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Family Health - Nursing in Scotland: A report on the WHO Europe pilot
What have we achieved?
The Education programme
The selection of Stirling University to lead the education programme was based on existing development work with service partners exploring a community nurse education model for remote and rural areas and the geographical proximity of its two satellite campuses in Inverness and Stornoway to the pilot areas.
The Family Health Nurse programme was developed from a competency and research based WHO Europe Curriculum for Family Health Nursing (WHO Europe 2000). On completion of the curriculum the Family Health Nurse was expected to be competent as, a:
care provider
decision-maker
communicator
community leader
manager.
Stirling University adapted and developed their programme from this original document to meet the requirements of the Nursing and Midwifery Council, and to fit with contemporary primary health care in remote and rural areas. A programme development group was convened comprising both educators and practitioners to produce a curriculum for the Scottish Family Health Nurse pilot. The Bachelor of Nursing in Community Studies (Family Health Nurse) was subsequently validated by the then National Board for Nursing, Midwifery & Health Visiting for Scotland. This curriculum comprised the following units of study:
| 1 advanced credit |
| 1 advanced credit |
| 2 advanced credits |
| 2 advanced credits |
(note each advanced credit is equivalent to 20 SCOTCAT points at level 3)
Originally the intention had been to create a shortened conversion course for those nurses with an existing specialist practitioner qualification. However, it soon became apparent that we would need to have a better understanding of both the Family Health Nurse role in practice and the necessary competencies before this would be possible.
The Family Health Nurse course was studied full time over one academic year. The programme was designed to reflect the remote nature of the practice sites and made extensive use of Information Technology and distance learning as well as more traditional teaching methods.
One difficulty associated with developing a new role in this way is providing appropriate practice-based education and supervision. Supervisors on the programme were experienced health visitors and district nurses from within the pilot sites, many of whom were heavily involved in developing the education programme. The preparation of practice supervisors was further developed in year 2 of the programme in response to a need identified by educators and practitioners. The reflection of one supervisor shows how their understanding of the Family Health Nurse role has continued to grow.
Although this is my first year as a supervisor I was one of the converted almost from the pilot outset. My understanding of the concept has been further assisted by now working alongside qualified Family Health Nurses.
A total of 31 students undertook the Family Health Nursing programme, 11 in the first year and 20 in the second year. This was a diverse group from a mixture of different Scottish cultural backgrounds and with a broad range of professional experiences. The student cohort included staff nurses from primary care settings, district nurses, a health visitor and a triple duty nurse. Many were also midwives. The enthusiasm of this group was inspiring and the opportunity to share learning with nurses from other areas provided a real catalyst for their personal development. For these nurses working in remote and rural areas the opportunity to network with others and undertake learning via web-based systems was highly valued. As part of their education programme they were asked to record their feelings and experiences in a reflective diary. These reflections provided unique insights into their commitment to family health nursing and highlighted their very personal achievement in successfully completing the education programme.
Throughout the pilot the education team worked closely with the other stakeholder groups and provided an invaluable input to the Steering Group discussions.
Reflections on the education experience 1. On new beginnings
"I'm at the beginning of a journey, I'm pleased to be here although the end is not yet in sight, but as yet that doesn't worry me. I'm not even sure of the route that I'm going to take but I'm happy just to take it one step at a time." 2. On the student experience
"Like the mobile analogy we have all effected movement and change in response to the whirlwind of campus life and psuedo-student status." 3. On group learning
"I find networking with others so inspirational, how many years experience are in that room, and almost everyone of us is there because we really want to be here at the cutting edge of nursing provision." 4. On working in a different way with families
"My previous ideas of family dynamics and communication needs questioning. Met two of the families, my previous perception of both families was wrong." 5. On the value of practice supervisors
"My contact with my supervisor has given me bursts of sunshine." 6. On life long learning
"Life long learning is a must and I have found this course has made me eager to learn more not only for my benefit but also the benefit of the community in which I work." 7. On the concept of family health nursing
"I am more convinced than ever that this is the model to pursue as the way forward for community nursing." |
Family Health Nursing in Practice
All of the students were identified to participate in the programme by a combination of their enthusiasm and interest in the pilot and consideration of current and potential workforce needs. For many of the Family Health Nurses, this meant that at the end of the programme they would return to their former practice areas to take up their new role as a Family Health Nurse. This transition back into practice was inevitably a challenging time as the new Family Health Nurses attempted to establish their new identity and consolidate learning from the education programme. The evaluation report captures some of the experiences of the first cohort of 11 students as they pioneered a new model of Family Health Nursing practice. For some, this proved to be easier than for others, due to a combination of workload and the expectations of both the Family Health Nurses and fellow team members. However, all of the Family Health Nurses have changed the way that they approach practice, which is demonstrated in the range of work they are involved in either individually or as part of the wider primary health care team.
The original vision of Family Health Nursing in Scotland was to create a role that had three underpinning principles:
It is a skilled generalist role encompassing a broad range of duties, dealing as the first point of contact, with any issues that present themselves, referring on to specialists where a greater degree of expertise is required.
It is a model based on health rather than illness - the Family Health Nurse would be expected to take a lead role in preventing illness and promoting health as well as caring for those members of the community who are ill and require nursing care.
The role is founded on the principle of caring for families rather than just the individuals within them.
The evaluation report details the extent to which this vision was achieved in the early months of practice of the Family Health Nurses.
The skilled generalist role is the underpinning core of the Family Health Nurse role. For a number of reasons this has been the most difficult aspect to realise for the nurses. Creating a generalist role, within a context of existing specialist roles has been challenging. Those nurses working as a single practitioner within an isolated community have inevitably had the greatest success in this respect and have been able to apply the learning acquired to expanding their existing generalist role to better meet the needs of communities.
The Generalist/Specialist Nurse Interface Collaborative working between the Family Health Nurse and Health Visitor in a Island community has enabled a Parenting Skills Group to be started. The Health Visitor will work with the Family Health Nurse to enable her to further develop skills and knowledge in this area of practice. The mentorship-type arrangement of the generalist being supported by a specialist community specialist is an example of a different way of developing services in response to local need. |
For other nurses, the lack on any preconceived boundary on their role has proven valuable to enabling them to expand into areas not well addressed by other members of the team. This is most notably the case with certain dimensions of public health practice.
Healthy Lifestyles Family Health Nurses are increasingly involved in developing new initiatives within communities. Some of these are in partnership with other professionals in primary care. Working collaboratively with the local health promotion department has also helped inform the public of the services provided by the Family Health Nurse. New projects include: The very popular Senior Swimmers Group celebrates the young at heart message with its oldest member of 80 years confirming that active lifestyles can be maintained regardless of age. Health checks at the local agricultural show have proved such a success that requests are now coming in from other workplaces. A Healthy Eating Initiative facilitated jointly by the Family Health Nurse and District Nurse will encourage people to make lifestyle changes which could make a real difference to their future health regardless of age. |
The focus on family is perhaps the most distinctive dimension of the role, which is markedly different to the approaches used by other nurses. Family Health Nurses have demonstrated skills in working with families with complex underlying health problems and in engaging the wider family in work to improve health and wellbeing.
Working with Families Family Health Nurses have identified the ways in which they are now working differently with individuals and families since returning to practice. One Family Health Nurse feels they are now recognising much more the resource of the extended family. Working with a family and a young child with special needs the inclusion of grandparents in the family health plan is something which they would not have considered previously. Another Family Health Nurse spoke of the value of including the whole family unit in a health discussion. Previously they would have targeted the individual but now by including other members, the family group is able to support that person. In this way responsibility is given back to the family to create their own healthy lifestyle. For one family the creation of a genogram (health history) enabled them to see with clarity the pattern of smoking-related disease and mortality in their background, and proved the incentive for them to work collectively with the Family Health Nurse on a smoking cessation programme. |
At its most extreme presentation, the effect of this has been to create a role which is essentially evolving as a separate specialism, with other community nurses referring on families with the most complex health problems. Clearly this is not what was envisaged, but indicates a need to equip a wider group of nurses with the skills and tools of Family Health Nurses.
Working in a Different Way Working with an individual with a chronic disease condition the Family Health Nurse discussed different treatment options and provided details which enabled an informed decision to be made by the person. This approach encouraged a previously reluctant person to accept the changes to their regime. In summing up their feelings about the approach used by the nurse the person stated You didn't tell me what I must do, you challenged my thinking, presented a rational argument and then backed it with evidence. For other Family Health Nurses their role as the lynchpin for families receiving input from many different specialists is really developing. Examples have been given on how they are working in this way with families who have complex mental or physical health needs providing the vital resource of a locally based key worker. |
The return to practice in January 2003 of the second cohort of 20 Family Health Nurses has helped to further consolidate and develop the role, with a number of primary health care teams now having two or more Family Health Nurses.
There remain however a number of challenges to be addressed in making the most of Family Health Nursing. These include developing effective and meaningful family health records, re-thinking the concept of caseloads in a role where a significant part of the community could become part of the Family Health Nurse's caseload and reviewing the balance of generalist and specialist functions within primary health care teams.
Evaluation
The research team from the Centre for Nursing Practice, Research and Development, Robert Gordon University were commissioned to conduct the evaluation study following a competitive tendering process. Their work encompassed a broad range of qualitative analysis of both the education programme and the practice of the first cohort of Family Health Nurses and paints a rich picture of how the role has developed.
The objectives of the evaluation 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 Family Health Nurses and the support provided to them in placements, focusing in particular on the role of mentors and differentiating between the requirements of community nurses who undergo re-education on the short course and registered nurses who undertake the full FHN course.
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 Family Health Nurse.
4 To explore the operation of the Family Health Nurse model, focusing on the nature of the services provided and drawing comparisons between the pilot sites.
5 To identify relevant stakeholders perceptions of the Family Health Nurse model.
6 To draw out implications from the study's findings for the future provision of education for Family Health Nurses and for the extension of service provision to other areas of Scotland, including urban areas.
These provided the basis for the research study. The findings are reported under three main themes:
The Education of Family Health Nurses
Includes a review of education curricula from existing community nursing programmes across Scotland as well as an analysis of the Family Health Nurse programme.
Family Health Nursing Practice
Provides an overview of practice from the perspectives of different stakeholder groups including Family Health Nurses.
The Wider Scottish Context
Addresses the issue of applicability of the model to the wider community through seeking views from other NHS Boards.
Implications for Role Development
Identifies the difficulties associated with the integration and development of the role and recommends areas for facilitation activity.
A full copy of the report can be downloaded from the Scottish Executive Social research website (
http://www.scotland.gov.uk/socialresearch ).
A summary of the evaluation findings covering these main themes in more depth is located in Appendix 2.
WHO Europe Multi-national Study
Scotland remains the lead pilot country in the multi-national study. Due to the different stages of readiness of interested countries it was necessary to have a degree of flexibility regarding start dates. Each member state was offered the chance to participate based on their ability to meet certain requirements. These included ministerial and local authority support, and the existence of a robust infrastructure to support and sustain the two-year pilot. Participation in the multi-national study was subject to approval of the country plan. Progress within other pilot countries has been variable. This is due to a range of circumstances. However enthusiasm and commitment remains high and there is evidence of preparatory work being undertaken to develop the practice and nurse education systems to meet the criteria for inclusion in the multi-national study.
Countries participating in the multi-national study include Armenia, Estonia, Finland, Kyrgystan, Lithuania, Republic of Moldova, Slovenia, Scotland and Tajikistan. Denmark, Germany and Spain remain interested but are still involved in discussions at a country level. The confirmed countries provide a good representation of member states from Western, Central and Eastern Europe. As part of the multi-national study a comparative analysis across the region is being undertaken by Dr Deborah Hennessy. Scotland was selected as the country to pilot the evaluation tools for this analysis.
The multi-national study group chaired by Ainna Fawcett-Henesy (Regional Advisor Nursing and Midwifery, Health Policies, Systems & Services) meets to review progress on Family Health Nurse implementation and to discuss the assistance required to support individual countries. As part of this support programme Scotland has worked closely with other countries. To date the project officer has delivered workshops to community nurse educators from Armenia and Uzbekistan, and guidance has been provided on curriculum development and Family Health Nursing practice.
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