaluation design was informed by two key approaches to evaluation research (Pawson and Tilley 1997; Guba and Lincoln 1989) and by case study methods (Yin 1994). As such, the evaluation was primarily grounded in qualitative research methodologies, but it also incorporated quantitative data obtained from questionnaires. Other data collection methods included: interviews with FHNs, professional colleagues and family members; literature search; documentary review; observation and field note construction.