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Evaluating Family Health Nursing Through Education and Practice

2.4 EVALUATING THE FAMILY HEALTH NURSING CURRICULUM

The educational curriculum for family health nursing was responsive to developments and changes and the teaching team generally adopted a dynamic student-centred approach to education. Throughout the programme the students were encouraged to reflect on their experiences and to submit these written accounts to the teaching team. Encouraging reflexivity in professionals has long been recognised as being of educational value. By reflecting on an event and responses to it the individual can learn through introspection. In this educational programme the students' reflections were used for additional purposes namely: to inform the teaching team of areas of satisfaction, growth, concern and confusion; and to inform the evaluators of the students' perceptions of events. The issues selected for detailed attention in the evaluation are those issues of concern to the students, teachers, other respondents and the evaluators themselves. Generally evidence has been synthesised from multiple sources prior to presentation.

In constructing the curriculum a range of generic and specialist content has been combined with complicated assessment processes. This combination has not always been congruent and has made for difficulties. This is best exemplified through a critique of the following: credit exemption processes; selected course content; specific assessment procedures and the sequencing of modules.

2.4.1 Credit exemption processes

No students from the first cohort obtained exemption based on accreditation of prior learning. In the second cohort however eleven students out of twenty obtained partial exemption under the course APL scheme. This meant that they did not need to attend for campus-based teaching but still were expected to undertake the modular assessment. Students were given between 4 and 8 weeks exemption from attending classes during semesters 1 and 2 when the modules on Communication, Working with families and Advanced Family Health Nurse practice were being offered. If granted time exemption these students were expected to return to their usual place of work and undertake duties as per their former role. This was an unsatisfactory practice from the perspective of students, teachers and by any contemporary understanding of APL and APEL processes.

The students' reflective accounts provide insight into the conflict caused by this approach

"I have APEL for 4 weeks which has caused, is causing me a degree of unhealthy stress. Once I get past the next few weeks I know this will settle, but getting there is no picnic". (Cohort 2 student).

"I have been fortunate enough to be given the names and phone numbers of my families but feel guilty if I contact them whilst on APEL" (Cohort 2 student).

"APEL is unsettling now back to work (Week3) have to keep explaining why I'm back in post". (Cohort 2 student).

" On returning to the community it was strange being an FHN student but also having APEL - caught in the middle of nowhere" (Cohort 2 student).

The APEL and APL processes and procedures need to be developed further in order that full and proper academic credit can be given. To do so may require the reshaping of modular content in order that there are credited components of each module which are assessed in such a way to enable students to obtain full exemption.

2.4.2 Selected course content

In the Advanced Family Health Nurse practice module in-depth material on specialist family nursing is covered alongside a number of skills workshops on a range of diverse topics. The aim of this module is to "provide the opportunity for a period of sustained study and practice of those therapeutic skills considered necessary for effective clinical practice with families and communities" (Extract from course unit descriptor). The unit is assessed by means of: a community portrait as specified by the Open University (1996); an Objective Structured Clinical Examination (OSCE) and the production of health promotion resource. Over the two years the module has undergone considerable change to incorporate locality-based learning and to develop the OSCE assessment process. The observations forthwith pertain to the experiences of Cohort 2 thereby keeping a constructivist approach to the overall evaluation.

The following Table 2.8 provides an overview of the suggested content of the skills workshops from the curricular documents; and summarised details of the actual workshops which were held within each of the four participating regions. The indicative content given in the curricular documents is elaborate and integrative of a range of competency domains. From the cited content in Table 2.8 it is difficult to know what would not be eligible to be considered as Advanced Family Health Nurse practice. Furthermore it is difficult to discern what makes this content "advanced" since the majority of the actual content delivered is basic community health care. The negotiation of the content was decided by the students and the clinically-based teaching staff. This raises some questions about the quality of the educational experience in terms of parity and equity of experience; variation in content; standards of teaching and application to the practice of family health nursing.

The complexity and generality of this module is of concern when thinking of the academic level of specialist practice and the use of the word "advanced" in the title. The content and learning outcomes of the skills-based workshops at first seem at odds with the notion of higher level practice. If the skills covered in the workshops are deemed to be specialist and advanced by practitioners and service managers then it is essential that the educational process facilitates deeper levels of understanding with regard to principles, theories and evidence base underpinning the skills.

Table 2.8 Content of skills based workshops for Advanced Family Health Nurse practice

Students were asked to evaluate these workshops as part of the educational process. The questionnaire used by the teaching team asked whether the content was relevant to their own family health nursing practice; met their own learning needs; and provided adequate resource materials. In general these workshops were seen as relevant to practice, informative and interesting and met the student's needs.

" Brill workshop. Very useful and relevant to FHN course" (Student from Region 2 on dental health session). For many of the students the workshops provided a refresher course on a particular topic. "Good to get refreshed and reassured that I am not completely rusty" (Student from Region 1 on diabetes sessions). In addition the students also commented on how useful in general were the resource materials which were provided. "Networking, leaflets, and web addresses very helpful" (Student from Region 3 on Rehabilitation session). Finally the majority of students appreciated the "hands on" nature of many sessions as exemplified by "Very informative session. Enjoyed audio-tapes to help us identify what people with hearing losses hear. Practical tips for caring for hearing aids very helpful." (Student from Region 4 on hearing- cradle to grave session)

It would appear that much of the educational content of this module did not challenge the students sufficiently. The assessment processes however certainly provided challenges for all students. In constructing and delivering this module it is contended that the academic team have burdened the student with assessment content and processes for which the module did not prepare them well. The assessment process was highly specialised yet the majority of content related to typical community nursing activity.

2.4.3 Specific assessment procedures

The following Table 2.9 presents an overview of the observations made about the assessment procedures and processes. To recap these observations were based on: scrutiny of the students' assignments; external examiners comments; teachers' feedback and assessment comments and direct observation by the evaluators of the OSCE procedures.

Table 2.9 Observations on assessment procedures and processes

Across the assignments there is some indication of academic progression and development for all students which is primarily observable through the standard of their written work. Although this is a modular course students are expected to follow a designated sequence of modules and cannot choose their own route through.

There is limited information from the external examiners reports to comment upon with the exception of the suggestion that there is a need to separate out the health promotion resource from the OSCE.

This course has an elaborate assessment process per module which aims to integrate theory and practice. Some of the assessment procedures are requiring students to carry out activities before cognitive assimilation has taken place. This is most evident in the first case study assignment of the first module. Students were asked to conduct a family assessment using a genogram and an ecomap. Genogram assessments are based on eugenic principles and aim to identify hereditary disease patterns. Ecomaps are derived from the principles of social interaction, group dynamics, and intervention therapy. Some of these major social science concepts are addressed in the communication module, however, there is limited content in this module on the science of epidemiology or genetics; the ethics of assessment; or the psychology of control. It is questionable if such family assessments should be conducted by naïve students at the beginning of a course. The process however is most appropriate to the assessment of the Advanced Family Health Nurse practice module and would allow for the integration of knowledge from across the modules.

2.4.3.1 Objective Structured Clinical Examination

Two series of these assessment processes were observed by the evaluation team and the following observations were made. This assessment procedure is complex, is conducted on site with individual students and clients and is time limited due to the human resource implications. The usual procedure involves all students being assessed by two members of the teaching team during the same week. Given the geographic remoteness of some students the travel logistics of this process require to be well co-ordinated. The following quote from one of the clinically based teachers illustrates the potential for farce.

"But the OSCE well ... Whistle stop, whizz around it was horrible ..., we had very restricted time limitations and it was like 90 miles an hour" (Teachers view of Cohort 2 OSCE)

The examination relies on a standardised approach to questioning. The schedule used has a range of thematic questions pertaining to Family assessment (19 questions); Individual goal setting (10) Family goal setting (10) Community goal setting (10) Family Health Nurse intervention plan (13); Health promotion resource (17); Therapeutic letter (9); Family Health Nurse documentation (5). Some of these questions are answered by scrutinising the written work submitted at the time of the exam others are asked directly of the student during the OSCE.

"There were many, many questions that repeated themselves and we took out probably half of what was in the original and reworded. A lot of the wording was ambiguous and the students all stumbled over the same questions which would tell you that the question was badly worded" (Member of teaching staff).

The students found the OSCE stressful and commented on the problem of finding a family member to bring along, and talking about this person without fully involving them in the discussion.

" the OSCE is looming large on the horizon with only one practice week to fully establish and develop our relationship, complete the documentation and prepare us all for the visitation" (Cohort 2 student)

A family member accompanied the student for the first part of the examination when the family assessment was discussed. Very few were incorporated into the discussion. Apart from occasionally verifying (through nodding of the head) the comments made by the student only 2 family members out of 12 observed actively participated in the discussion. The role of the family member in the proceedings has not been worked out.

"I hope I did the right thing for Una (the FHN). Was it all right? Has she passed? I don't want to let her down" (Young woman; island location).

This assessment procedure has potential as it does facilitate the integration of theory and practice but requires to be developed so as to:

• Reduce the number of questions.
• Restructure the schedule to separate out general questions about each of themes
• Restructure the schedule to pull together the specialist questions pertaining to the particular family.
• Ensure that genograms, ecomaps and nursing assessment documents are scrutinised prior to the oral exam.
• Clarify the role and involvement of the family member
• Remove the health promotion resource from this assessment

2.4.3.2 Clinical practice assessment

The documentation used for this assessment process was developed over the two years and is called a clinical practice profile. It is highly structured in specifying learning outcomes; and asking for verification of outcome achievement. Students, supervisors, and academic staff have recorded their comments in the profile in a very generalised way which provides limited information about the students learning experiences; capabilities and areas for further growth and development. The following quotes help to illustrate these observations:

" Video recorded interview of family interaction ... .Submission of communication assignment ... Analysed communication skills and passed assignment … Positive feedback from families; ... Discussion with family and informal carers - sharing information and design of care plan" (Extract from student's evidence statement pertaining to working with families in order to support achievement of clinical learning outcomes).

The supervisor's comments with regard to her verification of these statements "By discussion and demonstration ... Good"

The maintenance of clinical learning profiles or portfolios is difficult to do well. It requires time and commitment from all parties. In other specialist practice education programmes the student generally negotiates his or her learning needs with the supervisor and devises a portfolio of evidence to support the negotiated learning contract. Such an approach is partially incorporated in this programme through additional documentation entitled "personal learning objectives". It is suggested that the clinical assessment process is developed formally to:

• Reflect the idea of a negotiated learning contract which is student centred
• Focus distinctively on clinical learning outcomes as pertaining to the skills workshops and specialist activity (e.g. family assessments; goal setting and evaluation of interventions).

2.4.4 Sequencing of modules

The route of progression through the course over three semesters followed this sequence of modules:

• Working with families
• Communication
• Advanced Family Health Nurse practice
• Research, decision-making and evaluation in clinical practice.

The rationale for the module sequence is given in terms of academic credit of the modules. Several members of staff and several students have suggested that the research, decision-making and evaluation module should come earlier in the sequence as the skills are required in the other modules. This particular module has two distinct themes and has been constituted as a double credit module: learning how to retrieve and use evidence to inform and guide practice and a casuistic approach to learning which relies on effective supervision, in the practice context, and through the use of Web CT. Casuistry is a branch of philosophy which aims to resolve particular moral dilemmas that arise from general moral rules. Such as: typical intergenerational conflicts which arise in families; or the specious reasoning of the remit of one professional group compared to another. Having such knowledge before embarking on Advanced Family Health Nurse practice would enhance student's learning and facilitate a more sustainable interaction with families and professional colleagues.

"I wish we had this earlier". (Student Cohort 1)

"The research module should come earlier cause we need the skills in all our course work". (Student Cohort 2)

"I think maybe the research should come earlier in the programme. Lots of the students have suggested this. It makes sense really". (Academic staff)

Considering how to restructure the modular delivery is essential for APEL/APL purposes and for educational development. The following sequence is suggested as a discussion point to develop the existing course.

Table 2.10 Suggested modular sequence for course redesign

This revised structure allows for the development of transferable educational and learning skills; full credit exemption to be awarded; the incorporation of management content as identified in the WHO Europe curriculum and the availability of three specialist modules which could be taken by community nurses or midwives with other specialist qualifications.

2.5 EVALUATING STUDENTS', SUPERVISORS' AND TEACHERS' EXPERIENCES

This section provides insight into the experiences of students, supervisors and teachers whilst engaged in the educational programme.

2.5.1 Profile of the FHN students

The following table provides a profile of the two cohorts of students:

Table 2.11 Profile of FHN students

Table 2.11 clearly shows that the two cohorts of FHN students shared a very similar profile. The nurses who undertook this course were typically middle-aged nurses with very considerable experience of nursing in general, and of community nursing in their particular remote and rural location. Most were midwives. Most had no specific community specialist nurse qualification and were employed in E or F grade posts. Cohort 2 had a lesser proportion who were in part-time employment pre-course, and had a small sub-group who had only spent a few years working at their home base site and were typically rather younger. In general these were experienced nurses the majority of whom had established histories of practice in remote and rural contexts. Trying to understand why they should wish to undertake this programme of education has been illuminating. Quotes from the students own reflective summaries and the research field notes provide some insight. "On commencing the FHN course I felt very excited and motivated about taking part in this pilot study. I also felt very positive about the family health nurse concept" (Cohort 2 student reflective summary).

" Now I have to train myself to stop thinking like a nurse, task oriented, lost if I can't physically do something for people" (Cohort 2 student reflective summary).

"… watched a video on family health nursing. Ideas behind it that nurses should take a more holistic view and get a lot of family knowledge. Good to have a framework for that". (Cohort 1 student field notes).

"The course provided the opportunity for a specialist award … I was doing another course ... put that on hold when this came up". (Cohort 1 student field notes).

As external evaluators we were also interested in profiling baseline competencies of the nurses who undertook this course. Due to pressures of time and logistics it was decided to use a self-report questionnaire for this purpose. The Nursing Competencies Questionnaire (Bartlett et al 1998) was chosen as it appeared practical, had proved the most valid and reliable (Norman et al 2000) and it had been used with post-registration nurses (Bartlett et al 2000). This questionnaire covers the constructs or domains of: leadership; professional development; assessment; planning; implementation; cognitive ability; social participation; and ego-strength. As such it also seemed broadly comparable to the five core family health nursing competencies indicated in the WHO Europe curriculum and the four specialist domains of practice advocated by the former UKCC.

Thus early in the course students from both cohorts were asked to complete the questionnaire by considering their perceived levels of competency across eight domains immediately prior to coming on the course. Six months after completing the course, Cohort 1 nurses received the questionnaire again. Table 2.12 presents mean percentage competency scores for each construct.

Table 2.12 Mean percentage competency scores for each construct(range of scores in brackets)

There were no statistically significant differences between the pre and post-course mean construct scores of Cohort 1. When the mean pre-course scores of Cohort 1 and Cohort 2 students were compared, the latter group scored significantly lower in terms of leadership (p=0.007), professional development (p=0.016) and assessment (p=0.031).

Analysis of individual responses, however, suggested a need for caution in the interpretation of aggregate before and after results, in that one respondent from Cohort 1 scored lower for every construct and had clearly revised her interpretation of personal competency across all the domains. This may be an example of "the more you know, the more you know how little you know" which is embedded in the introspective nature of critical reflection advocated in the education programme, or in Allison et al (1997)'s terms " intra-subject construct dynamism" where there would be an expectation of dynamic change within the domains in any direction.

Comparison of pre-course results is more informative, and it is noteworthy that the level and pattern of scoring across all constructs, is very similar to the data reported by Bartlett et al (2000) for recently qualified nurses. This raises some questions over the questionnaire's sensitivity when used with very experienced staff. Ceiling effects must be considered as a possibility. The relatively low scoring of respondents in the domain of social participation is consistent. This particular construct is concerned with awareness and activity in relation to social issues, health-related policy issues and research. In comparison to other community specialist courses studied, the family health nurse course certainly devotes less coverage to health and social policy issues and the raising of political awareness. Thus overall we have self-reported high levels of perceived competence.

These students were part of a highly publicised and politicised initiative and, as such, some had feelings of needing to prove themselves and be highly competent whilst in a shifting spotlight. They were concerned to manage the course, improve their practice and develop themselves. Some of their reflective comments help to illustrate these observations.

"The year was a challenge but I have valued greatly being given the opportunity to study for a degree in FH nursing. My previous work as a community nurse has been a good job and has provided me with a great deal of personal and professional satisfaction. My expectation is that putting the FHN degree on top of that will be even more stimulating and a source of even greater satisfaction" (Cohort 1 student).

"Each semester had its own terrors at the beginning and sense of satisfaction at the end" (Cohort 1 student).

" I am now back in charge of my caseload, which has swollen so dramatically since I left it in the capable hands of my replacement. I am quite nervous about having the reins again and wonder if I will be compared unfavourably against her." (Cohort 2 student).

2.5.2 Students' perceptions of stress and job satisfaction

Further exploration of the student experience was undertaken by asking each student to complete a Stress and Job Satisfaction questionnaire at different points during the project. Table 2.13 provides details of these time points for each cohort:

Table 2.13 Time points for stress and job satisfaction questionnaire

A community-nursing specific questionnaire was selected for this purpose (Snelgrove 1998). This questionnaire asks respondents to rate themselves in relation to 46 possible sources of pressure for community nurses and an aggregate score can be derived. Smaller groups of questions similarly elicit feelings of stress and job satisfaction.

The content of the questionnaire emerged as very relevant to the students and their experiences. For Cohort 1 the main sources of pre-course stress were related to:

• change and instability at work (e.g. future of job; uncertainty about role; lack of involvement in decision making; not being notified of changes before they occur; lack of knowledge of role by other professionals; relationships with other professionals).
• work content (e.g. tedious routine work; getting cover; attending meetings). In one region in particular the nurses felt unable to use existing skills to full potential.

The actual demands of working with clients were cited as stressful less often, although there were some feelings of worry and isolation over decision-making. This was offset, however, by most of the nurses feeling free to choose their own method of work and being satisfied with their working hours. In general nurses were dissatisfied with: pay; career development opportunities; support and guidance from their supervisors, and quality of supervision.

Thus a general picture emerges of a Cohort of experienced rural community nurses who were feeling undervalued and under-developed prior to starting the course. A personal quote from one of the students helps to illustrate this observation.

"Looking back on the last 10 months I can trace a development process from an isolated District Nurse to a confident Family Health Nurse mentality with the associated diversification and extension in health care outlook". (Cohort 1 student)

During the first part of the course, stress relating to uncertainty about future job and role continued at a similar level. The students were particularly concerned about perceived lack of knowledge about their role by other professionals. Work content was generally less stressful and more interesting, with much better opportunities to use abilities. There was still relatively little stress reported in relation to direct involvement with clients but only 3 out of the 11 students were satisfied with their placement supervision at this time.

Perceived lack of knowledge about their role by other professionals proved a persistent theme during the first 6 months of working as FHNs. Other prominent concerns related to the organisation and content of work e.g. organisation of caseload; lack of time on visits; work overload; record keeping and quantifying work. However these Cohort 1 students were significantly less dissatisfied with their jobs after the course than they were prior to undertaking the course (p = 0.044). This trend was confirmed in the findings from the Quality of Working Life questionnaires which were administered at the same points in time.

Sources of pre-course stress for Cohort 2 were very similar to those emphasised by Cohort 1, but Cohort 2 were significantly less dissatisfied with their pre-course job situation than their predecessors (p=0.035). Feelings of isolation and concern over decision-making were of more concern for Cohort2.

During the first half of their course Cohort 2 students continued to feel stress in relation to role uncertainty and lack of knowledge about the role by other professionals. However, in sharp contrast to Cohort 1, none of the students were dissatisfied with the quality of their placement supervision. Indeed Cohort 2 were significantly less dissatisfied with their student experiences up to this point than Cohort 1 (p=0.031).

Two quotes from personal reflections help to further illustrate the positive experiences of students from the second cohort.

"The course drew attention to my social and physical isolation, to the fact that my nursing practice was in need of urgent overhaul, that my attitude was negative" (Cohort 2 student)

"I am pleased to have done this course … It is not just in the way of being glad to have stopped banging my head against a wall. But it has been very well worth pushing myself along the flinty road … even though it didn't seem like the right one to be on and surely I should be somewhere else? … I am not a natural student … so to have got me this far at my advanced age is nothing short of miraculous" (Cohort 2 student)

Thus what emerges overall is an indication that stress around role ambiguity and professional understandings are of concern to both cohorts of students. The deficiencies in the educational curriculum which led to stress were resolved for the second cohort.

2.5.3 Placement support and supervision

Providing support and supervision for family health nurse was a difficult undertaking as there were no role models or experienced supervisors who had worked as family health nurses. In addition the role of the family health nurse was evolving during the course of the evaluation.

Evaluation of the support and supervision received by the students during their community placements drew on a number of different information sources including a specifically designed questionnaire which was administered to students and supervisors at the end of the course. This was piloted with a small group of Community Specialist Nursing students at another University and minor revisions were made prior to use with the family health nursing students and their supervisors. The questionnaire was designed so that students and supervisors could rate a number of different aspects of the placement supervision experience (e.g. the initial matching process; the supervisor's understanding of the course and its learning outcomes). In addition it also sought information on the frequency of in-person and remote- mode supervision activities. Aggregate scores for perceived quality of placement supervision were subsequently derived from the students' responses, and comparison of students and their respective supervisors' ratings of a subset of matched questions were analysed using Cohen's kappa statistic (measuring level of agreement).

Table 2.14 Profile of supervisors

As can be seen from Table 2.14 there are many similarities between the first and second cohort of supervisors. The main differences pertain to the spread of professional working practice and the supervisory preparation undertaken.

Cohort 1 students' experiences of practice supervision were mixed, but were predominantly perceived as unsatisfactory . This is seen in the students' ratings of overall level of support from supervisors during the course (Table 2.15).

Table 2.15 Students' ratings of overall level of support from placement supervisors

A range of problems was apparent, especially during the first eight months of the first year of the course. Students and supervisors concurred on the main aspects needing improvement. These were:

• better arrangements for selection of supervisors with supervisors being allowed to refuse to take supervision on if too busy or if their skills are not suitable
• preparation of supervisors so that they have information and a clear understanding of their role and that of the FHN before the course starts
• allocated time for supervisors to provide supervision.

As Table 2.15 shows, Cohort 2 students' experiences were less mixed and more positive. Other questionnaire data confirmed that their perceived quality of clinical placement supervision was significantly better than that reported by Cohort 1 (p=0.004), with 90% thinking that the match between their supervisor's knowledge/skills and the knowledge/skills required for the FHN course were good/excellent. This compares to a figure of 46% for Cohort 1.

Nevertheless Cohort 2 supervisors felt that the process of preparing them to supervise was not good. Table 2.16 gives details of their perceptions alongside those of the Cohort 1 supervisors.

Table 2.16 Supervisors' perceptions of their preparation process

These perceptions persisted despite the University providing a customised short course to prepare supervisors prior to the start of the course. In addition some of the participating NHS Trusts offered places on a generic supervision skills course. There was still a feeling for many supervisors that they lacked allocated time for supervision and some had concerns about the lack of guidance given by the University.

"After a shaky start I now feel (at the end of the first semester) a bit clearer about the role of supervisors" (Cohort 2 supervisor).

Contact and communication problems arose for those supervisors who did not work in the same geographic area as the allocated student. However the use of telephone and/or e-mail modes of contact for supervision purposes was significantly less of a feature of Cohort 2 supervision than it was for Cohort 1 (p=0.028). Fifty eight percent of Cohort 2 students reported that their supervisor had never been present in person when they were working with families during the course (corresponding figure for Cohort 1 = 64%). Interestingly, supervisors were asked the same question. In 69% of the matched cases for Cohort 2 there was agreement between students and their supervisors that in-person supervision with families had never taken place (corresponding figure for Cohort 1 = 50%). If the more rigorous kappa statistic (which takes into account the amount of agreement that would be expected by chance) were applied these percentages would fall further. Indeed none of the kappa statistics we calculated to measure agreement between students and their supervisors on matching questions came near to the 0.8 (80%) figure generally used to infer good levels of agreement. This highlights how people often retrospectively view the same sequence of events in different ways, even where a matter of objectively verifiable fact (e.g. being there in person) is concerned. Moreover the likelihood of social desirability bias from respondents should be kept in mind with the latter example.

"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 working alongside qualified FHN. I feel that this positive perception of family health nursing has enabled myself and my student to get onto an even keel fairly quickly after a rather fragmented first month (due to APEL, orienting ourselves family dynamics etc)" (Supervisor Cohort 2 first semester).

We found that when experiences of support and supervision were explored with students and supervisors in private interview, many were much more critical than might be inferred by reading their collated reflective comments. Many supervisors felt that they should be getting some local support so that they could ring-fence time for supervising the students. A few received increased remuneration related to their supervisory activities. Both supervisors and students found the course documentation very hard to understand and work with. This resulted in some supervisors admitting that they were not at all sure what they were signing for. Several others were unclear about the criteria for selection of families for the FHN students on placement. These varied from ideas of incremental progression (i.e. selecting families with more simple needs/problems at first) through to selecting a range of families representative of the major prevalent health problems in the area. The supervisors often relied on the students for guidance in this and other matters such as the documentation.

2.5.4 Practice-based experiences

Both Cohorts of students were in close agreement, when it came to identifying the most valuable skills they had learned during their clinical placements. Overwhelmingly they 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 valued.

Working with families was the focus of the practical work experiences. For some of the students this required that they spent the first semester of the course working in a different locality and with different health professionals. From semester 2 onwards, however, the vast majority of Cohort 1 and Cohort 2 students had returned to their usual context of employment for their practice-based education.

Interestingly in the students reflective summaries several commented on the difficulty of finding families to work with. "I feel I am rushing to extract goals from my family without building a proper relationship first" (Cohort 2 student).

"Finding new patients for semester two was a difficult task" (Cohort 2 student).

" Gathering families slowly (I have heard that Rome wasn't built in a day). As far as the paperwork goes I'm still not happy with it but at least I understand it now. Last family I admitted and assessed were great. Went through the whole process with them, to discover that they really don't need me, but for them that was good, its reinforced the fact that they are coping well despite their problems". (Cohort 2 student).

Students were also concerned about using families for assessment purposes and then moving on and the family's care reverting 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. Service development requires a process of change management to be planned, articulated and facilitated. The evolving nature of the nursing role and its fit with service delivery posed many challenges for all of those involved.

2.5.5 Campus-based experiences

There was similarly emphatic agreement between the Cohorts when asked to identify the three aspects of campus based learning that they found most valuable. Overwhelmingly they identified coming together on campus to learn together, share ideas and experiences as major benefits. In addition family systems theory, communication and IT skills were emphasised, along with research.

The least valuable aspects of campus-based learning were seen as the content of some of the workshops in Semester 2 (especially for Cohort 1); problems with availability and functioning of IT equipment (especially in the first year of the course); limited time between assignments (especially in Semester 3); and guidelines for assignments being unclear or changed (especially in the second year of the course).

Students were asked to identify any topics that were not covered on the course that should have been. Some respondents from each Cohort identified input on child development and other health visiting skills as being lacking. Topics in the Cohort 2 responses included counselling skills; role-play and joint working with social work. Students were also asked to identify any topics that were not covered well. Both Cohorts identified various workshop sessions which could have been better (e.g. dietetics and coronary heart disease). Topics in the Cohort 1 responses included management skills and mental health, whereas a number of Cohort 2 respondents felt that the input on research should have come much earlier on in the course. Overall, however, both student Cohorts were very positive about their campus-based learning experiences and very much valued the input by teaching staff. The following quotes help to illustrate these points.

"Reflection for me has been a way forward and has assisted me to look at situations and critically analyse various situations where a scenario could have been avoided or improved upon". (Cohort 1 student).

"I feel I can ask the right questions and discuss sensible solutions, and now I think I may deserve the title - FHN" (Cohort 2 student).

" The Cohort has been supportive of one another and has been a great asset and strength. We have a unity that is fragile because 20 is a large social group and we are scattered far and wide. However we have a weapon - the bulletin board. We must continue to communicate through it and I take this opportunity to encourage everyone … to use it" (Cohort 2 student).

The last quote refers to one of the major innovations of this programme namely the use of information technology through a Web CT system which has encouraged the sharing of ideas between students and with staff. This system has provided the means of maintaining an action learning set at distance with very good effect.

"The Web CT has been a godsend for me. To have contact with the other students was all that kept me going" (Cohort 1 student).

"It has been brilliant … I don't know how we would speak ... [otherwise ].

Web CT is very interesting … now what you will find … , I don't know if you have read the bulletin board … but the girls this year seem to like the bulletin board rather than chatting privately so it is like what's meant to be … Supervisors are an interesting lot as they were all given the same training. They haven't used it once not once, now I thought that this would have been very useful … but they don' t use it". (Clinically based teacher and supervisor).

The Web CT has the potential to be developed further to provide student and supervisor support. Some formal structuring of academic sessions along with student initiated contact enables facilitation and involvement across the modules. This particular approach has worked well and could provide a model for other distance learning opportunities. Formally there is need to make explicit the educational principles behind the processes, namely action learning; simulated learning and peer review.

2.5.6 The teachers' experiences

Over the two-year period consultations were held with various members of the academic teaching team. All made time for us and were very supportive and helpful in providing information, facilitating access to students whilst on campus and generally looking after us when we arrived at the University.

A formal interview was held with each member of academic staff who had a key role to play in delivering the programme. These interviews aimed to explore the strengths and weaknesses of the course and to identify the lessons learned and the areas for potential development. Enabling reflexivity was one of the challenges of these interviews as a certain amount of guarding took place. Like the students, the teachers had been in the shifting spotlight and part of a highly politicised process for the last two years.

Questioning began by asking about the strengths and weaknesses of the curriculum; before reflecting on its fit with regulatory learning outcomes; the parity and quality of student experiences and learning; the role of the FHN; and finally focusing on their own personal experiences of being involved in the initiative.

The following Table 2.17 presents a summary of the common strengths and weaknesses as identified by teaching staff.

Table 2.17 Strengths and weaknesses of the curriculum

When asked about the role of the FHN comments were made regarding the project not connecting enough with the students' line managers to enable the role to be enacted more fully. The teachers recognised that there is a need to work in partnership with NHS providers to facilitate service redesign and to provide appropriate education for practitioners.

Several comments were made about the amount of course content which could be taught locally to avoid the students coming on campus. A few words of caution were expressed from the more experienced teachers saying that the students really needed time together on campus and that e-learning suits the educational establishment and the employer but not necessarily the students. Certainly these sentiments were borne out by the students stating how much they valued contact with one another on campus.

Finally comments were made about the way that the initiative was rushed through; the difficult validation processes; the functioning of the Steering Group and the personal strains experienced.

In their own words:

" The course was a very rushed affair with much of the lead in time devoted to contract negotiation and other structural issues. Consequently we pieced together a course in quick time".

" Uni is committed to a range of assessments. OSCE stretched the concept of OSCE beyond or almost beyond recognition. What it is trying to do is examine across a wide range what an FHN is doing as part of the practice of her work".

" There are things that this course is doing because of the pilot nature of it. If you get down to harsh economics things would have to go and I feel that the visits to clinical areas might go beyond what other courses provide"

"It would be great to go out and spend time with students working with families. But that's what we want supervisors to do. The Health Visitor Fieldwork Practice Teacher Role is one that we would aspire to … but we don't have FHNs to fulfil the role".

"… another potential area for development is that we deliver some of the FHN programme to community staff nurses … I think we need to think about what community staff nurses need to make them more effective … this is where our programme originally started"

" Things have worked out better than what I imagined … Lots of possibilities. I've been a wee bit disappointed when you get someone … you know … who's never going to change".

"I think quite a lot of work has to be done around how people understand family. I think there has been some misconceptions about that. I wouldn't like to see the name changed, cos I think we've come quite far in terms of getting the students to think of themselves as family health nurses rather than community nurses"

"The course should continue to be a judicious use of campus and on line learning. I think the most useful learning was the creation of virtual learning networks which could usefully be a model for all rural health care workers"

2.6 SUMMATIVE DISCUSSION

Evaluation of the educational course showed its structure and content to be distinctively different from the other community nurse specialist practitioner courses on offer within Scotland. The FHN course was less flexible in format, did not share core content with other community education courses, and did not dedicate modules to quality issues, teaching and supervision, management or leadership. Rather it emerged as much more focused on its speciality, being theoretically grounded in an ideology of nursing which combined elements of Family Nursing from North America with the promotional ideas from WHO Europe.

This mixture of content differed significantly from WHO Europe's own suggested Family Health Nurse curriculum. The WHO Europe curriculum has more emphasis on management and leadership. Indeed advocates of the FHN role (e.g. Kesby 2002) see the FHN as a nurse leader on equal partnership status with the GP. However the latter interpretation was not a prominent feature of the Scottish initiative. Rather these very experienced community nurses were educationally prepared in such a way that they would be enabled to personally deliver this particular family health nursing approach within their communities.

During the first year of the course a number of major curricular modifications took place, and generally the first cohort of family health nurse students were more dissatisfied with their educational experiences than the second cohort. Most modifications resulted in improvement, but some (such as the introduction of the course APL scheme) were also problematic. Congruence between generic and specialist content within the course curriculum remained difficult to achieve.

Our scrutiny of the educational course has resulted in a number of suggestions for further curriculum development. Table 2.18 summarises these:

Table 2.18 Suggestions for the development of the family health nursing curriculum

In many ways the difficulties that arose should not be surprising given the nature of the challenge which the educators faced. In essence they had to accommodate the need for a range of relevant generic content while developing a distinctive new specialist focus that also satisfied the requirements of the UKCC framework. This was a tall order, especially since the role of the FHN was essentially hypothetical during the first year of the course.

The course was very much tailored to a specific market context and the balance between campus attendance and distance learning emerged as being a real strength. Other strengths included the innovative web based facility and the learning of communication skills in the context of family health assessment. Indeed the new family health assessment /promotion skills (e.g. use of genograms; understanding family dynamics; empowerment) were valued very highly and these were seen as central to creating a distinctive new professional identity.

The latter aspect was also tied to the concurrent development of policy and practice. This linkage was innovative and to some extent challenged the existing UKCC specialist practice framework. The simultaneous developmental change process undertaken in the Family Health Nurse initiative did impose particular demands in terms of rapid initiation, creativity and responsiveness, and the effort sustained by individuals (teachers, students and professional colleagues) has been immense and very impressive.

The resultant programme is distinctively different from other specialist community nursing programmes. It emerges as a distinctive Scottish educational hybrid which has produced a skilled and knowledgeable generalist community nurse who has been specially prepared to work in remote and rural health care. It has growth potential unto itself, but it also provides a precedent for other educational providers to reconsider their approach to specialist practice degree level education.

In this regard it suggests the potential value of:

• developing clear theoretical and philosophical bases for specific programmes which encapsulate a strong value based approach to nursing, midwifery or health visiting in the context of primary care
• working in conjunction with service providers to customise courses for specific markets.
• incorporating e-learning approaches and work-based learning strategies alongside more traditional teaching and learning methods.
• working in conjunction with policy makers and service providers to facilitate an incremental approach to service and educational development

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