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Evaluating Family Health Nursing Through Education and Practice

CHAPTER ONE: THE CONTEXT OF THE EVALUATION

1.0 INTRODUCTION

This report presents the findings of a study commissioned by the Scottish Executive Health Department and carried out by the Centre for Nurse Practice Research and Development ² (CeNPRaD) between February 2001 and December 2002. 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 the evaluation of a new educational course devised to prepare Family Health Nurses (FHNs) for practice.

1.1 BACKGROUND

The Family Health Nurse (FHN) concept was introduced by the World Health Organisation (WHO) Europe as a possible means of developing and strengthening family and community oriented health services (WHO 1998a). Within the HEALTH 21 health policy framework it was proposed that this new type of nurse would make "a key contribution within a multi-disciplinary team of health care professionals to the attainment of the 21 health targets set in the policy." The full definition of the new role states that " The Family Health Nurse will: help individuals and families to cope with illness and chronic disability, or during times of stress, by spending a large part of their time working in patients' homes and with their families. Such nurses give advice on lifestyle and behavioural risk factors, as well as assisting families with matters concerning health. Through prompt detection they can ensure that the health problems of families are treated at an early stage. With their knowledge of public health and social issues and other social agencies, they can identify the effects of socio-economic factors on a family's health and refer them to the appropriate agency. They can facilitate the early discharge of people from hospital by providing nursing care at home, and they can act as the lynchpin between the family and the family health physician, substituting for the physician when the identified needs are more relevant to nursing expertise". (WHO Europe 1998a).

The framework posits the FHN and the Family Health Physician as the key professionals at the hub of a network of primary care services. The Scottish Executive Health Department (SEHD) saw this as a potential solution to some of the problems of providing health care in Scotland's remote and rural regions and during 2000 began preparatory work for a Pilot project. Three regions subsequently became involved in this work (Figure 1.1 overleaf). Within these regions populations are characteristically sparse, ageing and declining in numbers. Health profiles are poor, with high incidences of cardiovascular disease and cancer, and socio-economic problems such as unemployment and poverty are relatively widespread. Geographic isolation is associated with transport difficulties, and the regions suffer from migration of the young to urban towns and cities. Recruitment and retention of skilled nursing staff has become increasingly difficult.

The SEHD summarised the principles of the FHN role as:

• A skilled generalist role encompassing a broad range of duties, dealing as the first point of contact with any issues that present themselves and referring on to specialists where a greater degree of expertise is required.
• A model based on health rather than illness - the FHN 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.
• A role founded on the principle of caring for families rather than just the individuals within them.
• A concept of the nurse as first point of contact.

A Scottish University was commissioned to provide the 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 ³. Eleven students (Cohort 1) subsequently undertook this course during 2001 and twenty students in 2002 (Cohort 2).

The project in Scotland was initiated by The Scottish Executive Health Department. A Project Officer was appointed to co-ordinate national and regional activities, and to liase with other European countries. A National Steering Group was convened and met regularly during the course of the project. Local Steering Groups were also set up at regional level. During the evolution of the project a Role Implementation Group was also set up to address emergent issues around FHN documentation, activities and professional boundaries. A further remote and rural region joined the project in 2002.

Following a process of competitive tendering CeNPRaD was commissioned by Scottish Executive Health Department to undertake an independent research evaluation based on the following six objectives:

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 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 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.

This report addresses these objectives within five chapters. The current Chapter 1 develops context for the reader by critically reviewing several key concepts and by outlining the principles of the evaluation's design. Chapter 2 examines the educational preparation of the FHNs and considers implications for course development (objectives 1,2 and 6). Chapter 3 examines FHN practice at 10 sites, presents the typology that emerged, and draws together common themes from practice (objectives 3,4 and 5). Chapter 4 examines the wider Scottish context in terms of policy (objective 6), community nurse education (objective 1) and primary care practice (objective 6). This sets the scene for Chapter 5 which draws together the study's findings in order to consider the implications for further development of the FHN role through education and practice (objectives 1 and 6).

Literature searches and reviews of national policy, research documents and published information sources relevant to community-based education programmes and service development have been ongoing throughout this research. The following subject areas have been pursued through the literature:

• The Family Health Nurse as a concept and as a practised role
• Family nursing
• Community nursing (including district nursing; public health nursing and health visiting)
• Rural/remote nursing and primary health care
• Educational preparation for the above subject areas
• Research in the above subject areas

This has involved searching ASSIA, ASLIB, British Nursing Index, CINAHL, COCHRANE, IBSS, MEDLINE, Nursing Collection, Social Science Citation Index and ZETOC electronic databases for post 1990 journal publications and searching Scottish University Library databases for relevant publications in book format.

These searches have generated a great deal of literature that has informed our thinking during the project. Rather than presenting exhaustive and exhausting reviews of the above subject areas, we have chosen to use relevant literature primarily to inform interpretation of our findings. Thus the report is heavily weighted towards presentation of our own research findings. However to give a frame of reference for the reader, three key concepts are now briefly critically reviewed in relation to the Scottish context.

1.2 REVIEW OF KEY CONCEPTS

1.2.1 Community-based nursing

Within the UK community nursing denotes a very broad range of activities which can take place in a variety of settings (e.g. small community hospitals/doctor's surgeries; peoples' homes; the streets of large cities). Nurses working in these settings in the UK must be registered with the National Nursing and Midwifery Council (NMC; formerly known as the UKCC) who regulate standards of practice. In addition many nurses will also hold a community specialist practitioner qualification. These include:

• District Nursing (Nursing in the Home)
• Health Visiting (Public Health Nursing)
• General Practice Nursing
• Occupational Health Nursing

Brief explanations of these categories are given in the Glossary to this report. Other specialist nurses working in communities may have expertise in the care of people with specific disease (e.g. Macmillan Nurses for cancer care; Diabetic Specialist Nurses). Midwives are also active in UK communities, caring for women through pregnancy and childbirth.

This diverse array of professionals has evolved in an attempt to meet the health care demands of varied populations. However the community nursing workforce in the UK is frequently criticised as being over-specialised and fragmented (Hyde 1995) to an extent that may be dysfunctional not only for the professions, but also for the public whom they serve.

These types of concerns appear to have informed recent policy documents within Scotland. Nursing for Health (SEHD 2001) states that " The Scottish Executive will review with all interested parties the outcomes of the new public health and family health nurse programmes with a view to having only two routes to community specialist practice - the Family Health Nurse and the Public Health Nurse" (p.61).

1.2.2 Family Health Nursing

Unsurprisingly material pertaining specifically to the FHN concept as outlined by WHO Europe is limited, so most of our review on this concept pertains to the WHO publications and associated output. The definition of family health nursing as set out by WHO Europe is broad in its aspirations to meet the needs of individuals, families and communities. Thus it is almost impossible to articulate a unitary operational definition. In the WHO Europe video of family health nursing a range of very different nursing practices and practitioners are presented in order to exemplify practice. Such diversity helps to promote the ideology but causes problems for the analyst in trying to make sense of inconsistency and contradiction.

In effect the WHO Europe idea of family health nursing signifies an aspiration for a pan-European nursing role. Within the main WHO Europe document (2000) family health nursing is portrayed as the central stanchion in the " umbrella of public health and primary health care". In a context where there is inadequate or no multi-disciplinary community health care provision then the WHO Europe Family Health Nurse-led service has the potential to be enacted with the nurse being the key co-ordinator of all services and referrals. However an umbrella is seldom the covering of choice in remote and rural Scotland, and as a conceptual framework, and as a metaphor, this portrayal is rather naïve for a context where community health care provision is long established through resource deployment, professional power dynamics and political climate.

Three concepts that have positive connotations but are notoriously difficult to define (viz. family; health; and nursing), have been combined within one role descriptor . What emerges from reviewing this predominantly descriptive literature is the need for caution in assuming these commonly used terms have a unified meaning. Diffuse practice examples pertinent to specific cultural groups are used by WHO Europe and others to exemplify the concept and articulate the ideology of family health nursing (e.g. Chronic disease prevention and management for Type 2 diabetic patients; care of a family where the mother has breast cancer; care of a single person suffering from metastatic breast cancer; care of a family with mental health and alcohol related problems; or care of an elderly couple with poor health). Such examples suggest that a family health nursing approach to the delivery of care by nurses has universal utility. This in turn raises questions for the Scottish context where the educational award is a community specialist practitioner qualification.

There has been a tradition in North America for Family Nursing. Key authors such as Wright and Leahey (1994); and Friedman (1998) have been influential in contributing to the education of nurses, shaping practice and informing curricula development. In particular their frameworks for assessment and intervention with families have been widely deployed or used to inform practice in different countries. The frameworks draw upon ideas from a number of theoretical traditions and practice disciplines, but the dominant paradigms are systems theory and family therapy. Their frameworks are primarily designed for in-depth work where the family is the client and key unit of analysis. The influence of the Wright and Leahey (1994) and the Friedman (1998) texts is absent in the WHO Europe vision. These books, (along with Whyte 1997), have been used as core texts by the Scottish Educational provider of the family health nursing course. Two main paradoxes ensue from this observation. Firstly, is the Scottish approach a functional hybrid of family nursing and family health nursing as advocated by the key authorities or has it's germination been affected further by the Scottish environment?

Secondly, as Gillis (1999) comments the level and nature of nursing engagement proposed by Wright, Leahey and Friedman indicate a level of specialism in nursing practice. The envisaged role of the FHN from the WHO Europe, from the Scottish Executive Department of Health and the educational provider suggest that the role is one of a highly skilled generalist nurse. Is the Scottish approach therefore also an educational hybrid in terms of curriculum construction?

Generally speaking hybrids are difficult to nurture, sustain and develop where fertile species are well established. However within remote and rural Scotland concern has been increasing about the fertility and sustainability of existing species of community based nursing. In using this metaphor it is intended to articulate the potential vigour of such a hybridisation process to the construction of community-based education and the practice of nurses, midwives and health visitors especially in the remote and rural areas of Scotland. Thus we will return to these questions later in the report.

1.2.3 The remote and rural context

Literature on remote or rural health care in Canada, USA and Australia was also reviewed. In these contexts the role of the nurse practitioner or advanced practitioner has been developed as solutions to problems of remoteness. Educational courses up to Masters level have been developed to prepare these practitioners (Ross 1999). A shortage of family physicians or general practitioners coupled with the difficulty of recruiting health care professionals into these remote or rural areas have often been cited as precursors to the development of the nursing role.

The world organisation of family doctors (WONCA) has recognised since its inception in 1992 that there is a need for special preparation of health professionals to meet the health care needs of rural people and have recently stated that " The Rural Health Team is a multidisciplinary team of health workers functioning often in a way beyond the normal boundaries of their own discipline … Providing health care in rural areas requires a well trained and experienced health care team that works closely with a community and is responsive to their needs and preferences" (WONCA 2001 Policy on rural practice and rural health; cited in RARARI 2002a p62) .

The significance of the rural context for other services has also been recognised (for example relevant work has been carried out within social work (e.g. Horobin 1986; Lishman 1984) and by social geographers who have conducted studies in the remote and rural areas of Scotland (e.g. Clark 1997). Furthermore some small-scale medical studies of GP practices in such areas (e.g. Hamilton et al 1997; Cox 1997; Deaville 2001) also illuminate the special demands of context. This body of literature suggests that rural and remote areas have special conditions in terms of living environments, transportation, community cohesion and participation. Each of which it is contended affects the role of the health professional in particular.

Health professionals working in remote and rural contexts have expressed concerns about the community and the availability of telehealth and personally responsive health services (WONCA 2001 Policy on rural practice and rural health; cited in RARARI 2002a) . In the literature reviewed there has been a limited concern for the focus of health care to move away from the individual client to that of the family as client . Indeed the WHO framework for the development of general practice/family medicine in Europe (WHO 1998b) essentially views families as context, and the generalist paradigm prevails in literature from WONCA Region Europe (The European Society of General Practice/Family Medicine) and EURIPA (European Rural and Isolated Practitioners). The notion of family health nursing as promulgated in the Scottish context urges the nurse to relate to the family as the client. This again presents us with a paradox in that the notion of the client as the family contradicts with commonly held beliefs and practices of individualised health care. We will return to this observation in our examination of the actual practice of the family health nurses.

Undoubtedly remote and rural contexts have been recognised as different from urban contexts of health care. Concentrating the Family Health Nurse initiative within remote and rural areas provides us with the opportunity to evaluate its relevance and application for these contexts but does make sureness of transferability to major urban contexts difficult.

1.3 EVALUATION DESIGN

1.3.1 Overview of design

In conducting this evaluation, and in addressing the six given objectives, it has been essential to sustain research interpretations at four levels of analysis:

1. Application to the education and practice of community-based nurses, Health Visitors and midwives across Scotland.

2. Relevance to remote and rural health care provision in Scotland

3. Application and relevance to the particular local contexts where the Family Health Nurses have been working

4. Application and relevance to direct face to face experience of education and in practice.

This approach to knowledge building has its scientific foundations in frameworks of social science explanation building (Newman & Layton 1984 Fiske and Taylor 1991 Becker 1950 & 1976, Bandura 1986) and relies on the construction of meaning, through interaction, filtration, interpretation and inference. Figure 1.2 (overleaf) presents a model of the interpretative research processes which were followed in order to articulate our explanations.

Such a multiplex evaluation has required the integration and synthesis of the most useful parts of two key approaches to evaluation research (Pawson and Tilley 1997; Guba and Lincoln 1989). Thus in our design ⁴ we have utilised a longitudinal comparative approach to evaluate changes coupled with in-depth studies of the cultural constructions and the personal experiences of those involved in the education and practice of family health nursing.

Evaluation of the educational preparation of the Family Health Nurses entailed a systematic collection of evidence pertaining to comparative educational processes, participant experiences and performance. Details of the data collection and analysis procedures involved are presented in Chapter 2.

In evaluating practice our overall aim was to identify emergent patterns of context, process and outcome that might characterise each of the local sites involved in the pilot. This approach adapts Pawson and Tilley (1997)'s realistic evaluation framework in order to clarify what FHN practice is in these settings, and then clarify how, and to what extent, the FHN role works under various circumstances. As such, the ten FHN sites active during 2002 were seen as the main units of analysis in this study. Explanatory case study methodology (Yin 1994) also informed this approach. Details of the methods and procedures for data collection and analysis are presented in Chapter 3, Annex 1 and Annex 2.

Examination of the wider Scottish primary care context was undertaken through a combination of policy literature review and telephone interviews with key informants. Details of the data collection and analysis procedures involved are presented in Chapter 4.

1.3.2 The role of the evaluators

The research was designed to respond with some flexibility to an evolving project. This is a very necessary requirement for the evaluation of a policy initiative, as is an awareness of the inherently political nature of the undertaking. During the process of the evaluation there was a need to feed-in some intelligence (e.g. ethical clearance and access, reports to the advisory group, concerns over service issues, and assurances about the evaluation processes). We have also been aware of: the differential power of various voices, and the actual and imputed influence of these on the education and practice of Family Health Nurses (e.g. the Steering Group members; the FHNs themselves, the patients, key allies and professional rivals in primary health care teams). As evaluators there was always tension between getting close enough to engage with the experiences of the participants and maintaining independent, critical perspective .

Contemporary debate within the world of evaluation research is concerned about explicating the role of the evaluator. Leading theorists (Scriven 2003, Eisner 2001) have suggested that evaluators make judgements by bringing to bear a connoisseur's perspective which guides the reader and the sponsor to an appropriate judgement. Other evaluation researchers (House and Howe 1999) have argued that the evaluator should add intelligence into the evaluation context in order that those involved can make better judgements. Finally there are those (Lang 2001) who argue that evaluators have no warrant to make a judgement rather they should act as brokers to provoke and support the judgement of others.

We incline more to the first two positions and will endeavour in the ensuing three chapters to make explicit our evidence for judgements about key aspects of the education programme, family health nursing practice, and the wider Scottish context. However we are also mindful of the creative writing adage "show, don't tell" and have aspired to include sufficient qualitative data within the main text and annexes to allow the reader to draw his/her own conclusions.

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