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Evaluating Family Health Nursing Through Education and Practice

CHAPTER TWO : EDUCATING FAMILY HEALTH NURSES

2.0 INTRODUCTION

The establishment of degree level education for those nurses who work or seek to work in community and public health settings has resulted in an array of specialist qualifications designed to meet the health care demands of varied populations. In 1994 the former UKCC (now NMC) stated that:

"Specialist practitioners should be able to demonstrate higher levels of clinical decision making and will be able to monitor and improve standards of care through supervision of practice, clinical audit; the provision of skilled professional leadership and the development of practice through research, teaching and the support of professional colleagues" p3

Consequently community-based educational programmes have been constructed around these professional values. This part of the report aims to evaluate the curriculum of the family health nursing educational programme in order to consider how well it fits into the Scottish context of community based education and service requirements.

In addressing this aim a considerable volume of research, policy, educational and service information has been synthesised and simplified for reporting purposes. The knowledge utilisation processes adopted have been explained in Chapter 1.3.1 and Figure 1.2 .

2.1 RESEARCH PROCEDURES

Prior to commencing the research procedures the research protocol was subjected to peer review and ethical review by the appropriate committees ⁵

For the duration of the project 2001 - 2002 information has been gathered through processes of negotiation, conference and consultation. Such information has resulted in a record of complicated field notes and the construction of a research journal. These sources have enabled the educational, managerial and practical aspects of the family health nursing project to be articulated and reviewed. This information has contributed to the building of an explanation of what has been happening and why.

The following table outlines the modes of analysis used with each source of information.

Table 2.1 Sources of information and modes of analysis

Details of student response rates to the questionnaires are given below in Table 2.2

Table 2.2 Response rates to questionnaires sent to student FHNs (and qualified Cohort 1 FHNs in July 2002)

*At these time points the students were asked to complete these questionnaires retrospectively (i.e. thinking of the their functioning in the four months prior to starting the educational course). This was because ethical approval for the research was not obtained until May 01 and therefore we could not start to issue questionnaires before this.

Details of response rates to questionnaires sent to supervisors of FHNs are given below in Table 2.3

Table 2.3 Response rates to questionnaires sent to supervisors of FHNs

Data from the above questionnaires were entered on to SPSS V10 databases and data entry checking was undertaken. Frequencies were generated in order to summarise and describe quantitative data. Where inferential testing was appropriate, nonparametric statistics were used (following the principles in Pett, M (1997)). The main tests used were the Mann-Whitney U test to compare separate groups of subjects, the Wilcoxon test to compare consecutive data generated from one group of subjects, and Cohen's kappa statistic which measures agreement taking into account what would be expected through chance. Textual comments were collated and analysed in terms of content frequency and thematic coverage.

The remainder of this part of the report has been structured to enable the analysis to move from the general to the particular and back again: from consideration of all specialist practice educational curricula to a detailed evaluation of the family health nursing programme. Observations and findings are presented and discussed in such a way as to identify the major issues for consideration.

2.2 SPECIALIST PRACTICE EDUCATION: AN OVERVIEW OF STRUCTURE AND CONTENT

Service redesign and organisational change in the delivery of primary care services have resulted in a range of new roles for members of the nursing, midwifery and health visiting professions. Furthermore the establishment of a clinical governance management system across the NHS has required employing organisations to assess risk alongside professional liability in order to ensure that there are: clear lines of accountability and responsibility in clinical care; quality improvement systems in place; and clear policies for the management of risk and professional performance. Overall the combination of service redesign and clinical governance should provide a decision-making framework to determine the optimum mix of generalist, specialist and advanced practitioners needed in the nursing workforce in primary care. In operation the rationality behind developments is often obscured and difficult to articulate. This is the case for family health nursing both in terms of the education and the practice. The challenge for us, as evaluators, was to try and understand this educational and practice initiative which aimed at producing "generalist specialist" nurses who would work in primary care in selected remote and rural areas of Scotland. Clarifying the perceived benefits of any new role and innovative approach to community-based education poses general problems for evaluators. In this particular case, however, the combination of a broad range of educational preparation coupled with a very particular concern for personal practices in remote localities required immersion in fieldwork and a constant comparative approach to our analyses.

2.2.1 Overview of specialist practice curricula

Currently within Scotland there are nine Universities providing education for nurses and midwives who are working or seeking to work in primary care. The courses offered range from short courses with a specialist focus to Master's Level degree programmes. The curricula which have been reviewed pertain to those degree programmes which combine an academic award with a specialist practice qualification.

Thus curricula were obtained from the five Universities in Scotland offering community-based degree programmes with specialist qualifications across the following areas of practice.

• General practice nursing
• Community mental health nursing
• Community learning disabilities nursing
• Community children's nursing
• Public health
• Health visiting
• Occupational health nursing
• District nursing
• Family health nursing

The following Tables 2.4-2.6 provide an overview of the established programmes of study by degree award type rather than by Institution. Thus the Tables provide an overview of academic award; level ⁶ and credit transfer allowed using either the Assessment of Prior (Certificated) Learning (APL) or the Assessment of Prior Experiential Learning (APEL) ⁷; the nature of core and specialist modules ⁸; the mode of delivery and the general means of assessment.

Such an approach has enabled a summary situational analysis of educational curricula to be conducted in order to appreciate and distinguish the family health nursing curricula from the others. A range of judgements internal to the actual curricula has been made based on the following criteria: philosophy of health care and education advocated; concordance with regulatory frameworks; strengths, weaknesses and values inherent in the overall curricula; resources: human physical and financial.

External judgements have also been sought with regard to the nature of educational provision. This external process has involved seeking the views of key informants across Scotland with regard to the strengths and weaknesses of extant community-based services, educational provision for community-based nurses, midwives and health visitors and what health service deficiencies might be provided for by family health nursing. The findings from these interviews are presented in Chapter 4.

Table 2.4 Overview of community-based educational programmes leading to the academic of award of Bachelor of Science (BSc) and specialist qualification

Table 2.5 Overview of community based educational programmes leading to the award of Bachelor of Arts (BA) and specialist qualification

Table 2.6 Overview of community based educational programmes leading to the award of Bachelor of Nursing (BN) and specialist qualification

Reading through the curricula there are similarities in content and structure in accordance with the principles and specifications of the regulatory body (UKCC 1994 and 1995). The curricula are constructed around the four specialist domains ⁹ specified and generally speaking the learning outcomes of the programmes are mapped against these domains. In addition the curricula have identified core education for all nurses, midwives and Health Visitors working in community health services which aims to: monitor and improve standards of care; inform and facilitate the supervision of practice; contribute to research; inform the teaching and support of colleagues. Finally the curricula have been designed within the framework of post-registration education and practice (PREP) which is embedded in the following values: reduction of risk, enhancement of care, provision of support to patients and colleagues and the development of education and practice.

Three academic awards are available: Bachelor of Science (BSc), Bachelor of Arts (BA) and Bachelor of Nursing (BN). In making these academic awards there are strong arguments in the curricula documents supporting the educational theory of andragogy and a taxonomic approach to learning outcomes. The management of services and the importance of research are given prominence and generally all the curricula have been constructed in partnership with health service providers. Nursing and social science theories are deployed in the curricula but there is no curriculum based on a particular theory of nursing or health. Such an approach fits with the notion of "graduateness" in that the education is enabling the practitioner to utilise appropriate knowledge in a given context. Core modules are shared in an attempt to make explicit what is common to all community-based nurses, midwives and health visitors.

The word family appears in all the curricula with varying emphasis and sustained attribution. From the educational curricula there is limited insight into the way in which the concept is handled in the various specialist practice programmes. The sociological complexities; cultural biases; legal and fiscal confines or the psychological dynamics of kinship to the meaning or understanding of 'family' are either assumed or ignored. It is impossible to tell from what is written in the curricula documents. There is limited evidence in the curricular documents regarding what is actually taught about the family in any course. Generally the concept of family is treated in a stereotypical way and is elided linguistically as in the following examples from learning outcomes or course objectives: "Assess the health and health related needs of patients, clients, families and other carers" (district nursing, community mental health nursing, learning disabilities nursing, general practice nursing) "Discuss health profiling methods applied to individuals, families, groups or communities"(health visiting course).

All but one BA programme offer student exemption for up to 50% of the programme and all have elaborate processes for recognising prior learning. An array of assessment processes is used generally relying on the submission of written work and the completion of practice based portfolios of evidence. For the majority of the programmes the specific practice-based learning objectives and the content of the assessment portfolio are negotiated between the student, clinical supervisor ¹⁰ and academic supervisor.

Only one of the programmes offers the academic award at SCOTCAT Level 4. The rest are all at Level 3 (although some Universities also have the provision for specialist awards at Master's Level). As the pre-registration qualifications move to degree level (SCOTCAT Level 3 or 4) so the academic level of post-registration education for specialist practice will have to alter.

Students are generally recruited from the existing nursing workforces and undertake the educational programmes as part-time students. Some receive support from their employer (either in the form of payment of fees or in the form of paid study leave), many are self-funding and utilise time off from work and annual leave entitlement for study purposes.

The new public health nursing programmes in Scotland have been developed concurrently with, but separately from, the FHN project. They have involved a revision of the pre-existing health visiting courses to combine health visiting and school nursing. The Scottish Executive directly funded 128 places, including 48 for existing school nurses. By December 2002 172 public health nurses had successfully completed the programme and were back in practice (Nursing for Health Two Years On ; SEHD 2003). As such this initiative is on a larger scale than the FHN project yet there is no similar research evaluation of the impact on practice.

Thus what emerges is a flexible approach to education provision in which students can negotiate: learning outcomes; the time taken to complete the programme; and the amount of credit exemption in accordance with regulatory requirements. Furthermore the array of programmes on offer within one University ensures a pool of experienced academics who can contribute to various programmes and utilises resources in an efficient way.

The focus of this evaluation was not to assess the effectiveness and efficiency of all community-based education programmes but rather to use knowledge of these to facilitate the evaluation of the family health nursing programme. We now turn our attention to detailed consideration of this.

2.3 FAMILY HEALTH NURSING CURRICULA MARK 1 AND MARK 2

The original family health nursing curriculum was developed during the latter part of 2000 and in the first year of the course significant modifications took place. The overall structure of the programme and its constituent modules did not change, but many other aspects were substantially reviewed and developed in response to: the process of professional validation by the National Board for Nursing, Midwifery and Health Visiting; influences from the Scottish Executive Health Department and the NHS Boards and Trusts involved in the initiative, and through an ongoing process of review by the educational team and the students. Between the commencement of the first and second cohorts of students (Jan 2001 and Jan 2002) the following major curricular modifications took place:

• The unit outcomes and associated clinical outcomes were clarified and revised
• A scheme for the Accreditation of Prior Learning was constructed.
• A programme for the preparation of supervisors was enhanced and a new short course offered.
• The assessment methods, particularly the Objective Structured Clinical Examination (OSCE) were developed
• Course documentation, particularly the Course Information Booklet and the Clinical Profile documents were substantially revised and developed.
• The course content, particularly the workshops offered in the module "Advanced Family Health Nurse practice", was developed.
• A Project Director was appointed during the year to lead curriculum development

While some modifications would be expected with all new programmes, these constituted substantial changes over a short time period. In approving the programme on 12 ^th July 2001, the NBS acknowledged that its unique nature meant that development and modification would be ongoing throughout the pilot period. With so much development taking place it became difficult to know what we were evaluating at times and whether it would be possible to compare two cohorts of students.

For most purposes the evaluation has used the revised curriculum detailed in the Course Information booklet of October 2001. This is not to ignore the existence of the original curriculum, as we have considered both students and supervisors experiences of it. Rather it is to recognise that a number of perceived deficiencies in the original curriculum were acknowledged and addressed by the educationalists. The object of this evaluation is to be constructive in its frame of reference and analysis in order to fully appreciate what has happened and to give suggestions for future development.

Table 2.7 Extant Curricula for Family Health Nursing

The first curriculum summarised in Table 2.7 is that originally suggested by the WHO Europe (2000). This curriculum aims to develop each FHN to become competent in the following five core functions: care provider; decision maker; communicator; community leader; manager. Similarities with other community-based programmes are evident through the title of some modules and although no shared core modules are cited, decision making, information management and research, managing resources and leadership and multidisciplinary working could be core modules to be shared in the broad church of community nursing. The inclusion of this overview enables comparisons to be made with existing community-based programmes and the Family Health Nurse programme used in this initiative.

The validated Scottish curriculum leading to a Bachelor of Nursing (Family Health Nursing) award and specialist practice qualification (Table 2.7) differs from earlier curricula reviewed in that it has no common modules shared with other community nurses. Some content has been identified as core but this is drawn from three modules: Working with families, Communication and Research, decision-making and evaluation in clinical practice.

As can be seen from Table 2.7 there are no modules dedicated to quality issues, teaching and supervision of others or the management of services, although aspects of these topics are referred to in the modules. This curriculum is different from other specialist programmes in that it has been partially built around an ideology of nursing which combines elements of Family Nursing from North America with the promotional ideas from the World Health Organisation. In addition the curriculum has incorporated specific content to suit the nature of remote and rural nursing in Scotland. In short it is a customised degree programme.

Within the course curriculum document the rationale for the content and the integration of theory, practice and assessment is addressed in a complex conceptual framework which captures the theoretical foundations, operational practices, holistic family-based care and models of assessment, intervention and health strategy. This diagram highlights the range of knowledge and skills required for a role that is expected not only to work in-depth with families but also to do so with individuals and to work with communities. It is theoretically grounded both in its educational approach and in nursing values. The articulation of these issues indicates that this curriculum is attempting to be different from the WHO Europe curriculum and from other specialist programmes. The construction of the specialist award has been simplified and all effort has been concentrated on the speciality of family health nursing at the level of practice, education and assessment.

The isolation of family health nursing from other community-based specialist education programmes has neither facilitated the professional understanding of the role nor allowed the debate to take place between practitioners about role boundaries and optimum skill-mix in various contexts of practice. However running the programme in a University with no history of community based post-registration nursing education has advantages as well as disadvantages. On the one hand it can be argued that this isolation may have contributed to the confusions and perceived threats to established nursing, midwifery and health visiting roles and consequently may have impeded the adaptation and development of a family health nursing approach to community-based health care. On the other hand however, the lack of cultural legacy with regard to community nursing educational provision has contributed to curricula innovations as described above and a willingness to think differently about the provision of nursing in remote and rural primary care contexts.

The stated criteria for student selection on to the programme stipulated a minimum requirement that students would have two years post-basic experience. Health service managers in the participating regions were instrumental in the selection and nomination of interested personnel. Our enquiries into local managers' criteria for selection suggest that these varied in nature and weighting. The process was undertaken under considerable time pressure prior to the first course starting. Service development and succession planning issues informed this process but these were hindered to some extent by uncertainties about the nature and scope of the FHN role. Initially interest in participating in this initiative varied across personnel in the different regions, but overall there were less candidates who might realistically be released to undertake the course than had been hoped. Student motivation to do the course and the logistics of facilitating cover for a year seem to have been the two primary factors that determined who joined the cohorts. One region explicitly aimed at good geographic spread when recruiting potential students. Prior to the second year of the course the regions were encouraged to try to recruit some students with health visiting and other community specialist practitioner qualifications besides district nursing.

The educational course was based at a campus in the Highlands of Scotland and the students' clinical practice placements were within their own region. This course, like other specialist programmes, required students to undertake clinical placements as part of the educational process. Students' course fees, travel and accommodation were paid from a specially designated central budget which also paid the students' salaries whilst they were undertaking the course. As the students were existing employees, their employers in the participating regions could use the money saved on salaries as "backfill" monies, to resource temporary replacement staff to undertake the work previously carried out by the student. After completing the course it was anticipated that the new FHNs would return to their home base sites and start to develop the role in practice.

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