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Evaluating Family Health Nursing Through Education and Practice

CHAPTER THREE: THE PRACTICE OF FAMILY HEALTH NURSING

3.0 INTRODUCTION

This chapter of the report presents the main findings from our investigation of the practice of family health nursing during the first year of this new role. To recap, the Scottish Executive Health Department summarised the principles of the role as:

1 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.

2 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.

3 A role founded on the principle of caring for families rather than just the individuals within them.

4 A concept of the nurse as first point of contact.

The chapter is composed of four sections:

Methods: a summary of the methods used to investigate and evaluate FHN practice

Typology of FHN practice: this part presents the typology of family health nursing that emerged through comparing and contrasting practice at different sites. The typology is explained through summary analyses of the ten sites where the family health nursing role was introduced and partially developed.

Overview of FHN practice: this part draws together common themes that emerged across the ten sites and aggregates quantitative data to give an overview of FHN practice

Discussion: the final section summarises and analyses the findings

3.1 METHODS

Concurrent evaluation of an evolving, multi-factorial, and geographically diverse development such as the Family Health Nurse initiative mitigates against the use of quasi-experimental research designs that depend on notions of control. Accordingly our research is grounded more in the traditions of qualitative enquiry, while also incorporating survey methods.

In evaluating practice our overall aim has been to identify emergent patterns of context, process and outcome that might characterise each of the local sites involved in the pilot (i.e. context of development; process of engagement and outcome of practice). This approach adapts Pawson and Tilley (1997)'s realistic evaluation framework so that process rather than mechanism is studied. The goals have been 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 are seen as the main units of analysis in this study. Explanatory case study methodology (Yin 1994) informs this approach and knowledge was built at two distinct levels in order to address objective 4 (i.e. to explore the operation of the FHN model, focusing on the nature of the services provided and drawing comparisons between the pilot sites).

Firstly, at the micro level, a set of case studies was conducted which focused on the care received by six families in different locations where Family Health Nurses were employed. This involved in-depth, semi-structured interviews with family members, the Family Health Nurse and a maximum of two other key health care professionals involved in delivering care. These cases were selected from a pool of 20 "tracer families" (2 for each FHN site) whose progress was followed during the latter part of 2002. Details of the selection of tracer families and case study families are given in Annex 1. The family members who took part in the case studies were also asked to complete a consultation satisfaction questionnaire (Poulton 1996).

Study of the operation of the FHN model was further contextualised through the researchers making several visits to each site during the course of the project. Profiles of these sites were constructed based on the following data sets:

• Available documentation on the epidemiology and demography of each site location, including any extant health needs assessments
• The FHN students' community portraits
• Summary profiles of all health care staff comprising the core Primary Health Care Team for each site. Summary profiles of all other relevant health, community and social care staff involved closely with the PHCT at each site (e.g. social workers; voluntary sector workers; teachers). Together these groups comprised the "professional stakeholders"
• Community nursing caseload ¹¹ and mix data available from routine collations (variable in quality) and specifically obtained in-person by the research team
• Field notes from interviews with key site personnel. These gathered details of cultural context; working practices; referrals; local resources etc)
• Field notes from telephone discussions with practising FHNs (made throughout project)
• Field notes from direct observations of FHNs' work with selected families
• Scrutiny of the nursing case notes of the 20 "tracer families"

Much of this work was undertaken during 2001 as a baseline from which to address objective 3 (i.e. 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). The identification of professional stakeholders was also a first step in addressing objective 5 (i.e. to identify relevant stakeholders' perceptions of the FHN model). In November 2001 we mailed a questionnaire ¹² to professional stakeholders at each site seeking their baseline perceptions of the FHN role. This was repeated a year later using a similar questionnaire to gauge the emergent impact of the development.

Details of overall response rates to the professional stakeholder questionnaire on both occasions are given in Table 3.1

Table 3.1 Overall response rates to the professional stakeholder questionnaire

*Includes the site which wasn't subsequently studied in 2002 as the FHN was on maternity leave. Also includes the FHNs themselves. The replies from the FHNs were handled separately and are not included in any of the site summary analyses or other data aggregations used in this chapter of the report

** Excludes the site which wasn't subsequently studied in 2002 and includes the FHNs themselves. Between Dec 01 and Dec 02 some stakeholders left and consequently were not sent questionnaires in Dec 02. Also a number of new stakeholders were identified during 2002 and were sent questionnaires in Dec 02

Response rates for each site are given in Table 3.2

Table 3.2 Response rates to the professional stakeholder questionnaire at each site

A similar, but more restricted repeated consultation exercise was conducted with twenty randomly selected members of the public ("lay stakeholders") at seven of the FHN sites ¹³. Details of overall response rates to the lay stakeholder questionnaire on both occasions are given in Table 3.3

Table 3.3 Overall response rates to the lay stakeholder questionnaire

*Within each of 7 FHN sites, 20 questionnaires were sent to residents who had been selected at random from the electoral roll. One regional ethics committee refused permission for this one particular aspect of the study, therefore 3 sites were not included

** In Dec 01 , 10 envelopes had been returned by postal services indicating addressee no longer resident. Therefore we did not send questionnaires to them in Dec 02

Percentage response rates for each site are given below in Table 3.4

Table 3.4 Response to the lay stakeholder questionnaire at each site

Questionnaire data was entered into an SPSS V10 database and analyses followed the same procedures as described in Chapter 2.

Thus it was possible towards the end of 2002 to draw on all the data sets in order to analyse the emergent patterns of practice in terms of context of development, process of engagement and outcome of practice at each FHN site ¹⁴. This in turn allowed knowledge to be built at the macro level whereby the ten, site-specific case studies could be compared and contrasted so as to draw conclusions about what worked under what circumstances and for whom. Although the focus was very much on the first year of work by qualified FHNs, we also visited almost all of the twenty FHN sites scheduled to become active in 2003 and constructed limited profiles.

Figure 3.1 overleaf summarises the evaluation process pictorially.

3.2 TYPOLOGY OF FHN PRACTICE

Before presenting the typology of family health nursing that emerged, it is useful to clarify the context of practice. During 2002 there were ten sites where an FHN sustained activity over the whole year. The eleventh FHN who had completed the education programme during 2001 was on maternity leave for a major part of 2002 and consequently we did not attempt to study practice at her home site.

It must be emphasised that all 10 FHN sites are remote and rural as defined by The Scottish Household survey (SEHD 2000). That is, their main settlements all have a population of less than 3000 and are more than a 30 minute drive time from a settlement of 10,000 people or more. All the sites we studied fit easily into this definition.

Secondly it is useful to highlight two operational definitions:

Family Health Nurse site (FHN site): a distinct geographic area whose population are served by one (or occasionally two) district nursing team(s) and wherein an FHN is working. Other health professionals whose work involves the provision of primary care services to the population of this site are known as the Primary Health Care Team

Core Primary Health Care Team (core PHCT): a group of health care professionals whose everyday work is focused mainly or exclusively on the provision of primary care services for the population of the FHN site. The core PHCT usually comprises all the nurses involved in the care of the DN caseload(s), and all Practice Nurses and GPs from GP practices within the FHN site. It may include the Health Visitor and Midwife(s), but this tends to depend on whether they are based within the FHN site or not

At the FHN sites nursing personnel were usually located in buildings where local GP services were based. However the Practice Nurses were the only group employed directly by GPs and the only group whose work was necessarily confined to one GP practice list.

We categorised the sites primarily in terms of common contextual features related to their geography, population density and organisation of primary care services (Table 3.5).

Table 3.5 FHN sites categorised by common contextual features

This categorisation provides context for the typology of family health nursing practice that emerged through comparing and contrasting practice at the 10 different sites (Table 3.6 overleaf). Summary details of the particular sites are given in relation to their respective codes in Annex 3.

Table 3.6 Typology of family health nursing practice

Explanation and illustration of each pattern within the typology is now undertaken using summary analyses of the FHN sites. These site analyses draw on a number of data sources. Where professional and lay stakeholder data is utilised this is based on useable responses (see Tables 3.2 and 3.4 respectively). Firstly High scope-slow build is examined through analyses of the two sites characterised by this pattern.

3.2.1 High scope-slow build

As Category 1 denotes (see Table 3.5), these two small island sites shared common contextual features. The district nursing caseloads were small and had relatively few patients needing regular, intensive nursing input. Workload fluctuated but on the whole there was high scope for autonomous practice development within the existing staffing complement. On the other hand there was the responsibility to provide nursing services for the whole island population and this brought with it the particular demands of being almost constantly on-call and being expected to deal with a very wide range of clinical eventualities.

This situation was particularly pronounced at Site A where nursing is the only resident health service for an island with around 70 permanent residents. In this situation the nursing caseload is synonymous with the whole island population and nursing assessment is bound up in everyday social contacts with a substantial proportion of the population. Prior to undertaking the course, the FHN had a long established role as the island's District Nurse and Midwife.

Response to the lay stakeholder questionnaire was particularly good. Prior to the introduction of FHN practice, seven out of ten respondents (70%) had heard about the new role and they generally saw it as congruent with, and virtually indistinguishable from, pre-existing nursing. By the end of 2002 only one out of 10 of respondents (10%) viewed the FHN as a different kind of service:

"There has been no change"

"I think the FHN is ideally suited to our local situation in principle: in practice it has made no difference at all"

"FHN could have been modelled on what was happening here before i.e. District Nurse always providing a high level of care due to the exceptional circumstances of a small isolated community"

Professional stakeholder responses told a broadly similar story and again there was a feeling that the pre-existing service was satisfactory in meeting family needs. Interestingly, however the FHN herself felt that she was seeing practice differently in that the focus on family drew together many different elements of care. She was gradually working to transfer individual's nursing records to Family Health Nurse documentation, but this process was slow (7 of the island's 35 families were on FHN notes by the end of 2002). This was partly attributed to the need for full family assessment to occur but also to difficulties in using the FHN documentation ¹⁵ and doubts about its appropriateness for individuals needing only very specific nursing interventions.

Frustration with documentation was also a theme at Site B. The pre-existing district nursing caseload numbered around 15 clients, many of whom required regular input. Most of these clients and the relatives involved in their care have been assessed using the FHN documentation. Again, however this documentation is not seen as ideal for the nursing needs of some individuals (e.g. those with leg ulcers; wound care), therefore elements of the pre-existing nursing documentation are also incorporated. This has resulted in a number of "hybrid" notes.

New referrals for nursing input who were assessed as having more than very short-term needs were also then given fuller assessment using FHN documentation. This provided a "way in" to include other family members (the "FHN caseload" now totals around 35 individuals) but the depth of development of the assessment and intervention processes is very varied. This variation is not only in response to individual family members' needs but also a result of the FHN finding that such in-depth assessment is time consuming and practically difficult with family members who are out working. There is an aspiration to eventually have all the island's 450 residents as "the caseload", but also a realisation that this would take several years and would entail seeing "caseload" in a very different way.

None of the nine respondents to the lay stakeholder questionnaire at Site B had heard about the new role prior to its introduction. Only one respondent felt it might take away from pre-existing local services. This is relevant because the new FHN had been relief nurse on the island for many years but was now effectively replacing the triple duty nurse who had recently retired. At the end of 2002 there were still few respondents who knew about the role, but none felt that family health nursing was taking away from local services.

Professional stakeholders saw the FHN development as well suited to the site prior to its introduction. They continued to be positive at the end of 2002 with no respondents feeling that the development had been unsuccessful so far:

"Some families benefited considerably"

"They have benefited from the wider remit of the FHN vis a vis the District Nurse"

However opinion was divided about whether there was a specific need for the FHN role.

At both sites some close professional colleagues still did not fully understand the nature and scope of the FHN role. This seems related to the development of the role being confined to the individual FHN, with relief nurses having minimal involvement in the new style of family assessment that has taken up a lot of FHN time. As such, much of the FHN activity was visible only through the new hybrid documentation. Accordingly these local professional stakeholders comments are not surprising:

"I see no difference from what the nurses were already providing"

"Has always been good interdisciplinary working and this continues with FHN"

"Although well suited to island communities I think the FHN role still needs clarifying to fellow professionals as well as public"

Referrals from professional colleagues have continued to be for usual district nursing type problems (i.e. individual patients). There have only been very isolated occasions when a family has been referred. In effect, the bottom line for the development at both sites has been that the usual district nursing service (which tends to be focused on individuals with health problems) must continue with no detriment and that the new role should be supplementary to normal service. This has been achieved so far because there was already scope for supplementary development but it has meant that progress has felt slow to the FHNs.

Nevertheless they have both managed to develop different, new aspects of practice. At Site A, Healthy Living group-based sessions have been developed with the local community. At Site B, the FHN and local GP jointly initiated a mens' health clinic that has been well received, with substantial uptake of the service.

Role boundaries remain completely unchanged. On local islands where there is no resident Health Visitor or Community Psychiatric Nurse, the District Nurse has always carried out some informal monitoring of general child development and of clients with mental health problems. This has carried on. However, throughout the project there has been a degree of tension locally with the health visiting service due to a perception that FHNs might start to formally carry out child developmental assessments. This possibility was in fact rejected by a regional committee fairly early in 2002 but residual concerns about the definition and scope of the FHN role have persisted.

During the first year of FHN practice there has been no substantive change in the nursing staffing costs at both sites. The characteristic typology for both sites can be summarised as:

Context: Small, stable caseload. High pre-existing scope for nursing autonomy and practice Development.

Process: Gradual introduction by FHN only with little/no change in other professionals' working practices.

Outcome: Positively viewed by the limited number of families who received the service, but not seen by colleagues and the general public as substantially different from pre-existing service. More satisfying for FHNs but also more demanding.

3.2.2 Slow build-key ally

Three of the six Category 2 sites (C, D and E; see Table 3.5) were found to share the characteristic Slow build-key ally pattern (see Table 3.6). These sites also shared the following common characteristics as a baseline:

• The FHN was trying to introduce the role on top of a pre-existing district nursing caseload. Two of the FHNs had been allocated a distinct geographic patch within their PHCT site and their work was normally restricted to that patch unless called on to cover sickness or holidays.
• The district nursing caseloads inherited by the FHNs typically comprised 30-48 people, the majority of whom were elderly. The caseloads were not perceived as heavy and had relatively few patients needing very regular, intensive nursing input. Workload fluctuated (e.g. with terminal care cases) but on the whole there was scope for FHN practice development without changing the pre-existing working practices of the district nursing teams at these three sites.

Study of these sights yielded a further key characteristic that emerged during the year:

• The FHNs had one or more key allies within the core PHCT who recognised the need for the role and actively supported it through their routine working practices (e.g. by referring families to them).

At Site C the FHN was still practising as a Midwife and she expanded the FHN role from the basis of her small midwifery caseload. This was done by continuing to care for families after the usual 10 day post-natal period of community midwifery input ceased. She was very actively supported in this by a Health Visitor colleague who shared the same home base site. Joint visits to the families were conducted initially and there was sharing of skills. While an element of duplication was acknowledged (particularly as several different sets of notes were in use), this was seen as a useful joint basis from which to develop more complementary working. Because the HV covered such a wide geographical area, she felt that she tended to have to concentrate on child health, whereas the FHN seemed better placed to have more in-depth input with these local families. This would include doing routine child developmental checks when there was mutual agreement on competency.

With the encouragement and support of the local GP, this FHN also developed a hypertension clinic (there was no Practice Nurse locally). This was successful in terms of a service for individual patients but raised some dilemmas for the FHN in terms of how, when and why a specific family health nursing approach might be applied. She developed FHN notes for a few families through this clinic.

Prior to the introduction of the new role, professional stakeholders at Site C were generally supportive with none feeling that the development was unsuited to local context. The three respondents at the end of 2002, all positively saw the need for a distinct FHN role locally.

Initial opinions about the suitability of the FHN development were more mixed at Site D. Subsequent FHN working at this site involved some joint working with an HV, but it was less sustained than at Site C as the HV was based elsewhere. The FHN developed good working relations with the local Primary School and now has weekly sessions doing health education/health promotion work. She also developed some health educational materials for the local farming community.

The FHN has been supported in these endeavours by the local Practice Nurse whose routine work with the elderly of the local community involves some home outreach activities (e.g. blood pressure and pulmonary monitoring) and is well integrated with other services. Thus the FHN has had more chance to develop the child health/community aspect of her role. By the end of 2002 five out of nine professional stakeholders at Site D (56%) positively saw a need for a distinct FHN role locally and no-one thought the role unsuited to local context. The response rates for the lay stakeholder questionnaires were low at this site, but respondents were generally supportive of the idea in principle.

At Site E the FHN has developed a particular strand of her role in the area of mental health. This involves spending more time with individuals and families in the local community who are having problems with substance misuse (almost exclusively alcohol). Much of this has involved building trust. She has been supported in this work by the local Community Psychiatric Nurse and Substance Misuse Worker, who in turn have benefited from more regular linking. One local GP has also been particularly active in encouraging the FHN role and has referred several families to the service.

Site E is interesting in that prior to the introduction of the FHN role eight out of fifteen professional stakeholders (56%) saw it as unsuited to the locality and six (40%) thought it likely to fail. By the end of 2002 there was little change in the former figure, a slight reduction in the latter figure, and only three professional stakeholders out of twelve (25%) saw a positive need for a distinct FHN role locally. As such this site demonstrates the gradual development of a specific aspect of the role despite fairly high levels of doubt amongst fellow professionals. It also shows the importance of interpreting the stakeholder data in the light of site visits, in that some professional stakeholders are more active and influential than others in their ability to support role development. The majority of lay stakeholders who responded knew little about the FHN development but were generally supportive of the idea.

These three summaries show different aspects of the FHN role being developed. As yet most of these are small scale expansions into areas where there is an opportunity for service development and/or an acknowledged local gap in services. Sometimes there have been elements of duplication and not all professional stakeholders have seen the need for the role. The development of the role has typically occurred only within the specific FHN geographic patch and this may explain why some other members of the same PHCT have not been aware of any particular process or impact. It was notable that the key allies were always based in the same specific geographic patch as the FHN, rather than at a different base within the whole PHCT site.

The FHNs themselves have tried to apply their new way of nursing so that the whole emergent caseload is conceptualised as family health nursing. This has not always proved easy however and often there has been inherent tension amongst the constituent parts. These constituent parts would typically consist of the district nursing caseload of individual patients; a small number of families who have been fully FHN assessed and are receiving active interventions (some of whose members may be individual patients); and all the general public in the "patch" (i.e. the local community).

However the role development has been more sustained in these sites compared with the other Category 2 sites and the active support of one or more key allies emerged as an important contributory factor. Typically there has been no net increase in nursing staff/budget at these sites.

The characteristic pattern can be summarised as:

Context: FHN role super-imposed on non-heavy district nursing caseload within established and functional medium sized PHCT.

Process: Gradual introduction by FHN with active, focused support from one or more professionals within the core PHCT.

Outcome: Positively viewed by the limited number of families who received the service (often specific client groups). Normal district nursing services maintained. FHNs generally feel they are making progress.

The final two context-process-outcome patterns that emerged were the Slow/No go and Bold build patterns. Explanation and illustration of these patterns will continue with summary analyses of sites with these characteristics.

However, further illumination can be found in Annex 4 where one in-depth site case study is presented in relation to each pattern. We have chosen to do this as the Slow/No go and Bold build patterns represent different ends of the spectrum of family health nursing that we studied. Within this contrast lies a great deal of useful knowledge about how the FHN role may or may not work. These in-depth site case studies have been constructed to illustrate particular themes that are characteristic of these patterns. In doing so they also offer the reader further insights through the words of Family Health Nurses, family members, professional colleagues and the researchers. As such, Annex 4 supplements the more basic summaries that now follow.

3.2.3 Slow/No go

The remaining three Category 2 sites (F,G and H; see Table 3.5) were found to share the characteristic Slow/No go pattern (see Table 3.6). These sites shared the following common characteristics as a baseline:

• The FHN was trying to introduce the role on top of a pre-existing district nursing caseload. Two of the FHNs had been allocated a distinct geographic patch within their PHCT site and their work was normally restricted to that patch unless called on to cover holidays or sickness.
• The district nursing caseloads inherited by the FHNs typically comprised 33-55 people, the majority of whom were elderly. The caseloads were perceived as heavy. Workload did fluctuate, especially in relation to terminal care cases, but there was a general feeling of little time being available in which to develop the FHN role. One of the sites in particular was short in its staffing complement during the year of practice studied.

At Site F the FHN was allocated a distinct geographic patch within the PHCT site, but lacked access to any office amenities when working there. This resulted in long travel times. The FHN continued to practise as a midwife, providing ante natal and post natal care to a very small number of mothers.

Prior to the introduction of the new role most of the professional and lay stakeholders who responded were unsure whether it would be suited to the local context. During the ensuing year the FHN found it difficult to develop momentum in taking the role forward, despite her feeling that there was much potential in the area. She perceived the "hands-on" work demands of the district nursing caseload to have priority over her own goal of assessing families needs and developing related care packages. During the year she did achieve the latter with two families who had members who were already receiving district nursing interventions. Furthermore she developed her work with three families whom she had seen as a student. Generally, however, work with these five families was sporadic and fitted in around the demands of traditional district nursing caseload work. When the FHN was on holiday these families would not receive input unless there was a need for district nursing contact.

The FHN felt that she was now more aware of family problems in the course of her district nursing caseload work. However she would not necessarily use the full FHN documentation in these situations as she felt that it might open up a range of related issues that she would not have time to fully address. This caused the FHN significant intra-role conflict and she tended to use the traditional nursing notes to record relevant family issues in a more limited way.

Although treatment and intervention work tended to take precedence, the FHN managed to develop a local health support group with a particular focus on weight management and the prevention of related health problems. This was supported by the local dietician. Nevertheless most of the FHN work at this site was solitary in nature and this is reflected by the fact that she received no referrals of families from any colleagues during the first year of practice. By the end of the year only one of eight professional colleagues (13%) saw substantial change in professional working practices or service delivery. Similarly only one saw a positive need for a distinct FHN role locally. Despite this significant degree of professional isolation the FHN remained fairly optimistic that a family health nursing approach could be successful if it was supported through a team approach.

Professional isolation was also a feature at Site G despite colleagues being very personally supportive towards the FHN. The introduction of the FHN role at this site is described in greater detail in Annex 4, but one of the interesting features was the way that the core PHCT set up an open diary for ongoing team reflection on the process of implementing family health nursing. Professional stakeholders initially reported mixed perceptions in regard to the impending introduction of the role, with five out of eleven (46%) believing it to be unsuited to the local area and two (18%) thinking it well suited.

The FHN had previously worked at the site for many years as a District Nurse. Late in 2001 she was allocated a specific FHN geographic patch within the district. During the first three months of practice there were several terminal care cases within this patch and very regular, sustained input was required. This inhibited early development of the FHN role beyond the district nursing caseload. Yet throughout the year it also proved difficult to expand activity within families who already had a member receiving district nursing input. Again the demands of the district nursing caseload and lack of time were seen as the main reasons for this.

It proved possible to engage in sustained, in-depth family work with less than five families during the year. Customised documentation was used for these families. This involved a fusion of the full FHN notes with traditional nursing notes. The resultant documents provided comprehensive evidence of care but were unwieldy. Although the FHN enjoyed good relationships with patients and other family members within her patch it did not necessarily follow that she was seen as the first point of contact. Local custom was to contact the district nursing service or seek direct medical input as required, and this did not change during the first year of FHN practice.

Some health promotion and screening work was developed in the local primary school by the FHN with some support from the local HV. Again this activity was sporadic and difficult to sustain due to other perceived priorities. For the FHN's colleagues the priority was that normal district nursing service delivery within the whole district should not be adversely affected by the introduction of the new role, and this belief was largely shared by the FHN herself. The open diary entries included colleagues' concerns that the routine data returned monthly on patient contacts did not properly reflect their own input to the FHN patch.

During the year some extra nursing auxiliary hours were allocated to assist the development of the role, but by the end of the year there was general consensus that the role wasn't working. For the FHN and many of her colleagues the problem lay in the role being based on a busy district nursing caseload. Although a specific geographical patch had been hived off for the FHN, the advent of the new role was not seen as an opportunity for any substantive review of nursing caseloads or working practices within the team. During the year there were less than five referrals of families to the FHN.

Many colleagues felt that it would have been better if the FHN role had been supernumerary and not cover a district nursing caseload. When this scenario was explored in greater depth however, it became clear that the problem was more fundamental. In effect the PHCT felt that existing services for local families were already very good and there was no gap to be filled. Generally the team had not felt well consulted about the initial introduction of the role, and by the end of the year only one out of ten professional stakeholders (10%) felt that there was a positive need for a distinct FHN role. Most of the lay stakeholders who responded felt unable to give an opinion on the implementation of family health nursing so far.

Understandably the FHN at Site G felt frustrated that development of the FHN role had been so difficult to achieve. This feeling was shared by her colleague at Site H where there had been a persistent shortage of staff during the first half of 2002. This had resulted in the FHN having to cover the whole district during this time. In turn this had entailed particularly long travel times and she felt that the ongoing demands of the district nursing caseload (and the episodic demands of her small midwifery caseload) took priority.

Accordingly she was only able to develop the FHN role more fully with a few families during this time and her level of input varied. She found the full FHN documentation cumbersome and tended to customise the existing nursing notes. Professional colleagues were generally well disposed to the FHN concept prior to its introduction and they remained so during the first year. However they were small in number, geographically scattered and tended to be pre-occupied with maintaining pre-existing levels of service delivery.

Matters improved in the second part of the year with the recruitment of more staff, but it still proved difficult to gain momentum in developing work with families. At the end of the year one of the three professional stakeholders who responded saw a positive need for a distinct FHN role within the district. Nevertheless the FHN remained hopeful that family health nursing might develop well in the district if it could be supported and integrated within the overall team approach. This prospect was felt to be realistic as she already had close support from an FHN working in an adjacent district, and a further FHN was due to start work within Site H in 2003.

These three summaries of FHN role development at Category 2 sites show progress to have been slow or at a standstill during the first year of practice. While the presenting cause for this has usually been cited as the time demands imposed by heavy district nursing caseloads, there has been a more fundamental underlying lack of active support for the new role at these sites. Other team members have generally not engaged with the role to the extent that it could be seen as at all integrated with team practice. Rather there has been a pre-occupation with the maintenance of existing services and service priorities. Often this has reflected persistent professional perceptions that there is no clear need for this sort of new role in these districts. Typically there has been no net increase in nursing staff/budget at these three sites.

In summary family health nursing at these sites can be characterised as:

• sporadic, and seldom developed or sustained, despite much effort
• not necessarily seen as needed by professional colleagues

The characteristic pattern can be summarised as:

Context: FHN role super-imposed on "heavy" district nursing caseload within established and functional medium sized PHCT.

Process: Sporadic and limited introduction by FHN only, with little/no change in other professionals' activities.

Outcome: No substantive change in practice. "Normal" district nursing services maintained, but remains stressful for FHN and colleagues.

A variant of this characteristic pattern was also seen at one of the Category 3 sites (Site J). This site is interesting as the FHN had been working as G grade leader of a fairly large community nursing team prior to starting the course. As such there was the possibility that the site might offer particular potential to study the FHN as a team leader for a whole district. During the year, however, wider service management changes resulted in the FHN becoming Lead Nurse for the district. This brought with it the responsibility to lead the integration of community nursing services with local community hospital services. Preoccupation with this agenda meant that the development of the FHN role was never a priority. Accordingly assessment and planning of care for families using FHN documentation tended to be infrequent and fitted in around other work demands. As a practising midwife, however, the FHN did feel that the roles integrated well and enhanced her input with mothers and babies.

There was little substantive delegation of family health nursing work (rather than district nursing work) to other members of the team. In effect the FHN role remained marginal to service provision and this is reflected in the feedback from the six professional stakeholders who responded at the end of 2002. None perceived any substantive change in professional working or service delivery. None felt that the role was succeeding and none saw a positive need for a distinct FHN role locally.

This variant of the Slow/No go pattern can be summarised as:

Context: FHN role super-imposed on local management role at time of change towards an integrated hospital/community team. Background of "heavy" district nursing caseload within established medium sized PCT

Process: Sporadic and limited introduction by FHN only, with little/no change in other professionals working practices

Outcome: No substantive change in practice. FHN role not a priority as wider service management changes necessary first "Normal" district nursing services maintained, but stressful for FHN and colleagues

3.2.4 Bold build

The distinctive Bold build pattern (see Table 3.6) was found to be unique to Site I. Development of the role at this Category 3 site (see Table 3.5) is examined in greater detail in the site case study presented in Annex 4.

At Site I the FHN was responsible for family health nursing for the whole site, rather than having a specific geographic patch of her own within the site. The real novelty of the FHN role in Site I though, was that it was not superimposed on the existing district nursing caseload. Rather the FHN built up a group of clientele "from scratch", primarily through referrals from other health and social care professionals, but also through direct self-referrals from local people.

Prior to the educational course the FHN had been employed at the site as an E grade community staff nurse for 15 hours per week. During the education course the FHN and colleagues from the project team initiated meetings to try to explain the new role to professional colleagues and the local public. The FHN's colleagues generally felt, however, that they had been poorly consulted prior to the introduction of the role and many were unclear about what the role involved and did not involve. From the start of 2002 the new G grade full time FHN role was developed in such a way that it was distinct from the district nursing service. The process of introducing and establishing the role entailed considerable stress for the FHN and a number of colleagues within the core PHCT.

Nevertheless most colleagues within the team soon became active in making referrals. Some patients from the district nursing caseload were actively referred for family assessment and this resulted in a small number of patients receiving both services concurrently. As the year progressed the FHN developed work with a core group of around 20-25 families at any one time. Site I had a particularly high proportion of elderly patients with chronic conditions and much of the FHN's work focused on secondary and tertiary prevention work with these patients and their families.

Such work often involved regular and sustained input, with visits typically lasting between 60 to 90 minutes. FHN documentation was used comprehensively with evidence not only of assessment but also of very detailed care planning, interventions and evaluation of progress. Within the core PHCT it was generally acknowledged that the FHN service was providing this group of families with in-depth care and some colleagues saw it as a positive response to a real gap in service provision. These professionals felt that they themselves often didn't have time to provide this level of service. This view was not unanimous however and other colleagues felt that the pre-existing level of service was satisfactory and were unconvinced of any extra benefit that might be attributable to the new role.

Within the core PHCT there was also some concern about who should receive this new service and whether a "two-tier" situation might be arising. These concerns were related to perceptions that the FHN caseload was separate and finite, and that the role was not integrated in the sense of being a necessary part of an open, on-call primary care service that would have to respond to the full range of community nursing and/or medical priorities. In this regard colleagues questioned whether an FHN could truly be the first point of contact for local families.

As the year progressed the FHN vigorously developed more broad-based community work that focused on health promotion and empowerment. This came to assume around 30% of the FHN workload. Such activity included a regular, open general health clinic in the GP surgery; work as the health link person for the local community centre which included offering teenage girls the chance to discuss contraception and other health and lifestyle issues; joint facilitation of an exercise, music and health group for over 65s in the village; weekly visits to the local Day Care Centre offering ad-hoc health checks and information/advice; and setting up a community reference group to enable the local community to pass on their views on local health needs.

This work was particularly well received by professional stakeholders within the wider health and social care community at this site. Within the core PHCT however, some concerns remained that these FHN services were being developed in isolation from overall PHCT services. Anxieties over infringement of role boundaries remained a persistent feature during the first year of FHN practice at this site.

Nevertheless by the end of the first year four out of thirteen professional stakeholders (31%) locally did see it as providing a substantively different service, while two (15%) actively took an opposite view. This contrasts markedly with all the other sites and tends to confirm the distinctiveness of this FHN role development. Seven respondents (54%) felt the development to be well suited to the area. Eight (62%) thought it likely to lead to an improvement in local health service and none characterised it as a failure. Five respondents (39%) felt the development had involved substantial change for professionals in the way they work together.

The majority felt that the development had added to, rather than taken away from, pre-existing local services. This perception was not universally shared, however, and amongst the district nursing team there remained a feeling that they had lost 15 hours of service provision from their team. This highlights that family health nursing was being seen within the core PHCT as a different kind of service that should be supplementary to the maintenance of normal service, rather than supplanting it. Indeed district nursing activities continued very much as normal during the year. There was a small net increase in spending on the total nursing staff budget at the site during the period that FHN practice was introduced.

By the end of the first year six of the thirteen professional stakeholders who replied (46%) felt there was definitely a need for an FHN locally. Four did not know (31%) and two felt that there wasn't (15%). The fact that most of the core PHCT had actively referred families to the FHN in sufficient quantities to form a new caseload tends to confirm the need for an additional service of some kind. There were still doubts, however, about what the format of that service should be.

The characteristic pattern of FHN development at this site can be summarised as:

Context: "Heavy" district nursing caseload within established medium sized PHCT, but FHN not super-imposed.

Process: New FHN caseload built vigorously through referrals from professionals and public. Autonomous workload management with high community outreach element. Some friction at the boundaries of other professionals' roles. Tensions within the core PHCT.

Outcome: Positively viewed by the families who received the service and by a range of groups in the wider community. Some change in referral practices for a number of professionals. "Normal" district nursing services maintained, but persistent core PHCT concerns about perceived lack of integration of the FHN role and the resultant equity of the overall service. More satisfying for the FHN, but much more demanding.

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