The Scottish Government

« Previous | Contents | Next »

Listen

Evaluating Family Health Nursing Through Education and Practice

CHAPTER FOUR : THE WIDER SCOTTISH CONTEXT

4.0 INTRODUCTION

This part of the report considers contemporary policies which have influenced primary health care in general, and then moves on to an analysis of the effectiveness, deficiencies and requirements of community-based nursing, midwifery and health visiting services across the Scottish primary care sector.

4.1 CONTEMPORARY POLICY ISSUES

Over the last five years the popularisation of former academic interests in the determinants of health, differences in rural and urban life patterns and styles, and the functioning of health professionals has led to policy reviews; new legislation; new directives and administrative initiatives which have sought to redress concerns ¹⁶. In doing so central policy has changed, and a programme of initiatives have been introduced at grass-roots levels in an attempt to develop services and annexe previously uncharted health ground. The family health nursing initiative was one such of these. Other comparable initiatives can be seen in the various social inclusion programmes enacted across Scotland and the development of the role of public health practitioners. Funding for such initiatives has multi-various sources (e.g. National Lottery, New Opportunities Fund, NHS providers, Local Authorities and Scottish Executive Health Department) with the majority being time-limited thereby inviting problems of sustainability and proven long-term effectiveness.

4.1.1 Functioning of health professionals

Before considering some of the wider aspects of community-based nursing, midwifery and health visiting services it is worth reflecting on some of the restructuring processes which influence the working of health professionals. Local Health Care Co-operatives (LHCCs) were introduced to provide a different approach to primary care provision in Scotland. Service providers were brought together with the aim of facilitating community involvement in the design and delivery of primary health care services. Across Scotland there is no universal model for constructing LHCCs and the policy argument states that this is intentional to allow services to develop in accordance with local needs, conditions and circumstances. So we have diversity in primary care provision, not only in the remote and rural areas of Scotland, but across the country as a whole. During the time of the evaluation the notion of an LHCC has been revised for many localities. In remote and rural contexts and elsewhere in Scotland there have been shifts in service organisation in accordance with contractual agreements and service redesign ¹⁷ within primary care. This has added another dimension to the analysis of the role of the FHN: namely in what framework of care or at what level in an organisational structure do family health nurses operate?

4.1.2 Influences on health

Many factors are known to affect the health of individuals and groups within society. These range from infra-structural inequalities (such as inadequate provision of housing, transport, educational services and health services) to more socio-cultural issues (such as poverty, highly differentiated employment practices and institutionalised prejudices) ¹⁸. Variations in health care outcomes have been identified within rural communities both in Scotland and elsewhere (Campbell 2000, Jones, Bentham and Horwell 1999). In addition there have been concerns expressed about the recruitment and retention of health care staff into remote and rural areas. These issues along with others have contributed to a range of localised resource development initiatives being set up under the auspices of Scottish Remote and Rural Areas Resource Initiative (2002b).

Changing patterns of working-life; relaxation of the social mores regarding marriage and child rearing; and the sub-contracting of care for children and older people have all contributed to the reconstruction of family. It is no longer an objectified entity but rather it has become a subjective expression of individual agency i.e. it means what the individual says it means.

The evaluated Family Health Nursing educational programme has attempted to be inclusive of all permutations of family, been specific in its remote and rural focus and has relied on the assessment process to identify the complex nature of post-modern living and social networks. The assessment framework used to construct the official health records has caused problems for service managers across the regions. At present there are serious doubts about the utility of these family health nurse documents to other health professionals or to the patients themselves. The recording of quasi-genetic/hereditary data alongside value judgements about the dynamics of power in a family and the health care needs of individuals does raise many unresolved questions. Firstly the ownership of the records: (e.g. do they belong to the family health nurse; the family themselves; or a dominant member; or does it belong to the wider primary health care team?); secondly the utility of the information disclosed and the ability of the FHN to act on it; thirdly the value of the record to other health care professionals; fourthly incorporating the content of this record of health assessment, goals and care interventions with the proposed "Integrated Care Record" (SEHD 2003) will be problematic due to non-compatibility with existing record systems.

4.1.3 Nursing policies and public health

A number of nursing policies have been published during the research period, ranging from Nursing for Health and Caring for Scotland (SEHD 2001) through to the UKCC's Consultation on requirements for programmes leading to registration as a Health Visitor (UKCC 2001) and subsequent revision of health visiting competencies (NMC 2002). In addition we have seen the production of a strategy for nursing and midwifery research in Scotland (SEHD 2002) and a consultation document pertaining to the revision of the professional Register which has suggested the possibility of a third part of the Register pertaining to public health. Finally and most recently a new White Paper has been produced which advocates partnership working at multiple levels within the health service (SEHD 2003).

The contextualisation of this evaluation in the world of policy has been necessary in order to remind the reader of the complex influences on health care provision in primary care settings and the potential demands made of service providers. For the next section of the report tries to explore the application of policy in practice at the level of community-based health services across Scotland. This stage of the evaluation research was designed to inform our judgements about the applicability of a family health approach to community-based nursing in the wider Scottish context. Reservations about the automatic transferability of our findings, which were derived from studies of distinctive education and practice in remote and rural contexts, into the wider Scottish world of community care, have already been stated. In this section, however, we aim to identify common concerns about community nursing services in Scotland generally and to explicate requirements for the further development of services, education and practice with special reference to family health nursing.

4.2 COMMUNITY NURSING SERVICES: STRENGTHS, WEAKNESSES AND SCOPE FOR DEVELOPMENT ACROSS SCOTLAND

A series of telephone interviews were held with key informants selected from Scottish NHS Trusts and Health Boards providing primary care services and their respective Local Health Councils. Those Trusts and Boards involved in the initiative were excluded. A total of 22 telephone interviews were planned ¹⁹. Informants were asked to consider the strengths and weaknesses of existing community nursing services in their locality; the strengths and weaknesses of educational and continuing professional development activities; how they perceived the role of the Family Health Nurse and where they saw this role fitting or not with their existing service provision.

The initial point of contact was with the Directors of Nursing. They were invited to participate personally and to assist in the identification of a senior nurse at LHCC level who would be willing to participate and another senior person (either manager or chairman of an LHCC) from a non-nursing professional background) who would be willing to participate. In addition the chairman of the Local Health Council was independently invited to participate by the researchers.

Annex 6 presents details of those who were interviewed. along with the evaluators judgements about the level of knowledge that the interviewee had about community nursing services and the education of community nurses in general; the personal stance of the informant; the quality of the interview and a synopsis of the most interesting parts of the interview. The judgement about level of knowledge has been made to accommodate clichéd or stereotypical responses whereas the quality of the interview has been judged in order to try and identify differences between informants with regard to their analysis of complex and varied situations. Those interviewed are referred to as Key Informants in the sense that to understand what they are saying requires the researcher to move away from the notion of grand knowing (as though there is one definite answer) to an appreciation that the job is to build a science of personal perspectives which are localised, pragmatic and constructed based on personal experiences and actions. In this way it is possible to enter into a process of collaborative and co-operative enquiry (Heron 1996, Reason 2001) where meanings are checked out and compared both within and between informants.

Thus a total of 19 people were interviewed (12 senior nurses, 2 doctors, 2 representatives of the allied health professions and 3 chairman of local health councils). Another three interviews were planned but these were cancelled by the informants and no alternative arrangements were made. As illustrated in Table 4.1 the perspectives ranged from very localised levels of knowledge and understanding or a myopic individuated view of the world; to those with wider vision who attempted to incorporate fundamental values about health care provision; or nursing development; or strategic national directives ²⁰.

The following table provides a summary of recurring themes which emerged from the elicitations and subsequent narrative analysis carried out on the audio-tapes of the telephone interviews ²¹. Themes have been selected for inclusion when more than two people made reference to the same issue. The phraseology used to articulate the theme has been taken from the language used by the respondents during the interviews.

Table 4.1 Narrative analysis of recorded telephone interviews

Thus what emerged from these interviews was a general perception that the strengths of existing services lay in the experience, the flexibility, the adaptability and the team-working potential of the nursing workforce.

" Our strengths lie in our diversity of services and the people themselves. We have good relationships with three education providers and we have been working at up-skilling our health visitors, encouraging joint working with D/Ns, CPNs Learning Disability and Health Visitors" (Director of Nursing)

"We have good enthusiastic practitioners. A skilled workforce linked in with general practice"( Director of Nursing).

"Community management is good and the skill-mix is good. Community nursing teams keep close links with general practice … There is very effective core training for at G grade levels. The LHCC have been up-skilling nurses and there are opportunities for nurses to be involved in projects" ( Medical Chairman LHCC).

"Out in the shire services are developed in terms of knowledge of the population, the health professionals know the people and have good local knowledge. The LHCC is a major strength it gives support to team-working. In some areas there is more multi-disciplinary team working and the nurses are all experts. There have been no concerns raised through the patient line. It is more difficult in the big cities for the staff to know people" (Chairman Local Health Council).

Another minor theme, which was discussed in terms of strengths of the services, pertained to the use of record systems. A few respondents spoke of developments with "single shared assessments" or the attempt to plan your workforce and skill-mix in terms of patient need.

"We have nursing care plans linked in to Reid codes for ISD purposes. We can measure our care plan needs and match these to time for care and the allocation of appropriate staff. The whole system is also linked in to GPASS. At the moment it is based in district nursing but health visitors are feeding in to it slowly and we have 8 pilot sites working on a single shared assessment. We are trying to have our nursing data-bases [for management and care] mirror developments in policy." (Senior nurse LHCC).

"We have introduced a corporate case load for Health Visiting which is geographic and links with Schools … That's made for a strong service" (LHCC manager allied health professional)

The weaknesses of the services were described in terms of duplication of effort, recruitment problems, and the nature of the workload involved whether in rural or urban contexts.

"Not having a clear handle on workload and not employing staff on a basis of workload - rather we attach staff to GP practices. There is territorialism within community nursing. Pure territorialism … over the way we look after some clients … children and families. For years health visitors have done nothing in nursing and district nurses have not even thought about health". (Director of Nursing)

"Weaknesses in one area impact on others. For us the geography of the area and how we attract nurses. The main public issue is that we are not obtaining staff here" ( Local Health Council Chairman).

" Recruiting staff with the right qualifications might take two rounds" (Director of Nursing).

"Recruitment and retention are weaknesses we have no HVs in the Bank. Starting Well and other national projects ... you must feel this with NHS 24? ... Siphon off key staff without any consultation with service providers" (Medical Chairman of LHCC)

"Staff recruitment and retention and the diversity of care needs are challenging. The way the teams divvy up work is a weakness" ( Senior nurse LHCC).

When asked about education and training the majority of respondents saw strengths in the current provision and reported that weaknesses were to do with placements and funding.

"We have joint appointees and have been commended on our service education collaboration. The supervisors preparations are good the main weakness in finding placements for pre-reg students" ( Director of Nursing)

"Our post-reg courses are better now we have more control in terms of course content. The immediate post-reg bit is dodgy. We need a staff nurse development programme built on family" (Senior nurse LHCC).

"Education that produces a community nurse who is generalist might meet service needs but what the public require is a specialist. You see this … a lot in cancer … people say we want a specialist nurse" (Chairman Local Health Council).

"Distance learning is a saviour ... made a big difference to us … District nursing and health visiting have a common language in many issues ... common core of learning ... Everybody understands district nurse and health visitor. I can't see what Family Health Nurse will solve or mean … Public health is targeted to the health visitor … District nursing needs a boost". (Senior Nurse Executive Level)

The concerns raised about family health nursing as an approach to community nursing focused primarily on the scope for public confusion. Invariably at this point in the interview, the interviewer was asked many questions. The issues that were raised covered the following: How will the public health nurse role fit with this? (12 respondents) Who is going to look after sick people? (8 respondents) Why has there been such a lack of good quality information about this project (6 respondents). Answering these questions involved a dialogue of exchange to gauge insight - as there were no answers to give. The information gained during these additional discussions has informed some thinking about the nature and management of the initiative and the main work of community-based nurses, midwives and health visitors.

Other specific concerns about skill-maintenance of a generic community nurse and how Family Health Nurses would fit with existing community nursing services.

"I am concerned about the skills these nurses need and how they can be maintained". (Senior Nurse LHCC).

"I am worried about how it [family health nursing] fits into the existing system. It's not good enough or acceptable just to keep changing course names" (Senior Nurse LHCC)

"Family health nursing was seen as a solution to problems of recruitment. It's a mixture of everything. There may be a need for a role like this in very rural areas. Community nursing services are like fried eggs in a pan. When you fry eggs the whites mingle the yolks stay separate. Good teams mingle in places but each keeps their distinctive parts". (Senior nurse LHCC).

"You need to watch the erosion of specialisms"(Director of Nursing)

"It would be good to try it [family health nursing] in a big town area and see if it works. Staff here feel it is a jack of all trades approach and causes dilution of specialism. They can see that the role of the family is important" (Manager of LHCC Allied Health Professional)

Finally the informants identified the perceived benefits of Family Health Nursing primarily in terms of its applicability to remote and rural health care.

"The Family Health Nurse idea appeals. I am a great believer in holism, family and community, promoting health and treating illness. It would fit with our ideas of a healthy living centre" (Chairman Local Health Council).

" I am looking for ways it could fit. Possibly district nursing education … bring in family … also at pre-registration levels. We tend to be a bit over focused on deliverables but I think we could develop services using family health nursing concepts … in a home grown way rather than inventing another group of staff".

(Director of nursing services)

"The family group as the client has potential when families at younger age … Reconfiguring the work of community nurses into geographic collectives with the family as focus … the blurring of roles might be better for city wide management" ( Medical Chairman of LHCC).

"I like the idea in the rural area … you could redesign the staff nurse role … it fits with our ideas of practice teams" ( Senior Nurse LHCC).

"The Family Health Nurse is a positive move for rural areas ... it could be an attractive post for people to move into area. May even help in recruiting staff to stay … It adds to the public health agenda" (Manager of LHCC Allied Health Professional).

"It's to do with the education of nurses. Not just another level of nurse. There is a danger of confusing nurses … Our approach to care and caring skills are fundamental" (Senior Nurse LHCC).

" As I see it there could be two ways of developing services, one where the FHN is a specialist alongside other specialists like Public Health Nurses and Clinical Nurse Specialists. So family health nursing is a development of a new district nursing. The other approach is to consider the Family Health Nurse as the community nurse who then refers on to other specialists. This wouldn't work especially if they are all G grades. One nurse who looks at the whole family and builds up a relationship over a period of time would be good ... .District nursing and practice nursing have lost nurse-led services and confidence and have become medicalised. The role of the midwife needs to move into wider aspects of women's health maybe family health nursing would fit". (Director of Nursing Services).

4.3 SUMMATIVE DISCUSSION

These findings suggest that overall community nursing services are adapting to the policy changes which have been advocated and that current educational provision is generally perceived as good. Nevertheless a number of problem areas were highlighted, most notably duplication of effort, territorialism and recruitment problems. There was also a recognition that newly qualified staff may require additional education to work in the community and that family health nursing may enhance the role of the District Nurse, Community Staff Nurse or Midwife.

Informants' perceptions of family health nursing varied widely and there were some concerns about quality of information and public confusion. The majority agreed that remote and rural areas have special needs with regard to recruitment of staff and the design of services thereby suggesting that family health nursing has special meaning in these contexts. Such a value stance has been informed in some cases by experience of managing services in remote and rural areas but also by the fact that the initiative took place in remote and rural areas.

A further analysis of the interview data has identified an array of contemporary problems which are affecting community nursing services. These are summarised in Table 4.2

Table 4.2 Contemporary problems affecting community nursing in Scotland

Many of these issues also emerged as common problems at the Family Health Nurse sites.

This research was not primarily concerned to evaluate the nature or quality of community nursing services across Scotland, but rather to gain insight into common issues in order to consider how family health nursing may be extended to other remote or rural or urban areas of Scotland.

It is worth noting, however, the dearth of research-based evidence on the nature and quality of community nursing services across Scotland. This makes it difficult to know what baseline, pre-existing services are doing and how they are performing. Some of the difficulty for policy makers, service planners and researchers stems from the fact that community nursing is not a unitary discipline and has such a wide range of professional roles and entrenched interests. Moreover professional roles may be interpreted very differently within regions and even within local teams. Routinely collated data on professional activity is often of very limited value due to problems with its scope and its reliability. Thus reliable comparisons within and between regions at one point in time are difficult, and reliable longitudinal comparisons of service developments are even more problematic.

As such our interviews with key informants represent an attempt to elicit a range of relevant contemporary understandings of community nursing and family health nursing in Scotland. The final chapter of this report considers this evidence alongside our other research findings and evidence from wider perspectives in order to draw out the implications for development of the FHN role and to make explicit the lessons learned from this evaluation.

« Previous | Contents | Next »