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Evaluating Family Health Nursing Through Education and Practice
CHAPTER FIVE: IMPLICATIONS FOR THE DEVELOPMENT OF THE FAMILY HEALTH NURSE ROLE
5.0 INTRODUCTION
From the basis of the findings reported in the previous three chapters, this chapter now considers implications for development of the FHN role. This is done firstly in relation to the role as it currently exists in a number of remote and rural areas of Scotland. This leads to consideration of its possible introduction within other areas of Scotland. The final section of the report reflects on the nature of the Scottish project before exploring its potential to inform debate about practice development and nurse education within the UK and beyond.
5.1 THE FAMILY HEALTH NURSE ROLE AS IT EXISTS
Firstly it is necessary to re-iterate that this research has been conducted over a relatively short period of time which includes only the first year of FHN practice. As such we have studied the formative stages of the role as it exists and our initial understandings should be seen in this light. The emergent typology shows four distinct patterns of FHN practice, but the majority share a significant common feature: the pervasive influence of the traditional work and concerns of the district nurse role.
Given the professional backgrounds and employment contexts of the first cohort of family health nurses this should not be surprising. In Chapter 2 it was seen that the educational process for family health nursing provided these experienced nurses with personal and professional development, encouraging a graduateness to emerge whereby they could reflect and analyse situations. All students have attempted to embrace the ideology behind family health nursing, and this is seen particularly in their enthusiasm for trying to operationalise the distinctive assessment process. However, so far, the majority have struggled to substantively incorporate the ideas into practice.
The real world of primary health care is a psychodynamic place full of cultural history, hidden meanings and assumptions. For a role to be recognised and enacted requires joint action in concordance with other people. An overt and positive need for the role was generally not recognised within the core Primary Health Care Teams at most of the sites studied. Moreover there has been limited facilitation of the role to enable enactment to take place. In effect the nature and scope of the necessary change process has been underestimated.
Although a small number of key allies emerged during the year, there was generally a lack of active "champions" for the role at local grass roots level. Others within the core PHCTs didn't necessarily feel a need to actively engage with the new role and modify their practice. This has made it difficult for the new FHNs to develop and sustain their own new vision. For to meaningfully enact the concept of the whole family as the client would require at least a commitment to systems and role review within PHCTs whose service provision is typically predicated and prioritised on the basis of response to individuals needs. The practical difficulties around making the FHN the first point of contact illustrate the nature of the challenge involved in regard to integration of the role within PHCTs.
Figure 5.1 overleaf illustrates the context for role development. Using the principles of mapping we have identified the relative strength of associations between the major influences on the development of the FHN role.
Having conducted this eco-assessment we are able to identify the areas for planned intervention and development by means of a process of facilitation. 22 As Figure 5.1 shows there are very strong associations between current service provision (i.e. pre family health nursing) and the expectations of the public and the professionals involved in care delivery. Theories about family, health and assessment and the attempt to utilise this knowledge in practice were strong whilst the family health nurse was a student undertaking the education programme. Utilisation of comparable knowledge by the core PHCT is weaker as is the FHNs ability to utilise this new approach to nursing in the context of current service provision.
In effect the educational programme has attempted to lead practice. There is a need now for service development to be given more emphasis so that in turn it can inform future educational development. Having already made specific proposals for course re-design in Chapter 2, we suggest that there are now three areas where active facilitation is required in order that the role of those Family Health Nurses currently in post can be developed further.
1. Enabling the FHN role to merge with current service provision in a meaningful way.
2. Developing the core primary health care team in order that they can incorporate a more systematic focus on family and health into existing services and care practices.
3. Involving patients and the wider community to expect, accept and value a different approach to nursing care in particular and health care in general.
5.2 THE POSSIBLE INTRODUCTION OF THE ROLE ELSEWHERE IN SCOTLAND
The application of family health nursing to other remote and rural areas of Scotland or to the wider Scottish context requires careful consideration. A multi-skilled generalist nurse who can provide a range of services should be suited to remote and rural areas of Scotland where small teams exist and recruitment problems prevail. Whether the optimum knowledge and skill-base for this individual is premised on family health nursing requires careful assessment by service providers.
For in effect this initiative has served to open up a spectrum of possibilities. The Bold build pattern represents one end of the practice spectrum. This casts the FHN as a further specialist community nurse whose work involves more in-depth programmes of care for families than those typically offered by District Nurses and Health Visitors. Although the way that Bold build developed involved some duplication of service, it was mostly supplementary to existing services. Therefore if this role were to be developed in other villages or cities, with no concurrent revision of existing roles, this would be an extra service with cost implications.
At the other end of the spectrum the FHN is virtually synonymous with the District Nurse. In this context our research has shown that sustained development of family health care programmes is difficult if all other existing services are to remain unchanged. This was the case even where teams and caseloads were relatively small and stable. This would suggest more difficulty if the role were simply to be super-imposed on busy urban caseloads where throughput of individual patients may be much higher. Relevant research from other parts of the UK (Audit Commission 1999) and Aberdeen (McAskill 2002) strongly suggests that demand for an illness focused, medically responsive district nursing service remains a very high service priority.
What emerges strongly across the practice spectrum that we studied is the need for any introduction and development of the FHN role to be considered as part of wider service review and redesign. Thus we suggest that prior to introducing such a role service providers conduct a comprehensive analysis to plan, facilitate and sustain the development. This may require the deployment of an incremental approach to change management. We suggest there are four phases of analysis to be considered before deciding to introduce Family Health Nurses into the workforce.
1 Situational analysis: What needs require to be addressed and why? What are the current gaps in service provision? What type of FHN role would best meet these needs/fill these gaps? Could this be done by other means? What do others think of current services? Which aspects of current service provision will need to be modified to accommodate the new role?
2 Role analysis: What work will be done in the new role? Who will they work with? What type of person is best suited to the role? What education and training do they need? At what level in the organisation will they be employed?
3 Cultural analysis: What is the organisation's approach to health care? Is this understood by service providers? How will this new role be perceived? How will it fit with current understandings? Will the new role be accepted and supported by professionals and communities?
4 Business analysis: What resources are available for the development, support and facilitation of the new role? What resources are needed to sustain the development and allow for growth?
In considering each of these questions clarity of purpose for role development begins to emerge in such a way as to facilitate the customised integration of new roles into current service provision. These considerations would have relevance to urban applications and enhance the potential of the FHN role to be a solution to the particular problems of recruitment, development and retention of staff in remote and rural areas.
Given the diverse perspectives within Scottish community nursing and primary care that emerged in Chapter 4, and given the related concerns over public confusion about the FHN role, clarity is at a premium. It is hoped that this report proves useful in this regard, but it should also be noted that the situation is dynamic. As has been noted in Chapter 3, new interpretations of the role may emerge through the practice of the Cohort 2 students. Moreover the new Public Health Nurses, whose preparation combines Health Visiting and School Nursing, have recently started to practice in Scotland. This adds another element into the mix and many of the key informants interviewed in Chapter 4 were seeking more understanding of how this role will integrate with the emerging FHN role.
During the initiative it was sometimes suggested that the FHN role could be particularly well suited to distinct client groups such as travelling people, asylum seekers or the homeless. This could imbue the role with a particular specialist element. We have also already noted that one of the regions participating in the initiative has been exploring the possibility of the family health nursing course being the basis for a more advanced nurse practitioner role.
In many ways our considerations of the possible introduction of the FHN to other areas of Scotland are permeated by the idea of service design, and redesign, starting from the basis of local need. As indicated in Chapter 4, this is reflected to some extent in existing Scottish Executive policy towards the construction and working practices of LHCCs. Nevertheless it is easy to see how more local interpretations could lead to further expansion of the FHN typology and consequent diversity, rather than necessarily creating one distinct, defined role. This tension between local needs and the need for national/international health services to share common understandings of nursing roles sets the scene for our final reflections on the Scottish experience so far and our projections about its potential to inform practice development and nurse education within the UK and beyond.
5.3 REFLECTIONS AND PROJECTIONS
5.3.1. Changing community nursing: the wider issues
Although the Scottish initiative has so far been restricted in scope to remote and rural regions, it has raised many more general issues about change management, role development, practice development and the nature of health/healthcare services. Through the mechanisms of a national project Steering Group and a Project Officer concerted efforts have been made within a short space of time to introduce and nurture the new role. To date, however, it appears that the scope of the necessary change process has been underestimated, especially in terms of facilitating local engagement. While some of the reasons for this may be project-specific, we feel that further perspective can be gained through a brief consideration of other wider issues.
Over the past twenty years professional role development within UK nursing has been characterised by moves towards more specialist and advanced practice, bringing with it a profusion of new job titles (Tolson and West 1999; Cameron 2000). Community nursing has reflected this trend and often local necessity has driven evolution with professional education lagging somewhat behind (Spencer 2001). The UKCC educational framework published in 1994 was an attempt to address this but it can be argued that it has had the effect of reifying a fragmented and anomalous specialist superstructure for community nursing practice in the UK. For concurrently much of the nursing care delivered in communities has been devolved to registered nurses, nursing assistants and, arguably, home carers.
Therefore it is not surprising that, for some, resolution is seen in the form of a much more generic community nursing role. The WHO Europe FHN role represents one particular form of this through its focus on the family. The Scottish experience is interesting in that, to our knowledge, it represents the first UK attempt to systematically introduce at national level a new higher-level generalist role into a field that is now characterised by differentiated specialist roles. It is important to re-iterate that the introduction of the role was being underpinned by an educational course that had to also satisfy the requirements of the pre-existing specialist practice framework.
The initial process of introducing and managing this change has been driven forward within a relatively short period of time. During the first year of the initiative the efforts of the Steering Group and the Project Officer to engage with relevant members of the professions and the public through consultation were hampered by the fact that the FHN role was:
- hypothetical in nature and lacking in precedent
- very broad in its aspirations therefore difficult to define in operational terms
- consequently difficult to understand and therefore predisposing to disengagement or perceived threat
- not necessarily addressing a priority need as perceived by staff (i.e. in some areas there was a feeling that services for families were already very good)
Thus it is easy to see how the initiative could be viewed as essentially "top down" in nature. In a sense the importation of a concept such as the Family Health Nurse necessarily has something of this character. At this level there are plenty of broad precedents and parallels within recent nursing history such as regional introductions of the nursing process or specific nursing models.
Nevertheless lack of role clarity can also be a feature of new roles that evolve from very localised "bottom-up" developments. Cameron and Doyal (2000) cite findings from the Department of Health's "Exploring new roles in practice" project which suggest that new postholders, their colleagues and managers all experienced confusion in relation to expectations of new roles that had evolved in this way.
It is moot to consider how much the ground can be prepared for the introduction of a new role like the Family Health Nurse. To return to our horticultural metaphor of Chapter 1, the community nursing garden in Scotland has a number of mature, established species including some that poorer countries in Europe might consider exotic blooms rather than the hardy perennials that they are. New seeds have been sown quickly during the course of the Family Health Nurse initiative and so far the remote and rural Scottish soil has indeed produced some hybrids. Only one of the distinctive Bold build type has flourished. The other Slow build types have raised small shoots, while the Slow/No go type has lacked space and light.
This raises an obvious question about the growth and spread of pre-existing species. During our research some professionals raised the possibility of family health nursing replacing district nursing. Moreover this is implicitly suggested within recent Scottish policy (SEHD 2000). Our research suggests that simply replacing district nursing with family health nursing is likely to produce relatively minor change if the new incumbents are expected to maintain existing service priorities and work with families only when they have time.
In effect the FHN initiative raises a much broader question about the nature and scope of primary care provision. Hartrick (1997) highlights the tension between primary care provision of a service that is primarily problem-focused and the aspiration to enhance family capacity through health promotion. The latter wish is almost limitless in scope and poses both profound and practical questions for service managers if the whole family-as-client concept is to be integral to service provision. The Bold build type represented the most developed and sustained implementation of the family-as-client concept, and in doing so raised within the PHCT questions about relative equity and priority that were usually either dormant or unrecognised.
As Hanafin et al (2002) note, need is a contested concept. These authors propose a new model for provision of the public health nursing service in the Irish Republic based on revised understandings of the need for service at the point of delivery. The Irish experience is relevant in that the role of their long-established public health nurses is in many ways very similar to the aspirations of the FHN role (e.g. having a nurse who works with a wide range of client groups across the lifespan, and who may focus service on primary, secondary or tertiary nursing care). Hanafin et al (2002) note the increasing pressure on this generalist role and the relentless pull of specialisation. As such it provides a fascinating contrast for any country considering trying to move from specialism to a more generalist community nursing role like the FHN.
Such a large scale aspiration is not yet overt in recent primary care policy within England (DOH 2002). Valuing generalists is emphasised in relation to support workers/health care assistants and registered nurses, rather than FHNs. Although some examples of innovation in family-focused care are cited in this document there is no particular policy emphasis or priority ascribed to the care of whole families. Rather a new framework for nursing in primary care sets out three core functions for nurses, midwives and health visitors:
1) First contact/acute assessment, diagnosis, care, treatment and referral
2) Continuing care, rehabilitation, chronic disease management and delivering National Service Frameworks
3) Public health/health protection and promotion programmes that improve health and reduce inequalities
Mapping the WHO Europe and Scottish Executive vision of the FHN against this framework, it can be seen that the FHN would be expected to cover all three of these functions. Most of the FHNs in Scotland so far have been attempting this, but it is interesting to note how the Bold build type tended to concentrate effort on the last two of these functions as it was not super-imposed on a district nursing workload. It is also interesting to note how the ordering of the three functions in the DOH 2002 document reflects the hierarchy of priorities so often cited to us in relation to the other relevant role that would be attempting to cover all functions: the triple duty nurse.
Consideration of current primary care policy in England is relevant as it raises the question: if you did want a new, higher level generalist community nursing role, would it be useful to put such an overt emphasis on family? During the first year of the Scottish initiative the FHNs tried very hard to address whole families' needs through a detailed assessment and intervention framework that derived directly from the Calgary model. By the end of the year new abbreviated documentation had been produced which made the influence of this model much less overt, while simultaneously introducing an adaptation of the Omaha Activity Recording System. This reflects a pressure to spend less time on assessment and to adapt the more family specialist aspects of the role to the general demands of primary care practice.
It seems likely that in the short term in Scotland there will be inherent ongoing tension between the distinctive family focus of the role and the demand within the system for generalist activities prioritised around individuals needs. Whether this tension proves dysfunctional or not will depend on the extent to which the role can be facilitated and the extent to which PHCTs are willing to engage in practice review and service redesign. If the latter activities are successful it is possible to envisage the Slow build types, and the Slow/No go types, developing significantly as part of more integrated, family orientated services. In turn this would lead towards a critical mass being achieved that would present a stronger argument to inform debate about changing the present UK system of community specialist practitioner roles.
5.3.3 Educational development: the wider issues
The notion of changing the whole system has been a tangible element of the macro climate in which this initiative has evolved. At times it has cast the Scottish FHN initiative as something of a sparkling light in a new dawn for community nursing. At others it has hung like a dark cloud, imposing a heavy burden of expectation on one small project. Part of the climatic turbulence in the UK relates to proposed changes to the nursing register and their possible consequences for education as well as general concern about the nature and scope of specialist practice amongst educationalists and service providers.
It seems likely that educational providers in the UK may soon have to reconsider their approach to specialist practitioner degree level education. In September 2002 the NMC agreed the new structure and parts of the UK register. The new register will have only three parts: nursing, midwifery and specialist community public health nursing. Entry to the latter part can only follow initial registration as a nurse or midwife. Further consultation on the standards for the specialist community public health nursing part of the register are due to take place in autumn 2003, but the council has already "recognised the distinct difference between nursing and public health nursing and agreed that standards for health visiting clearly demonstrated the level of specialisation required for public health nursing" (NMC 2003).
This raises the question as to whether all the other existing specialist practitioner qualifications will have a similar claim and, in particular where family health nursing will fit in. Will health visitors have a monopoly on this part of the register or will others have legitimate claims that public health is their primary and/or definitive function? A further sub part of the register is likely to be developed for a level beyond initial registration. It may be possible that some of the other existing specialist practitioner qualifications will live within this category.
The following Figure 5.2 overleaf represents a fusion of current influences on professional education for nurses, midwives and health visitors and begins to conceptualise the main differences between the Scottish family health nursing curriculum and other specialist practice degree programmes. Some of the influences, referred to in Figure 5.2 as imploding forces, have resulted in educational curricula being more confined by regulation. Role development provides the opportunity for curricula to expand and explode into new structures. The Scottish family health nursing curriculum has weakened the pull of the imploding forces and allowed itself to explode (not always in a controlled way) into role development, health technology, evidence-based practice, the scope of practice, patient client expectations and career pathways. In doing so it has helped to prepare the ground for re-conceptualising specialist practice in community-based education.
5.4 CONCLUSION
This report has presented an evaluation of family health nursing through education and practice. In doing so it has highlighted strengths and weaknesses that have emerged during the two years of the Scottish initiative. The development of education, national policy and service delivery simultaneously is a very considerable challenge. The extent of the change required has been underestimated. Suggestions for potential development have been made throughout the report. To conclude, we now offer a brief synopsis of these based on the main lessons learned.
In order to capitalise on the achievements to date we suggest that:
- Planned development is facilitated with those PHCTs that include a Family Health Nurse in order that the role can be understood and developed further.
- The critical mass of FHNs is helped to grow in the remote and rural areas.
- The educational programme is further developed as suggested in Chapter 2.
- The evaluation process and resultant evidence is disseminated widely across the UK to foster debate and critical thinking about the nature of community nursing services and suitable educational preparation.
The evidence from this evaluation indicates that considerable effort has gone into this initiative. What has been achieved to date should neither be underestimated nor allowed to wither on the vine.
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