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Family Health - Nursing in Scotland: A report on the WHO Europe pilot
What have we learnt?
The project steering group took the view at the outset that as a pilot project any outcome would be regarded as a success, so long as we were able to learn from it and apply the learning to the further development of community nursing practice. So what have we learnt from the pilot?
At its last two meetings, the project steering group considered a number of different scenarios as potential outcomes of the project and discussed what would need to happen were any of these to be the final outcome.
Scenario 1 - The Family Health Nurse is not an appropriate model to meet the health needs of remote and rural communities. The pilot should end and alternative roles should be found for the existing Family Health Nurses.
Scenario 2 - There is sufficient evidence to suggest that the Family Health Nurse role is valuable and it should be further developed within the four pilot NHS Boards.
Scenario 3 - The Family Health Nurse role provides a worthwhile model for practice in remote and rural areas and it should be further developed in other remote and rural NHS Boards.
Scenario 4 - The Family Health Nurse provides a future model for community nursing practice and should be developed further in other settings, i.e. urban or with specific client groups.
It quickly became apparent from discussion that all participants believed that option one was not feasible. Having developed the approach to Family Health Nursing within the pilot sites none of the sites believed that it would be either possible or desirable to halt the development and expansion of the role at this point. Discussion therefore centred on the three remaining scenarios and was further developed at a two-day workshop informed by the first draft of the evaluation report and involving representatives from all four UK health departments.
The outcomes of those discussions summarise the learning from the pilot programme and form the basis for future development of the Family Health Nursing role in Scotland.
The pilot as a whole
The remarkable thing about the pilot has been the way in which the collective expertise of policy-makers, educationalists, practitioners and researchers has been brought to bear in a collaborative and developmental way. Practitioners have informed and supported the development of the education programme, which in turn has helped to shape a new model of practice. The researchers, whilst maintaining their independence, have been able to feed back emerging themes to the project steering group to help inform the direction of the project. This collaborative approach provides some important lessons about what can be achieved through working in partnership.
The education of Family Health Nurses and community nurses as a whole
The Family Health Nurse education programme sought to educate nurses for a role which, at that time, was still hypothetical. Clearly this was very challenging and the achievement is a tribute to both the education team and the students who pioneered the approach.
The greater emphasis within the programme on the practice of Family Health Nursing, including dimensions such as communication and assessment skills set it aside from existing community nursing programmes and provides a precedent to re-think existing approaches to community nursing education.
Our understanding has developed around the different ways in which education can be delivered to practitioners working in remote and rural areas where access to mainstream education programmes can be problematic. The experiences of the Family Health Nurses demonstrate the need to balance distance learning approaches with collective learning. In this sense there is a value in mixed methods where locally based learning is combined with bringing people together to create a group learning environment. In this way students can share experiences from different clinical backgrounds and organisations
Whilst acknowledging the range of work undertaken by the education team, the evaluation findings also make recommendations for Family Health Nurse curriculum development, which need to be taken forward in any future educational programme (see Appendix 2).
The Practice of Family Health Nurses
Inevitably, the evaluation concluded at a relatively early point in the development of Family Health Nursing practice. Family Health Nurses were allowed considerable leeway in developing their practice, although the ability to continue to network with their peers and the support of local implementation groups were an invaluable support. The four typologies of family health nursing practice referred to in the evaluation report highlight the influence of context and the nature of the impediments which have weakened or slowed the development of the role.
A clear message from the evaluation is the need to facilitate and support change within teams if the full potential of the Family Health Nursing approach is to be realised. In particular the experience of the pilot suggests that change needs to be directed at different levels within an organisation in order to sustain this new role. The evaluation report urges the need to invest time in supporting and sustaining changes in practice and offers two necessary factors for progress:
Anecdotal evidence from the pilot sites suggests that the cohort two nurses, whose practice was not included in the evaluation, are having an effect in shifting the critical mass of practice within the pilot sites, as is the growing experience and confidence of all the Family Health Nurses.
The way forward
With the evidence available to date, it is not possible to draw a definite conclusion about the future contribution of the Family Health Nurse as a generalist community nurse working with families. However, there is sufficient evidence of the value and potential of the role to continue to support its development and evaluate its impact. The overriding message from the pilot areas is that it would be undesirable if not impossible to dismantle this new approach to practice. Even though progress has been variable, the commitment to the model remains. The evaluation has provided recommendations that reflect discussions from the steering group members.
These are:
Planned development should be facilitated with those primary health care teams that include a Family Health Nurse in order that the role can be better understood and developed to respond to the needs of local communities.
The educational programme should be further developed as suggested in Chapter 2 of the evaluation report (summarised in Appendix 2 of this report).
The evaluation process and resultant evidence should be disseminated widely across the UK to foster debate and critical thinking about the nature of community nursing services and suitable educational preparation.
The Family Health Nurse model should be further explored in an urban context.
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