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Family Health - Nursing in Scotland: A report on the WHO Europe pilot
APPENDIX 2 FAMILY HEALTH NURSE RESEARCH EVALUATION EXECUTIVE SUMMARY
BACKGROUND
1 In 1998 the World Health Organisation (WHO) Europe proposed a "new type of nurse" that could be based in local communities. The envisaged role of this Family Health Nurse (FHN) was multifaceted and included helping individuals, families and communities to cope with illness and to improve their health. The FHN and the Family Health Physician were presented as the key professionals at the hub of a network of primary care services.
2 The Scottish Executive Health Department saw this as a potential solution to some of the problems of providing health care in Scotland's remote and rural regions. In these regions there is increasing difficulty in recruiting, developing and retaining all health professionals, and within nursing and midwifery sustaining the traditional double and triple duty roles has become particularly problematic. Early in 2001 a two-year "pilot" project began. Three regions in northern Scotland were involved initially, with a fourth joining the project in 2002.
3 A Scottish university was commissioned to provide an educational programme to prepare nurses from these regions. Initially it was envisaged that two educational programmes would be available: a shortened course for nurses with an existing community specialist practitioner qualification (e.g. District Nurses, Health Visitors) and a 40-week course for registered nurses with a minimum of two years post-registration qualifying experience. When education started in February 2001, however, only the arrangements for the 40-week course were in place. Eleven students (Cohort 1) subsequently undertook this course during 2001 and 20 students in 2002 (Cohort 2).
4 The educational course was based at a campus in Highland region but students' clinical practice placements and some theory-based learning took place within their own respective regions. The Scottish Executive paid the students' salaries, course fees, travel and accommodation, and the Health Trusts/Boards in the participating regions resourced temporary replacement staff. After completing the course the new FHNs returned to their home base sites and started to develop the role in practice.
5 In February 2001 the Centre for Nurse Practice Research and Development (CeNPRaD) at Robert Gordon University, Aberdeen was commissioned by the Scottish Executive Social Research Group to undertake an independent research evaluation. The overall aim of the study was to evaluate the operation and impact of family health nursing in specific remote and rural areas within Scotland. This included evaluation of the new educational course.
6 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.
7 The pilot project's goal was thus to simultaneously develop and integrate a new education programme and practice role within a short space of time while under the scrutiny of an independent research evaluation. This ambition was bold, innovative and inherently challenging.
THE EDUCATION OF FAMILY HEALTH NURSES
8 The educational 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 UKCC (now NMC) framework for nursing specialist practice qualifications. Validation by the NBS (now NES) was completed in July 2001. Students attended full-time and undertook a fixed sequence of modules.
9 Evaluation of this course involved systematic collection of evidence pertaining to comparative educational processes (e.g. review of other relevant curricula), participant experiences (e.g. interview and questionnaire data from students, supervisors and teachers), and performance (e.g. observation of teaching and assessment; review of course work).
10 Between the commencement of the first and second cohorts of students (Feb. 2001 and Feb. 2002) a number of major curricular modifications took place. These included clarification and revision of learning outcomes; construction of a scheme for Accreditation of Prior Learning; development of a programme to prepare supervisors; and development of assessment methods and course documentation. Evaluation has focused on this more developed curriculum.
11 Evaluation was also informed through review of educational curricula documentation pertaining to community-based courses for nurses, midwives and health visitors across all Scottish University Higher Education providers. These courses differed from the family health nursing course in that they gave students more flexibility to negotiate learning outcomes and the time taken to complete the programme. They also typically shared core modular content with other community education courses.
12 The family health nursing course differs from these courses (and WHO Europe's suggested curriculum) in that it has no modules dedicated to quality issues, teaching and supervision, management or leadership. Rather it is much more focused on its speciality and is theoretically grounded in an ideology of nursing which combines elements of Family Nursing from North America with the promotional ideas from WHO Europe.
13 However, the course also incorporates a range of generic content and the combination has not always been congruent. This is seen particularly in the module on Advanced Family Health Nursing Practice where there is lack of definition, challenge and match of content to assessment procedures.
14 Eleven of the Cohort 2 students obtained some exemption under the scheme for Accreditation of Prior Learning. This meant that they did not have to attend campus during their "AP(E)L" 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 understanding of APL and APEL processes.
15 As such there is scope for course redesign and the report suggests a restructuring of modular delivery as a starting point. This involves having two modules in the first semester that could be shared with other community based programmes and facilitate credit exemption.
16 The nurses who undertook this course were typically middle-aged females with considerable experience of nursing in general, and of community nursing in their particular remote and rural location. Twenty (65%) were midwives. Twenty (65%) had no specific community specialist nurse qualification and were employed in E or F grade posts. Cohort 1 students in particular felt undervalued and underdeveloped prior to coming on the course.
17 Practice placement supervisors were typically District Nurses or Health Visitors. During the first eight months of the first year of the course, a range of problems with support and supervision was apparent. Students and supervisors concurred on the need to improve selection, preparation and support for supervisors. Many of these difficulties were subsequently addressed and Cohort 2 students were significantly less dissatisfied with their placement experiences. However some problems persisted, with supervisors still not feeling well prepared and lacked dedicated time for the role.
18 Both cohorts of students identified communication skills (e.g. interviewing, listening) and family health assessment/promotion skills (e.g. use of genograms; understanding family dynamics; empowerment) as the most valuable skills they had learned during their clinical placements. The family health skills were seen as central to their emergent new professional identity. The single most valued aspect of campus based learning was the actual process of coming together to learn, share ideas and experiences. In addition family systems theory, communication and IT skills were emphasised, along with research.
19 Teachers also saw the balance between campus attendance and distance learning as being a strength of a course that was very much tailored to a specific market context. There was recognition that to be viable in other contexts the course would require modification. This might involve a greater proportion of distance learning through the innovative web based facility used during the course. On return to practice some of the new FHNs remained active in using the web based facility to maintain learning and support, but five lacked access to reliable internet facilities at work.
20 One of the persistent difficulties for students, supervisors and educators was the simple fact that until 2002 the FHN role was hypothetical. This entailed much uncertainty. Students were concerned about using families for assessment purposes and then moving on while the family's care reverted to established services. The fact that this new way of working was only being used for educational purposes in the first instance raises a number of important issues regarding: the introduction and management of a new role into an established service; the ethics of using students as change agents and the expectations of the public.
21 Considerable effort has gone into the educational preparation of Family Health Nurses. The resultant 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 this report.
22 The evaluation has highlighted strengths and weaknesses within an educational course that provides a precedent for other educational providers to reconsider their approach to specialist practice degree level education.
FAMILY HEALTH NURSING PRACTICE
23 In evaluating family health nursing practice the principle unit of analysis was the site where each FHN was working. During 2002 ten FHN sites were studied in depth. This involved extensive profiling of local context; health needs; Primary Health Care Team (PHCT) staff, roles and working practices; and caseload size and mix. Each site was visited several times to interview staff, collate data, take field notes and undertake limited observation of practice. The care of two families at each site was studied in detail.
24 From these 20 families six were selected for in-depth case study. This involved interviewing family members, the FHN, and a maximum of two other health professionals who had involvement with the family.
25 Questionnaires were sent to all the members of the Primary Health Care Team at each site prior to the introduction of the new role and again one year later. In the same way a more limited questionnaire was sent to a random selection of 20 members of the public at seven of the sites. These questionnaires asked for views on the operation and impact of the new role.
26 Through analysis and synthesis of the above data sets it was possible to construct a typology of family health nursing practice. This identified four distinctive patterns relating to the context of the development, the process of engagement and the outcome of practice. These "CPO" patterns were subsequently given brief labels.
27 Two small island sites shared the following
High scope-slow build pattern:
Context: Small, stable caseload. High pre-existing scope for nursing autonomy and practice development.
Process: Gradual introduction of the role by FHN only with little/no change in other professionals' working practices.
Outcome: Positively viewed by the limited number of families who received the service, but not seen by colleagues and general public as substantially different from pre-existing service. More satisfying for FHNs but also more demanding.
28 Three sites covering large geographic areas shared the following
Slow build-key ally pattern.
Context: FHN role super-imposed on "non-heavy" district nursing caseload within established and functional medium sized PHCT.
Process: Gradual introduction of the role by FHN with active, focused support from one or more professionals within the core PHCT.
Outcome: Positively viewed by the limited number of families who received the service (often specific client groups). "Normal" district nursing services maintained. FHNs generally feel they are making progress.
29 Four sites shared a
Slow/No go pattern, with three having the following pattern:
Context: FHN role super-imposed on "heavy" district nursing caseload within established and functional medium sized PHCT.
Process: Sporadic and limited introduction by FHN only, with little/no change in other professionals' activities.
Outcome: No substantive change in practice. "Normal" district nursing services maintained, but remains stressful for FHN and colleagues.
30 One site had a distinctive Bold build pattern:
Context: "Heavy" district nursing caseload within established medium sized PHCT, but FHN not super-imposed.
Process: New FHN caseload built vigorously through referrals from professionals and public. Autonomous workload management with high community outreach element. Some friction at the boundaries of other professionals' roles. Tensions within core PHCT.
Outcome: Positively viewed by the families who received the service and by a range of groups in the wider community. Some change in referral practices for a number of professionals. "Normal" district nursing services maintained, but persistent core PHCT concerns about perceived lack of integration of the FHN role and the resultant equity of the overall service. More satisfying for the FHN, but much more demanding.
31 Thus evaluation of the first year of family health nursing practice 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.
32 The presence of at least one of the following two factors appeared to be a necessary condition for progress: (i) the perceived scope/space to encourage implementing this approach (ii) the local presence of at least one active supporter who changes their own practice.
33 The in-depth family assessments that the FHNs tried to undertake tended to be time consuming and difficult to orchestrate. However this new approach was 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.
34 At one site the role was developed outwith the district nursing caseload and the FHN practised in a more autonomous way. Again family health nursing supplemented pre-existing services by expansion into gaps, but characteristically this involved more sustained, in-depth care programmes. This presents a different type of role that has more potential resource implications if replication is sought.
35 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
36 In order to inform our judgements about the applicability of a family health approach to community-based nursing in the wider Scottish context, we carried out 19 telephone interviews. These were held with key informants selected from other Scottish NHS Trusts and Health Boards providing primary care services and their respective Local Health Councils. Perceptions of existing community nursing services, education and the potential of the FHN role were explored.
37 These 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
38 We found that the educational process for family health nursing has provided experienced nurses with personal and professional development encouraging a graduateness to emerge whereby the individual can reflect and analyse situations. All students have attempted to embrace the ideology behind family health nursing but so far the majority have struggled to substantively incorporate the ideas into practice.
39 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 primary health care team 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.
40 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.
41 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.
42 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 as suggested in Chapter 2.
The evaluation process and resultant evidence is disseminated widely across the UK to foster debate and critical thinking about the nature of community nursing services and suitable educational preparation.
43 The evidence from this evaluation indicates that considerable effort has gone into this initiative. What has been achieved to date should neither be underestimated nor allowed to wither on the vine.
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