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Evaluating Family Health Nursing Through Education and Practice

3.3 OVERVIEW OF FAMILY HEALTH NURSING PRACTICE

In drawing together common themes that emerged across the ten sites, we can now make a number of more general points about the nature, coverage and extent of primary care nursing services pre and post introduction of the FHN role.

Firstly it is noteworthy that in our contacts with families and through the consultation with lay stakeholders there was very little evidence that local people were dissatisfied with pre-existing service provision. On the contrary several families compared the level of service very favourably with that received in other parts of the UK and abroad. These families valued the range, depth and personal nature of the health services provided and there was concern that these elements should be maintained and not eroded.

During the first year of practice the majority of families who had involvement with an FHN did so because a family member was on the district nursing caseload. Where the FHN role failed to thrive that involvement remained focused predominantly on the individual and was virtually indistinguishable from "normal" district nursing. However it is important to note that all the FHNs felt that they were seeing these families much more as a whole and that this gave their practice a different quality. The difficulty was that this was not tangible for many of their close professional colleagues. To some extent this relates to the more general problem of the invisibility of nursing work conducted in peoples' homes.

Across the 10 sites there was an embedded "bottom line" that the introduction of the new role should not adversely affect the pre-existing level of district nursing service. This was a belief held not only by professional colleagues but by the FHNs themselves who inherited district nursing caseloads. Although there have been stresses for colleagues in cross-covering FHN "patches", and some instances of FHNs insisting that they could no longer do some of the former routine work, on the whole the pre-existing district nursing services have remained unchanged. Indeed the FHNs have usually felt obliged to prioritise this sort of work over overt family health work.

This means that where the role has been developed it almost always supplements rather than supplants existing service. As the previous explanation of the typology illustrates, this has given rise to some interesting and varied developments of primary care nursing services. At some sites (e.g. Slow build-key ally) these developments were planned actively with colleagues and could be seen more as integrated PHCT initiatives for the local community. More often they were developed by the FHN alone as an opportunistic response to perceived need. Such need did not emanate solely from their assessment of services in their communities but also from their own felt need for a visible community role that broke free from the district nursing caseload.

Thus many FHNs started to run "healthy living" groups in the evenings that were open to all. These have allowed development of primary prevention work often focused on weight and diet. Such groups have had mixed success so far (men almost never attend) but have been a way of making the FHN service more accessible to the public. FHNs have also used local shops and media to advertise their role, and recently a generic information leaflet has been produced that can be distributed in communities.

Between this type of open outreach and the confines of the district nursing caseload there has been difficult ground to negotiate. One lay stakeholder's comments capture the dilemma:

"If prevention is the aim, how is this to be delivered? Are families to be chosen on perceived socio-economic criteria or some other at-risk category, and once selection is made, how will subject be broached? I would rather see those in need of care get it as priority over some service that could be delivered in an intrusive and ad-hoc manner"

None of the FHNs have done "cold calls" knocking on doors to offer the service, but some have made introductory phone contact with new families moving into these small communities.

In effect the FHNs have been dependent on professional colleagues for a "way-in" to families who do not already have contact with district nursing services. This was required when the FHNs were students on placement during the educational course, but since then referrals of families have been relatively low (78 professional colleagues replying to the stakeholder questionnaire reported referring a total of 30 families in all). The majority of referrals to FHNs have continued to be for district nursing type service to individual patients. There was evidence from site visits and stakeholder questionnaires that the new FHNs were themselves active in referring individual patients and families to other colleagues and services.

Preventative work usually involved FHN input at secondary and tertiary levels for couples of the same generation, two generational families, and single people living alone (i.e. the typical client groups for district nursing). However most FHNs had ongoing input with at least one family with young children and some of these families had more complex structures (e.g. two generations with two families coming together through re-marriage; three generational families with several households). The input here was usually primary prevention relating to common aspects of family living (e.g. diet; exercise). In the first year of practice very little FHN work has taken place in common dwellings such as residential homes or nursing homes, but some of the sites had no amenities of this sort anyway.

Operationalising the family-as-client philosophy became more difficult where several households were involved, but this does not mean it was easy within single households. The logistical difficulties of trying to see members of a family group individually and in combination cannot be overstated. Often evenings or weekends would be preferred by families, but regular work at these times was not provided for in FHN contracts and would not necessarily have been welcomed by all FHNs. Working men in particular had little contact with FHNs.

Moreover the nature of the family assessment process itself raised particular challenges. Completing a genogram and ecomap with family members was found to be a very time consuming process that typically involved a number of lengthy home visits. The 1-2 hour long visits referred to in the Site I case study were typical for FHN assessment visits. The following extract from another case study interview with an FHN highlights some common difficulties:

FHN: ... so this took a wee while and she then trusted me and had confidence in what she was saying to me. It took quite a few visits too and then once it was opened, where was the cut off point? You know there was so much that she has unspoken and then well a lot of it you just didn't record.

Researcher: I think again it is interesting when you elicit so much information there is only so much that you would be putting into the document.

FHN: There is also the confidentiality side when you have other professionals who could have access to your notes.

Researcher: It does raise the question for me of how you use the genogram then. Who is it for and what use is it?

FHN: Well exactly. It is only really for the FHN. I mean nobody else would understand the genogram, you know the ins and outs unless you are taking them through it. I mean I do outline to the family the reasons for the genogram and the ecomap to highlight strengths and weakness as you know.

Researcher: Do they have a copy of it?

FHN: No they don't have a copy of any of the notes, I keep the notes back here.

Researcher: But in terms of other professionals, they wouldn't …

FHN: I wouldn't show them myself.

Thus we see the power of the family health nursing assessment to elicit a range of narrative over time that gives insight into family health, background and functioning, but also the associated dilemma of what to do with such information and the resultant tendency for it to become the sole property and province of the FHN. None of the six families that we studied in depth actually had a copy of the genogram or ecomap in the house. This may be related to another practical ethical problem concerning confidentiality between individuals within families.

The original comprehensive FHN documentation developed during the educational course included in-depth questions on family power structure and dynamics. In practice such an overt focus on typically covert issues was found to be unsuited to Scottish Highland and Island culture. FHNs felt that such questioning could often be uncomfortable and inappropriate for family members, especially if several were present. It is interesting to note that the North American influence is much reduced in the most recent FHN documentation produced through the Role Implementation Group.

Some of the discomfort alluded to above undoubtedly belonged to the FHNs themselves. There was no doubt that insights into power and dynamics could be useful to inform care, but these could often be gleaned more subtly than by direct questioning. Some of the FHNs reported encountering families/family members who didn't wish to participate in the sort of in-depth assessment being offered, and this was usually because they found it intrusive and/or didn't see why it was needed. These sort of overt refusals were relatively rare and this is almost certainly attributable to the fact that the FHNs were very experienced community nurses who used their inter-personal skills to tailor the assessment content to the situations encountered.

Much of the explicit FHN activity during 2002 involved the assessment of local families. The depth and development of this work varied but, with the exception of Site I, it generally proved difficult for FHNs to progress sustained, in-depth programmes of interventions and evaluations for more than a few families. Although plans with goals were usually explicit in the FHN documentation that we studied, we found that family members usually struggled to identify any joint family plan or specific individual goals, and never portrayed themselves as active participants in a specific shared contract. Perhaps this is more a reflection of a general culture of patient passivity than a reflection on the efforts of the FHNs. This mother and daughter were typical:

Researcher: At the moment is there any sort of plan, if you like, for your health that you are working on with Una(FHN)? Any kind of plan?

Mother: She hasn't mentioned anything has she?

Daughter: No she hasn't.

Mother: And I've not thought to be honest. I haven't really thought about anything.

Nevertheless the family members that we interviewed were knowledgeable about the range of health services in their respective areas and it was interesting to note that they did not necessarily see the FHN as their first point of contact for a health problem. Typically they would say that it depended on the nature of the problem and who would be most suitable and readily available. Even where the problem was specifically within the nursing domain, it was not axiomatic that the FHN would be the first choice (unless at sites where only an FHN was available). These families valued FHN input, but they also valued choice of a range of responsive services. Talking of the FHN, HV and GP this couple said:

Pregnant mother: ... so you know that if you've got a problem you can just lift the phone and you'd get one of them.

Male partner: They have an understanding of what we're about- of the problems that we might encounter or how we deal with things … I guess it just prepares them more to give us a better level of care than just, you know, Glasgow or Aberdeen and walking in somewhere and you're a number.

Confirmation that these families were satisfied with FHN care was evident from their responses to the adapted version of the Consultation Satisfaction Questionnaire (Poulton 1996) that they completed towards the end of 2002. These highlighted the inter-personal skills of the FHNs and the value family members placed on the time that had been spent with them.

3.3.1 Professional stakeholders' views

The end of the year also saw the collation of responses from the follow-up professional stakeholder questionnaire. Although this material has been analysed primarily at the level of each site, there is some value in its aggregation to give an overview of colleagues' perceptions of the FHN development so far. Table 3.7 presents professional stakeholders' responses to a number of statements in the follow-up questionnaire (December 2002). The table is based on responses from a total of 78 professional colleagues of the FHNs.

Table 3.7 Professional stakeholders' responses to questions post introduction of FHN

Figures in bold text indicate actual number of respondents in each category and figures in brackets are percentages. Where row totals are less than 78 this indicates that the remainder of respondents did not answer that particular question.

The above results show that professional colleagues are still unsure about the impact of many aspects of the FHN development, but also that the status quo has not been substantially altered so far. Few see the FHN as taking away services and engendering deterioration. A comparison was also made using data from the 53 professional stakeholders who responded on both occasions ( Annex 5). This shows that there has been very little overall shift in these stakeholders' perceptions.

At follow-up we also elicited professional stakeholders' views on whether they saw the need for a distinct FHN role locally. Overall opinion was fairly evenly divided, with 31% seeing a need, 33% not seeing a need and 28% indicating that they didn't know. When this data is broken down into responses from distinct professional groupings the results are interesting. Table 3.8 provides details.

Table 3.8 Professional groups' responses at follow-up to question Is there a need for a distinct FHN role locally?Figures in bold text indicate actual number of respondents in each category and figures in brackets are percentages of each row

These results suggest that the other professional nursing groups at the core of PHCTs tended to be less receptive to the new role than the wider spectrum of professional colleagues. This affords opportunity to briefly summarise the perceptions of the different professional groups about the FHN development.

3.3.1.1 District Nurses, community staff nurses and auxiliary nurses

This group was generally the most affected by the FHN role development. Some adjustment of working arrangements was usually necessary to accommodate the new role, but this usually took the form of separation of FHN work into a "patch" rather than substantive, integrated site review of caseload management. Nevertheless at some sites there were strains relating to cross-cover especially when there was staff illness or shortages. Very few of these staff were hostile to the FHN role, but more felt that family nursing happened already and could not understand the new role and the need for it. It is important to note that four of the new FHNs were already qualified District Nurses and most of them found that colleagues and clients still saw them in their former role.

3.3.1.2 Health Visitors

At national level this is the group that voiced most concerns about the new role when it was first mooted. During the first year of FHN practice, however, there was very little substantive impingement on the work of the Health Visitors at the ten FHN sites. With the possible exception of Site I, FHN forays into overt child health work and community health promotion have been on a small scale. Some local HVs have welcomed this as extra help and worked closely with the FHNs to share skills and avoid future duplication. With their geographically widespread caseloads, these HVs have taken the view that another health worker could help address the needs of some family members that they don't often see (e.g. the elderly and men). Others have been more resistant and have either not engaged at all with the development or sought to re-enforce professional boundaries (often formal child health development checks are seen as "the line in the sand"). Many continue to have concerns about the integration of the FHN role into PHCT service provision.

3.3.1.3 Practice Nurses

There were Practice Nurses at seven of the ten FHN sites. Many had very little working contact with FHNs and felt unsure about what the new role entailed. At one site several Practice Nurses felt that the development had disrupted team working practices in that the FHN was no longer so willing to be involved in elderly assessments and immunisation programmes. Only one Practice Nurse was markedly enthusiastic about service development opportunities for the new role.

3.3.1.4 General Practitioners

GPs are key players in all PHCTs. A striking aspect of the FHN initiative was the extent to which it was kept separate from concurrent debates about recruitment and retention of GPs in remote and rural areas of Scotland (see RARARI 2002b). GPs generally did not feel threatened and felt there was little impact on their own roles. They were divided on the need for the FHN role but few were overtly opposed as long as normal nursing services were seen to be maintained. Some more actively supported the development of the role by referring families and sharing skills in a structured way.

3.3.1.5 Midwives

It is also important to emphasise the extent to which the FHN initiative was kept separate from concurrent review of midwifery services in remote and rural areas of Scotland. In these areas the community Midwife has traditionally been a key health professional and the role has usually been carried out in combination with a nursing role (i.e. "double duty" District Nurse and Midwife; "double duty" community staff nurse and Midwife; or "triple duty" District Nurse, Health Visitor and Midwife). Six of the ten FHNs were qualified midwives and five continued to practice during 2002. Their midwifery caseloads are typically very small, with home births in these areas now very rare indeed. Rather the majority of their care is ante natal and post natal. Where working relationships with Health Visitors have been good, some of the FHNs have taken the opportunity to continue and expand their work with young babies and their families beyond the traditional time when families are handed over to the Health Visitor. Such work is in its infancy just now but has usually involved some joint assessment whereby both professionals meet at the developmental milestones.

At sites where the FHN was not a Midwife, the role was usually carried out by a "single duty" Midwife who was part of a team based in an adjacent area. Generally the FHN development had little effect on this group.

3.3.1.6 Nurse managers

Managers of community nursing services in the regions studied were only included in the stakeholder questionnaires if they were identified exclusively with a particular site. This was rare as nurse managers were few in number and usually geographically remote from the FHN sites. More often we interviewed nurse managers individually. As a group they had mixed feelings about the introduction of the FHN role and different perceptions of why it might be being introduced. Facilitating student participation in the educational course required that replacement staff be found at short notice in 2001. By the end of 2002 most of the managers were cautiously positive about the FHN development but were waiting for the outcome of the evaluation before initiating any related action.

3.3.1.7 Other health professionals

As Table 3.8 shows, other health professionals who had some engagement with an FHN were broadly supportive. This included other community specialist nurses such as CPNs and Macmillan nurses.

3.3.1.8 Workers in the wider community

Again, as Table 3.8 shows, workers in the wider community at these sites who had some engagement with an FHN were enthusiastic about the role. Many welcomed the contact and found it useful to have the extra resource and support from the FHN.

3.3.2 Lay stakeholders' views

Finally by aggregating responses from lay stakeholders across the ten sites it is possible to obtain an overview. Table 3.9 shows data from the 34 individuals who responded on consecutive occasions.

Table 3.9 Comparison of the perceptions of 34 lay stakeholders who responded to the questionnaire pre and post introduction of FHN(* denotes wording used when questionnaire sent post FHN introduction). Figures in bold text indicate actual number of respondents in each category and figures in brackets are percentages. Where row totals are less than 34 this indicates that the remainder of the respondents did not answer that particular question.

Table 3.9 shows little change in these respondents' views. They remain unsure about several aspects of the FHN development but they have also maintained a generally supportive attitude towards it. Fear of service withdrawal does not emerge numerically as a big issue but it was prominent amongst initial comments:

"I hope the FHN is in addition to those here already- not taken or seconded from other staff"

"It is important that it is in addition to the service already provided and not in place of"

Pre-introduction of the role, sixteen respondents (27%) had heard at least something about it, usually through a friend/relative or a health care professional. By the end of 2002, ten respondents (22%) had been in contact with an FHN and some of this involved care for themselves or their family. These respondents generally saw the FHN as a similar service but one that they viewed positively.

3.3.3 Perceptions of consultation

During 2001 and 2002 work to explain the new role to local professionals and the public was co-ordinated at national and regional level. When professional stakeholders were asked at the end of 2002 whether they had been adequately consulted on the introduction of the FHN role twenty six (33%) replied positively, forty four (56%) said no and seven (9%) did not know. We also asked professional stakeholders whether they felt that consultations with the local public about the introduction of the role had been adequate. Ten (13%) responded positively, thirty eight (49%) said no, and twenty nine (37%) did not know.

3.4 SUMMATIVE DISCUSSION

Our evaluation has studied the first year of family health nursing practice in remote and rural Scotland. As a basis for drawing conclusions it is useful to map progress so far against the Scottish Executive's summary of the principles of the FHN role (see 3.0).

Looking first at points 1 and 4, it can be seen that during the first year the FHNs usually functioned as skilled generalists encompassing a range of duties. For many, however, the range of duties did not differ substantially from the traditional work and concerns of the district nursing role. As such there was usually little change in terms of them being first point of contact (i.e. some FHNs were necessarily the first point of contact as there was no other type of nursing service immediately available; others would potentially be the first point of contact for their "inherited" district nursing caseload patients and a small number of other families). There was evidence that typically the FHNs were active in making referrals where more particular expertise was required.

Points 2 and 3 relate to the essential identity of the new Family Health Nurse role. Our study of practice showed that all the FHNs actively tried to take forward some work encouraging healthy living and preventing ill-health. Sometimes this was at a primary level within communities, but more often it was at secondary and tertiary levels with individual patients and other family members. For most FHNs, however, the main part of their job remained caring for ill members of the community requiring nursing care. This made it difficult for them to really develop a lead role in preventing illness and promoting health at their home sites. The FHN at Site I was a notable exception in this regard.

Irrespective of circumstances at their sites, all FHNs reported approaching their daily work with a changed and enhanced awareness of the importance of the family dimension. As has been seen their capacity to implement the family-as-client concept through in-depth assessment often seemed to be inhibited by the traditional demands for primary care work focusing on individuals. In turn this raises questions about the extent to which caring for families is already integral to the work of local primary care health teams, and whether there is shared perception of a need for change.

Consideration of the above four principles of the FHN role also highlighted some of the differences that emerged through the typology, leading to the question: what factors make an FHN role work? From our findings so far it seems that there are two basic factors:

1. The perceived scope and space to encourage implementing this approach. This was seen to pre-exist in the context of the High scope-slow build pattern and was also seen in the context of the Bold build pattern where the FHN role was separate from the district nursing caseload.

2. The local presence of at least one active supporter who changes their own practice. This was evident in the process of implementation at sites that shared the Slow build-key ally pattern.

The presence of at least one of these factors appeared to be a necessary condition for progress. Where neither of the foregoing conditions existed, family health nursing failed to thrive. During the evaluation we were also aware that the individual creativity and drive of the FHN were influential factors.

Whether these factors together are sufficient to further develop and sustain the role is doubtful. In our judgement the following factors have largely been absent during the first year of family health nursing practice and would be worth considering as a basis for future development of the role

• a programme of support and facilitation of the development at site level.
• active team review of case loads and working practices to improve effectiveness and efficiency.
• concurrent review of nursing resources and staff skill mix.
• delegation of family health nursing work (possibly by putting FHN in a form of "triage" role, or as an active team leader).

In effect we found that the role can be developed in a limited way on top of a district nursing caseload and within pre-existing resources. Its introduction in these circumstances officially legitimises and raises awareness of nursing that has a strong family and health orientation in general. We would argue that this orientation is already apparent in some existing nursing practice within the Highlands and Islands of Scotland.

However the distinctive systematic approach that characterises family health nursing is new and different for the area. So far, many colleagues have found it difficult to engage with, and understand the need for, this particular approach. As such it has struggled to become a role in the sociological sense. Even where it has been legitimised through recognition (e.g. through referral of families by key allies within the PHCT) it cannot necessarily beprioritised if traditional community nursing service is to be maintained unaltered.

One of the key aspects that potentially gave the new role definition was the distinctive in-depth framework for assessment and intervention. From our study of the educational course it was clear that the FHN students saw this as a core element that was central to their new professional identity. The newly qualified FHNs spent much time trying to operationalise this framework within the context of other demands on their time. Many teething problems with the documentation were resolved creatively but during the first year it became particularly clear that the assessment process for a whole family was often complex, time consuming and difficult to orchestrate in practice. This caused intra-role conflict for the FHNs and sometimes inter-role conflict in terms of team functioning.

Through the use of community profiling the educational course also encouraged the students to conceptualise their whole home base site as the legitimate focus for their new role. This approach to practice would address the needs of individuals, families and communities. On return to practice, however, it has proved difficult for many of the FHNs to operationalise this vision in a balanced and meaningful way. For the community nursing culture from which they came, and into which they returned, tends to be permeated by the concept of caseload.

These listings of people receiving intervention/s serve to define the focus and limits for the organisation and delivery of care. In the context of introducing family health nursing so far the most relevant and dominant caseloads have undoubtedly been those of the district nursing service. Therefore it is not surprising that the FHNs who have had to develop the role at their sites from a basis of at least maintaining the current level of district nursing service have struggled to re-conceptualise and re-prioritise their working practices. When we studied current caseload lists there was often the traditional district nursing listing followed by a small list of family names. Integration of these listings was difficult as the family health nursing work was typically seen as done by the FHN herself while the rest of the team usually only focused on the main listing. Thus family health nursing activity tended to supplement rather than supplant traditional district nursing activity. Moreover, even in small remote and rural settings, re-conceptualisation of the notion of caseload could not occur without the active engagement of other key team members in the process.

The development of family health nursing at Site I offered possible solutions to some of the above difficulties. Here the role was developed outwith the district nursing caseload and with the FHN defining the role's boundaries in a more autonomous way. In some ways this led to a more specialist role, with referral patterns and caseload dynamics more analogous to those of a Macmillan nurse or diabetic nurse specialist. The specialism aspect was pronounced for the family part of the role, but also for the health part in terms of the primacy it gave to health education and promotion. A key feature was that this health work could cover a very large range of subject matter and client groups. The breadth of this health work brought with it some features of generalism, in the sense of having to have a broad knowledge base about a large number of topics. The key point, however, was that this FHN did not necessarily have to be generalist in the sense of concurrently addressing all the role expectations traditionally associated with the district nursing caseload. Within the existing primary care system, however, this made it more difficult for her to often act as the first point of contact.

Rather this role gave an in-depth service to a smaller number of patients and families. At the particular site we studied, the role only became very partially integrated within core, mainstream primary care team activity. However in a short space of time it made a substantive contribution to the development of health and social care in the wider community. There was some duplication of activity with the district nursing and health visiting services but the majority of the FHN activity was supplementary to the existing service. Compared to other sites, professional colleagues at Site I were more likely to see the FHN as providing a different kind of service.

As such there would appear to be cost implications if the Bold build pattern were to be developed and replicated in this way, in the absence of re-appraisal of existing PHCT roles and working practices. In essence a new, supplementary community nursing role would be created. One of the inherent aspirations of the Scottish Executive initiative has been that any viable change would be sustainable from within existing resources. In this regard it is worth noting that our previous suggestions for developing the other patterns of practice towards sustainability would also be likely to require some additional deployment of resource.

Before moving on from our analysis of practice it should be noted again that we have not studied the practice of the second cohort of FHN students. For this larger group are now qualified and currently developing the FHN role at their local sites. This includes three Health Visitors, and even within this sub-group it appears probable that distinctly different interpretations of the role may emerge.

One of the regions participating in the initiative has also been exploring the possibility of the family health nursing course being the basis for a more advanced nurse practitioner role. This remote and rural region has particularly acute problems with the recruitment and retention of GPs, especially in a number of small islands. The region already has at least one nurse practitioner who is the key health professional delivering services to the population of a small island with no resident GP. This role has a relatively high degree of autonomy that includes limited diagnostic capacity, management of social services and use of nurse prescribing.

Thus there are possibilities for other patterns of practice to emerge and other ways that the role might be developed in practice. For the Scottish primary care sector is currently diverse and dynamic. In order to examine this more fully, and to provide wider perspective to our findings in Chapters 2 and 3, we now consider the wider Scottish context.

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